Health Transition Fund Final Report - Projects Listed By Subject Area

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Health Transition Fund 

Final Report 

Project code: 

Project title: 

NA321 

The nature of the extended/expanded 

nursing role in Canada 

Date report received: March 30, 2001 

This document is an electronic version of the final report for the above-named 

project as it was received by the Health Transition Fund Secretariat on the 

above date. The Health Transition Fund Secretariat takes no responsibility for 

the completeness and/or accuracy of this report. 

If contact information is no longer current, the Health Transition Fund 

Secretariat cannot undertake to provide updated information. 

If subsequent versions of this report were prepared by the author(s), the 

Health Transition Fund Secretariat does not take responsibility for providing 

such documents. 

This project was supported by a financial contribution from the Health Transition Fund, 

Health Canada. The views expressed herein do not necessarily represent the 

official policy of federal, provincial or territorial governments.


The Nature of the Extended/Expanded Nursing Role in Canada 

A Project of the Advisory Committee on Health Human Resources 

Funded by the Health Transition Fund Secretariat 

Project Identifier - NA 321 

Project Consultants: 

The Centre for Nursing Studies in collaboration with 

The Institute for the Advancement of Public Policy, Inc. 

March 30, 2001 

This project was supported by a financial contribution from the Health 

Transition Fund, Health Canada. The views expressed herein do not 

necessarily represent the official policy of the federal, provincial or 

territorial governments.

Executive Summary 

Table of Contents 

Project Team and Acknowledgements 

Acronyms 

Glossary of Terms 

1.0 Introduction .............................................................1 

1.1 Overview and Purpose ...............................................1 

1.2 Rationale .........................................................2 

1.3 Background - Nursing ...............................................3 

1.4 The Public Policy Context - Policy Objectives and Extended/Expanded 

Nursing Roles .....................................................4 

1.5 Health Care Reform and the Extended/Expanded Role of the Registered Nurse .....5 

1.6 Overview .........................................................7 

2.0 Methodology ............................................................7 

2.1 Method ..........................................................7 

2.2 Determination of Terms and Definitions ...................................8 

2.3 Population and Sample ..............................................10 

2.4 Procedure .......................................................10 

2.5 Instruments ......................................................12 

2.6 Data Analysis .....................................................13 

2.7 Overview of Restrictions and Limitations .................................14 

2.7.1 Restrictions ................................................14 

2.7.2 Limitations .................................................14 

3.0 Results ................................................................15 


The Institute for the Advancement of Public Policy, Inc.

3.1 Policy and Legislative Frameworks for Extended/Expanded Nursing Roles .......15 

3.1.1 Title - Policy Framework ......................................16 

3.1.2 Scope of Practice - Policy Framework ............................19 

3.1.3 Educational Preparation - Policy Framework .......................21 

3.1.4 Summary ..................................................24 

3.2 Organizational Structure: Administrative Personnel Perceptions ................25 

3.2.1 Models of Practice ...........................................25 

3.2.1.1 Location and Setting ....................................26 

3.2.1.2 Job Requirements and Core Competencies ...................28 

3.2.2 Lines of Authority ............................................30 

3.2.3 Quality Measures and Evaluation of Outcomes ......................32 

3.2.4 Summary ..................................................33 

3.3 On-site Data Collection .............................................34 

3.3.1 Practical Knowing ...........................................34 

3.3.2 Collaborative versus Independent Practice Models ...................37 

3.3.3 Role Confusion: Patient Understanding, Acceptance and Satisfaction ......39 

3.3.4 Barriers to and Facilitators of Collaborative Practice Models ............40 

3.4 Patient Perceptions .................................................44 

3.5 Observation of Nurses Practice .......................................45 

4.0 Conclusions and Recommendations ..........................................46 

4.1 Policy and Legislative Frameworks .....................................46 

4.2 Regulatory Framework ..............................................49 

4.3 Terminology and Definition Problems ...................................51 

4.4 Availability of Quality Services to the Public ..............................53 

5.0 Dissemination Plan .......................................................55 

Appendix A Sources 

SD1 Profile of Extended/Expanded Nursing Practice in Primary Health Care Settings 

SD2 Research Protocol for on-site data collection 

SD3 Results of on-site data collection 

SD4 Dissemination Plan 



Executive Summary 

In March, 1999 the federal/provincial/territorial Advisory Committee on Health Human Resources 

(ACHHR) Working Group on Nursing and Unregulated Workers sponsored a study to describe the nature 

of the extended/expanded nursing role in Canada. The focus of this project was on the primary care aspect 

of registered nurses’ practice (i.e., assessment, diagnosis, and treatment of episodic, acute and chronic 

illness, and minor injury). The purpose of the current project was to identify facilitators of and barriers to 

the effective delivery of primary care services by registered nurses working in extended/expanded roles. 

A second purpose was to recommend policy options that would facilitate more effective utilization of 

registered nurses working in these roles. 

The extended/expanded role of the registered nurse is most often associated with the north and 

remote areas where there are limited numbers of health professionals to service the population. However, 

there are registered nurses practising in the role in other locations and settings. With health care reform, the 

possibilities offered by greater use of the extended/expanded nursing practice is a matter of interest to all 

levels of government. This report outlines the research activities undertaken by the project team, key study 

findings, and policy recommendations that are supported by study findings. 

Research Program 

The project used a research design which combined data, investigator and methodological 

triangulation. The phases of the research program included the following sequential activities: 

< establishing terms and definitions for the purposes of the project; 

< contacting representatives from nursing associations and provincial/territorial ministries of health to 

develop a profile of policy and legislative/regulatory frameworks governing nursing practice within 

each jurisdiction, while giving special attention to provisions for the extended/expanded nursing role 

in primary health care settings; 

< conducting an administrative survey of key informants present at sites within each province/territory 

to construct a profile of the organizational structures present in settings employing nurses to work 

in the extended/expanded role; 

< collecting data at selected sites to gauge physicians’ perceptions of the extended/expanded nursing 

role , as well as the perceptions of registered nurses’ working in the role; to describe the 



experiences of nurses working in the role; and to gauge patient satisfaction with the services 

delivered by nurses working in the extended/expanded role; 

< conducting an integrated analysis of all data sets to identify key facilitators and barriers to the full 

utilization of the extended/expanded nursing role. 

Results & Conclusions 

The different phases of the research program provides the framework for highlighting key study 

findings. The overview of the findings is followed by several important policy implications that emerged 

during the data analysis phase. 

< Developing a Glossary of Terms for the project proved to be problematic due to the absence 

of common understandings of key terms used in the field. 

< The Policy and Legislative Frameworks governing nursing practice in the extended/expanded 

role were found to be quite variable across provincial/territorial jurisdictions. Overall, the review 

indicated that the extended/expanded nursing role has evolved without a consistent policy direction 

and is highly dependent upon the circumstances present in the jurisdiction. While traditionally 

nurses’ authority for performing primary care functions has been derived through delegated medical 

functions, four jurisdictions have enacted legislation to legitimize the extended/expanded nursing 

role. The major limitations were noted from a review of provincial/territorial frameworks related 

to titling, scope of practice and education requirements. 

The findings revealed that several titles are currently in use across Canada to designate 

extended/expanded role nurses, ranging from nurse practitioner to primary care nurse to regional 

nurse. While the three provinces with legislation in effect have fairly consistent titling within their 

jurisdictions, the title for the extended/expanded nursing role varies by setting and by employer in 

all other provinces/territories, with the exception of Saskatchewan. 

In jurisdictions with legislation, the scope of practice parameters guiding implementation of the 

extended/expanded role are very consistent across primary health care settings. This situation was 

also observed for Saskatchewan which has a province-wide protocol governing 

extended/expanded nursing practice. Significantly, the scope of practice for the extended/expanded 



nursing role varies within and across provincial/territorial jurisdictions and are a function of 

delegated medical authorities. 

Provincial/territorial inconsistencies were noted in expectations regarding the educational 

preparation of registered nurses for the extended/expanded role in primary care. In addition, the 

nature and duration of education programs preparing registered nurses for the extended/expanded 

role in primary care varied across and within provincial/territorial jurisdictions (i.e., ranging from 

2 to 6 week intensive courses to one-year diploma programs to undergraduate and graduate 

programs). The most noteworthy variations were in program entry requirements, course and 

clinical requirements and status upon graduation. 

< A Profile of Extended/Expanded Nursing Practice was constructed from the data collected 

from a survey of administrators working at 44 provincial/territorial sites with different and similar 

organizational structures. The major content areas emerging from this phase of the analysis related 

to factors influencing different models of practice, lines of authority and quality of care initiatives 

and evaluation mechanisms for assessing organizational and client outcomes present in the different 

jurisdictions. The key factors identified during this phase of the analysis included: 

< Greater restrictions are placed on nurses’ autonomous performance of primary care 

functions when there is a greater concentration of physicians. 

< Limited availability of nurses with appropriate extended/expanded role preparation in 

remote regions of the country necessitated lowering expectations re education standards 

and experiential base. 

< Wide-variations existed in requirements for maintaining competency in extended/expanded 

role functions. 

< Limited support mechanisms in place for extended/expanded role nurses working in remote 

regions. 

< Legislative restrictions (e.g., Hospital and Diagnostic Act, etc.), as well as variations in 

policies/protocols between sites, sometimes limit or deny registered nurses access to 

necessary resources. 

< Minimal standards and guidelines for accessing the quality of primary care and the impact 

of services on organizational and client outcomes. 



The On-Site Data Collection occurred in urban, rural and remote settings with variant 

collaborative practice models and levels of autonomous practice. Information was gathered from 

registered nurses working in extended/expanded roles, physicians working with these nurses, and 

patients who received care from these nurses. The key themes emerging from the interview data 

obtained from physicians and nurses’ included: practical knowing, collaborative versus independent 

practice models, role confusion, and barriers to and facilitators of collaborative practice models. 

A brief summary is presented on each of these themes, as well as patient perceptions of the 

extended/expanded nursing role and observational sessions conducted with extended/expanded 

role nurses . 

With regard to Practical Knowing, both physicians and nurses voiced concerns about the 

adequacy of knowledge levels and practical skills of extended/expanded role nurses when first 

assuming the role. The diversities in knowledge and skills observed by physicians and low feelings 

of confidence and competence expressed by nurses, as well as the improvements noted after 

acquiring an experiential base, led both groups to recommend the following: 1) standardize entry 

requirements into programs preparing nurses for extended/expanded practice, 2) increase the 

clinical component of these programs, 3) access to continuing education opportunities to promote 

necessary competencies in expected primary care functions and, 4) establish well-defined and 

universal standards for extended/expanded nursing practice. 

With regard to the Collaborative versus Independent Practice Models theme, both physicians 

and nurses favoured team work or strong inter-disciplinary collaboration over independent practice 

for extended/expanded role nurses. Physicians supported autonomous practice so long as nurses 

working in these roles adhered to scope of practice guidelines and worked under collaborative 

practice arrangements with physicians. Nurses also felt that collaborative, as opposed to 

independent, practice arrangements offered the best care to patients, and facilitated full acceptance 

of extended/expanded nursing practice by physicians and patients. 

Role Confusion by patients was a concern of both physicians and nurses. The consensus was 

that patients experience difficulty differentiating extended/expanded nursing roles from medical 

roles. Despite this confusion, physicians and nurses believed that patients seemed to be satisfied 

with the level of care provided by the nurses in the extended/expanded role. 



There were commonalities and differences in the identified Barriers to and Facilitators of 

Collaborative Practice Models identified by nurse and physician participants. Both groups 

highlighted the benefits for and barriers to quality care delivery, especially from the perspective of 

comprehensiveness and continuity of services. Physician participants tended to focus more on the 

potential impact of the extended/expanded role nurses on patient accessibility to health care 

services, especially medical services. In contrast, nurse participants were more concerned about 

having the necessary supports in place to ensure full-implementation and acceptance of the 

extended/expanded role. 

The important benefits identified by physicians resulting from having nurses practising in 

extended/expanded roles included: 1) increased patient accessibility to medical services in rural and 

remote areas, 2) increased availability of comprehensive health care services, and 3) improved 

quality of care and increased probability of positive health outcomes. Conversely, physicians 

identified several important barriers to full-utilization and acceptance of extended/expanded nursing, 

including: 1) negative impact on the income of fee-for-service physicians; 2) potential for impeding 

physician recruitment and retention; 3) no mechanism in place for fee-for-service physicians in 

private practice to hire nurses to work in extended/expanded roles; 4) decreased effectiveness of 

extended/expanded nursing roles due to restricted prescriptive authority, absence of fraternity with 

speciality physicians and limited access to diagnostic services, especially in rural/remote areas; 5) 

potential for continuity of care problems when nurses order diagnostic tests independent of 

physicians; 6) inadequate nurse supervision may result in the provision of poorer quality care to 

patients; 7) responsibility and liability concerns for attending physicians when nurses see patients 

independently. 

With regards to the benefits from having extended/expanded role nurses, nurses participants 

identified the following: 1) increased access to supportive individuals and collegial relations with 

other health care providers, especially physicians, facilitates confidence building and adjustment to 

the extended/expanded role; 2) increased availability of comprehensive health care services (i.e., 

primary care coupled with prevention and health promotion strategies) to patients; and 3) improved 

quality and continuity of care and the probability of achieving positive health outcomes. The major 

barriers to the extended/expanded nursing role identified by nurse participants included: 1) 

decreased ability to provide comprehensive health care services due to skill/knowledge limitations; 

2) decreased effectiveness of the extended/expanded nursing roles due to restrictions imposed on 



scope of practice (e.g., prescriptive authority, ease of access to referrals and diagnostic services, 

etc.); 3) thwarted/delayed acceptance of extended/expanded nursing roles due to inadequate 

public/professional awareness; 4) restricted utilization of extended/expanded role nurses in private 

physicians practice due to the heavy reliance on a fee-for-service system and the absence of 

alternative funding mechanisms; 5) increased role strain and delayed confidence-building due to the 

presence of unsupportive physicians; and 6) resistance from physicians, especially those 

compensated by fee-for-service, impeded full implementation of the extended/ expanded role. 

With regard to Patient Perceptions, the surveys completed by 58 patients at the sites visited 

confirmed the diversity of the functions performed by extended/expanded role nurses. It was also 

apparent from the survey data that patients were a very satisfied with the care provided by these 

nurses. 

The final category of data is based on the Observations of Nurses while enacting the 

extended/expanded role. The 82 nurse-patient observation sessions provided insight into the 

nature of extended/expanded nursing practice. The observational findings suggested that nurses 

working in extended/expanded roles in all primary health care settings engage in autonomous 

practice and perform a broad range of activities when dealing with patients presenting with a variety 

of acute illness/injury, chronic illness and wellness issues. Overall, nurse participants demonstrated 

a high degree of confidence and consulted with other health care providers, especially physicians, 

when patients required care beyond their scope of practice. 

< There were several Recommendations derived from the findings generated during the different 

phases of this research project. The following is a detailed overview of this study’s 

recommendations: 

Recommendation 1 

It is recommended that legislation be introduced in all remaining 

jurisdictions to legitimize the extended/expanded role of the registered 

nurse and to facilitate access to necessary resources within the health care 

system. This approach will ensure that extended/expanded roles for 

registered nurses are included within the scope of practice of the nursing 

profession. 




It is recommended that all relevant legislation be amended to facilitate 

consistent access to necessary resources within the health care system and 

the full implementation of the extended/expanded nursing role as 

mandated in each jurisdiction. 


It is recommended that core competencies and consistent practice 

standards for registered nurses in the extended/expanded role be developed 

and used to facilitate consistency in education programs for beginning 

competency levels. 


It is also recommended that nurses working in extended/expanded roles be 

supported with continuing nursing education activities relevant for the 

primary care aspect of primary health care. This type of supportive 

structure is needed to ensure that registered nurses keep abreast of latest 

developments and maintain required competency levels. 


National, provincial and territorial nursing associations and stakeholder 

groups facilitate consistent language and definitions relative to the 

extended/expanded nursing role in primary health care. This approach 

will heighten awareness of the role and facilitate greater acceptance of 

registered nurses’ delivering primary care to diverse populations in all 

Canadian jurisdictions. 


It is recommended that collaborative practice arrangements between 

physicians and extended/expanded role nurses, along with other providers, 

be the norm for all practice settings. This type of approach will facilitate 

the effective use of all health care providers and ensure that the most 

comprehensive and integrated primary health care services of the highest 

quality are available to diverse population groups. 


It is also recommended that the necessary mechanisms be instituted in all 

provincial/territorial jurisdictions to ensure ongoing monitoring of the 



quality and comprehensiveness of primary health care services available 

to the public. 


It is recommended that alternative funding mechanisms for physicians be 

established. This will ensure that physicians are fairly compensated for 

collaborating with extended/expanded role nurses. 

< Dissemination Plan 

The Centre for Nursing Studies will assume responsibility for dissemination of the research. This 

report and supporting documents will be available at www.cns.nf.ca. 



Project Team 

This research project represents a collaborative effort of a public- private partnership with an interest in 

health care. This project was supported by a financial contribution from the Health Transition Fund, Health 

Canada. The views expressed herein do not necessarily represent the official policy of the federal, 

provincial or territorial governments. 

The Centre for Nursing Studies of the Health Care Corporation of St. John’s, Newfoundland offers a 

continuum of educational opportunities for those who wish to purse a nursing career. It provides a high 

quality nursing education in a wide range of programs and services in a continuously changing health care 

system. The Centre offers a Bachelor of Nursing degree through a partnership with Memorial University 

of Newfoundland and Western Regional School of Nursing. The degree is awarded by Memorial 

University of Newfoundland. The Centre is an Associate Member of the Canadian Association of 

University Schools of Nursing (CAUSN) and a member of the Association of Canadian Community 

Colleges (ACCS). 

The Institute for the Advancement of Public Policy, Inc. is a St. John’s-based private consulting firm 

specializing in comprehensive research and analysis along with advisory, advocacy, and management 

consulting services designed to advance a client’s interests in relation to public policy. Among its areas of 

particular interest are health policy and services, social policy, and information technology as it relates to 

public service delivery. 

Project Team 

Colleen Hanrahan, B.A., M.S.W., LL.B. 

Project Leader 

Director, The Institute for the Advancement of Public Policy, Inc. 

Christine Way, B.N., B.A., M.N. PhD 

Health Care Researcher/Educator 

Faculty of Medicine/School of Nursing 

Memorial University of Newfoundland 

John Housser, LL.B. 

Housser Consultants 

Madge Applin, R.N., B.N. 

Associate Director, Nurse Practitioner Program, 

Centre for Nursing Studies 



Acknowledgements 

The team extends its appreciation to the members of the Advisory Committee for their support and advice 

throughout the project. The members are: 

Linda Gee, Ministry of Health, British Columbia ( Chair) 

Nancy Rideout, Ministry of Health and Wellness, New Brunswick 

Wendy Wright, Ministry of Education, Saskatchewan 

Jan Horton, Ministry of Health, Yukon 

Jocelyne Lavinge-Robenhymer, Health Canada 

Lynda Danquah, Health Canada 

The project team wish to acknowledge the support extended by Joan Rowsell, Director, Centre for 

Nursing Studies. Thank-you to Colleen Kelly, B.N., M. N., for her advice and comments as an 

independent consultant to the project respecting the extended/expanded role from the professional practice 

perspective. 

The team was assisted with on-site data collection and analysis by the Centre of Nursing Studies faculty 

members Marcy Greene, R.N., B.N., M.Sc. and Joanne Simms, R.N.,B.N., M.N.. Assistance with onsite 

data collection in Newfoundland and analysis was provided by Cynthia Kettle, B.N., a graduate student 

of nursing at Memorial University. Assistance with data collection and compilation was provided by 

Madonna Kennedy. Professional word processing services were provided by Moya Hewlett, Cindy 

Andrews and Suzanne Browne. 

The project team wishes to recognize Jacquie Lemaire, Health Transition Fund, for her assistance and 

support throughout the course of the project. 

Finally, the team wishes to express its gratitude to the numerous informants who participated in different 

phases of this project, including officials of the federal and provincial Ministries of Health, the nursing 

associations across Canada, the administrative survey participants, and the on-site staff, especially the 

physicians, nurses and patients. 



Acronyms 

AARN 

ACHHR 

Alberta Association of Registered Nurses 

Advisory Committee on Health Human Resources 

ANPEI Association of Nurses of Prince Edward Island 

ARRNL 

CNA 

CNO 

Association of Registered Nurses of Newfoundland and Labrador 

Canadian Nurses Association 

College of Nurses of Ontario 

MARN Manitoba Association of Registered Nurses 

MSB Medical Services Branch 

NANB 

NWTRNA 

OIIQ 

RNABC 

RNANS 

SRNA 

YRNA 

Nurses Association of New Brunswick 

Northwest Territories Register Nurses Association 

Ordre des Infirmieres et infirmiers du Quebec 

Registered Nurses Association of British Columbia 

Registered Nurses Association of Nova Scotia 

Saskatchewan Registered Nurses Association 

Yukon Registered Nurses Association 



Glossary of Terms 

Primary Health Care is essential care (promotive, preventive, curative, rehabilitative and supportive), that 

is focused on preventing illness and promoting health. Primary health care is both a philosophy of health 

care and an approach to providing health services. It has been adopted by the World Health Organization 

and by Canada as the key to enabling people to lead socially and economically productive lives. Clients 

of primary health care can be individuals, families, groups, communities and populations. The principles 

of primary health care are accessibility, public participation, health prevention, appropriate technology and 

inter-sectoral cooperation (Canadian Nurses Association - Policy Statement, April 1995). 

Primary Care is initial client contact with the health care system for the purpose of assessment, diagnosis 

and treatment of acute episodic and chronic illness or injury. 

Nurse Practitioner refers to a registered nurse with advanced knowledge and clinical expertise in 

assessment, diagnosis and health care management. A nurse practitioner’s practice is comprehensive in 

scope and provides services that promote health, prevent injury and disease, cure illnesses and injuries, 

rehabilitate and support individuals, families and communities in all health care settings. 

Extended Practice refers to practice that is characterized by the use of competencies required to perform 

activities that are usually considered to be outside the current scope of nursing practice. These activities 

typically fall within the usual scope of medical practice and include such functions as diagnosing and 

prescribing as well as specific procedures or technical skills (Canadian Nurses Association, A Proposed 

Framework for Advanced Nursing Practice: Discussion Guide, March 1999). 

Expanded Practice refers to the development of new knowledge and skills within the practice of nursing. 

In expanded practice, functions historically performed only by physicians have been adapted and adopted 

such that they have become part of nursing. In expanded practice, competencies involved with diagnosing 

and prescribing are considered part of the scope of nursing practice and not as an extension into medicine 

(Canadian Nurses Association, A Proposed Framework for Advanced Nursing Practice: Discussion Guide, 

March 1999). 

Delegated Medical Functions/Protocol Arrangements are functions which registered nurses in 

extended/expanded roles are authorized to perform when the conditions (e.g., advanced preparation for 



skill transfer, etc.) have been satisfied as specified in protocol arrangements between various bodies (i.e., 

medical/nursing regulatory bodies, ministries of health, and/or employers). 

Autonomous Practice involves independent clinical decision making within the practitioner’s scope of 

practice and inherent level of accountability. 

Collaborative Practice involves jointly defining the professional relationship necessary to provide 

integrated care to clients through shared goal setting, shared decision-making and mutual respect. 



1.0 Introduction 

1.2 Overview and Purpose 

In March, 1999 the federal/provincial/territorial Advisory Committee on Health Human Resources 

(ACHHR) Working Group on Nursing and Unregulated Workers called for proposals to evaluate nursing 

practice models in different primary health care settings (i.e., rural, remote and urban) in Canada. The 

focus of this evaluation was restricted to registered nurses delivering primary care services (i.e., assessment, 

diagnosis, and treatment of episodic, acute and chronic illness, and minor injury) in variant settings. The 

purpose of the current project was to identify key aspects of primary health care settings that facilitate or 

impede the effective delivery of primary care services by registered nurses working in the 

extended/expanded role. A second purpose was to recommend policy options that would facilitate more 

effective use of registered nurses working in these roles. 

The research process in the current study was guided by the legislative, regulatory, policy, and 

organizational frameworks of each provincial/territorial jurisdiction. The following document is a synopsis 

of the research undertaken, major study findings and resulting policy recommendations. Throughout the 

report, the term extended/expanded nursing role denotes primary care practice by a registered nurse which 

includes the assessment, diagnosis, and treatment of acute, episodic and chronic illness, and minor injury. 

The report on the research project will focus on the following key areas: 

< commonalities and differences of extended/expanded nursing practice in primary health 

care settings in Canadian jurisdictions; 

< barriers to and facilitators of effective utilization of registered nurses with 

extended/expanded practice preparation in primary health care settings; and 

< future directions for extended/expanded nursing practice in primary health care. 

This report is also augmented by the following supporting documents (SD): 

SD1 

SD2 

SD3 

Profile of Extended/Expanded Nursing Practice in Primary Health Care Settings, 

Research Protocol for on-site data collection, 

Results of on-site data collection, and 


The Institute for the Advancement of Public Policy, Inc. 1

SD4 Dissemination plan. 

1.2 Rationale 

The full implementation of extended/expanded roles by registered nurses remains unrealized despite 

consistent empirical support for the positive impact on the accessibility, availability and comprehensiveness 

of health care services, consumer acceptance of and satisfaction with this nursing role, cost containment, 

and positive health outcomes. Since the early 1990s, the interest of governments and organizations in the 

extended/expanded nursing role has been inconsistent and reflective of differing agendas. Historically, in 

remote areas of Canada, registered nurses with advanced preparation have provided a full range of primary 

health care services, including primary care functions normally limited to general or family physicians. While 

the delivery of primary care services by nurses in remote regions is acceptable to both the public and 

physicians, the same can not be said for rural and urban areas where the use of nurses for this purpose has 

waxed and waned in response to the supply of and the demand for family physicians. 

In recent years governments across Canada have become increasingly interested in using registered 

nurses in an extended/expanding role. This renewed momentum is due to a number of factors, including 

reduced funding allocations throughout the health care system, restrictions placed on admissions to medical 

schools, and the looming shortage of nursing and other professional resources. These pressures coupled 

with the increased demand for primary care services, especially in rural and remote regions, have led 

provincial/territorial governments to re-evaluate how to best utilize all health care providers within their 

jurisdictions. One popular response has been to focus on greater use of registered nurses with advanced 

preparation to provide a broader range of primary care services. 

In response to the increased demand for extended/expanded nursing practice, there has been a 

proliferation of organizational structures, roles, competencies, regulatory regimes, educational programs, 

and titles. There are a number of problems that accompany this disparate mix. Most important among 

these are public and professional confusion over what is entailed in an extended/expanded nursing role, and 

the absence of national standards for core competencies that can be applied equally across all jurisdictions 

regardless of the setting (i.e., remote, rural or urban). 



1.3 Background - Nursing 

In Canada, issues concerning the definition, role and functions of registered nurses engaged in 

extended/expanded practice are being raised at the national, provincial and regional levels. The titles of 

nurse practitioner, extended class and expanded practice are reflective of common terms used to refer to 

registered nurses working in primary health care settings and performing primary care functions outside the 

traditional scope of nursing practice. The nursing profession is struggling to define the 

boundaries/parameters of its practice while ensuring that its members are providing quality care supported 

by sound research. An integral component of this process is to develop a national co-ordinated approach 

to advanced nursing practice that accommodates provincial and territorial variations. There is also a 

general desire by the nursing profession to ensure that its members receive recognition for and legitimization 

of the full scope of nursing roles and functions. 

Clinical and research data support the positive effects (e.g., increased availability of health services, 

achievement of health outcomes equal to or superior to physicians, decreased impact on physician 

workload, increased patient satisfaction, etc.) of extended/expanded nursing practice (Brown & Grimes, 

1995; Chambers & West, 1978; Spitzer et al., 1974, Feldman, Ventura & Crosby, 1987; Reveley, 1998). 

What is less clear is how the environmental context facilitates the utilization of registered nurses in 

extended/expanded roles. Several studies have investigated the influence of clinical settings on 

extended/expanded nursing practice and, to a lesser extent, the job expectations and satisfaction of 

registered nurses. The most consistent barriers to and facilitators of role development and performance 

identified from the research literature were: 

< resistance/acceptance by other health care providers, especially physicians (Crosby, 

Ventura & Feldman, 1987; Hupcey, 1993; Reveley, 1998), 

< efforts expended by the organization/agency to formalize the role (Crosby et al., 1987; 

Hupcey, 1993; Reveley, 1998), and 

< legal/legitimate status of the role (Reveley, 1998; Torn & McNichol, 1998). 

The scope of patient care activities, degree of autonomous and independent practice, sense of 

achievement/accomplishment, and funding models are additional aspects of the practice setting that 



influence role performance and job satisfaction (Chambers, 1978; Hupcey, 1993; Koelbel, Fuller & 

Misener, 1991; Manga, 1992; Torn & McNichol, 1998; Tri, 1991). 

The current study was undertaken at a time when there is a lack of consensus on what constitutes 

extended/expanded nursing practice in primary health care settings, as well as provincial/territorial variations 

in the degree to which these roles are legitimized through legislation. Furthermore, within the Canadian 

health care system, a number of extended/expanded nursing roles have evolved and are being implemented 

in different ways and guided by variant regulatory mechanisms. The provision of quality care can be quite 

a challenge for any health care system, especially one operating under severe cost restraints. Given the 

current pervasive restructuring and reform initiatives in the health care sector, there is an increased urgency 

to document key facilitators of and barriers to full implementation of extended/expanded nursing practice 

in remote, rural and urban settings across Canada. By identifying the most significant barriers and most 

helpful facilitators, efforts can be undertaken to remove problem areas and build on existing strengths. This 

approach is needed to ensure maximum utilization of the extended/expanded nursing role in all primary 

health care settings. 

1.4 The Public Policy Context - Policy Objectives and Extended/Expanded Nursing Roles 

Public policy refers to decisions or directions undertaken by government to maximize public 

benefits and protect the public interest. Associated with these decisions is the allocation of resources to 

support implementation of policy objectives. The division of powers within the Canadian constitution vests 

legal powers in either the federal or provincial/territorial governments. Jurisdiction over health care and the 

regulation of professions rest with the provincial/territorial governments. The federal government is involved 

in health care management through the exercise of the federal spending power as evidenced by the Canada 

Health Act. Provision of health services through the Medical Service Branch (MSB) of Health Canada 

emanates from federal jurisdiction over first nation people as determined in the British North America Act. 

The authority to establish professional standards and regulate entry to practice is delegated to 

professional groups through legislation, such as nursing and medical acts. The delegation of legislative 

authorities is a complex arrangement. While legislation creates rights for a professional group, the powers 



delegated must be used in accordance with the laws of Canada and the relevant province/territory. As with 

other self-regulating professions, the role of nursing associations include: 

< the establishment and enforcement of standards of practice; 

< control of entry into the practice of nursing; and 

< a mandate to ensure that nursing practice within the relevant jurisdiction is carried out 

consistently and safely. 

The interface between professional groups and the health care system is multi-faceted. The 

boundaries of a profession’s practice domain is defined within its “scope of practice” guidelines. Of 

significance to the extended/expanded nursing role are the “scopes of practice” of physicians, registered 

nurses and pharmacists. The primary care functions included within the extended/expanded nursing role 

which are of interest in the current study are those functions which have been delegated through legislation 

to physicians and/or pharmacists. If registered nurses are to perform functions that are within the scope 

of practice of another profession, authority to do so must be secured from the relevant regulatory body or 

specific legislation enacted to include them within nursing’s scope of practice. 

Certain functions may also be shared by nursing with medicine and/or pharmacy. Traditionally 

shared jurisdictions have been undertaken through protocol arrangements negotiated between the 

regulatory bodies of nursing, medicine, pharmacy, government, and/or individual employers. Protocol 

arrangements do not transfer the authority to perform shared functions to all registered nurses but rather 

restricts these functions to those who have been appropriately trained to undertake them. The important 

question is what are the most appropriate strategies for providing nurses with the authority and resources 

to undertake the functions of the extended/expanded role. This is a relevant public policy consideration 

for all governments, professional associations and the public. 

1.5 Health Care Reform and the Extended/Expanded Role of the Registered Nurse 

Canada’s health care system is being challenged on two fronts: 1) both the underlying fundamental 

assumptions of our publically funded system and, 2) sustaining the system itself. All levels of government 

have been promoting a policy direction that recognizes the broadness of the health concept and the need 



to balance institutional care with illness prevention and early intervention strategies focussed on maintaining 

wellness. In recent years, the health care agendas of all governments have been focussed on examining 

ways and means to effectively utilize human resources, especially nursing and physician resources. 

There is a growing interest in increasing the use of extended/expanded nursing roles in the future 

health care system, especially in delivering primary care services. This policy direction is supported by 

several key initiatives: 

< The health care reform initiatives of the federal, provincial, and territorial governments, 

including demonstration projects funded under the Health Transition Fund with nurses 

working in extended/expanded practice roles and this study, suggest there is interest in 

maximizing the utilization of registered nurses in the delivery of primary care services. 

< Support for the extended/expanded nursing role exists in the legislation of four Canadian 

jurisdictions. Although this trend across the country suggests that there is a fair degree of 

commitment to this role, it could be argued it is taking place without a well-defined national 

strategy. 

< One of the current efforts of the Canadian Nurses Association, through the 

CNA/Provincial /Territorial Working Group on Scope of Practice, is focussed on 

generating a framework of common elements to guide the development and implementation 

of legislation. In addition, considerable emphasis has been placed on developing 

parameters that address minimal educational standards and core competencies for 

registered nurses who undertake the extended/expanded role. The work of this 

Committee is directed toward realizing consistent standards for extended/expanded nursing 

practice. 

< In September 2000, the First Ministers agreed to make primary health care reform a high 

priority. There was consensus to promote further expansion of the primary health care 

teams which provide Canadians with the first point of contact with the health care system. 

Reaffirmation was given by all parties to ensuring that consumers receive the most 

appropriate care from the most appropriate providers in the most appropriate settings. 



In September 2000, the federal government announced the creation of an $800 million 

fund ($200 million per year for the next four fiscal years) for Primary Health Care Reform 

(PHC) to support the agreement reached by the First Ministers to broaden and accelerate 

PHC initiatives. 

It would appear that the policy environment is open to the possibility of formally adopting the 

extended/expanded practice role for registered nurses. The challenges presented by this possibility will be 

examined in this paper and options recommended for consideration by policy-makers and decision-makers 

in Canada. 

1.6 Overview 

The remainder of the report is divided into three major sections. The first section presents an 

overview of the methodology guiding data collection. The second section summaries key findings from 

a review of policy and legislative frameworks, a cross-country survey of organizations employing 

extended/expanded role nurses, and an in-depth study of select sites in three provinces. The final section 

highlights key issues emerging from the multiple data bases and recommends possible strategic 

national/provincial/territorial actions that could result in more effective utilization of registered nurses in 

extended/expanded roles. 

2.0 Methodology 

2.1 Method 

The current study used a research design which combined data, investigator and methodological 

triangulation. By using a flexible, methodological approach, the rich data that emerged helped the research 

team develop meaningful insights into the extended/expanded role of registered nurses working in primary 

health care settings. The Project Logic Model was the framework used to identify relevant sources for data 

collection. Figure 1 outlines the key components of the model, activities initiated with target groups, and 

the projected short and long term outcomes of this project. 



2.2 Determination of Terms and Definitions 

Given the wide differences in terminology across Canada in health care generally and the 

profession of nursing specifically, it was considered essential that the terms and definitions of the study be 

agreed upon as early as possible. The team used the working definitions provided in the Call for Proposals 

document as a starting point and began to construct a more comprehensive listing upon notification of 

project start-up. Finalizing this list proved to be extremely problematic because of the lack of agreement 

on the terms used to describe the extended/expanded role within the nursing profession. Despite the 

difficulties in identifying consistent terminology and/or definitions, the team selected the most commonly 

used ones for the purpose of this project. The finalized list is presented in the Glossary of Terms section 

placed at the beginning of this document. 



Figure 1 - Project Logic Model 

Components 

Policy 

Framework 

Legislation/ 

Regulation 

Organizational 

Structure 

Activities 

Survey Nursing Association 

Survey Health Ministries 

Survey Administrators 

Interview Nurses, Physicians & Clients 

Observe Nurses in Practice 

Target 

Groups 

ACHHR 

HTF 

F/P/T 

Governments 

Nursing Regulatory 

Bodies 

Health Boards/ 

Authorities 

Short Term 

Outcomes 

Long Term 

Outcomes 

Enhance understanding of 

facilitators and barriers to 

effective nursing practice in 

primary health care settings. 

Raise awareness of facilitators and 

barriers to effective nursing practice 

in primary health care settings. 

Increase access to effective nursing practice in 

primary health care settings. 



2.3 Population and Sample (see SD1 – Profile of Extended/Expanded Nursing Roles in 

Primary Health Care Settings) 

During the initial stages of the current project, all relevant provincial/territorial legislation and 

regulations were reviewed and a cross-country survey of key informants undertaken to document existing 

information on nursing practice models. Data were gathered from consultants employed by the nursing 

associations concerning the regulation of, as well as the policy and standards for, extended/expanded 

nursing practice in their respective jurisdictions. Representatives of provincial/territorial ministries of health 

were also contacted to augment and/or clarify information received from the nursing associations. 

Summaries of the information compiled for each jurisdiction were subsequently forwarded to the relevant 

ministries of health and provincial/territorial nursing associations for review and confirmation. All summaries 

were confirmed and/or updated in July and August 2000. The final component of this phase of data 

collection involved a survey of administrative personnel in different provincial agencies/organizations that 

employ registered nurses to work in extended/expanded practice roles. During the second phase of data 

collection, an in-depth study was conducted at select sites in primary health care settings in the provinces 

of Newfoundland, Ontario and Saskatchewan. The population of interest consisted of physicians working 

in primary care settings, and registered nurses working in extended/expanded roles with physicians in these 

settings. A third target population was patients/clients receiving care from registered nurses performing 

these roles at the study sites. 

2.4 Procedure 

The consulting team collected background information to describe the context for 

extended/expanded nursing practice. The first step in this process involved a review of relevant legislation 

across Canada, and initiating contact with Legislative Counsel offices or solicitors on staff with ministries 

of health. Nursing regulatory bodies within each jurisdiction were also contacted to obtain information on 

the interpretation and application of provisions relevant for extended/expanded nursing practice in primary 

care settings. The information on policy directions and planning for extended/expanded nursing practice 



collected from nursing associations and ministries of health was subjected to an in-depth analysis to identify 

commonalities and differences. 

The persons contacted at the provincial/territorial ministries of health and nursing associations were 

also asked to identify primary health care settings where registered nurses perform primary care functions, 

work under similar and different practice models, and have variant education preparation requirements. 

Interviews were subsequently completed with representatives from 44 provincial/ territorial sites. The 

findings suggested that there were significant differences among the approaches used to deliver 

extended/expanded nursing services. Although there were a number of possible explanations for these 

disparate conditions, one significant factor influencing the enactment of nursing roles in each jurisdiction was 

the environmental context (i.e., legislative, regulatory, employing organization, nurse/physician relationships, 

etc.). Thus, the decision was made to select sites from two provinces with legislation and regulations, and 

one with medical directives and/or protocol agreements in place. The final selection of sites was made 

following consultation with representatives on the Advisory Committee on Health Human Resources 

Working Group on Nursing and Unregulated Workers. 

Data collection at the sites selected for participation in this study was initiated following approval 

of the Research Protocol by relevant site personnel (see SD2). Data collection consisted of interviews with 

registered nurses working in extended/expanded roles and physicians working with these nurses, surveys 

of patients/clients accessing the resources at the centre/clinic, and participant observation sessions with the 

registered nurses during patient/client appointments. The nurses and physicians were identified through 

consultation with management personnel at each site. The contact person(s) approached nurses and 

physicians to briefly explain the study and provide them with a summary sheet of the project (see SD2, 

Appendix A), and ascertain their willingness to be contacted by a member of the research team. Those 

who indicated an initial willingness to participate were subsequently contacted, the study explained more 

fully and any questions/concerns addressed at this time. 

Data collection at the sites occurred over a four-week period. In Ontario and Saskatchewan, the 

data were collected by two Masters prepared faculty teaching in the Primary Health Care Nurse 

Practitioner Program at the Centre for Nursing Studies, the Health Care Corporation of St. John’s. In 



Newfoundland, data collection was completed by a registered nurse with extensive intensive care 

experience in a major tertiary care centre and enrolled in the Masters of Nursing Program at Memorial 

University. 

Informed, written consent was obtained prior to the beginning of interviews with nurses and 

physicians (see SD2, Appendix B). Most participants agreed to be audiotaped. All participants were 

asked to provide information on select demographic variables prior to the interview. The interviews were 

conducted using a semi-structured interview schedule (see SD2, Appendix C), and lasted approximately 

30 to 60 minutes. 

Patients were approached by the interviewer or site receptionist during a regularly scheduled 

centre/clinic visit. The rationale for the study was explained to them and any questions/concerns addressed. 

If they agreed to participate, the survey instrument was given to them to complete at this time (see SD2, 

Appendix D). The survey questionnaires were designed so that the patients were able to fill out the 

questionnaires anonymously while waiting to see the nurse. Thus, informed, written consent was not 

required for this group of participants. Depending on patient preferences, some of the surveys were 

administered by an interviewer. 

One to two participant observation sessions were conducted with registered nurses in their clinical 

practices at the study sites. The observation sessions were conducted on the same day of the interview 

and/or the following day depending on the nurse’s centre/clinic responsibilities. Observational checklists 

were used to collect data on each nurse-patient/client encounter (see SD2, Appendix E). 

2.5 Instruments 

The instruments used during data collection included surveys of Legal Role and Regulation of 

Nursing in Primary Health Care Settings (see SD1, Appendix A), Association Views: Nursing Practice in 

Extended/Expanded Roles and Regulation of Nursing in Extended/Expanded Roles (see SD1, Appendix 

C), and an Administration Survey Instrument (see SD1, Appendix E). Instruments were also developed 

for data collection at the selected sites, including the Interview Schedule: Nurses and an Interview Schedule: 

Physicians (see SD2, Appendix C), an Observation Checklist (see SD2, Appendix E), and a Patient/Client 



Survey (see SD2, Appendix D). Training sessions were conducted with interviewers/observers prior to 

data collection by the principal investigator for this phase of the project who has an extensive theoretical 

and experiential basis in qualitative and quantitative research methodologies. 

2.6 Data Analysis 

The data collected from the provincial/territorial statutes, regulatory bodies, ministries of health, 

nursing associations, and administrative personnel at various sites were summarized and described 

according to key variables. Further in-depth analysis of these data bases provided the Project Team with 

the necessary information to select appropriate sites for data collection in three provinces. 

The taped interviews were transcribed verbatim and checked for accuracy. Interpretive summaries 

were compiled for each transcribed data set. The interpretive summaries were forwarded to each 

participant for review and confirmation. A modified version of the constant comparative method of analysis 

as defined by Glaser and Strauss (1967) was applied to each data set by a minimum of two raters/coders 

(the principle investigator and research assistants) working independently. Debriefing sessions were held 

regularly to discuss major themes and to identify the conceptual categories and properties being generated 

by the initial joint coding and analysis. 

The categories in the participant observation checklists were developed based on commonalties 

found in a review of provincial regulations and nursing associations/colleges standards of practice and 

competencies for nurse practitioners. Data sets were reviewed to locate incidents of relevant content for 

each category. Counts of the number of times key components were identified in the data were tabulated. 

The data from the patient/client surveys were analyzed using descriptive and parametric statistical 

analysis. Descriptive statistics included appropriate summary measures and frequency distributions. A 

series of one-way analysis of variances were conducted to determine if there were variations across sites. 

An alpha value of 0.91 for the current study suggested that the satisfaction scale had strong internal 

consistency. 



2.7 Overview of Restrictions and Limitations 

2.7.1 Restrictions 

It was decided at the outset of the project that the primary focus would be on the 

extended/expanded nursing role in areas where physicians have traditionally been responsible for the 

delivery of primary care services. The MSB of Health Canada has played a significant role in supporting 

the educational preparation of registered nurses for assuming extended/expanded nursing roles. Nurses 

sponsored by the MSB have provided primary care services to residents of northern Canada and 

rural/remote areas that have been under serviced by physicians. The contribution of the MSB is 

acknowledged by the research team. Within the parameters defining the current project, the settings utilizing 

MSB guidelines were not the primary focus of research activities. 

Limited attention was also given to primary care delivery by nurses working in extended/expanded 

roles in First Nations and Inuit settings. Due to the cross-cultural diversities and complexity of issues 

present in aboriginal settings, the project team, following consultation with the Advisory Committee, decided 

to restrict data collection in these settings. 

2.7.2 Limitations 

The research team did not address the cost effectiveness of the extended/expanded nursing role. 

Besides the time and cost constraints on the project, recognition was given to the inherent difficulties in 

trying to access data under the control of Ministries of Health and/or employing organizations. In addition 

to access problems, it was acknowledged that there are different tracking mechanisms in place to account 

for expenses associated with human resource utilization. The level of meaningful comparisons required 

within and across jurisdictions was well beyond the expertise of the research team and, in fact, the scope 

of this project. Evaluation of the cost effectiveness of extended/expanded nursing roles could certainly be 

the focus of a separate study. 



3.0 Results 

3.1 Policy and Legislative Frameworks for Extended/Expanded Nursing Roles 

Diverse models have been used across Canada to provide authority to registered nurses performing 

extended/expanded roles. Diagnostic and treatment functions have been delegated by government to the 

medical profession through legislation. Registered nurses have been assessing, diagnosing and treating 

acute, episodic and chronic illness and injury under the authority of delegated medical functions in remote 

and rural areas of Canada, as well as in a few more populace areas. 

The delegation of medical functions is normally through protocol arrangements negotiated between 

the professional bodies, the employer and sometimes government. Saskatchewan tried to ensure greater 

consistency across primary health care sites by developing province-wide protocols to facilitate the transfer 

of medical functions and to clarify the parameters of the extended/expanded nursing role. Although this type 

of protocol may reduce role uncertainty, the downside is that it does not bring the functions within nursing’s 

scope of practice as defined by the professional legislation. Some nursing associations indicated that the 

provincial/territorial legislation/regulations governing nursing practice are of sufficient breadth to 

accommodate extended/expanded nursing roles. In contrast, other associations raised concerns about the 

inconsistency between the scope of nursing practice outlined in the professional legislation and employer 

expectations of nurses. 

Over the past decade, certain jurisdictions have opted to legitimize the extended/expanded nursing 

role beyond protocol arrangements by enacting legislation (i.e., Ontario, Newfoundland and Labrador, 

Alberta and Manitoba). The regimes in Ontario and Newfoundland and Labrador are very similar with 

both requiring that nurses practice in a collaborative relationship with physicians and receive advanced 

preparation for the primary care role. Registered nurses regulated within the extended/expanded class have 

the authority to engage in autonomous decision-making, perform primary care functions in a variety of health 

care settings (e.g., community health centres, long-term care facilities, nurse-managed clinics, etc.), and 

access resources within defined limits. When encountering problems beyond their scope of practice, nurses 

are required to consult with a participating physician. 



Manitoba has enacted similar legislation to Ontario and Newfoundland and Labrador which will 

be proclaimed pending the development of regulations. Alberta’s legislation for regulating 

extended/expanded nursing role also requires registered nurses to receive advanced preparation. The 

regulations enacted in February of 1999 gave registered nurses the authority to diagnose and treat common 

disorders of adults and children, and to refer and provide emergency treatment. However, Alberta limited 

the extended/expanded role to registered nurses employed by a regional health authority or a provincial 

health board. 

The Canadian Nurses Association has formed a committee of provincial and territorial 

representatives to establish a framework to guide the development and implementation of legislation dealing 

with nursing roles requiring additional regulation (i.e., primary care functions). This committee is also 

focussing on identifying the basic standards and competencies required in the role. If these 

standards/competencies are accepted by all jurisdictions, they would be used to highlight the essential 

components of education programs preparing registered nurses for primary care roles. 

There are key features which must be considered from a global perspective with the 

extended/expanded nursing role across Canada. Among these are the elements of title, scope of practice 

and education. As noted previously, there is no consistent policy guiding the advancement of the 

extended/expanded nursing role across Canada. The repercussions of the absence of such a policy will be 

highlighted in the discussion that follows. 

3.1.1 Title - Policy Framework 

The titles used across the country to identify registered nurses practising in extended/expanded 

roles vary by jurisdiction. Titles are determined by the employer, the Ministry of Health or a combination 

of stakeholders. The exceptions are those provinces which have enacted legislation. A nurse in an 

extended/expanded practice role is designated as a RN - Extended Class (RN - EC) in Ontario, and a 

Nurse Practitioner (NP) in Newfoundland and Labrador. In Alberta, the nurse with the RN - Expanded 

Practice (RN - EP) designation is usually referred to as a Community Nurse Practitioner. 

Table 1 summarizes the various titles in current use across Canada. It is evident from this listing 

that there is a proliferation of titles for registered nurses who practice in extended/expanded roles. Although 



there are some similarities in the titling, there is certainly no agreement on the use of the NP term across 

Canada. 

The Canadian Nurses Association has expressed a desire to eliminate the proliferation of nursing 

titles. In spite of its use in the literature and in some areas of Canada, there is a certain degree of 

discomfort with the term “nurse practitioner”. Despite this reluctance to refer to nurses in 

extended/expanded roles as NPs, registered nurses licenced in the extended class in Ontario are hired as 

NPs and have formed an association by the same name. The protection of the NP title under legislation 

in Newfoundland and Labrador is unique in Canada. 

While provincial legislation and protocols may vary, there seems to be recognition by the public 

that registered nurses in extended/expanded roles undertake some functions that are similar to physicians. 

Because this is a nursing role not a medical one, practitioners view themselves as working from a nursing 

perspective. For the purposes of consistency there ought to be some uniformity in the titles used throughout 

the country to facilitate easy identification of registered nurses with extended/expanded nursing practice 

roles by the public and other health care providers. 



Table 1 - Titles for Registered Nurses in Extended/Expanded Roles by Jurisdiction 

Jurisdiction 

British Columbia 

Alberta 

Saskatchewan 

Manitoba 

Ontario 

Quebec 

New Brunswick 

Prince Edward Island 

Nova Scotia 

Newfoundland & 

Labrador 

Yukon 

Northwest Territories 

& Nunavut 

Title 

Registered Nurse (RN). Unofficial use of the title Nurse Practitioner 

(NP) in Community Health Centers. 

RN - EP (Expanded Practice) officially, but usually called 

Community Nurse Practitioners. 

No fixed titles. Referred to as Primary Care Nurses in protocols. 

No title regulated or sanctioned by MARN at this time. Employers 

may choose to use a specific job description title. 

RN- EC (Extended Class) and other titles, such as Nurse 

Practitioner, used by employing organizations. 

RN (infirmiere/infirmier). 

No separate title; referred to as RN. 

Not applicable; no RNs practicing in the extended/expanded role 

Primary Care Nurse Practitioner. 

NP and Regional Nurse. 

Community Nurse Practitioner. 

Community Health Nurse but also referred to as Primary Health 

Care Nurse Practitioner. 

Source: Associations of Registered Nurses and Ministries of Health in the respective jurisdictions as of August 2000. 



3.1.2 Scope of Practice - Policy Framework 

Provincial nursing legislation provides guidance on the functions and activities that constitute the 

scope of nursing practice. There is no one consistent definition or scope of practice for nursing across 

Canadian provinces and territories. The title of “registered nurse” may not be defined but is inferred by 

referencing the definition of the “practice of nursing”. The definitions of “registered nurse” or “nursing 

practice” are used to set parameters around the activities undertaken by members of the profession. 

Though some statutes are dated, the definitions contained therein are believed to be broad enough to 

incorporate extended/expanded roles within existing scope of practice guidelines. Table 2 contains a 

summary of the extended/expanded scopes of practice by jurisdiction across Canada. 

The data collected from the various Ministries indicated that there is no agreement on the 

parameters of the extended/expanded role across and within jurisdictions. This was particularly true for 

those provincial/territorial jurisdictions which rely on delegation of medical functions as opposed to 

legislation. Generally, protocol arrangements determine the breadth of delegated medical acts to registered 

nurses practising in extended/expanded roles. Often accompanying this delegation is the right to access 

certain health care services (e.g., ordering diagnostic tests, prescribing medications, making referrals to 

other providers, etc.) which are viewed as essential for nurses to perform the extended/expanded role. One 

glaring problem identified is the lack of consistency in the protocol arrangements which delegate authorities 

across and, in some cases, within jurisdictions. The one exception is Saskatchewan where a province-wide 

protocol is in effect for primary care settings. 

During the course of the current study, it became evident that some informants believed that the 

extension/expansion of nursing’s scope of practice can be achieved by “pushing the boundaries”. In New 

Brunswick the legislation governing the nursing profession contains a very broad definition of nursing 

practice. However, this definition does not seem to be adequate enough to allow for an extension of the 

nursing role into primary care. More importantly, support for “pushing the boundaries” of nursing’s scope 

of practise to cover primary care functions does not provide registered nurses with the necessary authorities 

to access services required to execute 



Table 2 - Summary of Scope of Practice by jurisdiction 

Jurisdiction 

British 

Columbia 

Alberta 

Saskatchewan 

Manitoba 

Ontario 

Quebec 

New Brunswick 

Prince Edward 

Island 

Nova Scotia 

Newfoundland 

& Labrador 

Yukon 

Northwest 

Territories 

& Nunavut 

Scope of Practice 

Extended/expanded practice is undertaken by delegated acts which are established by 

working arrangements according to location, organization and training. RNABC has 

guidelines for Delegated Medical Functions. 

The Extended Practice Roster Regulation governs registered nurses in 

extended/expanded roles. AARN has developed competencies and guidelines to 

govern nurses providing “extended health services”. 

Scope of practice is defined by the province-wide clinical practice guidelines but subject 

to site modifications. 

Under the new legislation, regulations will be developed for required competencies in 

extended/expanded nursing practice. MARN has established standards of practice which 

apply to all practicing registered nurses in the province regardless of their roles or practice 

settings. 

Legislated scope of practice is relative to primary care functions only. These controlled 

acts are to be performed by RNs with an extended class designation. 

Delegated medical functions are not necessarily supported by protocols. Concerns have 

been raised by nurses about situations where they could be exposed to liability and have 

no protection. 

Site specific protocols govern the delegation of function. 

Not applicable at present. However, if there were a movement to introduce 

extended/expanded nursing roles, the nursing association would establish guidelines for 

core competencies in accordance with CNA guidelines. 

Scope of practice is defined by delegation of medical functions under guidelines negotiated 

between the College of Physicians and Surgeons of NS and RNANS. 

The ARNNL approves standards of practice and competencies for NP- PHC. 

Employers have adopted the MSB Scope of Practice Guidelines for Community Health 

Nurses, Nursing Stations and Health Care Treatment facilities. 

All extended/expanded practice is under the authority of protocols with the medical 

profession and employer organizations. 

Source: Associations of Registered Nurses and/or the Ministry of Health in the respective jurisdiction August 2000. 



these functions. In fact, registered nurses who perform primary care functions in New Brunswick do so 

under the authority of delegated medical acts which are site-specific, for example the MacAdam project and 

demonstration projects in remote areas. 

To gain an appreciation for the mechanisms which facilitate implementation of extended/expanded 

roles, the legislation governing nursing cannot be read without reference to the Medical Act, the Pharmacy 

Act and related statutes. The interrelationship among the scopes of practice of physicians, pharmacists and 

registered nurses is a key consideration. For example, in Nova Scotia the function of diagnosis is clearly 

within the medical profession’s scope of practice. The Medical Act contains legislative authority to delegate 

functions to nursing which is usually accomplished through protocols negotiated by the relevant regulatory 

bodies. Thus, the delegated authorities are negotiated by the respective professional licensing bodies. 

Amending the legislation relevant to nursing only represents one side of the issue. There must also 

be amendments to other legislation if nurses are to fully implement the extended/expanded role. In 

jurisdictions where legislation has been enacted, there are situations were consequential amendments to 

related statutes have not been pursued as part of the legislative package (e.g., the Hospital Act, Pharmacy 

Act, Vital Statistics Act, etc.). To illustrate this point nurses working in extended/expanded roles may not 

have the necessary authority to order certain diagnostic tests (e.g., Newfoundland regulations governing 

radiology do not grant authority to nurse practitioners for certain x-rays), or are subject to restrictions on 

their prescriptive authority (e.g., a formulary with an approved list of medications, not able to access 

narcotics, etc.). However, this raises another issue relating to the potential costs of authorizing another 

provider to access scare resources. 

3.1.3 Educational Preparation - Policy Framework 

Education programs preparing registered nurses for extended/expanded roles have been present 

in Canada for a period of time. In the early years advanced preparation for the role was primarily delivered 

through employers, such as the Medical Services Branch. Basically, the educational requirements of nurses 

working in extended/expanded roles were determined by the particular circumstances of individual settings, 

as well as the availability of medical personnel on-site. 



One significant concern raised in this phase of the research was in relation to the delegation of 

primary care functions to registered nurses without adequate educational preparation to perform them. 

Several nursing associations indicated that some of their members were wary about being liable when 

performing primary care functions that required them to go beyond normally expected competency levels. 

For example, nurses practising in northern Quebec voiced concerns to the Ordre des infirmières et infirmiers 

about their responsibility and liability when working under the authority of protocols. In particular, these 

nurses were concerned about the adequacy of their preparation for performing certain delegated functions 

in a competent manner. 

Today, there are several education programs in place in most Canadian jurisdictions which provide 

registered nurses with the necessary knowledge and skills to undertake extended/expanded roles. The data 

collected by jurisdiction are summarized in Table 3. As noted with the title and scope of practice elements 

of this role, the absence of a consistent policy direction is reflected in the variant education requirements 

across provincial/territorial jurisdictions. Importantly, some provinces and territories either do not have 

specific education requirements or rely on employers to determine them. 

There are also obvious variations between the different education programs. Noteworthy 

differences among these programs are the entry requirements and status upon graduation. The education 

requirements for admission into programs range from diploma to baccalaureate level of preparation. A 

similar trend is noted in the awarding of a diploma, certificate and/or degree, among others, following 

program completion. Besides entry requirements and graduation status, the programs also vary in curriculum 

content, length, and the nature of clinical experiences, especially with regard to the intensity and duration of 

the clinical practicum. With these program differences, it is questionable as to whether the competencies and 

skills of the graduates are comparable withoin and across provincial/territorial jurisdictions. 



Table 3 - Education Programs for Extended/Expanded Nursing Roles in Primary Health Care 

Settings by Jurisdiction 

Jurisdiction 


Alberta 

Saskatchewan 

Manitoba 

Ontario 

Quebec 

New Brunswick 


Nova Scotia 

Newfoundland & Labrador 

Yukon 

Northwest Territories & 

Nunavut 

Education Program 

Educational qualifications are set by employing organization. 

BN or graduate degree required for entry and an Advanced Graduate Diploma in 

Community Health at Athabasca University. 

SRNA’s criteria for practice in extended/expanded roles is outlined in “ The Registered 

Nurse Scope of Practice: Special Nursing Procedures and Nursing Procedures by 

Transfer of Medical Functions, 1993". Graduation from a formal course of study is 

required. The Advanced Clinical Nursing Program at Saskatchewan Institute of 

Applied Technology is the usual course of instruction. 

Standards for registration under the enacted, but not proclaimed, legislation, have not 

been determined. There is a Masters level program in Advanced Nursing Practice at the 

University of Manitoba. 

In 1994, the Council of Ontario University Programs in Nursing approved a program 

for RN - EC at 10 sites co-ordinated by McMaster University. Program graduation 

criteria includes: completion of a 24 month course by a diploma graduate to attain a 

Bachelor of Nursing and NP certificate; or a BN preparation plus completion of a 12 

month course to attain a NP certificate. 

No specific courses identified. 

NANB has published a policy statement supporting education at the Masters level. UNB 

has introduced a nurse practitioner stream in its Master’s program. The nurses 

practising in the IT/SP projects were given additional educational preparation prior to 

entering the role. 

Not applicable at present. 

For demonstration projects, a NP certificate will be required from a recognized 

program, or a licence to practice as a primary care NP. 

RN diploma and at least 2 years practice for entry to Nurse Practitioner Program 

offered by Centre for Nursing Studies. Graduation with NP Diploma. Regional nurses 

require an RN diploma plus employer in-service education. 

Employers accept a variety of education options. 

Preference is for training at Aurora College in the Advanced Nursing Skills Education 

Program but this is not a fixed requirement. 

Sources: Associations of Registered Nurses and/or Ministry of Health in the respective jurisdiction as of August 2000. 



3.1.4 Summary 

The extension of authority through protocol and legislation is accompanied by rights of access to 

health care services, for example diagnostic facilities, traditionally limited to physician-use. With most 

legislation, these rights are extended throughout the jurisdiction to all registered nurses who are licenced to 

perform the role. Importantly, the right to access resources is not limited to a specific practice setting as is 

the case with protocols. Furthermore, in jurisdictions with legislation in effect, practitioners with advanced 

preparation and deemed competent to deliver primary care functions to the public are especially authorized 

to do so by the regulatory body of nursing. 

The common thread permeating this profile of key factors influencing the policy framework is the 

inconsistencies in the extended/expanded nursing role across Canada. Besides the absence of a common 

title to describe the role, there are differences in the educational requirements and scope of practice 

parameters guiding the implementation of a role touted to hold much promise for achieving the objectives of 

federal and provincial/territorial health care agendas. To complicate matters further, geography and the 

relative availability of health care providers, particularly physicians, influence the full implementation of the 

extended/expanded nursing role. While four jurisdictions have enacted legislation to legitimize the position 

of the extended/expanded nursing role within the health care system, this is not a universally accepted 

approach. The difficulties encountered by organizations employing registered nurses to work in 

extended/expanded roles are outlined in the next section on administrators’ perspectives on this situation. 

From a policy perspective, it is much better to deal with the extended/expanded nursing role through 

legislative change. This type of approach will ensure that extended/expanded roles are within the purview 

of nursing practice. Importantly, with the extended/expanded nursing role regulated by the relevant 

professional body, there would be more stability in the scope of practice guidelines, education requirements, 

and expected competency levels. 



3.2 Organizational Structure: Administrative Personnel Perceptions (see SDI) 

The purpose of this phase of the project was to identify and describe the practice models under 

which registered nurses in extended/expanded roles perform primary care functions. Particular consideration 

was given to the following: scope of roles and responsibilities, position title, client populations served, most 

common practice settings, job requirements and expected core competencies, expectations regarding 

autonomous and collaborative practice, scope of referrals to other providers, and extent of independent 

access to other available resources. A second purpose was to describe organizational lines of authority for 

supervising/monitoring registered nurses working in extended/expanded roles. A final purpose was to 

identify organizational mechanisms for assessing the quality of extended/expanded nursing services and their 

impact on client outcomes and organizational costs. 

The findings reported are exploratory in nature, although common links were observed between an 

organization’s mandate and the nature of extended/expanded nursing practice. The findings are presented 

in four major sections. The first section presents a descriptive profile of different models of practice. The 

second section describes the lines of authority in different jurisdictions. The third section reviews quality of 

care initiatives and evaluation mechanism for assessing organizational and client outcomes. The final section 

presents a summary of the key issues. 

3.2.1 Models of Practice 

The findings from the forty-four sites surveyed for this study indicated that registered nurses working 

in extended/expanded roles provide a wide array of services under similar, as well as disparate, collaborative 

practice arrangements. Despite observed variations, the norm was for nurses and physicians, as well as other 

health professionals, to engage in an interactive process of joint decision-making and problem-solving based 

on mutual respect and appreciation for each others knowledge, skills and abilities. This sharing of information 

and knowledge helped all providers develop better insight into clients’ health needs and provide appropriate 

and efficient primary health care to various population groups. 

The findings also indicated that there are significant variations within and between 

provinces/territories with regard to the enactment of primary care functions by registered nurses. The 



autonomous nature of extended/expanded nursing practice and collaborative practice relations were the byproduct 

of a peculiar set of separate and interrelated factors: location and setting, client populations, 

physician and other provider resource adequacy, organizational accountability, educational preparation and 

experience, access to resources and authorities/protocols. Given the interrelationship among many of these 

factors, the presentation of findings is organized according to two major themes: 1) location and setting, and 

2) job requirements and core competencies. 

3.2.1.1 Location and Setting 

Organizational structures, employer expectations and job functions changed rapidly for registered 

nurses performing extended/expanded role functions as one moved from urban to rural to remote areas 

regardless of whether it was the same or a different provincial jurisdiction. While all nurses working in 

extended/expanded roles are expected to practice autonomously, variations were noted across practice 

settings. The key factors influencing the autonomous nature of the role were the supportiveness of the work 

environment, physician supply, organizational goals and strategies, and the health needs of the local 

population. 

Urban 

A total of 14 urban sites participated in the survey. For the most part, registered nurses with 

extended/expanded practice roles were autonomous members of multi-disciplinary teams and worked with 

different client groups in a variety of settings (e.g., community health centres, satellite clinics and/or off-site 

clinics, medical clinics, resource centres, etc.). Without exception, there was a strong emphasis placed on 

autonomous practice while maintaining collaborative relations with all health care providers, especially 

physicians for primary care activities. The normal requirement was also for nurses to carry independent 

caseloads, consult with team members for input into decision-making (i.e., diagnosing health needs and care 

management), and initiate referrals to other providers when care was deemed to be outside their scope of 

practice. 



Rural 

In rural areas, registered nurses who performed extended/expanded role functions were expected 

to work autonomously, as well as collaboratively with physicians and other health care providers in a variety 

of settings (e.g., community clinics, health care centres, medical clinics, etc.). The norm was for physicians 

to be present on-site but to have limited involvement with the clinical supervision of nurses. In most 

instances, rural-based nurses carried independent patient caseloads, consulted with physicians by telephone 

or in-person for input regarding client care, initiated referrals to other providers and specialists, and accessed 

available community resources. 

The diversity of extended/expanded role functions and required skills observed across rural sites 

seemed to be contingent upon two main factors: 1) the shifting supply of health care providers, especially 

physicians, and 2) the willingness of other providers, especially physicians, to engage in collaborative 

practice arrangements. For example, in rural settings with a sufficient complement of physicians to meet 

local demands, registered nurses, regardless of their level of preparation for and experiential base in 

performing primary care functions, exercised a fair degree of autonomy in their role but often shared 

caseloads with physicians and worked under their direction. In contrast, when there was an insufficient 

complement of physicians to meet local demands, registered nurses not only practised autonomously but 

were often expected to provide services that sometimes stretched the boundaries of their defined scope of 

practice. This situation was more common in settings which operated under delegated functions or protocol 

agreements. 

Remote 

Registered nurses constituted the largest group of health care providers working in remote settings 

(i.e., isolated communities primarily accessible by air). The norm was for the nurse to be the only available 

health care provider and to assume a very independent role. These nurses worked in a variety of settings 

(e.g., community health centres, community clinics, nursing stations, etc.) and performed diverse primary 

care functions (i.e., routine assessment, diagnosis and treatment, as well as dispensing medications, stabilizing 

and transferring patients to the closest tertiary care centre). Although most of the clinics were nurse- 



managed, nurses were expected to work in collaboration with other health care providers, especially 

physicians. With on-site services limited to visits varying from once a week to every 6 to 8 weeks, physician 

input into clinical decision-making was mainly by telephone consultation and team conferences to review 

clinical issues. 

In general, the extended/expanded nursing role in remote areas was more challenging and diffuse 

(i.e., involved the delivery and coordination of a broader range and scope of primary care services) than in 

rural and urban areas. On the negative side, limited diagnostic and treatment modalities were available onsite 

and collaborative practice arrangements were significantly compromised because supportive interactions 

with other providers was mostly from a distance. Given the scope of the nursing role and ensuing 

responsibilities, it was apparent that time and resources, both human and physical, only allowed for the 

provision of primary care with limited opportunities for health promotion and illness prevention. 

3.2.1.2 Job requirements and Core Competencies 

One of the most serious and persistent problems confronting health care organizations in rural and 

remote locations was recruiting and retaining the number and mix of health care providers required to 

provide the clinical services needed by the local population. A problem of equal significance, especially for 

remote areas, was the recruitment and retention of registered nurses competent to perform primary care 

functions and capable of maintaining consistency in delivering high quality care 24-hours a day. 

Job Requirements 

The job requirements for registered nurses varied considerably across the survey sites and were 

dependent upon organizational expectations regarding the level of autonomy within the extended/expanded 

role nursing. Diploma or bachelor of nursing educational background with two to three years of clinical 

experience in tertiary care or community/rural health care were the minimal requirements. Unfortunately, 

these requirement were not always met in the more remote areas due to recruitment difficulties. In an effort 

to circumvent the potential problems posed by limited competency in performing primary care functions, 

employers developed contingency plans (i.e., intensive skills training with physicians prior to entering the 



field), especially for those nurses being placed in remote areas. In the territories and some parts of British 

Columbia and Manitoba, registered nurses are required to complete a program of study offered/sponsored 

by the Medical Services Branch. 

In general, most of the participating organizations in rural and urban settings hired only registered 

nurses who had completed an approved program. This was particularly true for the community health 

centres in Ontario which limit extended/expanded practice to nurses who have met the certification 

requirements for the Registered Nurse - Extended Class (RN - EC) category. A similar situation was noted 

in Newfoundland where nurse practitioner graduates of a certified nurse practitioner program were 

employed by several contact sites (i.e., medical clinics affiliated with a cottage hospital, emergency/outpatient 

department of a rural hospital, health centre, and a Primary Health Care Enhancement Project affiliated with 

a local hospital). 

Saskatchewan has wide-variations in extended/expanded nursing practice across its health districts. 

However, registered nurses employed by the Beechy Project, as well as a number of other sites which have 

adopted the primary health care model, are required to have completed the advanced practice program at 

the Saskatchewan Institute of Applied Technology. Several health authorities in Alberta also only employ 

those nurses for extended/expanded practice who have completed the certification requirements for the 

Registered Nurse - Expanded Practice (RN - EP) category. 

Core Competencies 

All of the survey respondents indicated that registered nurses who were working in 

extended/expanded roles were required to have well-developed assessment skills and capable of advanced 

clinical decision-making. Particular importance was placed on not only having the necessary competency 

to perform functions within one’s defined scope of practice but also to recognize situations outside of ones 

scope and to initiate referrals or consultations with other providers. Without exception then, all respondents 

placed equal emphasis on the nurse’s ability to perform primary care functions autonomously, as well as 

his/her ability to forge strong collaborative relations with members of other provider groups, especially 

physicians. 



Expected core competencies for registered nurses in extended/expanded roles were either a 

function of provincial legislation, regulations and/or protocols, scope of practice guidelines developed by 

nursing associations, colleges of nursing and/or employers, or physician expectations with regard to the 

performance of each delegated medical function. Further information on specified lines of authorities for 

ensuring that nurses possessed the required competencies is presented in sections 3.2.2 and 3.2.3. 

Most of the sites surveyed also had mechanisms in place to ensure the continued competency of 

registered nurses working in extended/expanded roles. Without exception, all of the respondents 

encouraged these nurses to participate in medical and nursing continuing education activities on a regular 

basis. Some of the sites instituted additional measures to ensure that nurses maintained expected 

competencies in performing existing, as well as new or revised, primary care functions. Examples of these 

measures were regular team conferences, in-service activities with visiting physicians/specialists, regular 

seminars on a variety of topics, internet and teleconferencing access, and support to attend one professional 

conference annually. In certain provinces, the nursing regulatory bodies required that nurses participate in 

a minimal number of continuing education activities to meet re-certification guidelines. 

3.2.2 Lines of Authority 

All of the administrative personnel surveyed referenced organizational efforts to achieve an 

appropriate balance of co-ordination and integration among the various provider groups, especially 

registered nurses in extended/expanded roles and physicians. While many organizations had clear guidelines 

to follow for extended/expanded role functions, others were less fortunate and subject to the constant shifting 

of role parameters in response to client needs and physician availability. When provincial legislation 

legitimizing the role was absent, the authority to order diagnostic tests, prescribe medications and perform 

other primary care functions was addressed through different protocol arrangements. The diversity observed 

in the lines of authority for extended/expanded role nurses is captured, to a degree, in the three scenarios 

that follow. 

The first scenario relates to registered nurses in extended/expanded roles certified to perform 

primary care functions (i.e., graduates of an approved program of at least one year in duration) and operated 



as full autonomous members of multi-disciplinary teams. The constant factor was the lines of authority for 

supervising and monitoring these nurses: provincial legislation (i.e., Ontario and Newfoundland and 

Labrador) and/or the scope of practice guidelines developed by the relevant college of nursing or nursing 

association. There were definite variations, within and between provincial jurisdictions, with regard to the 

person (s) responsible for overseeing nurses’ clinical practice. For both Newfoundland sites, the nurse 

practitioners reported to a nurse manager. In Ontario, there were four distinct categories of responsible 

persons. Some sites referenced the self-monitoring clinical team (i.e., nurse practitioners and physicians coordinating 

their efforts as part of a clinical team) and its accountability to the executive director. Other sites 

reported that nurse practitioners were accountable to the executive director/administrator. Still other sites 

identified the responsible party as the physician. Finally, several sites emphasized the dual accountability of 

nurse practitioners to the executive director/administrator and physicians. 

A second scenario relates to registered nurses in extended/expanded roles who had variable levels 

of preparation for performing primary care functions (e.g., masters preparation with NP certification, 

advanced clinical preparation in a post-RN program, basic diploma preparation with on-site physician 

direction and guidance in performing specified functions, intensive orientation to promote skill competency 

and sound clinical judgments prior to entering clinical situations, etc.). Most of these nurses worked in 

remote areas, as well as urban and rural areas to a lesser degree, and assumed a very autonomous role while 

engaged in collaborative practice arrangements with other providers (i.e., mostly nurse colleagues and 

physicians). Respondents reported wide variations in the lines of authority for supervising and monitoring 

these nurses. The following are examples of such authorities/protocols: 1) delegated medical functions based 

on protocols negotiated between medical and nursing associations, ministries of health and employers, 2) 

amended Public Health Act (1995) and accompanying regulations covering extended practice, 3) transfer 

of functions - umbrella document negotiated between medicine, nursing and pharmacy regulatory bodies, 

4) delegated functions under the provincial medical act, and 5) Medical Service Branch Scope of Practice 

Guidelines. The persons responsible for overseeing the clinical practice of nurses working in 

extended/expanded roles were also quite variable, including immediate nursing supervisors/nurse managers 

alone, physicians alone, or nursing supervisors/nurse managers and physicians. 



The final scenario relates to registered nurses in extended/expanded roles who were required to 

meet the minimal requirements for performing primary care functions before actually doing so in clinical 

situations. Most of the nurses in this category had restricted autonomous functioning in clinical situations 

(e.g., limited access to diagnostic facilities, no prescriptive authority, restricted referrals, etc) and worked 

under medical directives or protocol arrangements. In addition, they were mostly accountable to either 

physicians alone or a combination of immediate nursing supervisors and physicians. 

3.2.3 Quality Measures and Evaluation of Outcomes 

The performance activity which received the most attention was nurses decision-making and its 

outcomes. While expertise provides the source and legitimization for the extended/expanded nurses’ 

professional autonomy, organizational outcomes and client outcomes are important indicators of effective 

clinical decision-making. Organizational outcomes are measured by cost effectiveness and efficient 

delivery of quality care. Client outcomes are measured by such things as patient satisfaction with care and 

achieving an optimal level of health. Effective clinical decision-making is measured by the ability to 

make sound judgments while assessing clients’ health problems, arriving at a diagnosis, and choosing the 

most appropriate plan of action. 

Quality Measures 

Wide-variations were noted in on-site strategies for monitoring the competency levels of registered 

nurses working in extended/expanded roles. For the most part, survey respondents reported that evaluation 

was limited to periodic chart reviews by nursing supervisors and/or physicians. An additional monitoring 

mechanism instituted at some of the sites was performance appraisals. The more formalized appraisal 

process involved observing nurses in clinical situations and identifying strengths and areas of weakness on 

an annual or bi-yearly basis. The informal process primarily consisted of the nursing supervisor and/or 

physician querying nurses on clinical issues/decisions on an ad hoc basis. Without exception, all of the 

respondents indicated that this was an area that required further attention. In fact, some sites were in the 

process of instituting such procedures as peer evaluations and/or self appraisals, as well as developing 



performance standards. The sites most likely to be actively engaged in formalizing evaluation/monitoring 

procedures were either preparing for accreditation or were required to do so by the funding or regulatory 

body. 

Organizational/Client Outcomes 

The majority of the sites surveyed had not participated in a formal evaluation process either in-house 

or by external consultants since employing a registered nurse with extended/expanded role capabilities. Only 

three respondents reported that an independent evaluation had been conducted to evaluate the impact of 

this type of nursing practice on organizational or client outcomes. In most instances, this was a requirement 

imposed by the funding body. Respondents from seven other sites reported that an independent evaluation 

was in-progress or about to commence in the near future. As well, there were a number of other sites that 

had either completed patient satisfaction surveys or taken steps to do so within the year. 

3.2.4 Summary 

In summary, registered nurses working in extended/expanded roles are providing a full-range of 

primary care services in accordance with relevant authorities in the region and/or province. The geography 

of the region was identified as a key factor influencing not only the availability of provider resources but also 

the nature of collaborative relations between registered nurses and other providers, the level of preparation 

for and competency in performing extended/expanded role functions, and on-site evaluation procedures for 

ensuring quality of care and positive organizational/client outcomes. A few of the key issues affecting 

effective utilization of registered nurses in extended/expanded roles emerging from the administrative data 

include: 

< Greater restrictions are placed on nurses’ autonomous performance of primary care 

functions when there is a greater concentration of physicians. 

< Limited availability of nurses with appropriate extended/expanded role preparation in 

remote regions of the country necessitated lowering expectations re education standards 

and experiential base. 

< Wide-variations existed in requirements for maintaining competency in extended/expanded 

role functions. 



Limited support mechanisms in place for extended/expanded role nurses working in remote 

regions. 

< Legislative restrictions (e.g., Hospital and Diagnostic Act, etc.), as well as variations in 

policies/protocols between sites, sometimes limit or deny registered nurses access to 

necessary resources. 

< Minimal standards and guidelines for accessing the quality of primary care and the impact 

of services on organizational and client outcomes. 

3.3 On-site Data collection 

In the provinces of Saskatchewan, Ontario and Newfoundland and Labrador, face-to-face 

interviews were conducted with fourteen nurses who were working in extended/expanded roles, as well as 

eleven participating physicians. The purpose of this phase of the study was to develop a greater 

understanding of physicians’ experiences while working with nurses who performed extended/expanded 

role in primary health care settings. A second purpose was to document nurses’ experiences while 

performing the extended/expanded role in primary health care settings with similar and different practice 

models. A third purpose was to identify physicians’ and nurses’ perceptions of the barriers to and 

facilitators of full implementation of the extended/expanded nursing role. 

The interview data from both groups were subjected to the constant comparison method of analysis 

to highlight differences and commonalities within and between each provincial jurisdiction. The following 

sections present a discussion on the dominant categories (i.e., practical knowing, collaborative versus 

independent practice models, role confusion, and barriers to and facilitators of collaborative practice models) 

generated from the thematic analysis of study data. Each section also highlights the similarities and 

differences between physicians and nurses on key issues. 

3.3.1 Practical Knowing 

A common theme throughout the interview transcripts was participants’ perceptions of the 

knowledge levels and practical skills of registered nurses working in extended/expanded roles. The practical 

knowing theme reflected improvements in nurses’ skills and abilities for performing primary care functions 

from the early stages of role enactment to the development of an experiential base. All of the participants 

identified ways to ensure that nurses not only possessed minimal competency levels when assuming 



extended/expanded roles but also were able to access the necessary resources to help refine/enhance their 

skills/abilities. 

Early Stages of Role Enactment 

Several physicians indicated that they were dissatisfied with nurses’ theoretical and practical 

knowledge base when they first assumed extended/expanded roles. The wide variations observed in clinical 

competencies affected the degree of confidence and trust that they had in a nurse’s ability to provide and 

maintain quality health care. Any perceived deficits in knowledge and/or practical skills were attributed to 

either inadequacies of educational programs preparing nurses for the role and/or their limited experience in 

performing primary care functions prior to assuming the role. 

Many of the nurse participants described the early stages of role enactment as being extremely 

difficult for a number of reasons. Several participants noted an increased awareness of the gaps between 

their theoretical and practical knowledge, and overwhelming feelings concerning the diverse skill 

requirements while dealing with clients. Overall, many of the nurses attributed feelings of low confidence 

and competence to limitations in the theoretical and clinical components of the educational programs 

preparing them for the extended/expanded role. 

Both physician and nurse participants recommended possible ways to circumvent some of the 

problems with beginning knowledge levels and practical skills/abilities. Some physicians suggested that 

curriculum changes were needed in programs preparing nurses for this type of role. Particular emphasis was 

placed on practical skill enhancement by requiring nurses to spend more time with physicians during clinical 

rotations. A couple of physicians also commented on the importance of setting minimal competency 

standards and requiring nurses to participate in continuing medical education. 

Several nurse participants commented on the importance of having a standardized entry level for 

extended/expanded nursing practice. Some participants indicated that they would have felt more 

comfortable working in the role initially if they had a baccalaureate degree prior to receiving preparation for 

the extended/expanded role. The general position was that common educational standards are required to 

ensure greater acceptance and credibility of the role. 



Development of an Experiential Base 

Most of the physicians attributed the observed improvements in nurses’ practical skills and abilities 

to working more closely with and under their direct supervision, as well as dealing with a variety of clinical 

problems. As time passed and nurses gained more experience in the role, physicians became more confident 

with nurses’ ability to handle independent caseloads. Overall, physician participants reported having positive 

experiences while working with nurses in extended/expanded roles. 

The nurse participants commented on how their comfort with and confidence in the role increased 

with the passage of time and exposure to different conditions and clinical situations. Most of them described 

their movement into primary care as a “learning process”. By working collaboratively with physicians in the 

clinical area and participating in continuing education activities, participants gradually incorporated more 

primary care functions into their practice, developed greater self-confidence, assumed a more independent 

role, and consulted with physicians in a more collegial manner. 

Summary 

Despite the variant experiential base, physicians expressed confidence with the quality of care 

provided by most nurses after a period of time practising in the extended/expanded role. Significantly, nurse 

participants emphasized the immeasurable value of experience and the benefits of a strong support system 

in facilitating their delivery of quality care to clients. The following recommendations about ways to 

improve nurses’ competency for extended/expanded roles were endorsed by many of the nurses and 

physicians: 

< standardize entry level into programs preparing nurses for extended/expanded practice; 

< increase the clinical component of programs preparing nurses for extended/expanded roles; 

< ongoing continuing education to ensure competency in expected primary care functions; 

< well-defined and universal standards on expected competency levels for extended/ 

expanded nursing practice. 



3.3.2 Collaborative versus Independent Practice Models 

Participants’ descriptions of their experiences with extended/expanded nursing roles portrayed the 

most conducive and acceptable practice environment as one which favoured team work or strong 

interdisciplinary collaboration over independent practice. The dominant themes in this category were 

autonomous practice, balancing collaboration and independent practice, and the rationale for supporting 

collaborative practice. A brief summary is presented on each of these themes. 

Autonomous Practice 

Physician participants were supportive of autonomous practice for nurses as long as they operated 

within their defined scope, consulted with them as required, and did not try to replace them or provide 

substitute medical care. In fact, most physicians were of the opinion that nurses engaged in independent 

practice would encounter opposition from their physician colleagues. 

All of the nurse participants reported feeling comfortable performing primary care functions 

autonomously in different settings. The degree of autonomous practice was a function of the scope of 

practice guidelines and/or protocols governing nursing practice in each jurisdiction. For example, 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. 

Regardless of the region or jurisdiction, many of the nurses commented on the challenges of, as well as the 

personal satisfaction derived from, assessing client health needs, reaching an accurate diagnosis, and 

facilitating positive health outcomes. As well, most of the participants emphasized the value of using nursing 

skills and abilities in clinical situations, and the importance of maintaining a nursing focus when performing 

primary care functions. 

Balancing Collaborative and Independent Practice 

All of the physician participants believed that a collaborative arrangement was the best practice 

model for nurses working in extended/expanded roles. However, physicians working in remote and rural 

areas with limited medical personnel supported greater independence for nurses than their counterparts 



working in urban areas. Regardless of the location, all of the physicians reported that working in primary 

health care settings with nurses in extended/expanded roles resulted in strong collaborative relations. More 

efficient management of physicians time was identified as another important benefit. On the negative side, 

collaborative practice arrangements with nurses also resulted in a refocusing of physicians’ practice on higher 

acuity and/or more complicated medical cases, leaving less time for a more holistic approach and continuity 

of care. As well, frequent consultations with nurses disrupted physicians’ practice and increased the 

demands on their time. 

All of the nurse participants felt secure working independent of physicians, but emphasized the 

importance of collaborating, especially on matters outside their scope of practice. In fact, nurses considered 

the collaborative approach to be more beneficial for everyone (i.e., patients and health care providers). 

When collaboration worked best, referrals flow both ways between nurses and physicians. Collaboration 

was not always viewed positively, with some participants noting that the time spent consulting with physicians 

sometimes resulted in appointment delays for both parties. In addition, participants expressed frustration 

when the nature of the work environment restricted physician contact to telephone consultations. 

Rationale for Supporting Collaborative Practice 

Most physician participants were of the opinion that extended/expanded role nurses should work 

in collaboration with them. This would ensure that patients received optimal care quality. Some physicians 

were also of the opinion that the nurse’s emphasis should be more on wellness than primary care. One 

special area of concern identified was how well prepared nurses were to deal with patients presenting with 

high acuity levels, especially when doing on-call coverage without physician back-up. 

Nurse participants were of the opinion that a collaborative 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. 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, and increased the probability of 

providing more comprehensive care. 

Summary 

In summary, physicians supported the autonomous practice of nurses with regard to performing 

primary care functions with the caveat that it occurs within a defined scope of practice, and necessary 

consultations are being made with physicians. Physicians, in general, did not support independent practice 

by extended/expanded role nurses unless there were limited medical resources. Nurse participants also 

supported autonomous practice, with the understanding that this would occur within the context of 

collaborative, as opposed to independent, practice arrangements. 

3.3.3 Role Confusion: Patient Understanding, Acceptance and Satisfaction 

Both physician and nurse participants agreed that patients experienced difficulty differentiating 

extended/expanded nursing roles from medical roles. Despite these difficulties, most physicians and nurses 

indicated that patients seemed to be quite satisfied with the level of care provided by extended/expanded 

role nurses. 

Physicians comments differed slightly from the nurses on a couple of issues. Most physicians 

believed that patient acceptance of nurses was generally positive, especially for health issues related to 

wellness and minor illnesses. However, some were of the opinion that, for most things, patients would prefer 

to see the doctor. While a small number of participants felt that limited patient understanding of the role 

acted 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. 

Many of the nurse participants believed that patients generally accepted them, were very satisfied 

with the increased availability of health care services, and experienced a greater sense of stability and 

continuity of care. Increased acceptance of nurses in these roles was attributed to the quality of the time 

spent with each person and educating him/her 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. 

3.3.4 Barriers to and Facilitators of Collaborative Practice Models 

Many of the physician participants considered the potential impact of the presence of 

extended/expanded role nurses in collaborative practice arrangements on patient accessibility to health care 

services, especially medical services. In contrast, nurse participants tended to focus more on the importance 

of having supportive structures in place to ensure full-implementation and acceptance of the 

extended/expanded role. Besides the accessibility factor, nurse and physician participants were especially 

cognizant of the benefits for and barriers to quality care delivery, especially from the perspective of 

comprehensiveness and continuity of services. The findings are organized around the three major themes 

that emerged from the data: 1) accessibility to health care services, 2) supportive structures, and 3) 

implications for quality. 

Accessibility to Health Care: Implications for Medical Services 

Due to observed decreases in the number of practising physicians in certain areas, physician 

participants recognized the need for alternative ways to deliver primary health care services and 

acknowledged that extended/expanded role nurses could buffer the negative impact of limited medical 

personnel. Conversely, some participants were of the opinion that these nurses posed significant barriers 

to physician recruitment and retention. This was especially true for fee-for-service physician colleagues who 

would perceive extended/expanded role nurses as a threat to their income. One negative consequence of 

not being able to attract sufficient numbers of medical personnel was the increased workload for physicians 

already present in the system. 

Supportive Structures 

Nurse participants identified the presence of strong working relationships with other health care 

providers, especially physicians, as an important factor facilitating adjustment to the extended/expanded role. 



It was also apparent that not all of the nurses received the same level of support from physicians, with 

participants clearly indicating that fee-for-service physicians were more resistant to their presence than 

salaried physicians. The combination of physician resistance and the newness of the role impeded the pace 

at which confidence was developed in implementing the role. 

Particular emphasis was placed 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. 

Implications for Quality 

Several physicians working in under-serviced areas identified an increase in the comprehensiveness 

of services as an important benefit of having extended/expanded role nurses. Specifically, the quality of 

patient care was believed to be enhanced because the presence of a collaborative approach meant that more 

time was available for providing primary care, as well as health promotion and prevention activities, and 

ensuring greater continuity of care. The downside was that nurses assumed 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. Furthermore, some 

physicians believed that without adequate supervision, nurses were operating at increased risk for 

unexpected problems which could compromise the quality of patient care. As well, continuity of patient care 

could be jeopardized when nurses referred to specialists without consulting with the primary care physician. 

Finally, concerns were raised about responsibility and legal issues with regard to who the responsible 

clinician should be in situations where nurses are seeing patients independently, screening them and deciding 

on the appropriate treatment plan. 

Overall, nurse participants felt that the services being provided by nurses working in 

extended/expanded roles were having a positive impact on the overall wellness of the community. The 

success of ongoing public and staff education promoting greater awareness of extended/expanded nursing 



oles was reflected in increased utilization of nurses in various settings. When collaborative practice models 

were present onsite, team work was believed to be the key factor responsible for improving the 

comprehensiveness of health care services available to clients (i.e., health promotion and illness prevention 

were given as much weight as curative function) and promoting optimal health outcomes. 

It was evident that nurse participants’ satisfaction with the extended/expanded nursing role was 

strongly influenced by their ability to provide quality care and improve patient accessibility to different 

services. Nurse participants’ identified several significant barriers to the full utilization of the 

extended/expanded nursing role within the health care system. One important impediment to the provision 

of comprehensive care was skills/knowledge limitations and/or scope of practice restrictions, especially with 

regard to diagnoses, treatment and referral abilities. Additional areas of dissatisfaction included the overall 

lack of recognition given to the extended/expanded nursing role, consumers’ and other health care providers’ 

perceptions of the role, the political climate, professional isolation in remote areas, limited human resources 

in remote areas restricted participation in continuing education activities, and inadequate financial 

reimbursement for extended/expanded nursing services. Furthermore, the physician fee-for-service system 

was identified as a barrier to the full implementation of the extended/expanded role. Participants emphasized 

the importance of developing an alternate funding mechanism. 

Summary 

Nurse and physician participants identified the pros and cons of working together under 

collaborative practice arrangements and being jointly responsible for providing primary care services to the 

public. The benefits and barriers for both groups of participants are itemized below. 

Important benefits identified by physicians: 

< increased patient accessibility to medical services, especially in rural and remote areas 

where there is a shortage of family doctors; 

< increased availability of comprehensive health care services (i.e., primary care coupled with 

prevention and health promotion strategies); 



improved quality of care and increased probability of achieving positive health outcomes; 

Important benefits identified by nurses: 

< increased access to supportive individuals and collegial relations with other health care 

providers, especially physicians, facilitates confidence building and adjustment to the 

extended/expanded role; 

< increased availability of comprehensive health care services (i.e., primary care coupled with 

prevention and health promotion strategies) to patients; 

< improved quality and continuity of care and the probability of achieving positive health 

outcomes. 

The barriers to full-utilization and acceptance of extended/expanded nursing roles identified by 

physicians: 

< negative impact on the income of fee-for-service physicians; 

< potential for impeding physician recruitment and retention; 

< no mechanism in place for fee-for-service physicians in private practice to hire nurses to 

work in extended/expanded roles; 

< decreased effectiveness of extended/expanded nursing roles due to restricted prescriptive 

authority, absence of fraternity with speciality physicians and limited access to diagnostic 

services, especially in rural/remote areas; 

< potential for continuity of care problems when nurses order diagnostic tests independent of 

physicians; 

< inadequate nurse supervision may result in the provision of poorer quality care to patients; 

< responsibility and liability concerns for attending physicians when nurses see patients 

independently. 



The barriers to full-utilization and acceptance of nurses with extended/expanded roles highlighted 

by nurses were as follows: 

< decreased ability to provide comprehensive health care services due to skill/knowledge 

limitations; 

< decreased effectiveness of the extended/expanded nursing roles due to restrictions imposed 

on scope of practice (e.g., prescriptive authority, ease of access to referrals and diagnostic 

services, etc.); 

< thwarted/delayed acceptance of extended/expanded nursing roles due to inadequate 

public/professional awareness; 

< restricted utilization of extended/expanded role nurses in private physicians practice due to 

the heavy reliance on a fee-for-service system and the absence of alternative funding 

mechanisms; 

< increased role strain and delayed confidence-building due to the presence of unsupportive 

physicians; 

< resistance from physicians, especially those compensated by fee-for-service, impeded full 

implementation of the extended/expanded role. 

3.4 Patient Perceptions (see SD3) 

The surveys completed by 58 patients in the study sites provided information about their 

experiences and satisfaction levels with registered nurses working in extended/expanded roles. With regard 

to how patients experienced nurses during clinic visits, special consideration 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 the frequency of referrals to and from nurses. The 

findings on patient experiences indicated that: 

< 83% of visits were for regular checkups and the management of ongoing conditions. 

< 62% of patients did not require a new or renewed prescription during any of the visits. 

< 79% of patients were not referred to the nurse by another health care provider. 



52% of patients reported that the nurse did not refer them to other health care providers. 

< 69% of nurses usually performed physical exams and 85% provided advice on self-care 

measures. 

< Nurses rarely or never ordered blood tests (60%), x-rays (85%) or prescribed medications 

(61%). 

The second area of investigation focussed on patients level of satisfaction with the care received, 

information provided on their illness, the amount of time spent waiting to see the nurse, follow-up care, the 

level of knowledge and abilities that nurses had to treat them, and the time spent by nurses to help them 

understand illness and treatment requirements. The findings on patient satisfaction were as follows: 

< 98% of patients were satisfied with the care received, from nurses, the information provided 

on their illness (92%), the amount of time spent waiting to see the nurse (84%), and followup 

care (88%). 

< 90% of patients were satisfied that nurses had the necessary knowledge and abilities to treat 

them and spent enough time helping them understand their illness and treatment requirements 

(96%). 

In 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 nurse, the diverse 

activities initiated and/or performed by nurses during clinic visits, and the frequency with which patients 

continued to schedule appointments with nurses. In addition, the high degree of satisfaction with the care 

provided by nurses working in extended/expanded roles is a further indication that respondents had 

accepted the extended/expanded role. 

3.5 Observation of Nurses Practice (see SD 3) 

Findings from 82 nurse - patient observations conducted at the study sites provided insight into the 

nature of nurses’ practice while working in the extended/expanded role. Nurse - patient observation 

sessions revealed that: 

< The majority of patients seen were adult females. 



84% of patient visits lasted less than 30 minutes. 

< 50% of patient visits were for the assessment and management of acute illness or injury, 

23% for the management of chronic illness and 27% for well person screening. 

< 77% of patients seen were assessed, diagnosed and treated independently by the nurse. 

< Nurses, in managing patient care, went beyond the presenting health need and addressed 

the physical, psychological, emotional and social well being of patients. 

< Nurses performed a broad range of preventive, promotive and supportive activities. 

< Nurses, when faced with complex medical problems outside their scope of practice, 

consulted and referred to primary care physicians and/or specialists. 

In 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 when seeing patients present with acute illness/injury, chronic illness and wellness issues. 

Nurses demonstrated a high degree of confidence, sensitivity and definiteness in their interactions with 

patients. Nurses consulted with other health care providers especially physicians, when it was felt that 

patients would benefit from being seen by someone else with a different level of expertise. 

4.0 Conclusions and Recommendations 

4.1 Policy and Legislative Frameworks 

The extension/expansion of the nursing role through legislation has not been universally accepted 

across Canada. While some provinces/territories have legitimized, or are contemplating legitimizing, primary 

care functions through legislative intervention, other jurisdictions prefer to rely on protocol arrangements. 

Delegated medical functions have traditionally been the means by which nurses have been able to legally 

undertake the curative functions of primary health care. Unfortunately, there is no consistency in protocol 

arrangements across jurisdictions as the authorities are reflective of the unique circumstances of the practice 

setting. 



The findings from the administrative survey and on-site data collection indicated that the full 

utilization of nursing competencies in the extended/expanded role is dependent upon the location (i.e., 

remote, rural and urban) and relative supply of other health care providers. The more remote the location 

and the lower the concentration of physicians, the greater the reliance on the nurse for providing a broad 

range of primary care services. In contrast, when there are greater concentrations of physicians and other 

providers in rural and urban areas, there is more competition for access to scarce resources and less 

evidence of delegation of medical authorities even though extended/expanded role nurses have the required 

competency to perform primary care functions. 

The one great advantage of delegated medical functions is their flexibility which allows for more 

situational-specific responses. Although Saskatchewan implemented a province-wide protocol agreement 

as part of its primary health care initiative, both the primary care nurses and physicians interviewed noted 

that delegated medical functions vary by site and depend on physician preference. The administrative survey 

results also indicated that extended/expanded role nurses in other provinces/territories perform primary care 

functions under the authority of site-specific protocols. The disadvantage of relying upon delegated functions 

is that the parameters of the extended/expanded nursing role are subject to influence from the medical and/or 

pharmacy professions, and employers. One important question that surfaces from all of this is whether or 

not registered nurses who are operating under protocols are performing medical or nursing acts. Stated 

somewhat differently, if the authority to perform primary care functions is by protocol arrangements through 

the authority of medicine as opposed to nursing legislation, is this really extended/expanded nursing practice 

Advocates within the nursing profession who endorse a legislative approach argue that deriving authority 

under delegated medical functions does little to establish the extended/expanded role nurse as a legitimate 

provider in the health care system. 

Another area of concern emanating from delegated medical functions relates to responsibility and 

liability issues. This seems to be true regardless of provinces’/territories’ educational requirements for the 

extended/expanded nursing role. The reality of this situation is supported by the issues confronting the 

nursing association in Quebec (i.e., adequacy of existing legislation and/or protocol agreements to authorize 

nurses’ to perform certain primary care functions). Furthermore, several of the physicians who participated 



in the on-site data collection phase in different jurisdictions expressed concern about the level of autonomous 

practice that nurses were expected to assume in certain situations (e.g., on-call coverage, remote clinics, 

etc.). In fact, some of them questioned whether the nurse or physician would be held accountable in the 

event of problems. The general feeling was that there should be a better match between what employers 

expect of extended/expanded role nurses in the practice setting versus what they are prepared to do in their 

education programs. 

A final area of concern that surfaced during the course of this study related to legislative barriers 

that prevented full enactment of the extended/expanded role, even in areas where the role was protected 

by nursing legislation and regulation. As reported by participating individuals in both the administrative 

surveys and study sites, registered nurses working in extended/expanded roles may have restrictions 

imposed on diagnostic, prescriptive and referral authorities, as well as hospital admitting privileges. The 

relevant legislation which covers these matters also require amendment to accommodate extended/expanded 

role nurses. 

In conclusion, a more coordinated approach is required in extending authorities to registered nurses 

responsible for delivering primary care services. As long as the extended/expanded role is a delegated 

medical function, it is difficult for the nursing profession to regulate extended/expanded nursing practice 

and/or ensure that registered nurses are appropriately educated for and competent to perform primary care 

functions. A legislative approach will ensure that the nursing profession has more control over the scope of 

practice for registered nurses working in extended/expanded roles. The most conducive approach then is 

to amend nursing legislation, develop additional regulations for the extended/expanded nursing role, and 

amend other relevant legislation to facilitate full enactment of the role. 


It is recommended that legislation be introduced in all remaining jurisdictions to legitimize the 

extended/expanded role of the registered nurse and to facilitate access to necessary resources 

within the health care system. This approach will ensure that extended/expanded roles for 

registered nurses are included within the scope of practice of the nursing profession. 




It is recommended that all relevant legislation be amended to facilitate consistent access to 

necessary resources within the health care system and the full implementation of the 

extended/expanded nursing role as mandated in each jurisdiction. 

4.2 Regulatory Framework 

There are educational programs in most Canadian jurisdictions that provide nurses with the required 

knowledge and skills to perform primary care functions. In the provinces which participated in the on-site 

data collection component of this project (i.e., Ontario, Newfoundland and Labrador, and Saskatchewan), 

many of the registered nurses practising in the extended/expanded role had successfully completed an 

advanced program of study. However, inconsistencies were observed in the level of nursing education 

requirements for entry into these programs. It was also noted in the cross-country survey of administrative 

personnel in organizations employing nurses to work in extended/expanded roles that mechanisms for 

ensuring beginning and continued competency in performing primary care functions were quite variable 

regardless of whether the responsible authority was legislation or delegated medical functions. 

One significant concern raised throughout the different phases of this research project was the 

delegation of medical functions to registered nurses without adequate educational preparation and/or the 

required clinical expertise to perform them. Several nursing associations indicated that some of their 

members were wary about being liable when performing primary care functions which required them to go 

beyond their defined scope of practice and/or normally expected competency levels. Physicians interviewed 

during the on-site data collection phase expressed similar concerns about the uncertainty surrounding the 

scope of extended/expanded nursing practice and the required competencies of registered nurses performing 

primary care functions. While physicians indicated that nurses were valued members of the collaborative 

team, one significant barrier to wide-spread acceptance was the inadequacies observed in nurses’ 

educational preparation, especially with regard to practical knowledge and abilities. Without exception, 

every physician stressed the importance of ensuring that nurses receive adequate practical experience before 

assuming extended/expanded roles. In addition, some physicians raised concerns about the absence of 



minimum standards for entry into the extended/expanded role and stressed the need for more extensive 

clinical experiences with physicians during education programs. 

The nurses interviewed were concerned about the absence of standards of practice for 

extended/expanded nursing roles and inconsistent entry requirements into education programs which 

impeded their mobility within and across Canadian jurisdictions. In essence, the findings from different 

sources highlighted the need for more clearly defined scope of practice parameters for the 

extended/expanded nursing role, as well as the development of consistent standards for entry into this type 

of nursing practice. If such measures were instituted, registered nurses who practice in extended/expanded 

nursing roles would have the required core competencies to perform all functions expected of them. 

Some of the nurses who participated in the interviews on-site 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. 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. 

Another area of concern was the variant practice requirements for registered nurses working in 

extended/expanded roles in remote versus rural versus urban settings. From a practice perspective, remote 

settings may present particular challenges. The obligation is on the employer to ensure that nurses practising 

in the extended/expanded role have access to the resources needed to deliver services to the public that are 

safe and of acceptable quality. From a public policy perspective, the location of a nurse in an 

extended/expanded role should not be an issue. It is the responsibility of the licensing body to ensure that 

all registered nurses working in this role are licenced to meet expected core competencies. With the license 

to practice in extended/expanded roles, nurses must satisfy minimal education requirements and be deemed 

competent to perform required primary care functions. 

Every physician stressed the importance of ensuring that nurses receive adequate practical 

experience before assuming extended/expanded roles. In addition, some physicians raised concerns about 



the absence of minimum standards for entry into the extended/expanded role and stressed the need for more 

extensive clinical experiences with physicians during education programs. 

The nurses interviewed were concerned about the absence of standards of practice for 

extended/expanded nursing roles and inconsistent entry requirements into education programs which 

impeded their mobility within and across Canadian jurisdictions. In essence, the findings from different 

sources highlighted the need for more clearly defined scope of practice parameters for the 

extended/expanded nursing role, as well as the development of consistent standards for entry into this type 

of nursing practice. As well, many of the nurses indicated that they were restricted to continuing medical 

education offerings. While it is positive that such continuing education opportunities are accessible to nurses, 

they also need access to programming that is based on the philosophy, values and knowledge of the nursing 

profession. This is an issue that must assume high priority in the immediate future. 


It is recommended that core competencies and standards of practice for registered nurses in the 

extended/expanded role be developed and used to facilitate consistency in education programs for 

beginning competency levels. Importantly, education programs must ensure that the clinical 

component is of sufficient breadth, length and intensity to facilitate registered nurses’ entry into 

primary care practice. 


It is also recommended that nurses working in extended/expanded roles be supported with 

continuing nursing education activities relevant for the primary care aspect of primary health care. 

This type of supportive structure is needed to ensure that registered nurses keep abreast of latest 

developments and maintain required competency levels. 

4.3 Terminology and Definition Problems 

Early in the research process, the project team searched for an appropriate and acceptable glossary 

of terms to use in this study. This proved to be quite challenging due to the inconsistences noted across 



Canada. In particular, there was no common understanding of the terms and definitions used to describe 

those aspects of the extended/expanded nursing role which relate to the performance of primary care 

functions in primary health care settings. This state of affairs was evident in the data collected from the 

organized nursing community, other professional groups, Ministries of Health and members of the public. 

A few of the problem areas are outlined below: 

< Primary health care is defined in accordance with the World Health Organization’s 

definition. However, the primary care component of primary health care does not have 

a commonly accepted definition, and in fact is often used interchangeably with primary 

health care. 

< Nursing associations are disinclined to use the terms extended nursing practice and 

expanded nursing practice. This is true despite their common usage in the literature to 

distinguish primary care functions from other aspects of nursing practice. Furthermore, 

Ontario has made provisions through legislation for the extended class of registered nurses. 

Alberta has created a roster for expanded practice nursing. Based on information collected 

from key informants participating in various phases of this project, the terms 

extended/expanded practice are commonly used by nurses and other health practitioners 

to distinguish primary care roles from other nursing roles. 

< Although advanced practice was not the subject of this study, this term is used to capture 

the extended/expanded nursing role in certain jurisdictions. At least one nursing association 

and some provincial government representatives indicated that advanced practice was the 

shorthand used to describe extended/expanded nursing practice which involves the 

performance of primary care functions. 

The confusion over terminology and definitions does little to facilitate full implementation of the 

extended/expanded nursing role in all jurisdictions. There is an obvious need for greater consistency in term 

usage, as well as greater clarification of the parameters of extended/expanded nursing role which relate to 

primary care functions. When professionals outside nursing and decision-makers are asked to support 

greater use of extended/expanded role nurses in providing primary care services, there must be a clear 



understanding of what they are being asked to endorse. Goals are not easily attained when there is an 

absence of common understandings. 


National, provincial and territorial nursing associations and stakeholder groups facilitate 

consistent language and definitions relative to the extended/expanded nursing role in primary 

health care. This approach will heighten awareness of the role and facilitate greater acceptance 

of registered nurses’ delivering primary care to diverse populations in all Canadian jurisdictions. 

4.4 Availability of Quality Services to the Public 

Overall, key informants who participated in all phases of this project indicated that the most 

conducive situation for ensuring that quality primary health care was available to the public was for all health 

care providers to work collaboratively within close proximity to each other. The administrative survey 

participants felt that provider collaboration and team work enhanced the coordination and continuity of care 

provided by their organizations. The physicians and nurses who participated in the on-site study component 

viewed the presence of nurses with extended/expanded roles in primary health care settings as having a 

positive impact on the quality of health care services available to patients (i.e., improved accessibility to 

primary care services and health promotion and illness prevention activities). 

While physicians participating in this study 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 medicine. Physician resistance to the extended/expanded nursing role was identified 

as one barrier to its full implementation. The heavy workload for all providers in under-serviced areas was 

also identified as a major barrier to delivering primary health care. Additional physician concerns related 

to the negative repercussions of having nurses assume too much autonomy or independent function (i.e., 

greater potential for compromising continuity of care; decreased ability to recruit and retain physicians, 

especially fee-for-service physicians; and increased responsibility and legality issues). 



Nurse participants in the on-site data collection phase also identified some of the 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. A third theme related to the 

significant changes experienced in their practice with the changing supply of local physicians. 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. In areas with a greater concentration of physicians, especially 

those working under fee-for-service mechanisms, participants had restrictions imposed on their scope of 

practice and access to diagnostic services and other community resources. 

Both the nurse and physician participants mentioned the negative impact of current physician 

compensation schemes on effective integration and coordination of primary health care services. Resistance 

from fee-for-service physicians and specialists was highlighted by both nurses and physicians as a significant 

barrier to full-implementation of the extended/expanded nursing role in certain jurisdictions. Participants 

identified a number of reasons for this resistance: 1) fee-for-service physicians working in private practice 

cannot charge for consultation with a nurse in an extended/expanded role; 2) fee-for-service physicians can 

not hire extended/expanded role nurses because they are prevented from billing the compensation scheme 

for the services rendered to patients by this provider; and, 3) specialist physicians can not be compensated 

at specialty rates for services rendered when referrals are initiated by a nurse practising in the 

extended/expanded role. Without an adequate compensation package for physicians, successful integration 

of the extended/expanded nursing role is being severely compromised. 


It is recommended that collaborative practice arrangements between physicians and 

extended/expanded role nurses, along with other providers, be the norm for all practice settings. 



This type of approach will facilitate the effective use of all health care providers and ensure that 

the most comprehensive and integrated primary health care services of the highest quality are 

available to diverse population groups. 


It is also recommended that the necessary mechanisms be instituted in all provincial/territorial 

jurisdictions to ensure ongoing monitoring of the quality and comprehensiveness of primary health 

care services available to the public. 


It is recommended that alternative funding mechanisms for physicians be established. This will 

ensure that physicians are fairly compensated for collaborating with extended/expanded role 

nurses. 

5.0 Dissemination Plan 

The Centre for Nursing Studies will assume responsibility for dissemination of the research. The 

plan for dissemination is contained in SD4. 



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Supporting Document 1 (SD1) 

Profile of Extended/Expanded Nursing Practice in Canada 


Submitted to: 

F/P/T Advisory Committee on Health Human Resources 

March 30, 2001 






Introduction ...................................................................1 

1.0 Background to this Research Study ...........................................1 

2.0 Methodology ............................................................3 

3.0 Profile of Extended/Expanded Nursing Practice ..................................4 

3.1 Policy Framework ..................................................5 

3.2 Legislative Framework ...............................................7 

3.3 Key Elements of Extended/Expanded Nursing Practice ......................17 

3.4 On-Site Data Collection - Criteria for Site Selection ........................26 

4.0 Organizational Structure by Jurisdiction .......................................26 

5.0 Conclusions and Implications ...............................................38 

APPENDIX A: 

APPENDIX B-1: 

APPENDIX B-2: 

APPENDIX C-1: 

APPENDIX C-2: 

APPENDIX D: 

APPENDIX E: 

APPENDIX F: 

Interview Protocol - Legal Role and Regulation of Nursing in Primary Health Care 

Settings 

Legal Definition of Nurse / Nursing 

Definition of Extended Certificate of Registration/Nurse Practitioner Canadian 

Jurisdictions 

Interview Protocol - Association’s Views : Nursing Practice in 

Extended/Expanded Roles 

Interview Protocol - Regulation of Nursing in Extended/Expanded Roles 

Background information by jurisdiction 

Administration Survey Instrument 

Summary of Survey Data: Agency Administrative Personnel

Profile of the Extended/Expanded Nursing Role in Canada 

Introduction 

This background paper supports the data presented in the report “The Nature of the 

Extended/Expanded Nursing Role in Canada” presented to the Federal/Provincial/Territorial Advisory 

Committee on Health Human Resources (ACHHR). The research project is funded under the primary care 

component of the Health Transition Fund of Health Canada. 

The purposes of this paper are: 

< To provide an overview of the status of legislative frameworks governing nursing practice across 

Canada, and more specifically, for the extended/expanded nursing role in primary care in primary 

health care settings; 

< To summarize the definitions employed in Canadian legislation that describe the role of nursing 

involved in assessment, diagnosis and treatment; and 

< To provide a profile of extended/expanded nursing practice currently operant in Canada. 

The elements of the profile of nursing practice were identified in the terms of reference for this 

research study by the ACHHR. For the purposes of this document, the registered nurse practising in the 

extended/expanded role is referred to as “ nurse” unless otherwise indicated. 

1.0 Background to this Research Study 

The nursing profession is experiencing significant pressures from a number of fronts. There is a 

shortage of nurses available to the health care system at a time when skilled professionals are in demand. 

Further, the nursing profession is attempting to define the boundaries/parameters of its practice and, most 

importantly, struggling to ensure that its practitioners are providing care that is supported by sound research. 

Finally, there is a general desire by the profession to ensure that its members receive recognition for and 

Centre for Nursing Studies in collaboration with 

The Institute for the Advancement of Public Policy 1


legitimization of the true extent of the roles and functions assumed by nurses often carried out under 

delegation from medical and other professional disciplines. This is particularly the case with respect to 

northern, rural and remote areas where physicians and pharmacists are often in short supply and nurses are 

the only health care provider on-site to serve the residents. 

There is a growing view among nurses that particular functions could, and should, be included within 

the scope of nursing practice and not be seen as functions delegated from medicine or pharmacy. This 

position has and will continue to have far reaching implications for the regulatory regimes for nursing and 

those of other health professions. This is a view held that sees delegation of function as a method of control 

for a given profession over another. Further, questions have been raised as to whether it is the best method 

to provide competent health care to the public. 

There have been numerous demonstration and pilot projects undertaken throughout Canada which 

have shown that nurses are capable of performing primary care roles effectively and efficiently in diverse 

settings. These projects usually have been legitimized through working relations with other health 

professionals by way of protocols, primarily with physicians, which allow nurses to undertake specific 

additional functions. Meanwhile, there is considerable frustration due to the lack of funding to support these 

initiatives on an ongoing basis. 

At a time when the profession is evolving, important issues are being raised concerning nursing roles 

that are guided by nursing competencies. Where nurses are practising beyond the generally accepted 

traditional scope of nursing practice, i.e. through delegation of function, concerns respecting public protection 

arise. Additional regulation to incorporate those functions into nursing practice may be advisable. 

This evaluation is being undertaken at a time when extended/expanded nursing functions are in 

various stages of being legitimized through legislation in some provinces or territories. There is a state of flux 

existing within the nursing profession on this and related matters. There are significant external factors that 

are having an impact on the nursing profession and its ability to undertake new directions. Thus this paper is 




intended to present a profile of the policy and legislative frameworks and the organizational structure of 

nursing practice associated with extended/expanded practice roles. 

2.0 Methodology 

The information in this report was gathered from a variety of sources: 

< legislation related to nursing practice in provincial/territorial jurisdictions and through 

Legislative Counsel and/or solicitors associated with the Ministry of Health in respective 

jurisdictions; 

< consultants from provincial/territorial nursing associations and/or the Ministries of Health in 

each jurisdiction(contact could not be established with Nunavut); and 

< key informants (e.g. administrators/managers, nurse practitioners, etc.) affiliated with 

organizations/agencies that hire nurses to work in extended/expanded practice roles. 

The starting point was the legislative regimes for the regulation of nursing as a profession. These 

range from statutes passed in the early part of the century to recent enactments. The more recent regimes 

reflect the significant shifts that have occurred in the field of regulating occupations and, more importantly 

for the purposes of this paper, the evolution of nursing practice. 

The definition of ‘nurse’ in statute law is instructive as it varies by jurisdiction. The definitions of 

‘nurse’ or ‘nursing practice’ assist in setting parameters around the activities undertaken by members of the 

profession. Though some statutes are dated, the definition may prove to be broad enough to contemplate the 

inclusion within the scope of practice of nursing extended/expanded roles in same statutes. The term may 

not be defined but be inferred by reference to the definition of the ‘practice of nursing’. See Appendix B-1 

for the specific provisions governing nursing or the practice of nursing by province and territory. 

The general statutory provisions are broadened by more specific provisions to determine the extent 

of the authorities and responsibilities of nurses in extended/expanded roles. A key component of primary 




care, that of assessment, diagnosis and treatment may be absent in the definition of nursing but be included 

in regulations made under the statute. Appendix B-2 highlights the provisions in statutes or regulations 

which extend authority for extended/expanded practice in the three jurisdictions with these authorities in effect 

and in Manitoba where the legislation has not been proclaimed. 

The focus of the data collection was on identifying relevant information to assist the consultant team 

in constructing a profile of nursing practice models in primary health care settings. The interview schedules 

used to guide data collection during the telephone surveys are presented in Appendix C-1 and Appendix 

C-2. The data gathered from these information sources are summarized by jurisdiction in Appendix D. 

The discussion that follows presents a general sense of the status of extended/expanded nursing 

practice across Canada. A cross Canada survey of administrators in 44 practice settings was conducted in 

November 1999 using the interview protocol contained in Appendix E. It is supported by tabular summation 

of key aspects of the data collected from legislative, regulatory, and organizational information sources; refer 

to Appendix F. 

The reader is reminded that this study is restricted to a consideration of practice models where the 

primary care functions of assessment, treatment and diagnosis of episodic, acute and chronic illness and injury 

are performed by registered nurses in primary health care settings. Although this narrows the focus of the 

evaluation, it does not suggest that the other components (e.g., health promotion, illness prevention, etc.) of 

primary health care are not of equal significance to the delivery of quality health care. 

3.0 Profile of Extended/Expanded Nursing Practice 

During the initial stage of developing profiles of registered nursing practice models in Canada relating 

to primary care in primary health care settings, it became evident that there are significant differences among 

the provinces and territories with respect to approaches to the delivery of nursing services. Although there 

are a number of possible explanations for these disparate conditions, one key influencing factor is the 

environment in which the profession is operating under in each jurisdiction. 




In order to develop a profile of registered nursing primary care practices in primary health care 

settings, it is necessary to state the assumption underlying the profile, and to identify the factors used in the 

development of the profile. Upon completion of the profile, this information was used to assist with the 

selection of sites deemed most appropriate for in-depth research to contribute to an assessment of nursing 

practice models in primary health care settings. 

Several key factors were identified across jurisdictions which provide an overview of the legislation, 

policy and standards guiding the various nursing practice models operant in Canada today. 

These factors are: 

< Policy Framework 

< Legal Authority 

< Title 

< Scope of Practice 

< Education Programs 

< Organizational Structure 

There is an inconsistency in the approaches taken across the provinces and territories with regard 

to the types of extended/expanded practice models in operation. This is not surprising as each jurisdiction 

is responsible for the regulation of nursing within its boundaries and each province or territory must respond 

to differing needs and circumstances. The factors forming the profile help to highlight the broad parameters 

of the practice models. 

3.1 Policy Framework 

Public policy refers to decisions or directions undertaken by government that are intended to benefit 

or protect the public interest. Associated with these decisions are allocations of resources to support the 

implementation of the underlying policy objective. To consider various nursing models, and more particularly 




the functions under consideration in this research, they must be considered in the context of public policy and 

how the goals of public policy relate to the extension/expansion of nursing roles. 

When a public policy issue arises, there are many options that can be considered. Government may 

decide to do nothing if intervention is not seen as appropriate or required to protect the public interest. On 

the other hand, government may decide to intervene, for example, by the introduction of legislation. It depends 

on the nature of the issue and the circumstances that determine the action by government. 

The functions under consideration of this study, namely assessment, diagnosis and treatment of acute, 

episodic chronic illness or injury, have traditionally been delegated by government exclusively to the medical 

profession. For the purposes of this paper, these functions are described as functions of primary care. In 

certain circumstances, these been delegated to nurses to respond to the need for primary care services 

particularly where there is an inadequate supply of physicians to provide these services. In this case, the nurse 

must undertake special preparation before performing these functions. Nurses in these roles have extended 

or expanded their practice into the these areas of medical practice. 

Some Canadian jurisdictions prefer to rely on the delegation of medical functions through protocol 

arrangements between licensing bodies, employers and sometimes government to provide authorities for 

nurses to perform primary care. The protocol arrangements do not transfer the authority to all nurses to 

engage in the activity, only those who are subject to the arrangement. Nurses have to be educated to 

undertake the functions transferred. In order to perform the role there is a requirement to access resources 

of the health care system such as ordering diagnostic tests, prescribing medications and/or referring to other 

heath care providers. Some protocols permit the nurse to access resources that are not otherwise available 

to them, e.g., authority to order tests at the employing hospital. 

In recent years these have been delegated to nurses in some through specific legislation. This 

intervention essentially expands the scope of practice of nursing, but only for those who qualify to practise 

in extended/expanded role. 




Thus the policy context of this study is the policy direction of the provincial and territorial governments 

have authorized nurses to primary care services. Either it has been delegated to the medical profession which 

in turn has delegated certain functions to nurses within limits. Alternately, if has been through the enactment 

of specific legislation extending authority, within defined limits, to nurses to undertake these functions. 

In under serviced areas, like the north, physician shortages mean greater reliance on nurses for 

primary care delivery. The Medical Services Branch (MSB)of Health Canada guidelines deal, in part, with 

functions undertaken which lie outside the traditional scope of registered nursing practice. Although this is 

a situation of long standing, present day concerns about jurisdictional autonomy, legality, responsibility and 

accountability are being expressed more frequently by various nurses’ associations. 

There are provinces/territories contemplating legislative intervention; others have no plans to do so. 

There are implications for either decision for the nursing profession. There is evidence of a movement toward 

uniformity and consistency in the policy positions related to extended/expanded practice which is driven in 

part by national agreements and also by the efforts of the Canadian Nurses Association. While the broader 

implications for the nursing profession are beyond the scope of this research, the issues must be highlighted 

from a public policy perspective. 

3.2 Legislative Framework 1 

Under the Canadian constitution, the regulation of occupations such as medicine and nursing is the 

responsibility of each province and territory. Through the passage of legislation, professions have been 

extended authorities of self-regulation. All jurisdictions with Canada have delegated authorities of selfregulation 

to the nursing profession. 

There are three provinces that have recognized, through legislation, the extended functions of 

registered nurses - Ontario, Alberta and Newfoundland. In these jurisdictions, there is a specific class or 

certification process undertaken that gives registered nurses the privilege to practise in the 

1 

Information confirmed by the Nursing Association and Ministries of Health as of August 2000. 




extended/expanded roles. Manitoba has enacted legislation but it is not yet proclaimed. In these jurisdictions, 

practitioners who are prepared through additional education and those who are deemed competent to deliver 

these services to the public are authorized by the regulatory body to do so. Yukon has legislation sufficiently 

encompassing to accommodate a broad scope of practice when combined with the adoption of the Medical 

Services Guidelines. 

The circumstances of each jurisdiction will be considered from the policy and legislative frameworks 

currently in place. 

The legislative frameworks can be classified as broadly falling into one of several regimes: 

< Specific reference of extended/expanded scope of practice under nursing legislation; 

< Regulation of nursing practice, including nursing practice in extended/expanded roles, under 

delegated authority of a Medical Act; or 

< Nursing practice within the scope of nursing practice in nursing legislation that does not contemplate 

extended/expanded roles; 

< Jurisdictions in which the situation is not so well defined or clear. These range from: 

• a jurisdiction being required to revise the legislative framework to accommodate modern 

views of nursing practice; 

• a jurisdiction being positioned to avail of extended practice when conditions indicate that it 

is acceptable to proceed; 

• a jurisdiction which has enacted legislation which has yet to be proclaimed; 

• a jurisdiction which has sufficiently encompassing legislative provisions to accommodate 

growth in the areas of extended/expanded practice. 

These regimes will be addressed in turn. 




Specific Authorities for Extended/Expanded Nursing Practice in Legislation by Jurisdiction 

Three jurisdictions that specifically accommodate extended/expanded nursing practice through 

legislation, namely Alberta, Ontario and Newfoundland. This regulation is related to nursing practice in 

primary care settings and namely for the purposes of this study the functions of assessment, diagnosis and 

treatment of episodic, acute and chronic illness or injury. Each province has addressed the situation slightly 

differently in response to the sensitivities in its respective jurisdiction. 

Alberta 

The provision of extended health services is provided for through an amendment to the Public 

Health Act (1996) and accompanying regulations. A companion regulation under the Nursing Profession 

Act is titled: “Nursing Profession Extended Practice Roster Regulation”. This regulation was enacted in 

February1999 to set out a specialty roster for those registered nurses who require additional regulatory 

authority enabling them to diagnose and treat common disorders of adults and children, and to refer and 

provide emergency treatment as is appropriate. Specific requirements must be met in terms of education and 

experience to be eligible for the roster. 

The regulations are intended to provide the basis for the continuing development of extended practice 

initiatives in the province. In the regulations, “extended practice” is defined as “the practice of a registered 

nurse that is authorized under an enactment and has been recommended by the Registration Committee as 

extended practice and approved by the Council”. In 1998, a regulation was made under the Pharmaceutical 

Profession Act to enable registered nurses to prescribe drugs if they are permitted to do so under the Public 

Health Act regulations. 

Currently, Alberta is making use of extended practice nurses in some community health centres 

where their practice is the complete responsibility of the governing body of the centre. They can only be 

employed by the Department of Health, a regional health authority or a regional health board. 




Ontario 

Under the Regulated Health Professions Act, Ontario has relatively well-defined scopes of practice 

for each profession because the functions of practice or “controlled acts ” for each profession are defined. 

This method of operation does not prevent the possibility of overlap between professions. “Authorized acts” 

as identified in the Nursing Act, can only be performed when permitted by regulation or when ordered by 

a physician, midwife, dentist, chiropodist or RN (EC). 

Ontario has created an extended class certificate of registration by way of an amending statute under 

the Nursing Act for those who practice in primary care as a “Nurse Practitioner”. This statute, known as 

Expanded Nursing Services for Patients Act, was enacted in 1997. It defines the scope of the role of the 

nurse practising in the extended class. 

including: 

Generally speaking, the registered nurses in the extended class RN (EC) have additional authorities 

< communicating a diagnosis of a disease or disorder; 

< ordering the application of a form of energy as prescribed in the regulations under the Act, 

< prescribing and administration of medications within a Schedule of medications; and 

< administering, by injection or inhalation, a drug that may be prescribed under the Schedule of 

medications. 

These authorities are subject to terms and conditions identified in regulation. The Standards of 

Practice for RN (EC)s clearly identify expectations for consultation with members of other professions. 

Related professional statues were amended to accommodate the extension of the authorities to nurses 

practising in the extended class. 




Newfoundland and Labrador 

The Newfoundland Nurse Practitioner - Primary Health Care Regulations are prescribed under 

the Registered Nurses Act. The regulations have created a regime extending similar authorities as the 

Ontario regime, that is, the ability to assess, diagnose and treat emergent, urgent and non-urgent illnesses and 

injuries as per the approved schedules. This includes the ordering of diagnostic tests and prescribing of drugs 

as per approved schedules. The statute also specifically protects the title “nurse practitioner” or “NP”. This 

is the only jurisdiction in the country which does so. 

As with any new regime or program, there are issues identified through experience that require 

attention. For example, there is a requirement to consult with a physician in circumstances defined in the 

regulations, such as when chronic illness or injury destabilizes. There have been concerns raised by the 

Newfoundland Medical Association respecting the potential liability of physicians arising from the overall 

responsibility of physicians. This seems to have been settled for the moment. 

Complicating the issue of liability are the policies governing physician compensation in the Province. 

The policies allow payment for fee-for-service for “consultation” defined as physician consulting with a 

physician, not a nurse practitioner. Thus there are circumstances where a physician may not be paid for 

services rendered. This situation is recognized by the Department of Health and Community Services and 

proposals to alter the compensation scheme are under consideration. 

There are other issues which are under review that may require amendment to existing statutes 

and/or additional access to health care resources by Nurse Practitioners. 

Manitoba - enacted by not yet proclaimed 

Manitoba has nurses practising in extended/expanded roles under the authority of delegated medical 

function. The province has taken the step to prepare and pass new legislation (The Registered Nurses Act, 

SM 1999, Chapter36). This Act, once proclaimed, will specifically permit nurses who have fulfilled regulatory 




requirements to perform “included practices”. The included practices cover ordering and receiving reports 

of screening and diagnostic tests designated in the regulations, prescribing drugs designated in the regulations 

and, performing minor surgical and invasive procedures designated in the regulations (sect. 2(2)). No 

specific title relative to extended/expanded nursing role practice is protected in the new legislation. 

Other frameworks 

Yukon 

The statutory framework of the Yukon , while not specifically referencing extended/expanded 

practice, was crafted to permit a wide scope of practice for registered nurses which may include 

extended/expanded practices for which nurses have satisfied required competencies. The Registered 

Nurses Profession Act was enacted in 1992. The completion of the transfer of all health services and 

administration formerly provided by the Medical Services Branch (MSB) of Health Canada to the 

Government of Yukon was accomplished in 1997. Yukon adopted the MSB scope of practice guidelines to 

guide nursing practice in community health facilities. The legislative framework for nursing in Yukon is 

sufficiently open to accommodate the growth of extended/expanded nursing practice within the existing 

provisions. Some extended/expanded functions may require additional regulatory provisions. 

Nova Scotia 

The definition of “ nursing ” in the Registered Nurses Act does not include medical diagnosis within 

the scope of nursing practice. Physicians have the sole authority to diagnose under the Medical Act. In the 

Medical Act there is authority to create regulations enabling the delegation of functions. Delegation of the 

function of diagnosis to nurses is as determined by regulations issued under the authority of the Medical Act. 

Through guidelines negotiated between the Nova Scotia College of Physicians and the Nova Scotia 

Association of Registered Nurses, an expanded/extended role/nurse practitioner position was introduced for 

tertiary care settings. The guidelines provide for certain authorities to be delegated from physicians to 




facilitate the expansion of the nursing functions for registered nurses with additional educational preparation 

at the graduate level. These delegated functions are to be exercised within defined parameters, e.g. a 

prescription can be written by an expanded role nurse/acute care nurse practitioner but a physician must cosign 

the prescription within 12 hours. 

Similar guidelines have been negotiated for use in a demonstration project funded by the Health 

Transition Fund where there will be four (4) sites with nurses practising in extended/expanded roles primary 

care roles. Recent amendments to the Pharmacy Act will facilitate nurse practitioners to prescribe medication 

from a list to be designated by regulation. 

New Brunswick 

New Brunswick has no specific provision for extended practice in its Nurses Act 1984. However, 

the definition of nursing is broad enough to include diagnosis and treatment. There is a delegation process 

whereby medical functions can be delegated to nurses. Protocols are used to accomplish this delegation. 

There has been relative success in expanding the nurses’ role given the limitations of pilot projects 

and the lack of legitimization of the role through legislative means. A model based on the delegation of 

medical functions used initially in a pilot project at Mc Adam will be replicated in 8 other health centres in 

Region 3 under the jurisdiction of the Board concerned. An effort by the Department of Health and Wellness 

to introduce a similar model in three other rural health settings has met with limited success to date. 

Explanations of the extent of progress vary by site. 

These projects are concerned with those functions of assessment, diagnosis and treatment of 

common, minor, acute illness or injury and ongoing management of uncomplicated chronic illness. These 

functions traditionally lie in the scope of medical practice. From the perspective of the nursing association 

in New Brunswick, these functions can be accommodated under the Nurses Act. They are exercised by 

nurses, through delegation by way of protocol. Plans for the introduction of expanded nursing functions have 

been suspended subsequent to a change in government. 




Saskatchewan 

Saskatchewan’s operative statute, The Registered Nurses Act, 1988, does not refer to ‘advanced 

or extended’ practice or to ‘nurse practitioners’ though the statute is structured in such as way that it is 

viewed as broad enough to provide authority for nurses to undertake extended/expanded roles. Under the 

legislation there is provision for “special categories ” none of which have been used by the Association. The 

extended/expanded role is carried out under the authority of delegation of medical functions embodied in a 

province-wide protocol. Site specific protocols may be enacted to recognize the particular needs of a health 

care setting. Currently there are discussions ongoing between the Ministry and the Association to ensure 

nurses are adequately protected from the perspective of legal liability. 

Saskatchewan is undertaking a primary health care reform initiative that favours a collaborative model 

of service delivery. There are several pilot projects operating in the Province that are using integrated teams. 

To date there has been good response from the public to the demonstration projects. 

The SRNA is monitoring initiatives throughout the country. These developments may affect 

Saskatchewan’s future direction with respect to the enhancement of extended/expanded practice. There is 

no intention to introduce legislation at this point in time. 


NWT does not provide for extended or advanced practice in its statute or regulations. Nursing 

services provided by Health Canada were transferred to the authority of Northwest Territories Government 

in April, 1988. The nurses previously employed by Health Canada are now employees of the territorial 

government. The Northwest Territories Registered Nurses Association (NWTRNA) has regulatory 

authority over nursing in the territory. 

The NWTRNA has been lobbying for legislative changes and is actively involved in establishing 

competencies for primary health care nurse practitioners in the jurisdiction. 




Nunavut 

As Nunavut is so recently formed, the Northwest Territories Registered Nurses Association 

(NWTRNA) has been given the legislative authority for the registration, licensure and discipline of nurses in 

the new territory until a Nunavut association is fully formed and operational. Officials with NWTRNA said 

that nurses in Nunavut continue to provide expanded services throughout the new territory in the same way 

as when they were still a part of NWT, that is, by delegation of medical functions. As the governing body for 

two territories, the NWTRNA does not feel it necessary to separate issues relating to nursing according to 

the specific territory as the issues are similar in both territories. 


British Columbia does not have any specific regulation or statutory reference to ‘extended practice’ 

for nurses. There are several projects and services that have been identified as providing extended/expanded 

functions. The nurses derive authority under either delegated medical functions or, if the setting is under 

federal jurisdiction, the Medical Services Branch guidelines 

British Columbia is in a state of transition with respect to all health professions as, under the Health 

Professions Act, the Health Professions Council is charged with the responsibility to review all health 

professions and provide a statutory scope of practice which includes ‘reserved acts’. This approach is much 

like that which has been implemented in Ontario. The Health Professions Council (HPC) held public hearings 

on June12 and 13, 2000 to accept submissions based upon its recommendations concerning the practice of 

nursing and the RNABC’s response to the HPC initial recommendations. 

Quebec 

The nursing profession in Quebec is governed by the Nurses Act which does not recognize extended/ 

expanded practice. As in Nova Scotia, the Medical Act outlines the acts which may be performed by 

medical doctors and there is regulatory power to delegate medical functions. The function of diagnosis is 




reserved exclusively for physicians. There has been little development to enable nurses to share this or other 

functions. The Order of Nurses is working toward proposing legislative amendments to update the scope of 

practice of nursing. 

The Association is developing a position paper on advanced nursing practice (not the subject of this 

research) which is due for public release for purposes of consultation. As well, a Commission of Inquiry on 

health services and social services has commenced work in the Province. The goal of the commission is to 

present recommendations for revision to the health care system. There have been three consultation 

documents released for public discussion: 

< The Health of Quebecers: a few indicators; 

< Funding: current situation and outlook; 

< Organization of services: current situation and outlook. 

The Association will be providing its view to the Commission. 


Prince Edward Island. has no provision for extended/expanded practice in its legislation governing 

nurses. There are no nurses currently involved in extended practice hence there has been no regulation of 

such a class. The original Nurses Act (1974) regime was revised in 1988 but remains dated in its provisions. 

The PEI Nurses Association has indicated that the statute may be considered for revision in the near future. 

Summary 

The policy framework for practice of the extended/expanded nursing role is inconsistent across 

Canada. While it is understandable that variances will be present to reflect the unique circumstances in a 

jurisdiction this does raise issues for consideration. Governments and nursing associations are aware of 




< the need to ensure the public is protected through appropriate regulation; and 

< the need to legitimize extended/expanded nursing practice and that practitioners are able to practice 

an within authorized scope of practice. 

Governments are being challenged by the pressures in the environment to maximize human health 

resources. Allocation of resources to facilitate the execution of the extended/ expanded nursing practice role 

may require amendments to legislative provisions of related statutes. The legitimization of this role through 

legislation presents an opportunity to achieve this goal. 

3.3 Key Elements of Extended/Expanded Nursing Practice 

This section of the report will address the general legal authority extended to nursing generally. The 

key issues of title, scope of practice and educational programs will be addressed by jurisdiction 

whether under the authority of delegation of medical functions or specific legislation. 2 

< Title 

The nurses performing the functions under consideration in this study do not have a consistent title 

across all jurisdictions. At the present time in Canada, the title “nurse practitioner” is protected legislatively 

in only one jurisdiction, namely that of Newfoundland and Labrador. In both Alberta and Ontario, nurses 

performing the functions of assessment, diagnosis and treatment of episodic, acute and chronic illness and 

injury, are registered in a class specifically requiring additional regulation. These nurses are thereby entitled 

to use the designation, RN - EC in Ontario to indicate licensing in the Extended Class, or RN - EP in Alberta 

as nurses licenced in the expanded practice category. 

2 

Information as of August 2000 




The following is a summary of the titles in use by jurisdiction across Canada. This not an all inclusive 

list as there are nurses practising in roles with job titles that vary by employer. 

Table 1 - Titles for Registered Nurses in Extended/Expanded Roles by Jurisdiction 

Jurisdiction 


Alberta 

Saskatchewan 

Manitoba 

Ontario 

Quebec 

New Brunswick 


Nova Scotia 


Yukon 


& Nunavut 

Title 

Registered Nurse (RN). Unofficial use of the title Nurse 

Practitioner (NP) in Community Health Centers. 

RN - EP (Expanded Practice) officially, but usually called 

Community Nurse Practitioners. 

No fixed titles. Referred to as Primary Care Nurses in 

protocols. 

No title regulated or sanctioned by MARN at this time. 

Employers may choose to use a specific job description title. 

RN- EC (Extended Class) and other titles, such as Nurse 

Practitioner, used by employing organizations. 

RN (infirmiere/infirmier). 

No separate title; referred to as RN. 

Not applicable; no RNs practicing in the extended/expanded 

role 

Primary Care Nurse Practitioner. 

NP and Regional Nurse. 


Community Health Nurse but also referred to as Primary 

Health Care Nurse Practitioner. 

Source: Associations of Registered Nurses and Ministries of Health in the respective jurisdictions as of August 2000. 

There is reference to nurse practitioner in the literature, however, there is considerable debate as to 

whether titles such as nurse practitioner should be used at all. It is apparent both from the literature and the 




interviews conducted for this study that without unanimity of acceptance of such titles, their use could do 

more to divide rather than unite the profession. It is argued by some that new descriptions are redundant as 

all nurses are practitioners of nursing. Thus the title is susceptible to constant interpretation which may 

reduce its usefulness as a formalized term. Notwithstanding the objections, other sources that favour the title 

view the term ‘nurse practitioner’ as imparting a general understanding of a professional who is a registered 

nurse but performs certain functions that are comparable to those of physicians. This also begs the question 

if the functions performed by these nurses are similar by jurisdiction and whether the skills are comparable 

across the country. 

Although the title of nurse practitioner is not usually protected, it appears to be in common usage. 

In Ontario, the nurses registered in the extended class are called nurse practitioners and have a similarly 

named division of the nursing association representing their interests. The research team has been advised 

that the term nurse practitioner, although not recognized in legislation, is often used to refer to nurses 

employed in roles in rural and remote areas, and more recently in specialty areas such as acute and long-term 

care. Thus it is not necessarily the legislated titles that will assist in identifying primary care functions. 

Employers may label nurses who perform these functions in any number of ways such as community nurse 

practitioner, regional nurse, or outpost nurse. There is a question as to the similarity of functions performed 

by these nurses and whether there is one title that is sufficient in describing all the aspects of the role. 

The Canadian Nursing Association’s view is that the crucial concern must be the characteristics of 

the practice role and the competencies required to undertake the role. The title and credentials are not the 

material issue; rather, it is the characteristics of the role a registered nurse undertakes, whether within the 

existing scope of nursing practice or if delegated thus specifically regulated, that determine if one is practising 

in a nursing role in need for additional regulation. The competencies required to undertake such roles are 

currently under consideration by the Canadian Nurses Association. Indications are that the provincial nursing 

associations are supportive of this approach. 

There is a dichotomy regarding the title used to describe nurses in extended/expanded practice roles. 

On one hand, reportedly there is public recognition of the fact that there is a difference between a registered 




nurse and a nurse who practices in an extended/expanded role. On the other hand, there is an effort by the 

Canadian Nurses Association to eliminate or lessen the proliferation of titles which is seen as divisive among 

nurses. Preference appears to be for the use of the common designate “registered nurse” with specific 

designations added as deemed appropriate by the licensing body. 

< Scope of Practice 

The degree to which the statutory and regulatory provisions for nursing have been modernized or 

recently amended is often a mark of the degree to which scopes of practice are definitively dealt with by a 

province or territory. The older the statute and accompanying regulations, the more likely it is that the scope 

of practice for nursing will be relatively vague, as in Prince Edward Island. Comparatively, with more modern 

legislative regimes that reserve specific functions or acts to a profession, as is the case in Ontario, the lines 

are more definitive between the profession and others. The discrepancies among the different jurisdictions’ 

scopes of practice of nursing are becoming more obvious. Across Canada, in provinces without special 

legislative authorities outlining the parameters of the extended/expanded nursing practice role, there is an 

absence of consistency in the scopes of practice. This arises from the variations in the delegation of medical 

functions by way of protocol arrangements designed to respond to particular circumstances. 

The table below summaries the scope of practice by jurisdiction. 




Table 2 - Summary of Scope of Practice by jurisdiction 

Jurisdiction 

British 

Columbia 

Alberta 

Saskatchewan 

Manitoba 

Ontario 

Quebec 

New Brunswick 

Prince Edward 

Island 

Nova Scotia 

Newfoundland 

& Labrador 

Yukon 

Scope of Practice 

Extended/expanded practice is undertaken by delegated acts which are 

established by working arrangements according to location, organization and 

training. RNABC has guidelines for Delegated Medical Functions. 

The Extended Practice Roster Regulation governs registered nurses in 

extended/expanded roles. AARN has developed competencies and guidelines to 

govern nurses providing “extended health services”. 

Scope of practice is defined by the province-wide clinical practice guidelines but 

subject to site modifications. 

Under the new legislation, regulations will be developed for required 

competencies in extended/expanded nursing practice. MARN has established 

standards of practice which apply to all practicing registered nurses in the 

province regardless of their roles or practice settings. 

Legislated scope of practice is relative to primary care functions only. These 

controlled acts are to be performed by RNs with an extended class designation. 

Delegated medical functions are not necessarily supported by protocols. Concerns 

have been raised by nurses about situations where they could be exposed to 

liability and have no protection. 

Site specific protocols govern the delegation of function. 

Not applicable at present. However, if there were a movement to introduce 

extended/expanded nursing roles, the nursing association would establish 

guidelines for core competencies in accordance with CNA guidelines. 

Scope of practice is defined by delegation of medical functions under guidelines 

negotiated between the College of Physicians and Surgeons of NS and RNANS. 

The ARNNL approves standards of practice and competencies for NP- PHC. 

Employers have adopted the MSB Scope of Practice Guidelines for Community 

Health Nurses, Nursing Stations and Health Care Treatment facilities. 

Northwest 

Territories 

& Nunavut 

All extended/expanded practice is under the authority of protocols with the 

medical profession and employer organizations. 

Source: Associations of Registered Nurses and/or the Ministry of Health in the respective jurisdiction August 2000. 




The Medical Services Branch scope of practice guidelines seem to be applied wherever the MSB 

serves although, in some instances, nursing services provided by the Branch have been transferred to 

provincial and territorial authorities. The difficulty that can arise is that the scope of practice for nurses 

practising in northern, rural and remote areas is apparently used in other areas whether under-serviced or not. 

The consulting team has been apprised of concerns of the licensing bodies as these nurses may be operating 

outside their legislated scope of practice. 

The scopes of practice for nursing vary reflecting the age of the statutes and the relative complexity 

of the regulation of professions within the jurisdiction or if the nurse is practising in a remote area, as in the 

north. There are developments occurring within the profession such that expanded/expanded roles are 

becoming recognized within more modern legislative regimes. 

< Education Preparation 

Educational preparation with respect to extended/expanded nursing practice is divergent across 

Canada and educational preparation required by employers of primary care nurses varies. Generally, nurses 

working in rural and remote settings are not required to have completed a formal education program specific 

to the primary care role. Employers tend to provide focussed, role-specific, and short duration orientation 

programs, as well as requiring nurses to have recent experience. In urban areas, employers tend to require, 

minimally, baccalaureate preparation in nursing with experience. Not uncommonly, employers require a 

Masters degree in nursing preparation with experience. 

In the three provinces with legislation in effect, regulations specify the educational preparation 

required to assess, diagnose and treat episodic, acute and chronic illness or injury. In those provinces or 

territories where formal education programs for this role are available, employers generally require the 

completion of a recognized program. Overall, however, the data indicate that the number of nurses practising 

in the extended role, with formal preparation, is low. This is likely linked to the limited, until recently, and 

inconsistent availability of formal education programs specific to the role. The following table summaries the 

educational requirements by jurisdiction. 




Table 3 - Education Programs for Extended/Expanded Nursing Roles in Primary Health Care 

Settings by Jurisdiction 

Jurisdiction 


Alberta 

Saskatchewan 

Manitoba 

Ontario 

Quebec 

New Brunswick 


Nova Scotia 


Yukon 

Education Program 

Educational qualifications are set by employing organization. 

BN or graduate degree required for entry and an Advanced Graduate Diploma in 

Community Health at Athabasca University. 

SRNA’s criteria for practice in extended/expanded roles is outlined in “The Registered 

Nurse Scope of Practice: Special Nursing Procedures and Nursing Procedures by 

Transfer of Medical Functions, 1993". The Advanced Clinical Nursing Program at 

Saskatchewan Institute of Applied Technology is the usual course of instruction. 

Standards for registration under the enacted, but not proclaimed, legislation, have not 

been determined. There is a Masters level program in Advanced Nursing Practice at the 

University of Manitoba. 

In 1994, the Council of Ontario University Programs in Nursing approved a program for 

RN - EC at 10 sites co-ordinated by McMaster University. Program graduation criteria 

includes: completion of a 24 month course by a diploma graduate to attain a Bachelor of 

Nursing and NP certificate; or a BN preparation plus completion of a 12 month course 

to attain a NP certificate. 

No specific courses identified. 

NANB has published a policy statement supporting education at the Masters level. UNB 

has introduced a nurse practitioner stream in its Master’s program. The nurses 

practising in the IT/SP projects were given additional educational preparation prior to 

entering the role. 

Not applicable at present. 

For demonstration projects, a NP certificate will be required from a recognized program, 

or a licence to practice as a primary care NP. 

RN diploma and at least 2 years practice for entry to Nurse Practitioner Program offered 

by Centre for Nursing Studies; graduation with NP Diploma. Regional nurses require 

an RN diploma plus employer in-service education. 

Employers accept a variety of education options. 

Northwest Territories & 

Nunavut 

Preference is for training at Aurora College in the Advanced Nursing Skills Education 

Program but this is not a fixed requirement. 

Sources: Associations of Registered Nurses and/or Ministry of Health in the respective 

jurisdiction as of August 2000. 




A review of Canadian schools of nursing web-sites revealed that while most offer Masters of Nursing 

or Health Sciences Programs with advanced practice courses, only five sites (University of Toronto, Council 

of Ontario University Programs in Nursing, Athabasca University, Dalhousie University, and the Centre for 

Nursing Studies) specifically indicate having nurse practitioner programs. (The nurse practitioner program 

at the University of Toronto prepares nurses at a graduate level for the role of acute care nurse practitioner 

not primary health care). The University of Manitoba, the Saskatchewan Institute of Science and 

Technology, and the University College of the Caribou offer courses to prepare nurses to assume select 

primary care functions. 

In the three jurisdictions that have legislated extended/expanded practice for nurses, that which is 

required for a registered nurse to attain the extended designation is explicitly stated: 

< Ontario, the Primary Health Care - RN (Extended Class) programs are in two streams. Nurses with 

diploma preparation take a two year course and, if successful, finish with a baccalaureate degree and 

an NP certificate whereas, those already holding a BN degree are only required to complete a one 

year nurse practitioner certificate program. 

< Newfoundland and Labrador - Nurse Practitioner- since 1997, registered nurses with diploma or 

baccalaureate preparation, as well as a minimum of two years experience in a direct care role, can 

enroll in a one year Nurse Practitioner - Primary Health Care Program. The ARNNL minimum 

education standard as outlined in its position statement on NP-PHC is a BN with a one year NP 

program that carries credit toward an MN degree. 

< Alberta - RN ( Expanded Practice) requires a Bachelor degree in Nursing, or equivalency, at least 

three years of practice as a Registered Nurse, and successful completion of an approved educational 

program in an area of extended practice. 

The eventual employers of nurses practising in extended/expanded roles in jurisdictions not yet 

regulated often dictate the content of the programs offered. Nurses practising in extended/expanded roles 




prescribe and dispense drugs, and therefore require the necessary knowledge to identify the appropriate drug 

for treatment. Educational programming for non-legislated practice of this nature has been sponsored by 

employers such as, Medical Services Branch, Health Canada, or Grenfell Regional Health Services, to 

prepare nurses for rural and remote locations within their jurisdictions. There have been other programs 

implemented to provide education and training for ‘outpost nursing’. The majority of these programs prepared 

nurses to practice in those areas specifically covered under the provincial/Medical Services Branch scope 

of practice guidelines. 

The Medical Services Branch has made a significant contribution to the education of nurses who 

undertake extended/expanded roles through the various programs sponsored across the country. From 

interviews conducted with nurses who have experience in the north, there seems to be a general satisfaction 

with the education programs, as well as the broader guidelines under which the nurses practice. Nurses who 

have relocated to less isolated settings commented that the scope of practice guidelines are narrower and 

relations with physicians are less open and more hierarchical. 

As extended/expanded practice for nurses gains credibility and acceptance throughout the country, 

the availability of formal education programs will likely increase as will requirements for admission to the 

class. Currently, the content and design of these programs, as well as the qualifications for admission to them, 

are not standardized. As the profession develops competencies which are national in scope, education 

programs will also become standardized. This is in keeping with the movement toward uniformity within a 

profession across the broad jurisdictional spectrum which is being imposed by the provisions and requirements 

of the Agreement on Internal Trade and other agreements. 

Summary 

It is evident that there is a lack of consistency across Canada in the approach to regulating the 

extended/expanded role of nursing - either it is by delegation of medical functions or through specific 

legislation. There does appear at this point to be agreement on one policy direction. Within the practice itself, 

there is a inconsistency in the use of titles, the scope of practice and the educational preparation expected of 




nurses before undertaking the role. These issues are to be addressed if the extended/expanded role is to 

utilized across Canada. 

3.4 On-Site Data Collection - Criteria for Site Selection 

From this review of the circumstances across Canada a profile of practice models emerged. As part 

of the terms of reference of the study, on-site data collection was to be undertaken to gain an appreciation 

of the extended/expanded nursing role in practice settings. The consulting team identified the criteria for 

possible selection of two or three sites for further research. These were: 

< urban, rural, or remote settings; 

< clientele - general population vs. special needs groups (e.g., women, students, aboriginal, homeless, 

low income and young families, at-risk elderly, etc.); 

< funding arrangement - physician fee-for-service, salary, capitation, direct to physician for funding 

nurse position in extended/expanded role; 

< nurse-managed or nurse-operated clinics vs. physician dominated clinics vs. collaborative practice 

between physicians and nurses; 

< authority by legislation vs. agreements vs. medical directives; and 

< ease of access to all resources by nurses vs. restricted access to resources by nurses. 

The project team was cognizant of the need to use a broad cross section of sites, embodying as many 

of the characteristics as possible, to gain an appreciation of the types of nursing practice models in operation 

across Canada. However, it was evident that further research was required to select the sites for data 

collection. Hence the team undertook a cross country scan of settings to apply the criteria to identify the 

sites. 

4.0 Organizational Structure by Jurisdiction 

One objective of this phase of the study was to describe the nature of nursing practice in primary 

health care settings within different Canadian jurisdictions. As specified by the project’s guidelines, the focus 




of this documentation was restricted to the primary care aspect of the nursing role (i.e., assessment, diagnosis 

and treatment of episodic, acute and chronic illness or injury). A second objective was to identify potential 

sites for more in-depth data collection. 

Data Collection - Phase I 

Initial contact was made with key personnel in the nursing associations in each jurisdiction, Ministries 

of Health, and regional health authorities. The persons contacted were asked to identify primary health care 

settings where nurses perform primary care functions, work under similar and different practice models, and 

have differing educational preparation requirements. Respondents provided an overview of the situation in 

each jurisdiction and identified specific sites that met the inclusion criteria for the project. 

Data Collection - Phase II 

During the second phase, a cross-country telephone survey was conducted with administrative 

personnel working in agencies/organizations which employ registered nurses to perform primary care 

functions. The interview schedule used during data collection is presented in E. 

Initial efforts focussed on contacting persons responsible for nursing services within each organization 

(e.g., CEO, executive director, vice-president, clinical co-ordinator, etc.). This proved to be very tedious and 

time consuming (i.e., identifying the appropriate person, leaving messages, returning calls, scheduling 

appointment times, or rearranging appointments). When contact was made with appropriate persons, each 

interview lasted about 30 minutes. 

Overview of Findings 

The data collected from the various provincial/territorial contacts are presented in tabular form in F. 

The findings suggest that there are significant variations within and between provinces/territories with regard 

to the type of practice models present in different settings. There are also notable differences across settings 

with regard to the degree with which nurses enact the primary care role. Although there are a number of 

possible explanations for these disparate conditions, one significant factor is the environmental context (e.g., 




legislative, regulatory, employing organization, nurse/physician relationships, etc.). A brief summary is 

presented of the information collected from identified contacts at different sites in each province/territory. 

• Atlantic Canada 

Newfoundland has had a long history of nurses working in extended/expanded roles in rural and 

remote settings. Currently, there are two title designations for this role - regional nurse and nurse practitioner 

(NP). While regional nurses function under a protocol agreement negotiated between the regulatory bodies 

of medicine and nursing and the employer (i.e., Association of Registered Nurses of Newfoundland and 

Labrador, Newfoundland Medical Association, Newfoundland Medical Board, and Grenfell Regional Health 

Services), the NP role is legitimized through the Newfoundland Nurse practitioner - Primary Health Care 

Regulations. 

The introduction of the Nurse Practitioner Primary Care Regulations coincided with the 

commencement of a program of study offered by the Centre for Nursing Studies, as well as the piloting of 

the Primary Health Care Enhancement Project in three rural communities. Many of the first and second 

classes of NP graduates were nurses who had been sponsored by employers from rural and urban areas. 

With the introduction of the NP regulations, regional nurses have not been automatically granted the NP 

designation. An accreditation process is currently being developed by the Association to determine eligibility 

for the new class. 

Information concerning regional nurse primary care practice was collected from administrative 

personnel at the head office and supervisory personal at a remote site. Regional nurses are expected to work 

autonomously, as well as collaboratively with physicians in community clinics and health care centres. They 

have access to a wide spectrum of resources, excluding hospital admitting privileges, and may initiate 

referrals. With regard to the health care centres located in rural areas, physicians are present on-site and 

regional nurses’ are expected to assume more of a collaborative practice, as opposed to autonomous, role. 

In fact, physicians are more involved in the actual supervision of nurses at these sites. The reverse is true 




in community clinics located in remote areas where nursing supervisors are present on-site and oversee 

nursing practice. The community clinics are nurse-managed with physicians making on-site visits about every 

8-weeks. As such, the primary care aspect of the role (i.e., assessment, diagnosis and treatment) is more 

extensive with physician input into decision-making mainly by telephone consultation. 

While the employing organization prefers that regional nurses have a bachelor of nursing degree and 

2 years of critical care experience, these conditions are not always met due to recruitment difficulties. The 

employer also provides an intensive 6-week orientation to new recruits to help refine required practical 

skills/abilities, and to strengthen communication relations with other providers. Regional nurses are also 

expected to participate in available continuing education activities and take courses toward a degree, when 

not completed. With regard to on-site strategies for monitoring competency levels, most respondents reported 

that there were monthly audits of nursing practice, caseloads and charts by nursing supervisors, as well as 

periodic chart reviews by physicians. None of the sites reported having conducted a formal evaluation of 

the impact of extended/expanded role nurses on health outcomes or service costs, but recognized the 

importance of undertaking such a venture. 

Contact was also made with administration in organizations which have NPs performing primary care 

functions in rural and remote areas. Two of the contact sites were on the Northern Peninsula (cottage 

hospital with medical clinics in several communities, and a health centre) and the other at one of the 

designated sites for the Primary Health Care Enhancement Project. The roles and responsibilities of NPs 

were very similar across the three sites, with full-enactment of the primary care role the norm. All of the 

NPs were graduates of a certified nurse practitioner program, had extensive experience working in rural 

health care, participated in continuing education activities on a regular basis, and were expected to work 

independent of and in collaboration with other health care providers. In most instances, the NPs carried 

independent caseloads, managed the total care in nurse-run clinics, consulted with physicians as required, 

initiated referrals, and accessed available community resources. With regard to on-site strategies for 

monitoring competency levels, most respondents reported that there were no specific measures for evaluating 

practice, with NPs answerable to nursing supervisors and/or physicians for their clinical work. Although all 




sites recognized the importance of conducting a formal evaluation to assess the impact of the 

extended/expanded nursing role on health outcomes and costs, a provincial evaluation was only being initiated 

at the site of the Primary Health Care Enhancement Project. 

Nova Scotia is about to embark upon a demonstration project, funded by the Health Transition Fund, 

which will introduce nurse practitioners into the health care system. When the cross-country telephone 

survey was conducted in the Fall of 1999, the pilot sites had not been selected for this project. 

Registered nurses do perform extended/expanded role functions in collaboration with physicians in 

tertiary care settings, but are not permitted to engage in autonomous practice. Legitimization of the expanded 

practice role is by delegated functions under the Medical Act. Nurses working in these roles are required 

to have completed or to be currently enrolled in a masters of nursing program, and have a minimum of 3 to 

5 years of clinical experience. With regard to continuing education, respondents noted that these nurses have 

access to teleconferences and physician mentors. Significantly, nurses working in these roles must be recertified 

annually to ensure acceptable competency levels with regard to the performance of delegated 

medical functions. The on-site strategies for monitoring competency levels included annual performance 

appraisals by nursing supervisors and periodic reviews by the Health Professions Liaison Committee. As 

well, there are a number of mechanisms in place for monitoring the impact of the role (e.g., cost 

effectiveness, patient satisfaction surveys, etc.). 

Prince Edward Island has limited experience with nursing roles outside traditional scopes of 

practice. There were no settings identified where nurses were performing primary care functions. 

New Brunswick initiated a pilot project, the MacAdam project, to coincide with the closure of a 

hospital that was replaced with a community health centre. Through regionalization of health services, the 

MacAdam Health Complex has 14 facilities under its jurisdiction. The program at the Complex empowered 

nurses to engage in expanded practice functions under protocols negotiated between the Complex, the 

regulatory bodies for nurses and physicians, and the Ministry of Health. Although basic RN preparation is 




required for access to the role, additional training is undertaken by the employer. A clinical nurse specialist 

is present on-site and provides or co-ordinates educational opportunities. However, the more isolated sites 

have restricted access to continuing education opportunities. With regard to on-site strategies for monitoring 

competency levels, respondents indicated that this was the responsibility of nursing supervisors and physicians. 

As well, one of the sites at a provincial evaluation completed three years after project start-up. The other 

site’s formal evaluation was restricted to a patient satisfaction survey. 

Nurses are not permitted to engage in autonomous practice with regard to primary care functions, 

but are expected to work collaboratively with and under the direction of physicians. Relative success has 

been achieved with expanding nurses’ roles in this setting, given the absence of role legitimization through 

legislation. The model used at MacAdam was intended to be replicated in 8 other centres. However, efforts 

by the Ministry to introduce similar models in three other rural settings has met with limited to no success. 

Plans for the introduction of expanded nursing functions in other areas have been delayed due to the change 

in government. 

• Quebec 

There are 146 community health centres in Quebec which offer primary health care services. These 

operate under multi-disciplinary teams of which nurses are members. Although nurses may participate in 

assessment and treatment activities, there is limited opportunity for involvement in diagnosis. Because the 

expanded/extended nursing role has not been authorized in legislation, it varies from site to site and is guided 

by setting-specific protocols. Furthermore, nurses in northern and remote locations seem to be performing 

functions outside the scope of their practice and without authority through protocols to do so. This has raised 

liability concerns among nurses who are now seeking protection. According to the Association, physicians 

are vigilantly protecting the function of diagnosis as exclusive to the medical profession. 




There are two hospitals located in Montreal which have nurses practising in extended/expanded roles. 

These are tertiary care settings, not primary health care settings, and therefore did not meet the criteria for 

the current study. 

• Ontario 

Ontario has the greatest number of nurses performing primary care functions (i.e., assessment, 

treatment and diagnosis of episodic, acute and chronic illnesses or injury). Similar to Newfoundland, nurses 

in extended/expanded roles, titled Registered Nurse - Extended Class (RN - EC), are governed by provincial 

legislation and the College of Nursing’s scope of practice guidelines. The community health centres (CHC) 

which are designated as non-profit entities were the primary focus of the consultant team’s efforts since these 

entities are the major employers of the RN- ECs in the Province. 

Of the 56 CHCs listed by the Ontario Ministry of Health and Long-Term Care on its web site, initial 

and follow-up calls were made to a random survey of 29 centres. In some instances, personnel at the sites 

indicated that the focus was health promotion not primary care. The response was relatively low despite 

several calls to other sites. The research team terminated its efforts following completion of interviews with 

11 management personnel at sites where primary care was a significant component of nurses’ 

extended/expanded roles. With regard to the 10 aboriginal centres located in Ontario and funded under the 

Aboriginal Healing and Wellness Strategy, representatives from 3 centres were interviewed. 

The final sample reflected a cross-section of settings located in remote, rural and urban settings (i.e., 

7 urban, 4 rural only, 2 remote only, and 1 rural & remote). Nurses in the extended/expanded role are 

required to obtain an RN - EC certification, to practice autonomously within the parameters specified by the 

province’s legislation and the College’s scope of practice guidelines, and to maintain strong collaborative 

relations with other health care providers, especially physicians. Furthermore, nurses at most of the contact 

sites had access to a wide spectrum of resources and initiated referrals to other health care providers. 




All of the respondents noted that some form of collaborative practice model was in place at their site. 

However, there were notable variations in how collaborative practice was being defined, especially with 

regard to the performance of primary care functions. One differentiating criteria was whether or not nurses 

had independent versus shared patient caseloads. While independent caseloads was the norm for nurses at 

most sites (i.e., 9 out of 14), their colleagues at the other sites predominately shared caseloads with 

physicians. Regardless of caseload arrangements, the emphasis was on effective and efficient team 

functioning to promote quality patient outcomes. The second differentiating criteria was the expected balance 

between primary care and health promotion activities. While all of the sites expected nurses to engage in 

health promotion, the scope and intensity of this component was a function of the adequacy of human 

resources (i.e., number and mix of health care providers). 

There were definite variations across the Ontario sites with regard to the person (s) responsible for 

overseeing nurses clinical practice. Some sites referenced the self-monitoring clinical team (i.e., nurse 

practitioners and physicians co-ordinating their efforts as part of a clinical team) and its accountability to the 

executive director. Other sites reported that nurse practitioners were accountable to the executive 

director/administrator. Still other sites identified the responsible party as the physician. Finally, several sites 

emphasized the dual accountability of nurse practitioners to the executive director/administrator and 

physicians. 

Most of the Ontario sites surveyed also had mechanisms in place to ensure the continued competency 

of registered nurses working in extended/expanded roles. Regardless of the presence of site specific 

measures, all respondents encouraged these nurses to participate in medical and nursing continuing education 

activities on a regular basis. Continuing education measures instituted by some of the sites included regular 

in-service activities, off-site seminars on a variety of topics, internet and teleconferencing access, and support 

to attend one professional conference annually. 

With regard to on-site strategies for monitoring competency levels, most respondents reported that 

there were specific measures in-place. Most of the Ontario sites were more likely than not to have, or in the 

process of implementing, more formalized evaluation procedures (i.e., quality assurance practice reviews, self 




and peer reviews/evaluations, supervisor performance appraisals, etc.). Although all of the contact sites 

recognized the importance of having external consultants undertake a formal evaluation to assess the impact 

of the extended/expanded nursing role on health outcomes and costs, only a few were actually in the process 

of doing such an evaluation or preparing for one. Nevertheless, all of the respondents indicated that this was 

an area that required further attention. 

• Western Canada 

Manitoba has enacted amendments to the legislation governing extended/expanded nursing roles, 

however it was not proclaimed at the time of this survey. Regulations are being developed and, once 

approved, the statute will take effect. Meanwhile, the Manitoba Regional Health Authorities are preparing 

for the new regime with the development of a series of Community Nursing Resource Centres. 

There is a community health centre and a community nursing resource centre that co-exist in one 

community. However, recently issues have surfaced about nurses’ scope of practice in primary care roles 

and physician liability concerns. These issues are currently under consideration and extended/expanded 

nursing services have been suspended pending their resolution. 

Contacts were also made with administrative personnel at four urban-based clinics in the province. 

Only two of these clinics have nurses working in extended/expanded roles. The primary care activities 

performed by the nurses are classified as delegated medical functions. The nurses at these clinics manage 

an independent caseload and maintain a collaborative practice arrangement with physicians who supervise 

their clinical activities. These nurses do not have any prescriptive authority and a physician signature is 

required for diagnostic tests. Although continuing education activities are self-directed, a minimal number of 

credit hours is required for NP re-certification. Only one of the sites reported that a proposal had been 

submitted to access funds to conduct a formal evaluation of the role. A second site was in the process of 

developing a satisfaction questionnaire to survey clients in the near future. 




Saskatchewan is of particular interest given the efforts taken to expand nursing roles through a 

province-wide protocol agreement negotiated between nursing, physician and pharmacist regulatory bodies 

and the Ministry of Health. This agreement governs all nurses performing extended/expanded roles. 

The Beechy project, located in a rural community, has recently received national exposure as a model 

supported by the physician and community. The primary care nurses working at the Project sites have 

completed the advanced clinical program at the Saskatchewan Institute of Applied Technology. These nurses 

carry an independent patient caseload and work out of community health centres or off-site clinics. Although 

nurses may assess, diagnose, and treat, they are also expected to consult with the physician responsible for 

clinical activities. 

In the northern part of the province, primary care nurses work in community health centres or nursing 

stations. Nurses are often the only health care provider available, with physician visits restricted to once a 

week. These nurses have a wide-range of primary care responsibilities, including prescribing and dispensing 

medications, as well as stabilizing patients and transferring them to appropriate teritary care centres. 

Although the clinics are nurse-managed, the primary care nurses are expected to work in collaboration with 

other health care providers, especially physicians. 

Wide variations were reported in continuing education opportunities with the more remote sites 

limited to regular inservicing by visiting physician. Other sites had continuing education available via 

telehealth, specialist inservice activities, and annual conferences. However, all sites encouraged these nurses 

to participate in medical and nursing continuing education activities. With regard to the person (s) responsible 

for overseeing nurses clinical practice, both physicians and nursing supervisors/managers monitored clinical 

functions. Furthermore, all of the primary care nurses had to meet physician competency expectations before 

performing each delegated function. 

Most of the survey respondents reported monitoring of the extended/expanded role nurses was limited 

to periodic chart reviews by nursing supervisors and/or physicians. An additional monitoring mechanism 




instituted at a couple of the sites was performance appraisals. One site, in particular, had taken measures 

to institute a more formalized appraisal process (i.e., regular peer and physician reviews, formal client 

interviews, and indirect monitoring of client satisfaction. 

Alberta is the third province that regulates the expanded/extended roles of nurses employed by a 

health authority. The Minister must approve the locale where the health authority intends to employ a 

Registered Nurse - Expanded Practice (RN - EP). A total of 12 sites have been approved, with 5 health 

authorities employing these nurses to date. 

There are nurses working in extended/expanded roles in northern and remote locales. Several of 

these settings were included in this survey. The nurses at these sites carry independent patient caseloads and 

are expected to practice autonomously within their defined scope of practice. Collaborative practice 

arrangements are also maintained with consulting physicians. The person responsible for overseeing 

extended/expanded practice was either the medical director or the immediate nursing supervisor. Although 

there are no specifications regarding continuing education activities, these nurses are encouraged to 

participate regularly to enhance their knowledge and skills. It is interesting to note that with nurses working 

in extended/expanded roles who have had experience practising under the MSB guidelines find the new 

legislative regime far more restrictive. 

There is also a demonstration project currently operating in an urban area which is funded by the 

Health Transition Fund. The RN - EC at the family resource centre performs independent activities in on-site 

and off-site clinics. The nurse is expected to work in a collaborative manner with all health care providers, 

and consult with physicians as required. 

British Columbia is also taking steps to regulate extended/expanded roles for registered nurses. 

The provincial government is considering incorporating guidelines for advanced nursing practice into the 

legislation governing the profession. Currently, various settings have implemented clinical guidelines or have 

adapted nursing practice to suit the limitations placed on nurses’ scope of practice. 




Data were collected from several sites with nurses working in extended/expanded roles. There 

seems to be a number of practice models operant in the province. Health clinics in Vancouver, Victoria and 

the southern interior of British Columbia have nurse practitioners on-site. The absence of legislation 

legitimizing the role and extending authorities to order diagnostic tests and prescribe medications have been 

addressed through protocols. However, there are restrictions on the extent to which these nurses may 

perform primary care functions, with other authorities, such as legislation governing hospitals, overriding these 

protocols. 

In some rural and remote areas, nurses work in health centres, nursing stations, or outpost hospitals. 

Nurses located in these areas carry independent caseloads and perform primary care functions as specified 

under the Medical Service Branch Scope of Practice Guidelines. These nurse are expected to work 

collaboratively with physicians and other health care providers during site visits, and consult with physicians 

via telephone as required. Most of these nurses are responsible to an immediate nursing 

supervisor/administrator for clinical functions. With regard to continuing education activities, the onus is 

placed primarily on the nurse, with most sites encouraging participation in available continuing medical 

education offerings. 

Only one of the contact sites had conducted a formal evaluation of the efficiency of service offerings 

or the impact that extended/expanded role nurses were having on health outcomes. The other sites indicated 

that these issues were addressed through existing quality assurance programs and/or informal mechanisms. 

• Medical Services Branch and the Territories 

The Medical Services Branch of Health Canada is responsible for delivering health services to 

Canadians residing on lands under the administration of the federal government. Historically, this has included 

the lands under the administration of the Territorial governments including reserves for aboriginal peoples. 

The Medical Services Branch (MSB) has developed a policy governing the delivery of health services, 




including the provision of nursing services. Nurses are required to be registered with the relevant nursing 

association. The MSB has established courses for nursing in remote areas. According to representatives 

interviewed from provincial/territorial regulatory bodies, questions have been raised about the MSB guidelines 

exceeding nurses’ scope of practice as outlined by associations. 

Notwithstanding these observations, the Medical Services Branch has made a significant contribution 

to the education of nurses who perform extended/ expanded roles across the country. From interviews 

conducted with nurses who have worked in the north, there seems to be overall satisfaction with the MSB 

education programs, as well as the broader guidelines under which the nurses practice. Nurses who have 

relocated to less isolated settings commented that the scope of practice guidelines are narrower and relations 

with physicians are less open and more hierarchical. 

Interviews were conducted with key representatives in Nunavut, the North West Territories, and the 

Yukon. All of the nurses in the territories work under the MSB Scope of Practice Guidelines. Nurses in the 

Yukon are called community nurse practitioners. Nurses who work in health centres located in rural and 

remote areas without on-site physicians services assume a very independent role. However, they are 

expected to maintain some kind of collaborative practice arrangement with consulting physicians. 

In Nunavut and the North West Territories, the scope of nurses’ primary care functions are similar 

to their counterparts in the Yukon. Nurses work at health centres operated by regional health boards. 

Physician services are usually limited to bi-weekly or monthly visits to nurse-run clinics held at the different 

sites. Nurses are expected to work autonomously and maintain collaborative relations with consulting 

physicians. 

5.0 Conclusions and Implications 

It became apparent to the consultant team that there are several factors that influence the practice 

of nursing in extended/expanded roles. Important factors identified include: 




1. The relative positions of nurses and physicians varies by location and setting. In the more remote 

areas, where resources are in short supply, there appears to be a greater willingness to collaborate 

and rely on nurses to maximize the use of their skills. When the nurse is placed in a setting where 

there are greater resources available to meet client needs, the issues raised by physicians tend to 

focus on protecting the medical profession’s scope of practice. Thus, nurses encounter greater 

restrictions in performing shared primary care functions depending on the local supply of physicians. 

2. Another issue of concern is the need to protect nurses who perform extended/expanded roles while 

working in settings without legislated authorities. The legitimized profession (usually medicine) 

delegates certain primary care functions as required. With this delegation, the responsibility is jointly 

shared. The profession with the legal right to perform the function maintains accountability, while 

the nurse, who is deemed competent by a physician to perform the function, is accountable for 

performing it in accordance with protocols and guidelines. 

In certain instances, nurses are directed or asked to perform functions outside the scope of their 

practice or for which there is no formal delegation by way of protocol agreements. These nurses are 

correct in questioning the extent of their responsibility and liability if something transpires that results 

in adverse consequences for the client. Territorial associations have expressed concerns about 

nurses who practice under the MSB scope of practice guidelines which are broader than those 

contained in their legislation governing nurses. 

3. The expectations placed on nurses in lieu of their current level of educational preparation are often 

disparate. Based on the research findings, nurses working in remote and rural areas are expected 

to stabilize patients and prepare them for medical evacuation. In reality nurses practising in these 

locations, like primary care physicians, have limited medical resources available. Given these 

expectations the need for advanced education and training for nursing practice must be implemented 

for the benefit of the nurse and, most importantly, for the protection of the public. There are 

inconsistencies in the educational requirements of nurses across the country. Also variable are the 




requirements imposed to maintain competency. There may or may not be employer sponsored 

continuing education opportunities available on site or funding to attend programs off-site. 

4. Nursing practice in urban settings is markedly different than in the north. Access to diagnostic testing 

facilities, laboratories, and prescription medications that would be of benefit to help nurses perform 

functions within the scope of extended/expanded role, are often denied. Some of these resources 

are strictly controlled by a combination of forces, namely, protectionist behaviours of physicians and 

legislation which reserves access to professions other than nursing. While it is recognized that 

restrictions on access are necessary for control and cost containment, there are situations where it 

makes sense to allow shared access to certain resources. An example are the statutes which allow 

only physicians to admit a patient to a facility. Thus, these provisions require reconsideration to more 

accurately reflect the realities of practice and more effective utilization of health resources. 




APPENDIX A 

Legal Role and Regulation of Nursing in Primary Health Care Settings 

Province: Leg. Counsel Contact:_______________________________ 

Telephone:__________________FAX: ____________________Email:___________________ 

Legislation:___________________________________________________________________ 

Regulations:__________________________________________________________________ 

_____________________________________________________________________________ 

Title: _______________________________ (Tick T) Legislation ” Regulations ” 

S c o p e o f P r a c t i c e ( d e g r e e o f s p e c i f i c s ) : 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

Limitations on Scope of Practice (including other professional statutes): 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

Educational Requirements:______________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

Qualifications for Registration:__________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 




Continuing Education Requirements:______________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

Issues:________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

Comments: ___________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

DATE:_________________________ 

Consultant:_________________________ 




APPENDIX B-1 

Legal Definition of Nurse / Nursing 

“ Nurse “ / “ Nursing Practice ” Legislation 

Practice of Nursing A registered nurse and a certified graduate 

nurse are entitled to apply professional knowledge for the purpose 

of 

(a) promoting, maintaining or restoring health; 

(b) preventing illness, injury or disability; 

(c) caring for the injured, disabled or incapacitated; 

(d) assisting in childbirth; 

(e) teaching nursing theory or practice; 

(f) caring for the dying; 

(g) co-ordinating health care; 

(h) engaging in the administration, education, teaching or research 

required to implement or complement exclusive nursing 

practice or all matters referred to in clauses (a) to (g). 

ALBERTA 

Nursing Profession Act, 

SA 1983, Chap. N-14.5 




s. 3 “ The practice of nursing is the promotion of health and the 

assessment of, the provision of care for and the treatment of health 

conditions by supportive, preventive, therapeutic, palliative and 

rehabilitative means in order to attain or maintain optimal function.” 

ONTARIO 

Nursing Act, 1991, 

SO 1991, c. 32 

S. 4 Authorized acts: 

In the course of engaging in the practice of nursing, a member is 

authorized, subject to the terms, conditions and limitations imposed 

on his or her certificate of registration, to perform the following: 

(a) 

(b) 

(c) 

Performing a prescribed procedure below the dermis or a 

mucous membrane 

Administrating a substance by injection or inhalation 

Putting an instrument, hand or finger 

(i) beyond the external ear canal 

(ii) beyond the point in the nasal passages where they 

normally narrow 

(iii) beyond the larynx 

(iv) beyond the opening of the urethra 

(v) beyond the labia majora 

(vi) beyond the anal verge, or 

(vii) into an artificial opening in the body. 

“ registered nurse” means a person possessed of the qualifications 

required by this Act, and who is authorized to offer services for the 

care of the sick and to give care intended for the prevention of 

disease and to receive remuneration, and who is a member in good 

standing of the association 

NEWFOUNDLAND 

Registered Nurses Act , 

RSN 1990, c. R-9 




s. 2 (k) practice of nursing means the performance of professional 

services requiring substantial specialized knowledge of nursing 

theory and the biological, physical, behavioural, psychological and 

sociological sciences as the basis for 

(i) assessment, planning, intervention and evaluation in 

(A) the promotion and maintenance of health, 

(B) the facilitation of the management of illness, 

injury or infirmity, 

(C) the restoration of optimum function, or 

(D) palliative care or 

(ii) research, education, management or administration 

incidental to the objectives referred to clause (i) 

__________________________________________________ 

__ 

s. 2 (w) “ practice of medicine” includes ...(iii) offering or undertaking 

to prevent or to diagnose, correct or treat in any manner or by any 

means, methods, devices or instrumentalities any disease, illness, pain, 

wound, fracture, infirmity, defect or abnormal physical or mental 

condition of any person 

NOVA SCOTIA 

Registered Nurses Act, 

SNS 1996, c. 30 

_______________________ 

Medical Act, 

SNS 1995-96, c. 10 

s. 3 Regulations 

( p) respecting delegation of medical acts 

s. 1 (g) nurse ..any person who is possessed of qualifications required 

by the Act, and who is authorized to offer service for the care of the 

sick and to give care intended for the prevention of disease and to 

receive remuneration therefor, and any member of the Association 

PRINCE EDWARD ISLAND 

Nurses Act, 

SPEI 1988, c. N-4 




s.2 Nursing is the practice of nursing and includes nursing 

assessment and treatment of human responses to active or 

potential health problems and the nursing supervision thereof 

s.2 Health professional means a person who provides a service 

related to 

(i) the preservation or improvement of the health of 

individuals, or 

(ii) the diagnosis, treatment or care of individuals who are 

injured, sick, disabled or infirm and who is regulated under a 

private Act of the Legislature with respect to the provision of 

the service and includes a social worker registered...under the 

Social Workers Act, 1988 

NEW BRUNSWICK 

Nurses Act, 

SNB 1994, c.71 (a private 

statute) 

Practice of Nursing: Every act the object of which is to identify the 

health needs of persons, contribute to methods of diagnosis, provide 

and control the nursing care required for the promotion of health, 

prevention of illness, treatment and rehabilitation, and to provide care 

according to a medical prescription constitute the profession of 

nursing. 

QUEBEC 

Nurses Act, 

SQ 1996 c. I 

British Columbia’s statute does not define ‘nurse’ or ‘practice of 

nursing’. A registered nurse is simply defined as someone who is 

registered under section 14 of the Act which sets out the criteria for 

registration. 

BRITISH COLUMBIA 

Registered Nurses Act 

RSBC 1996 Chap. 335 




Practice of nursing means the performance or co-ordination of health 

care services including but not limited to: 

(i) observing and assessing the health status of clients and 

planning, implementing and evaluating nursing care; and 

(ii) the counselling, teaching, supervision, administration and 

research that is required to implement or complement health 

care services; for the purpose or promoting, maintaining or 

restoring health, preventing illness and alleviating suffering 

where the performance or co-ordination of those services 

requires: 

(iii) the knowledge, skill or judgement of a person who qualifies for 

registration pursuant to section 19 or 20; 

(iv) specialized knowledge of nursing theory other than that mentioned 

(v) 

in subclause (iii); 

skill or judgement acquired through nursing practice other than 

that mentioned in subclause (iii); or 

(vi) other knowledge of biological, physical, behavioural, psychological 

and sociological sciences that is relevant to the knowledge, skill 

or judgement described in subclause (iii), (iv) or (v). 

S. 2(1) Practice of nursing means representing oneself as a registered 

nurse while carrying out the practice of those functions which, directly 

or indirectly in collaboration with a client and with other health 

workers, have as their objective, promotion of health, prevention of 

illness, alleviation of suffering, restoration of health and maximum 

development of health potential and without restricting the generality 

of the foregoing includes 

SASKATCHEWAN 

Registered Nurses Act, 1988 

SS 1988-89 c. R-12.2 

MANITOBA 


R.S.M. 1987, c. 40 

(a) collecting data relating to the health status of an individual or 

groups of individuals 

(b) interpreting data and identifying health problems, 

(c) setting career goals, 

(d) determining nursing care approaches, 

(e) implementing care, supportive or restorative of life and wellbeing, 

(f) implementing care relevant to medical treatment, 

(g) assessing outcomes, and 

(h) revising plans 




The practice is the application of nursing knowledge, skill and 

judgment to promote, maintain and restore, health, prevent illness 

and alleviate suffering, and includes, but is not limited to, 

(a) assessing health status; 

(b) planning, providing and evaluating treatment and nursing 

interventions; 

(c) counselling and teaching to enhance health and well-being; and 

(d) education, administration and research related to providing 

health services. 

Nursing means the application of professional nursing knowledge or 

services for compensation for the purpose of 

(a) promoting, maintaining, and restoring health, 

(b) preventing illness, injury, or disability, 

(c) caring for persons who are sick, injured, disabled, or dying 

(d) assisting in pre-natal care, childbirth, and post-natal care, 

(e) coordinating health care, or 

(g) engaging in administration, teaching, or research to implement a 

matter referred to in paragraphs (a) to (f). 

“Nurse” or “nursing practice” are not defined in the statute. Titles 

are referred to in section 20 which says that a “person who holds a 

certificate of registration may use the title “Registered Nurse” and 

use after his or her name the letters “Reg. N.” or “R.N.” 

The Nursing Act (Nunavut) is referred to in section 35 of the 

Nursing Profession Act of NWT as the operative statute to give 

the NWTRNA the transitional powers to regulate nursing in 

Nunavut. To date we have been unable to secure a copy of this 

document. 

MANITOBA 


S.M. 1999, c. 36 

( Not yet proclaimed) 

YUKON 

Registered Nurses Profession 

Act 

SY 1992, c. c. 11 

NORTHWEST 

TERRITORIES 

Nursing Profession Act, 

R.S.N.W.T. 1988, c. 4 

NUNAVUT 

Nursing Act (Nunavut) 




APPENDIX B-2 

Definition of Extended Certificate of Registration/Nurse Practitioner 

Canadian Jurisdictions 

“Extended Certificate”/ “Nurse 

Practitioner” 

The Public Health Act was amended in section 21 

in 1996 to allow registered nurses to provide 

extended health services as permitted by the 

regulations. 

Sect. 1 of the regulations says that extended 

practice nurses must be employed by a regional 

health authority, a provincial health board or the 

Department. 

Sect. 3 says that ministerial approval is required 

before an extended practice nurse is employed 

other than by the Department. 

Sect. 4 says that an employment agreement must 

exist which sets out the specifics of what services 

will be provided by an extended practice nurse. 

Sect. 5 gives the scope of the services which may 

be provided: 

(a) diagnoses and treatment of common disorders 

affecting the health of adults and children; 

(b) referral; 

(c) emergency services 

Legislation/Regulation 

ALBERTA 

Legislation: 

(1) Nursing Profession Act, SA 1983, Chap. N- 

10.1 

(2) Public Health Act, SA 1984, Chap. P-27.1 

(3) Pharmaceutical Profession Act, SA 1988, 

Chap. P-7.1 

Regulations:- 

(1) General Regulation, Alberta Reg. 454/83 

(1) Nursing Profession Extended Practice Roster 

Regulation, Alberta Reg.16/99 (expiry date - 

January 31, 2004) 

(2) Registered Nurse Providing Extended Health 

Services Regulation, Alberta Reg. 224/96 (expiry 

date - June 30, 2001) 

(3) Prescription of Drugs By Authorized 

Practitioners Regulation, Alberta Reg. 83/98 

(expiry date - August 31, 2002) 

It is not clear if the powers listed in a, b and c are 

intended to allow for prescribing of drugs but the 

Pharmaceutical Profession Act regulations were 

enacted in 1998 to permit prescribing for Extended 

Practice nurses if authorized by the Public Health 

Act regulations. 




s. 5.1 In the course of engaging in the practice 

of nursing, a member who is a registered nurse 

and who holds an extended certificate of 

registration in accordance with the regulations is 

authorized, subject the terms and conditions and 

limitations imposed on his or her certificate of 

registration, to perform the following acts in 

addition to those the member is authorized to 

perform in section 4 

ONTARIO 

Expanded Nursing Services for Patients Act, SO 

1997, c.9 (amendment to Nursing Act) 

1.1 Communicating to a patient or his 

representative a diagnosis made by the member 

identifying as the cause of the patient’s 

symptoms, a disease or disorder that can be 

identified from 

i. the patient’s medical history 

ii. the findings of a comprehensive 

medical examination 

iii. the results of any laboratory tests or other 

tests and investigations that the member is 

authorized to order and perform 

2. Ordering the application of a form of energy 

prescribed by the regulations under this Act 

3. Prescribing a drug designated in the 

regulations 

4. Administering, by injection or inhalation, 

a drug that the member may prescribe under 

paragraph 3 

5.2 A member is not authorized to communicate a 

diagnosis under paragraph 1 of subsection 

(1) unless the member has complied with the 

prescribes standards of practice respecting 

consultation with members of other health 

professions. 




“ nurse practitioner” means a registered nurse 

who meets the requirements for licensure by the 

ARNN for practice as a nurse practitioner within 

the primary health care model 

NP to establish collaborative relationship with 

primary care physician and other health 

professionals for purposes of consultation 

NEWFOUNDLAND 

Newfoundland Regulation 65/98 

Nurse Practitioner Primary Health Care 

Regulations 

• NP to consult with primary care physician 

but, when not available, may consult with 

specialist physician 

• NP shall consult with a primary health care 

physician in circumstances specified in Regs/ 

in urgent and emergent circumstances as 

outlined in Regs./ when chronic illness or 

injury destabilizes in circumstances specified 

in Regs and regarding annual reassessment 

of Pt. with a chronic condition 

• NP can expect to encounter illnesses and 

injuries as listed in Sch. A of Regs. 

• NP can order diagnostic tests as outline in 

Sch B of Regs/ tests not listed but required 

for monitoring Pt’s chronic illness or injury 

ordered by NP after consultation with 

Primary care physician and requisition to 

reference physician’s name 

• NP may prescribed and administer drugs as 

listed in Sch C (non-narcotics) 

• NP may prescribe over the counter 

medication to access drug plan for Pt. 




s. 2 (2) In accordance with any requirements set 

out in the regulations, a registered nurse my do 

any of the following in the course of engaging in 

the practice of nursing: 

(a) order and receive reports of screening and 

diagnostic tests designated in the regulations; 

(b) prescribe drugs designated in the regulations; 

(c) perform minor surgical and invasive 

procedures designated in the regulations. 

MANITOBA 


S.M. 1999, c. 36 

( Not yet proclaimed-awaiting regulations) 




APPENDIX C-1 

Association’s Views : Nursing Practice in Extended/Expanded Roles ** 

** nurses in primary care roles involved in assessment, diagnosis, and treatment of episodic, 

acute, and chronic illness or injury 

Province: ____________________________Association_______________________________ 

Name:________________________________________________________________________ 

Contact:______________________________________________________________________ 

______________________________________________________________________________ 

Telephone:______________ FAX:___________________Email:___________________ 

Background: 

Are there nurses in the jurisdiction whose practice involves assessment, diagnosis and treatment 

of episodic, acute and chronic illness and/or injury 

_____________________________________________________________________________ 

______________________________________________________________________________ 

If so, in which specific settings are they practising ( e.g., name and location) 

______________________________________________________________________________ 

Contact person in the setting(s): 

_____________________________________________________________________________ 

Employer rep:_________________________________________________________________ 

Nurse manager: _______________________________________________________________ 

What are the titles or position descriptions used to label these roles 

______________________________________________________________________________ 

Are there existing position descriptions for these roles Yes____ ; No____. If yes, is it possible 

for you to provide us with copies 




______________________________________________________________________________ 

Are there written scope of practice guidelines, by-laws, standards of practice or competency 

statements to describe these roles: (obtain copies if possible) 

______________________________________________________________________________ 

Challenges/Issues re Nursing Practice in Extended/Expanded Roles in Province 

(facilitators/barriers) 

______________________________________________________________________________ 

Challenges to Extended/Expanded Roles vis-a-vis other professionals ( e.g. reserved acts): 

______________________________________________________________________________ 

Challenges re Education & Continuing Ed. of Nurses in Extended/Expanded roles: 

______________________________________________________________________________ 

Is there a separate association/interest group representing these nurses and what is it called: 

______________________________________________________________________________ 

Contact person:________________________________________________________________ 

Issues re assessment, diagnosis and treatment: 

______________________________________________________________________________ 

From public: 

______________________________________________________________________________ 




From unregulated occupations: 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

From other Regulatory bodies: 

______________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

Other matters impacting regulation/practice : ______________________________________ 

_____________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

Additional comments, issues or unusual circumstances concerning nursing practice in primary 

care in your jurisdiction: 

Date:________________Consultant:______________________________________________ 




APPENDIX C-2 

Regulation of Nursing in Extended/Expanded Roles ** 

** nurses in primary care roles involved in assessment, diagnosis, and treatment of episodic, 

acute, and chronic illness or injury 

Province:_______________________Regulatory Body:______________________________ 

Contact Person:_______________________________________________________________ 

Telephone:_____________________Fax:__________________Email:__________________ 

# of Registered Nurses:__________________________________________________________ 

# of Nurses registered in advanced practice roles 

” Extended/Expanded practice _______ 

” Nurse Practitioners _______ 

” Other ___________ (Titles - protected title or as position 

descriptions)___________________________________________________________________ 

______________________________________________________________________________ 

_____________________________________________________________________________ 

For Extended/Expanded Nursing Practice Roles: 

Scope of Practice for nurses in extended/expanded roles ( including limitations, i.e., acts reserved 

to another profession): 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

Approved Educational programs in jurisdiction (entry requirement, designation at graduation, 

length of study, institutions providing educational instruction): 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 




Qualifications required for entry to practice ( e.g. RN with certificate or experience, employment 

contract): 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

Can a nurse be assessed for entry to practice and registration for practice in an extended/expanded 

role based on a combination of training and experience without having taken the formal course 

requirements Yes_____; No_____. If yes, what are the basic minimum requirements that would 

be factored into the assessment 

______________________________________________________________________________ 

______________________________________________________________________________ 

Practice settings in jurisdiction where nurses practice includes assessment, diagnosis, and 

treatment: 

______________________________________________________________________________ 

______________________________________________________________________________ 

Settings and contact persons: (i.e. employer or nurse manager) 

______________________________________________________________________________ 

______________________________________________________________________________ 

Liability Insurance Requirement/Availability and Limitations on Coverage: 

______________________________________________________________________________ 

______________________________________________________________________________ 

Have any issues concerning liability or specific cases involving liability arisen in extended 

/expanded nursing practice settings in jurisdiction 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 




Have any issues concerning discipline or specific cases involving discipline arisen in 

extended/expanded nursing practice settings in the jurisdiction 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

Additional comments, issues or unusual circumstances concerning nursing practice in primary care 

in your jurisdiction: 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

DATE:______________________________ Consultant:_______________________________ 




APPENDIX D 

Background information by jurisdiction 

Background Information Gathered from Nurses Associations, Regulatory Bodies and Ministries 

of Health 

BRITISH COLUMBIA 

Names of organizations contacted 

Registered Nurses Association of British Columbia 

(RNABC) 

B.C. Ministry of Health 

Nurses on active practice RN roles 29,033 Practising Registered Nurses, December 1998. 

Data source: Rollcall Update 98, Health Human Resources 

Unit, University of British Columbia 

Nurses in province or territory whose 

practice involves assessment, 

diagnosis and management of episodic, 

acute and chronic illness or injury as 

components of primary health care 

Nurses registered or licensed to 

practice in extended/expanded roles as 

described above 

Settings in which they practice 

Position titles or descriptions 

No legislative basis. Variety of extended/expanded 

practice roles being fulfilled. Some of these practice roles 

are within the existing scope of nursing practice. There are 

some nurses working in extended/expanded roles through 

medical delegation. 

None registered or licensed to specifically fulfill extended/ 

expanded practice role. Accomplished through MD 

delegation. No central registry kept by RNABC so difficult 

to estimate #s. In 1998, 85 nurses were employed in 

Nursing Stations/Outpost/Clinic. Data source: Rollcall 

Update 98 

Examples are: Red Cross Outposts, MSB locations, Comox 

Valley Nursing Center,. RN First Call, some Community 

Health Centres. 

NB - Comox Valley practice is not fully 

‘extended/expanded’ practice as far as prescribing drugs 

and ordering tests. The practice is extended/expanded but 

within the existing scope of practice. 

RNs, unofficially as NPs in Community Health Centers 

Registered Nurse is the legislated title; however, there are 

some nurses who call themselves Nurse Practitioners. 




Educational qualifications and 

programs for practice in 

extended/expanded roles 

Scope of practice guidelines, by-laws, 

standards of practice or competencies 

to define roles 

Facilitators to nurses practising in 

extended/ expanded roles 

Barriers to nurses practising in 


Challenges to extended/ expanded 

roles for nurses posed by relationships 

with other health professionals 

Challenges concerning education and 

continuing education for nurses 

practising in extended/ expanded roles 

Disciplinary or liability actions arising 

with respect to practice in 


Other organizations representing 

nurses 

Issues arising from public 

Issues arising from other professions’ 

regulatory bodies or from unregulated 

professions 

Educational and other qualifications for employment are set 

by the employer, i.e. Red Cross or MSB. Employers may 

pay for or require a specialty course. Diploma is the 

minimum qualification as for all Registered Nurses. 

Virtually all extended/expanded practice in BC is by 

delegation of function. The delegated acts (i.e. functions 

beyond the scope of practice) are established by working 

arrangements according to location, organization and 

training. RNABC has established guidelines for DMF 

(Delegated Medical Functions) 

There appears to be acceptance by the public of increasing 

responsibility and independence for the practice of nursing 

where the extended/expanded roles exist. 

No consultation fee for physicians; legislative barriers exist, 

e.g. Medical Practitioners Act and the Nurses 

(Registered) Act which has an imprecise definition of the 

scope of nurses (the "ordinary calling of nursing"). 

Doctor/nurse traditional roles are difficult to modify 

substantially in the absence of substantive legislative 

change. Physicians in rural/remote areas often welcome 

extended/expanded nurse roles whereas similar attitudes 

may not always be present in urban locations. 

At the present time there are only limited education 

programs, primarily sponsored by employers, for nurses 

practising in extended/expanded roles. 

Presently liability coverage is provided by the employer and 

what is normally carried as a member of RNABC. There 

have been no reported incidents related to 

extended/expanded practice 

BC Nurses Union 

As throughout the country, there is a demand for better 

health care services in rural/remote areas and other underserviced 

areas 

Liability is a continuing and growing concern for physicians 

and pharmacists in the absence of legislation 




Other matters having an impact on 

nurses practising in 


Under the relatively new Health Professions legislation in 

BC, the Health Professions Council is reviewing all health 

professions’ scopes of practice with a view to prescribing 

‘restricted acts’ which will then be set by regulation. The 

RNABC and the BC Nurses Union have jointly presented 

a proposed list of reserved acts to the HPC. Some of these 

suggested reserved acts would require additional regulatory 

authority, e.g. prescriptive authority. The final assessment 

of the HP Council following public hearings in June, 2000 is 

expected at some time in 2000 or early in 2001 and it will 

play a large part in determining the future of 

extended/expanded practice for nurses in BC 

Prepared with information gathered from the Association December 1999 

Reviewed and revised by the Association and the Ministry of Health June-August 2000 






ALBERTA 







Alberta Association of Registered Nurses (AARN) 

Alberta Health 

Registered Nurse - Extended Practice (RN-EP) under 

legislation. Northern nurses have been practising for many 

years under protocols in more limited capacities of 

extended/expanded practice 

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


practice in extended/expanded roles 






16 at time of survey 

Minister has pre-approved 11 sites. Presently 16 RN-EPs 

are working within provincial Regional Health Authority 

sites and federal Medical Services Branch approved 

locations. 

RN-EP officially, but usually called Community Nurse 

Practitioners 

The Extended Practice Roster Regulation provides two 

avenues by which a registered nurse can apply to the 

Roster. The requirements include 1). a baccalaureate 

degree, three to four years of relevant clinical experience 

and completion of an educational program that prepares the 

registered nurse to provide extended services. The 

Advanced Graduate Diploma in Community Nursing 

practice at Athabasca University has been approved as an 

educational program or 2). There is a two year grandparenting 

clause ( February 1999-February 2001) for nurses 

who do not meet the educational requirement but have been 

successfully providing these services. These nurses undergo 

an assessment process to ensure they have the necessary 

knowledge and skills. 







Competencies and guidelines are prepared and published by 

the AARN to govern the practice of nurses providing 

‘extended health services’ The Extended practice Roster 

Regulation governs the registration of nurses on the Roster. 

Relevant documents include: 

• Competencies for Registered Nurses Providing 

Extended Health Services in the Province of Alberta 

( December 1995) 

• Prescribing and Distributing Guidelines for 

Registered Nurses in Advanced Nursing Practice 

Providing Primary Health Care Services ( February 

1995) ( Re-endorsed February 200 for two years) 

• Alberta Health: Guidelines for Registered Nurses in 

Advanced Nursing Practice Providing Primary 

Health Care Services in Under-serviced 

Communities in Alberta ( August 1994) 














Shortage of physicians in rural/remote areas 

Physicians and pharmacists have been reasonably 

supportive 

Provinces future health strategy incorporates increased use 

of RN-EPs 

There is one urban centre (Calgary) where an RN-EP is 

practising. In general, physicians appear to recognize the 

role of RN-EPs in a supportive role however they do not 

support complete independence of this practice. 

There is no mechanism to date to address for fee-forservice. 

Enhancing physician and pharmacist cooperation. Alberta’s 

Health Professions Act sets ‘restricted activities’ for 

professions. 

RN - EPs must demonstrate full competence in the entire 

scope of practice for extended practice. Nurses registered 

to practice as RN-EPs must apply for renewal each year. 

No actions reported 





nurses 




professions 




United Nurses of Alberta 

The RN-EP extended/expanded role has recently been 

developed (1999). The public may not be aware of the role 

for nurses who are accepted on the extended Practice 

Roster. Overall, the public does appear to be supportive of 

increased responsibilities for nurses. 

Physicians and Pharmacists want practice of RN-EPs to 

remain structured under health care organization 

employment 

Urban practice setting (Calgary) may lead to greater urban 

use of RN-EPs 

Additional comments 

Information verified by the AARN December 1999 

Updated with the input of the AARN and the Ministry in July 2000 

Alberta appears committed to the increasing use of nurses 

practising in extended/ expanded roles including in urban 

areas but there is direct control over sight approvals by the 

Minister 

Regulations are being developed under the Health 

Professions Act 

and will probably include RN s practicing in 

extended/expanded practice roles. 






SASKATCHEWAN 


Saskatchewan Registered Nurses Association (SRNA) 

Saskatchewan Health 

Nurses in active practice RN roles Approx. 9,000 











Saskatchewan has a significant number of nurses practising 

in extended/expanded roles throughout the province through 

delegation of medical functions and cooperation with the 

pharmacy profession. It is expected that the delegation 

model will give way to expanded scope of practice for 

nurses when Council specifically prescribes ‘special 

categories of practice’ under the operative statute. 

Although the Registered Nurses Act contains provisions for 

the Council to prescribe ‘special categories of practice’, 

there are no nurses yet actually licensed in this capacity. 

With no central registry held by the SRNA, it is not possible 

to identify all the sites where nurses are practising in 

extended/expanded roles. There are 32 health districts in 

the province and 27 nurses are employed in 

extended/expanded roles as primary care nurses. However, 

these estimates do not include nurses employed by Tribal 

Councils. There are 10 nurses employed in the primary 

health care demonstration sites. 

No fixed titles. Referred to as Primary Care Nurses in 

protocol. 














SRNA has criteria for practice in extended/expanded roles 

under guidelines established in a document titled The 

Registered Nurse Scope of Practice: Special Nursing 

Procedures and Nursing Procedures by Transfer of 

Medical Functions, 1993. The latest document on 

prescribing is Guidelines for Nurses Prescribing and/or 

Distributing Drugs by Transfer of Functions, revised 

May 1999. The criteria require that a nurse wishing to 

practice under these guidelines must take a “formal course” 

of instruction. The Advanced Clinical Nursing Program at 

Saskatchewan Institute of Applied Technology is a course 

of instruction to prepare a nurse for an extended/expanded 

role. 

Scope of practice is defined by the province-wide clinical 

practice guidelines and as modified by site. 

Legal advice has been received by SRNA that ability of 

Council to prescribe special categories of practice (sect. 15 

(2)(f)) is sufficient to provide for extended/expanded 

practice roles without having to further amend statute. There 

also appears to be. widespread and historical acceptance of 

extended/expanded practice for nurses and significant and 

longstanding co-operation of nurse, physicians and 

pharmacists. 

Uncertainty as to the degree of support from physicians for 

moving from the delegation of function model. Pharmacy 

legislation permits prescribing by professions, however, 

nurses have not been specifically designated. Awaiting 

regulations under the Pharmacy Act. 














nurses 




professions 

Nurses, physicians and pharmacists appear to act 

cooperatively. There is growing support for a licensing 

model. While physicians are supportive of 

extended/expanded roles and perhaps legitimatization of 

these roles, it is acceptable if this move is as part of 

collaborative practice arrangements. 

There have been concerns expressed on the part of 

physicians and pharmacists about liability though liability is 

not increasing. 

The biggest challenge in primary health care is the loss of 

physicians and ensuring nurses have the skills to take on 

added responsibility. 

In the absence of legislation and a lack of a central roster of 

nurses practising in these roles, it will continue to be difficult 

for the SRNA to oversee the continuing competencies of 

these nurses 

No actions reported. 

Saskatchewan Nurses Union 

General acceptance by the public of the need for nurses to 

act in extended/expanded practice roles where appropriate. 

Concerns about liability and uncertainty as to the degree of 

acceptance and support from physicians for nurses exerting 

more autonomous and direct authority over patient treatment 

in primary health care. 





Information verified by the Association December 1999 

Updated with input of the Association and the Ministry July 2000 

Saskatchewan appears to have a well established system of 

extended/expanded practice for nurses based on the 

cooperative transfer of medical function model. SRNA is 

moving towards changing the model to more autonomous 

extended/expanded practice for nurses. However, it 

appears that the Association is moving cautiously in this 

direction, most likely because of concern that a legislatively 

imposed regime will likely mean changes in existing 

interrelationships among the affected professions. 

The legal advisors within government have questioned 

whether the regulation is specific enough to cover nurses for 

the functions that could be considered special categories as 

have been delegated under the clinical practice guidelines 

and guidelines for transfer of functions documents. This 

issue is under active consideration. 

From a human resources planning perspective, it is a 

challenge to ensure there is good complement of knowledge 

and skills with a range of health care providers to deliver 

primary health care services. 



MANITOBA 


Manitoba Association of Registered Nurses (MARN) 

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

















New legislation governing the profession is passed but not 

proclaimed. A component of the new legislation will be the 

expanded the scope of practice through “included 

practices’.which encompass prescriptive authority, 

performance of minor surgical and invasive procedures and 

ordering and receiving results of screening and diagnostic 

tests. Existing extended/ expanded practice is performed 

under delegation of medical functions and collaborative 

practice agreements. 

The new Registered Nurses Act will allow for a separate 

register for nurses practising in extended capacities 

(included practices) under the competencies to be developed 

Extended/expanded practice is carried out in some urban as 

well as remote and northern regions. Settings include 

tertiary and community hospitals, community health centres, 

community nurse resource centres and community 

programs. 

The title “Registered Nurse” is the only title regulated by 

MARN at this time. The new legislation once proclaimed 

will also protect the title “Graduate Nurse”. Employers may 

choose to use a specific position title such as nurse 

practitioner or advanced practice nurse but these are not 

regulated titles in Manitoba. 

The focus will be on the competencies required to perform 

the services identified in the included practices. Nurses may 

develop the required competencies through various 

educational activities. Concerning advanced nursing 

practice, there currently exists a Masters level program in 

Advanced Nursing Practice at the University .of Manitoba; 

completion of this program is one educational options. 





















nurses 


The Registered Nurses’ Act identifies the scope of practice 

of registered nurses. Under the new legislation, regulations 

will be developed to set the competencies required for 

included practices. Registered nurses with the required 

competencies will have the legislated authority to perform 

the included practices and delegation of function will not be 

required for these services. MARN has established 

standards of nursing practice which apply to all practising 

registered nurses in the province regardless of their roles or 

practice settings. MARN has adopted the CNA Code of 

Ethics for Registered Nurses which provides the ethical 

guidelines for practice. 

The new legislation will facilitate this once it is proclaimed. 

The existence of a program of studies for the advance 

practice role may facilitate this as well. 

At this point the major barrier is waiting to have the enabling 

statute proclaimed. An additional barrier may be the 

understanding by the employers, other professions, etc. of 

the scope of practice of registered nurses that is based on 

traditional perceptions rather than contemporary reality. 

To date, there have not been significant challenges posed by 

other health care professions. 

Regulations will be developed that will address the education 

and continuing education required. In accordance with the 

new legislation, a program must be established to ensure 

continuing competence for all registered nurses practising in 

Manitoba. 

Registered nurses acting in these roles will be subject to the 

usual statutory disciplinary processes. 

Manitoba Nurses Union is the union representing most 

registered nurses. A small number are represented by other 

unions such as Manitoba Government Employees Union. 

There appears to be acceptance by the public of the concept 

of extended/expanded roles for nurses in the delivery of 

health care 






professions 




There has been no appreciable opposition to the new 

legislation which is evidence of a significant degree of interprofessional 

cooperation. 

Manitoba, as with other provinces of similar geographical 

size and consequent widely dispersed population, has an 

indicated need for innovation in the delivery of health care 

services. 


Information verified by the Association December 1999 

Updated and revised by the Association and the Ministry June-July, 2000 

There is no mention of title or protection of title for nurses 

practising in extended/expanded roles in the new Manitoba 

legislation. It appears that the new roles will be seen as 

variations within the overall scope of nursing practice in the 

province. 






ONTARIO 


College of Nurses of Ontario 

Registered Nurses Association of Ontario (RNAO) 

Nurses on active practice RN 

roles 

Nurses in province or territory 

whose practice involves 

assessment, diagnosis and 

management of episodic, acute 

and chronic illness or injury as 

components of primary health 

care 


practice in extended/expanded 

roles as described above 



Approximately 80,000 reported working in nursing (1997) 

Registered Nurse-Extended Class (NP-EC) under legislation 

proclaimed February, 1998. 

There are nurses practising who are not covered by legislation but 

practice under medical directives 

350 registered (est.) though not all employed in the role 

The Ministry of Health and Long-term Care has announced 

funding for an additional 106 positions in long-term care (20) , 

under-serviced areas (80) and aboriginal community health access 

centres. The Primary Care Reform project sites also have 5 

positions and the Ministry recently announced funding for 5 more 

NP s to provide women’s health services through public health 

units in areas that have low participation in cervical screening and 

above average rates of cervical cancer ( hard to reach 

populations).positions in under serviced areas ( non-aboriginal). 

Pilot projects in long-term care, primary care and public health. 

The only protected title is RN-EC (Extended Class) Titles, such as 

Nurse Practitioner, is commonly used but not title protected in 

legislation. 







Scope of practice guidelines, bylaws, 

standards of practice or 

competencies to define roles 

Facilitators to nurses practising 

in extended/ expanded roles 



In 1994, the Council of Ontario University Programs in Nursing 

approved a program for RN- EC, at 10 sites to be co-ordinated by 

McMaster University. Program criteria to graduate is via one of 

two streams; a student with a diploma completes a 24 month 

course to attain a Bachelor of Nursing and NP certificate/ a 

student with a BN must successfully complete of a 12 month 

course to attain a NP certificate. 

Legislated scope of practice is relative to primary care only with 

controlled acts which are to be performed by those RN with the 

designation of the extended class. 

A complex human resource problem respecting physicians looms. 

Both a maldistribution and shortage of physicians exists. 

Reductions in medical school enrolments have not yet begun to 

impact physician supply but are predicted to do so. There are 

projected increases in physician retirements and medical care is 

becoming more complex. These factors create opportunities for 

nurses to function in a complementary role to physicians. Fiscal 

constraints make NP practice attractive to governments that are 

trying to keep pace with demographic and technological changes 

in health care., reform the system and deliver safe effective care 

within provincial budgets. NPs may be a cost effective way of 

delivering some primary care services. 

Provincial health care strategy to restructure the system will focus 

more on primary care where nurses can play greater role. 

Nurses working as employees of physicians will have greater 

difficulty establishing collaborative working relationships 

NP s do not support a fee-for-service approach to remuneration 

for NP services. Adding NP s to the system currently requires 

additional funds to augment global budgets. Ontario now has a 

$16M per year budget for NP services. 

There is evident confusion with the public as between GPs and 

NPs. There is also confusion between the terms “nurse 

practitioner” and “practical nurse”. 




Challenges to extended/ 

expanded roles for nurses posed 

by relationships with other health 

professionals 

Challenges concerning education 

and continuing education for 

nurses practising in extended/ 

expanded roles 

Disciplinary or liability actions 

arising with respect to practice in 



nurses 


Issues arising from other 

professions’ regulatory bodies or 

from unregulated professions 

NPs are educating physicians as to their competencies and the 

potential for the physician to maximize their skills and nurses theirs. 

An amendment is required to the federal Narcotics Control Act 

to allow NP s to prescribe analgesics independently. 

Public Hospitals Act specifies who may provide service in 

hospitals. Current regulation permits NPs to admit as outpatients 

only and just for diagnostic tests ( Labs and x-rays). Another 

amendment is needed if NP s are to permitted to independently 

admit a patient for treatment, e.g., emergency. 

NP referrals to specialists are often not accepted. There are 

implications for payment of the specialist without a referral by a 

physician and/or countersignature by a physician. 

There is a move towards developing competencies for NPs across 

jurisdictions within Canada. There needs to a greater degree of 

uniformity of educational training to satisfy competencies. 

None reported. 

Nurse Practitioners Association of Ontario, a speciality interest 

group of the RNAO 

Ontario Nurses Association ( Labour Union) 

Nurses practising in extended/expanded roles is still relatively new 

and the public is not generally aware of the role and when to seek 

services of a nurse in this role. Greater public education is needed. 

This has been evidenced by clients’ comments to the College 

regarding the expectations and the scope of practice of the RN- 

EC. Inquires have been received from the public seeking 

clarification of the role. 

Public confuses nurse practitioners with practical nurses. Some 

members of the public believe that NPs are a cheap, second rate 

physician substitute. Some MDs tend to reinforce this while 

patients are positive about the services received from NPs. 

Physicians have expressed concerns about competencies of the 

RN-EC. Also, physicians are concerned about economic 

competition from NPs. 




Other matters having an impact 

on nurses practising in 



The policy direction if the current Government is supportive of the 

use of NPs as evidenced by an allocation of $16M to fund NP 

positions. 

The union has been supportive of the move toward 

extended/expanded practice and has stated its position. 

There is professional support for Masters preparation of RN-ECs 

but recognizes that the public may not be ready to accept this 

standard at this time. 

The Government is supportive of the Canada Health Act and 

supports the multi-disciplinary approach to primary health care and 

the role of the NP. The pace and timing may not be in step with 

nursing organizations. 

Reviewed by the College December 1999 

Updated with input by the College June 2000 and the Ministry in July 2000 

Background Information Gathered from Nurses Association and Ministry of Health 

QUEBEC 


Nurses on active practice RN 

roles 


whose practice involves 

assessment, diagnosis and 

management of episodic, acute 

and chronic illness or injury as 

components of primary health 

care 


practice in extended/expanded 

roles as described above 

Ordre des Infirmieres et Infirmier du Quebec (OIIQ) 

Ministry of Health 

63, 000 

Limited types of extended/expanded practice. Limited delegation 

to nurses of specific medical acts which are supervised by 

physicians and not based on a collaborative model of practice. 

The function of diagnosis has been reserved exclusively to 

physicians and there is little to no development in nursing to share 

this function. 

None registered; no legislation to enable the creation of a separate 

class. 









Scope of practice guidelines, bylaws, 





There are 146 Community Health Centres (CLSC) in the Province 

employing 4000 nurses across the Province. They feature triage 

at the entry point with a nurse involved in screening and 

evaluation. The physicians protect the function of diagnosis. There 

are protocols established site-by-site. There is no Provincial-wide 

agreement covering the centres. 

In the northern regions of Quebec there is some delegation of 

medical function with physician supervision. There are no 

standard protocols. 

Nurses (infirmiere/infirmier) 

No specific courses of instruction identified. 

Delegation of function not necessarily with supporting protocols. 

There have been concerns raised by nurses as there are situations 

where they believe they could be exposed to liability and have no 

protection. This is an issue for the nurses association. 

In the very limited scope in which these roles occur, there appears 

to be a positive response with demonstrated patient satisfaction 

and favourable costs. 

Technological advances in health care delivery have heightened 

the awareness of the need for more specialized knowledge for 

nurses. This supports the move to specialization and advanced 

practice initiatives. 

Quebec has a great need for better continuing care following 

discharge from hospital. Therefore, the demand for nurses to 

deliver care in complex cases in the community is growing. 






Challenges to extended/ 

expanded roles for nurses posed 

by relationships with other health 

professionals 


and continuing education for 

nurses practising in extended/ 

expanded roles 





nurses 





Physicians are resistant to the delegation of the function especially 

diagnosis. 

The shortage of nurses means that the workforce is stretched and 

it is difficult to advocate for expanding roles when basic care is 

difficult to deliver. Thus there is seemingly little interest in the 

profession for advanced practice alternatives. This reality coupled 

with a significant number of nurses who are leaving the profession 

thus this further inhibits developments toward specialization. 

Employers resist higher qualification levels because of higher pay 

demands. 

There is limited support for extended/expanded roles from the 

union which holds the view a nurse is a nurse. 

Legislative barriers exist given the limited scope of practice of the 

nurse. Physician dominance and desire to protect medical domain 

i.e. diagnosis. 

The certification of nurses at present is in one class. At the 

present time 70% of nurses hold diplomas while 30% of the 

membership have a university degree. There is interest in the 

OIIQ in introducing extended/expanded roles. This will influence 

educational requirements. 

No actions reported . 

Nurses practising in extended/expanded roles under delegation of 

medical functions in the absence of protocols are becoming more 

concerned about their liability. 

Quebec Nurses Union 

Little apparent awareness of the public to possibilities for nurses 

practising in extended/expanded roles 

Physicians are concerned given the lack of physicians in remote 

areas. 




Other matters having an impact 

on nurses practising in 



The funding mechanism is an inhibitor as there are different 

envelopes for physicians fees and there is no fee for physicians 

consulting with a nurse. 

The role of nurses in the CLSCs is broad. They offer front-line 

practice in clinics and in a 24 hour telephone consultation service, 

Info-Sante. This service is very successful and is recognized as 

such by the public. 

Lack of union support is an obvious detriment to expanding scope 

of practice. 

The Nurses Association of Quebec is working toward the release 

of a discussion paper regarding “ advanced nursing practice” of 

which extended expanded roles form a part. 

There has been relatively little work undertaken to develop 

competencies in this regard. 

A pilot project for the northern part of the Province has been 

approved involving delegated medical acts and collaborative 

practice. 

Reviewed by the Order of Nurses in December 1999 

Updated by information received from the Order of Nurses June 2000 

Ministry invited to comment- 






NEW BRUNSWICK 


Nurses Association of New Brunswick (NANB) 

Department of Health and Wellness 

Nurses on active practice RN roles 8700 

















The practice of nurses who are part of the Interdisciplinary 

Team/Shared Practice ( IT/SP) model in three rural sites ( 

Grand Manan, Lameque and Saint Quentin), and nurses who 

work in MacAdam, involves assessment, diagnosis etc. but 

to a limited extent and through delegation from physicians. 

The Clinical Nurse Specialist role in New Brunswick is not 

extended/expanded practice. They function mostly in 

mentorship /development roles. 

No special regulation/licensing at present. 

MacAdam Project - completed 4 years ago based on 

delegation of functions by protocol. This model is still being 

used and is being expanded to cover 8 additional facilities. 

Three ( 3) project sites have been designated as 

Interdisciplinary Team/Shared Practice ( IT/SP) Projects, 

again based on limited delegation of medical functions. Sites 

are: Lameque (most established), Grand Manan Island and 

St. Quentin. 

No separate title - referred to as RNs 

NANB has a position statement on advanced practice at 

Masters level. UNB has introduced a NP stream in its MN 

program. 

The nurses practising in the IT/SP projects were given 

additional educational programs prior to entering the role. 

Site specific protocols govern the delegation of function 






Public acceptance of extended/expanded roles for nurses in 

rural areas. 

Limited access to services due to shortage of physicians in 

geographic/specialty areas. 













nurses 




professions 




Physician resistance to extended/expanded nursing role 

without MD control 

Current funding mechanisms, i.e., fee-for-service, put nurses 

in competition with GPs 

Use of protocols for delegation of function is well fixed and 

substantial change in that model is not imminent 

The Association’s preference is for an autonomous role for 

nurses in advanced practice within Masters stream 

None reported 

New Brunswick Nurses Union 

The Department of Health and Wellness had undertaken a 

public consultation regarding several issues, including the 

role of nurses in expanded/extended roles. Although there 

was some confusion as to functions nurses could undertake, 

there was an intention by the previous government to 

support an extended role. Plans to implement an extended 

role for nursing suspended with the change in government. 

In the pilot site at MacAdam there was evidence of the 

acceptance of the extended role of the nurse. 

Physicians wish to retain direct control over any increase in 

extended/expanded practice for nurses 

New Brunswick is experiencing significant difficulties in 

recruiting and retaining physicians 





Government appears to be leaning towards increased 

funding to allow for greater placement of nurses in 

physicians’ offices rather than committing to introduction of 

extended/expanded practice initiative 

Reviewed by the Association December 15, 1999 

Updated with the input of the Department and the Association June 2000 






PRINCE EDWARD ISLAND 


Association of Nurses of Prince Edward Island 

(ANPEI) 

Department of Health and Social Services 


















None 

None 

Not applicable 

RN 

Not applicable at present. A degree program has been 

available at UPEI for undergraduate nursing education 

since 1994. It is unlikely that a program to educate nurses 

for extended/expanded roles will be available in the Province 

given the small population base of PEI. 

Not applicable at present. However, if there is movement 

toward the introduction of an extended/expanded role for 

nursing, the Association would establish guidelines etc. 

based on assessment of competency and in accordance with 

guidelines of the CNA. 


















nurses 




professions 




The Department of Health and Social Services is currently 

undertaking a discussion of a redesign of primary health care 

in the Province. Consideration is being given to the 

community health centre model which is based on increased 

collaboration between disciplines. 

If there is another role for nursing, it would not be physician 

substitution but be complementary to physicians. 

The need for a greater understanding of the role of the nurse 

in an extended/expanded role. Should the role be introduced, 

there would need to be education among health care 

practitioners and the public. 

There is a need to clarify the role of the nurse in an 

extended/expanded practice setting vis-a-vis other 

professionals. It would be important to stress the fact this 

role is complementary to physicians and not physician 

substitution. 

The need for flexibility for nurses in the role may be 

challenging given union contracts. 

The need for maintenance of competence is an issue, 

particularly should nurses become involved in 


Not applicable 

Prince Edward Island Nurses Union 

None raised 

Not at issue 

ANPEI believes that extended/expanded roles fall within the 

scope of nursing practice and therefore does not support the 

separation of roles within nursing and consequently would 

not support title protection, i.e. NP 





There was a family practice demonstration project over the 

past 2 years which has led to increased consideration of 

collaborative models. 

There are many issues to take into consideration in 

expanding nursing roles ( e.g., impact on physician 

remuneration, skepticism in the medical society ) 

Reviewed by the Association December 15, 1999 

Revisions suggested by the Association and the Department June 26, 2000 



NOVA SCOTIA 


Nurses on active practice RN roles 











Registered Nurses Association of Nova Scotia 

(RNANS) 

Department of Health & Community Services 

9300(est) 

No legislated extended/expanded practice. Clinical nurse 

specialists in tertiary care settings only. Demonstration 

projects underway in 4 locations for nurse practitioner 

practice. 

The selected demonstration sites. 

Four demonstration sites: 

< North End Community Health Centre-Halifax 

< Queens Community Health Centre-Caledonia 

< Pictou 

< Springhill 

Primary Care Nurse practitioner 




















Disciplinary or liability actions with 

respect to practice in 



nurses 




professions 




For demonstration projects, a NP certificate will be required 

from a recognized program, i.e. Alberta, Ontario or 

Newfoundland, or a licence to practice as a primary care 

nurse practitioner in another jurisdiction. 

Scope of practice is defined by delegation of function from 

physician under guidelines developed through discussion and 

negotiation between College of Physicians and Surgeons of 

NS and Registered Nurses Association of NS. 

There appears to be interest in the concept of nurse 

practitioners, especially in rural/remote areas of province. 

Nurse practitioners and physician consultants available to 

NP s at the demonstration sites. 

< Physicians retain control over ability of nurses to 

expand scope of practice (legislative dominance). 

< Funding mechanisms 

< Medical Act will need amendment 

< Pharmacy Act amended for demonstration sites only; 

regulations forthcoming 

Dalhousie University will be offering a Nurse Practitioner 

certificate program for rural and under served communities. 

None reported 

< Nova Scotia Nurses Union, and 

< NS Government Employees Union 

Calls for greater health care resources in rural/remote areas 

Medical Act powers require delegation of function to nurses 

None raised 




Reviewed by the Association and the Department of Health & Community Services December 

1999 

Updated with the input of the Association and the Department of Health July 2000 






NEWFOUNDLAND AND LABRADOR 

Organizations of contacted 

Association of Registered Nurses of Newfoundland 

(ARNN) 

Department of Health and Community Services 

















Nurse Practitioner - Primary Health Care (NP-PHC) 

defined under legislation. As well there are several regional 

nurses who practice under protocol agreement in 


22 NP and approximately 70 regional nurses 

Three Primary Health Enhancement Projects at Port-aux- 

Basques, Twillingate and Happy Valley-Goose Bay; 

Other sites include, but are not limited to, Bonavista 

Hospital; Ramea Clinic; Harbour Breton; Norris Point; 

Health Labrador Corporation and Grenfell Regional Health 

Services Board 

Nurse practitioner 

Regional Nurse 

Current RN practice certificate and at least 2 years practice 

for entry to Nurse Practitioner Program offered by Centre 

for Nursing Studies. Graduation with NP Diploma. 

Regional nurses require current registration as RN in 

Newfoundland. 

Scope of practice, standards of practice and competencies 

for NP- PHC developed and approved by regulatory body. 














There is stakeholder support for NP practice, acceptance by 

the ARNNL membership and by Regional Boards. 

Efforts are being made to enhance understanding in the 

community. As NP s are present in a number of settings, 

clinical competence demonstrated on-site. 

The ARNNL had initiative underway when Minister 

announced regulation introducing NP. 

Other professions lack of understanding of NP role 

Funding mechanisms; fee for service physician cannot bill 

for consultation with NP 

NP pay classification not nationally competitive 

Establishing the required collaboration with MD may prove 

to be problematic due to physician shortage 

Lack of prescribing authority for regional nurses (Grenfell 

Regional Health Services) 

Overlapping roles with Community Health nurses may 

present challenges 

The Physio- therapy legislation has been amended to allow 

referrals from NPs 

Experience with the regulations has highlighted the need for 

consideration of making consequential amendments to 

statutes to facilitate full scope of practice of NP, e.g., Vital 

Statistics Act 

The current entry requirement for practice is successful 

completion of the program for NP training offered through 

the Centre for Nursing Studies 

The policy position of the ARNNL is a minimum standard of 

BN with one year NP program that carries credit toward an 

MN degree. There is an issue of the local availability and 

access to education program(s) that satisfies the ARNNL 

preference. 





nurses 

None reported 

Newfoundland and Labrador Nurses Union 







professions 





No issues raised other than continuing calls from public for 

better health services in rural/remote areas 

Pharmacist regulatory body is concerned about issues of 

liability with respect to regional nurses and prescriptive 

authority. 

Physicians initially had concerns respecting their liability and 

NP practice. 

Assessing competency, maintaining competencies and the 

responsibilities of the employing organizations to support 

ongoing maintenance of competency. 

Further refining of definition of primary health care services, 

primary care services and how the NP role fits in the models 

for service delivery is needed. For example, developments 

in midwifery in the Province may impact on NP practice. 

Evaluation and research is required to ensure a cost 

effective model of service is in place. 

Reviewed by the Association December 1999 

Revised with assistance from the Association and the Department of Health & Community 

Services June 2000 






YUKON 


Yukon Registered Nurses Association (YRNA) 

























Community Nurse Practitioners working in rural 

communities practice in this capacity which falls within the 

current legislative framework. 

No central registry, so it is not possible for YRNA to 

specify numbers. Approximately 50 are employed by Health 

and Social Services, Government of Yukon in sufficiently 

extended/expanded roles to note in this survey 

12 rural communities have nurses acting in these roles, three 

of which also have physicians. 

Community Nurse Practitioner 

No fixed program approved by YRNA. (Employers accept 

a variety of options regarding education.) 

Employers have adopted the Medical Services Branch 

Scope of Practice for Community Health Nurses, Nursing 

Station facilities and Health Care Treatment facilities. 

Wide acceptance by the public of nurses practising in these 

roles 

Good cooperation from physicians and pharmacists 

No legislation planned in the immediate future and this is not 

viewed as a particular barrier by the YRNA. 

There are no indications of challenges from other health 

professionals. 











nurses 




professions 




Small number of YRNA members. YRNA is participating 

in multi-jurisdictional initiatives which seek to address these 

issues from a national perspective. 

None reported 

Unions represent both hospital and government-employed 

nurses. 

Public is satisfied with role nurses play in health care 

delivery and there is no indication that they would be 

adverse to a greater expansion of extended/ expanded 

practice for nurses 

Pharmacy Act Regulations were recently amended to allow 

direct prescribing. It is assumed that very little will occur 

under the authority of the regulatory changes until 

prescribing competencies are developed. 

YRNA’s legislative framework is sufficient to 

accommodate a significant level of extended/expanded 

practice. This has been confirmed by legal counsel. It is 

possible that additional regulations will be added in the 

future in order to address the issue of mobility of nurses 

moving to and from the territory. 


The territories are unique in their approach to nursing in 

extended/expanded roles. They have a pragmatic view of 

how best to deliver primary care in areas with physician 

under resourcing and there appears to be a high degree of 

cooperation with the Medical and Pharmacy professions. 

Information confirmed by the Association in December 1999 

Updated with the input of the Association and the Ministry July 2000 






NORTHWEST TERRITORIES 

**(see end of summary for reference to NUNAVUT) 


Nurses in active practice RN roles 


whose practice involves assessment, 

diagnosis and management of 

episodic, acute and chronic illness or 

injury as components of primary 

health care 



as described above 











Northwest Territories Registered Nurses Association 

(NWTRNA) 

Ministry of Health 

765 (*including nurses practising in Nunavut) 

NWT and Nunavut considers itself different from the rest of 

Canada in health care delivery in that organized delivery did 

not really occur until the 1950s. As a consequence, nurses 

have been practising in extended/expanded roles for many 

years. The territory has no specific legislation but is watching 

the CNA and other provinces initiatives with interest. 

765 nurses registered a majority would provide some level of 

extended/expanded services to clients 

Throughout the NWT and Nunavut under ten (10) Regional 

Health Boards. There are other employers of RN s such as 

non-profit organizations, clinics and mines. 

Usually simply referred to as Community Health Nurses but 

also as primary health care nurse practitioners 

Preference is for training through Aurora College 

“Introduction to Nurse Practitioner Programme” , however, 

this is not a fixed requirement. 

All extended/expanded practice is undertaken under the 

authority of protocols with the medical profession and 

employer organizations. 

Traditional role is widely accepted by the public. Good 

cooperation with physicians and pharmacists. 







roles for nurses posed by 

relationships with other health 

professionals 


and continuing education for nurses 

practising in extended/ expanded 

roles 





nurses 





No legislative basis for extended/expanded role at present. 

Given the relatively small population base and the relatively 

small number of members in Association, it will be difficult to 

carry out a major legislative initiative. The introduction of 

legislation could have a significant impact on the existing 

system that is built on delegation of function and co-operation. 

Joint statement (1998) from the NWT Medical Association 

and the NWTRNA calls for collaboration of the two 

professions in a model based on the delegation of medical 

function. 

NWTRNA is in the process of finalizing competencies for the 

Primary Health Care Nurse Practitioner. 

There have been incidents where RNs practising in 

extended/expanded roles (under delegation of function) have 

been the subject of disciplinary investigation. These incidents 

are not necessarily related to the extended/expanded role and 

are not viewed as being out of proportion when compared with 

other jurisdictions. 

Union of Northern Workers (NWT) 

Nunavut Employees Union (Nunavut) 

Public would be concerned if a more formalized role for 

nurses in extended/expanded practice lessened access to 

nurses providing point of first contact primary care 

The NWTRNA is currently lobbying for a new Act, finalizing 

competencies for Primary Health Care Nurse Practitioners, 

etc. 




Isolation, under resourcing of physicians, widely dispersed 

population means that NWT will likely continue with its 

present model until a national initiative is well established 

Information verified by the Association in December 1999 

Revised with comments from the Association and the NWT Ministry of Health and Social Services 

JULY 2000 







APPENDIX E 

Administration Survey Instrument 

Survey of Administrative Personnel in Identified Organizations: 

Nurses Employed in Extended/Expanded Roles 

Province: 

Organization Name: 

Contact: 

Person: 

Telephone: FAX: Email: 

Type of Practice: 

What are the scope of roles/responsibilities of nurses within your organization who practice in 

extended/expanded roles that involve assessment, diagnosis and treatment of episodic, acute and chronic 

illness and/or injury 

What are the titles or position descriptions used to describe these roles 

What client populations are the primary focus of this particular group of nurses 

What are the most common practice settings for care delivery Do you have nurse managed-clinics 

(Specify clinic types and whether or not physicians are required to be present on-site) 

What are the expected core competencies of nurses working in extended/expanded practice roles regarding 

common and unusual/atypical health problems 




Knowledge Levels (Specify areas): 

Skills/Abilities: (Specify) 

Clinical Judgments: (Specify) 

What is your organization’s expectation concerning the degree of autonomous practice to be assumed by 

nurses in these roles (e.g., independent caseloads, managing care in select settings, prescribing diagnostic tests 

and medications, making referrals, etc.) 

What is your organization’s position on the degree of collaborative practice expected of nurses in these roles 

(Special emphasis should be placed on gathering information on the health care provider mix - numbers of 

extended/practice nurses and other professional groups, including other types of nurses - as well as, 

expected/anticipated working relations) 

What degree of independence do these nurses have with regard to accessing resources 

Referrals: 

Clinic/Hospital/Community Services 

Lines of Authority: 

What lines of authority does your organization have for supervising/monitoring nurses who practice in 





Who is responsible for overseeing the clinical practice of nurses working in extended/ practice roles (e.g., 

nurse manager, physician, etc.) 




Job requirements: 

Does your organization have educational requirements for nurses working in extended/ expanded roles If 

so, what are they (e.g., completion of an approved program, degree in nursing, certification, etc.) 

Does your organization have requirements with regard to the number of years of practice as a registered 

nurse prior to employment in extended/expanded roles If so, what are your minimal requirements 

Are nurses working in extended/expanded roles within your organization required to participate regularly in 

continuing education activities If so, what type and how often 

Measures to Ensure Quality PHC: 

What organizational mechanisms are in place to evaluate/monitor nurses working in extended/expanded roles 

to ensure they have the necessary competencies to function independently with select client groups in 

specified settings 

Are there standard protocols operant which define/guide care delivery or do physicians supervise all 

extended/expanded activities (e.g., diagnostic tests, diagnosis, treatment, etc) 

Impact on Health Outcomes/Health Care Costs: 

Has your organization undertaken an independent evaluation of the impact of this type of nursing practice on 

client health outcomes and the cost effectiveness of service delivery If so, could you identify the type of 

research design (s) and summarize key findings. 




APPENDIX F 

Summary of Survey Data: Agency Administrative Personnel 

Province 

Location 

Position title 

Client populations 

Common practice settings 

Physician services 

Expectations regarding level of autonomous 

and collaborative practice 

Access to resources 

Lines of authority for supervising/ 

monitoring nurses in expanded roles 

Job requirements 

Core competencies 

Continuing education 

Authorities and protocol 


Site 1 (rural & remote) 

Nurse Practitioner 

Regular caseload is a mixture of clients with 

acute and chronic illness, as well as women’s 

wellness and the elderly. 

Hospital clinics and emergency department, as 

well as nurse-operated clinics in remote areas. 

Health care centres - physicians on-site; nursing 

clinics - physicians not on-site. 

Independent caseload and manage total care in 

nurse-run clinics. Collaborative practice with 

physicians and other health care providers. 

Initiates referrals and has access to most 

community resources; no hospital admitting 

privileges. 

Director of Patient and Resident Care Services at 

local hospital. Physicians do not supervise 

nurses’ practice. 

Extensive clinical experience in rural health care 

and a graduate of a certified Nurse Practitioner 

Program. 

Emphasis is placed on experience with a proven 

record of skills and abilities, sound clinical 

judgments, and dedication. 

Opportunities are provided via videoteleconference. 


Regulations. 




Province 

Location 
















Regional Nurse I & Nurse Practitioner 


acute and chronic illness. 

Community clinics, health care centres (HCCs), 

and the local hospital emergency department. 

Physicians are on-site at the HCCs but not 

community clinics. 

Collaborative practice with physicians at HCCs. 

Independent caseload and routine assessments at 


Initiates referrals and may access most 


privileges. 

Regional nurses Y immediate supervisor Y 

regional supervisor Y district coordinator Y 

assistant CEO of nursing services. 

Regional nurses: BN degree and 2 years of 

critical care experience preferred but not always 

met due to recruitment difficulties. 

Nurse Practitioner: Extensive clinical experience 

in rural health and graduate of a certified Nurse 

Practitioner Program. 

Intensive 6-week orientation to promote 

competency re skills/abilities, and soundness of 

clinical judgments. 

Expected to participate on a regular basis. 

Medical directives for regional nurses. 


Regulations. 




Province 

Location 





Site 3 (remote) 

Regional Nurse I 


acute and chronic illness. 

Community clinic. 


Physicians are not on-site, visit every 8 weeks. 










Independent caseload and routine assessments at 


The emphasis is on collaboration, with team 

conferences held regularly to review patient 

caseload. 

Initiates referrals and may access most 


privileges. 

Regional nurses Y regional nursing supervisor 

(nurse II) Y district coordinator Y assistant CEO 

of nursing services. 

Regional nurses: BN degree and 2 years of 

critical care experience preferred but not always 

met due to recruitment difficulties. 

Intensive 6-week orientation to promote 

competency re skills/abilities, and soundness of 

clinical judgments. Expected to have excellent 

assessment skills, and capable of working 

independently of, as well as collaboratively with, 

other providers. 

Mostly restricted to team conferencing. 

Medical directives. 




Province 

Location 















Site 4 (rural) 


Regular caseload is a mixture of clients from all 

age groups with acute and chronic illness. 

Health care clinics. 

Alternates clinics in 5 communities spread over a 

large geographic area with 2 physicians. 

Collaborative practice with physicians (i.e., runs 

clinics independently, but shares a caseload and 

consults with physicians by telephone when 

beyond scope of practice). 



privileges. 

Immediate supervisor is head nurse at local 

hospital but mostly physician supervision for 

clinical activities. 

Expected to have a wide-range of skills/abilities. 

Frequently expected to work beyond defined 

scope with clinical guidance provided by 

physicians. 

Access to continuing medical education activities 

which are available every month. 

Extensive clinical experience in rural health care 


Program. 


Regulations. 




Province 

Location 













Regular caseload is a mixture of clients from all 

age groups with acute and chronic illness. 

Health centre. 

Health Care Centres - physicians on-site; Nursing 

Clinics - physicians not on-site. 

Independent caseload (i.e., booked appointments 

& walk-ins), as well as a collaborative practice 

with physicians. 



privileges. 

Director of Patient and Resident Care on-site 

who reports to a site facilitator in nearby hospital. 





Two years clinical experience in rural health care 


Program. 

Expected to have a wide range of skills/abilities, 

and capable of working independently of, as well 

as collaboratively with, other providers. 

Weekly medical rounds via teleconference from 

the Faculty of Medicine, in-house education 

activities and nursing courses in a degree 

program. 


Regulations. 




Province 

Location 

Nova Scotia 

Sites 1 & 2 (urban) 

Position title Expanded Role Nurse * 






Hospital inpatients on cardiac, medicine, dialysis, 

geriatric, and neurosurgical units. 

Tertiary care facility. 

Physicians on-site. 

No autonomous practice. Collaborative practice 

with physicians and other health care providers. 








Initiates referrals to physiotherapy and 

occupational therapy, as well as health care 

providers in the community (e.g., social work, 

etc.). 

Immediate nursing supervisor, as well as 

physician for delegated medical functions. 

Masters of Nursing (completed or in-progress); 

and 3 to 5 years of clinical experience. 

Well developed skills acquired through knowledge 

and experience, as well as advanced clinical 

decision-making. 

Access to teleconferences and physician mentors. 

Must be re-certified annually to ensure that one is 

competent to perform delegated functions. 

Delegated functions under the Medical Act. 

* 

Note: Does not fit the criteria of working in primary health care settings. 




Province 

New Brunswick 

Location Site 1 














Registered Nurse - no extended class. 

General population. 

Community health centres. 


No autonomous practice for curative functions 

and has limited access to diagnostic tests. 

Collaborative practice with physicians. 

Restricted referrals as per protocols; no hospital 

admitting privileges . 

Physicians for delegated medical functions. 

Registered nurse. 

Basic RN skills/abilities at present. Growing 

recognition that nurses with BN level education 

are better prepared to handle expanded role 

functions. 

Strong emphasis is placed on the importance of 

continuous learning. There is however restricted 

access to continuing education resources. 

Negotiated protocols between physicians, 

employers, and Ministry of Health. 




Province 

Location 














New Brunswick 

Site 2 - rural & remote areas. 

Registered Nurse - no extended class. 


Local hospital - ambulatory clinics. 


No autonomous practice for curative functions 

and has limited access to diagnostic tests. 

Collaborative practice arrangements stymied at 

present. 

Restricted referrals as per protocols; no hospital 

admitting privileges . 

Immediate nursing supervisor, as well as 

physicians for delegated medical functions. 

Registered nurse. 

Basic nursing skills/abilities plus some extra 

training in trauma and multi-disciplinary team 

work. 

Only the training provided by employer. 

Negotiated protocols between physicians, 

employers, and Ministry of Health. 




Province 

Location 















None. 

No extended class. 

N/A. 

N/A. 

N/A. 

N/A. 

N/A. 

N/A. 

N/A. 

N/A. 

N/A. 

N/A. 




Province 

Quebec 

Location Sites 1 & 2. 














No nurses in extended/expanded class. 

N/A. 

N/A. 

N/A. 

N/A. 

N/A. 

N/A. 

N/A. 

N/A. 

N/A. 

N/A. 




Province 

Location 










Ontario 

Site 1 (urban) 

Registered Nurse - Extended Class. 

General population with special emphasis placed 

on the homeless & transient, high risk families and 

preschool children, and low income families. 

Community health centre clinics; works with 

vulnerable adults in their environment; drop-in 

centre; and a satellite clinic. 

Community Health Centre - salaried physicians 

on-site. 

Shares caseload with physicians; and provides oncall 

services in conjunction with physicians. 

Collaborative practice with physicians and other 

health care providers. 

Initiates referrals, however physician must cosign. 

Has access to most community resources 

but no hospital admitting privileges. 

Nurses and physicians work together to form a 

clinical team and report to the Executive Director. 

Job requirements RN - EC certification required, as well as 3 to 5 

years of progressive clinical experience in the 

health care sector. 




As specified by RN -EC Regulations. Able to 

work independently and deal with a broad range 

of issues. 

Available and expected for all employees. 

RN - EC Regulations and the College of Nursing 

Scope of Practice Guidelines. 




Province 

Location 







Ontario 



General population with a mix of aboriginal and 

Caucasian. 

Community health centre clinics. 

Salaried physicians on-site. 

Independent caseload. Collaborative practice 









New to role - full scope of responsibilities not yet 

realized. No hospital admitting privileges. 

Responsible to physician and administrator of 

centre. 

RN - EC certification required. 

As specified by RN -EC Regulations. 

None specified. 






Province 

Location 



Ontario 





Community health centre. 


Two salaried physicians on-site. 



Independent caseload and works collaboratively 









Initiates referrals with specialists, and does on-call 

in the emergency department similar to 

physicians. 

Physicians supervise NP. Executive Director 

supervises all staff. 



Available through RN - EC Network. Additional 

training provided as dictated by recognized needs. 






Province 

Location 














Ontario 



Mixed aged and ethnic group affiliations. 

Population groups with high needs - low SES 

families, the homeless, young teens, and young 

moms. 


Four physicians affiliated with centre - 3 PT and 

1FT. 

Independent caseload, and runs own clinics. 

Shared practice arrangement with 1 physician. 

Contacts physician on-call or on-site if needed. 

Initiates referrals directly to a variety of providers 

(e.g., gyneologists, emergency physicians, 

physiotherapist, & optomologists). No hospital 

admitting privileges or access to diagnostic 

facilities. 

Accountable to Executive Director. 



The centre pays for 5 continuing education days 

for NP to attend conferences. Monthly inservice 

is also provided. 






Province 

Location 







Ontario 


Registered Nurse -Extended Class. 

Inner city clientele - mostly women and the 

elderly. 

Satellite clinics - mostly in women’s shelters. 

Salaried physicians at centre. 

Independent caseload. Collaborative practice 









Initiates referrals, however physician must cosign. 

No hospital admitting privileges. 

Executive Director oversees the clinical practice 

of all staff. 









Province 

Location 














Ontario 



High risk groups. 


Two salaried physicians on-site. 

Independent caseload within scope of practice. 

Provides on-call services with physician backup. 



Initiates referrals to specialists and other health 

care providers. No hospital admitting privileges. 

Self-monitoring by clinical team. 

RN - EC certification required, and must have 

extensive clinical practice. 


Monthly inservice education activities. 

Encourages & supports participation in outside 

seminars. 






Province 

Location 








Ontario 



High transient population, and elderly with chronic 

conditions. 

Clinic associated with Health Authority. 

No physician on-site; monthly visits. 

New role in area - not yet defined. 

Initiates referrals to professionals within district. 



Reports to Director of Acute and Chronic Care 

who is located off-site. 







No established program but has internet access. 






Province 

Location 



Ontario 



General population - mostly women and children. 













Salaried physician on-site. 

Acts within legislated scope of practice. 

New clinic and role - uncertain about access. 

Executive Director supervises all staff. 



Experiential base with aboriginal peoples. 



Scope of Practice Guidelines 




Province 

Location 



Ontario 


Registered Nurses. 

Special groups - high incidence of chronic illness. 













No salaried physician on-site. 

Independently manages caseload. Clients are 

linked to physician resources within the 

community. Unable to prescribe medications or 

order diagnostic tests 

Referrals limited to physiotherapy and 

occupational therapy. 

Accountable to Nurse Manager. 

Preference is for BN degree but RN - EC 

certification not required due to limited 

extended/expanded role. 

Capable of forging strong collaborative relations 

with other health care providers and community. 

Mostly in-house inservice activities. 

Organization’s terms of reference. 




Province 

Location 














Ontario 



Large group of ethnic elderly, transient native 

population, and single moms and infants. Mostly 

chronic illness. 

Community health centre and a satellite station. 

Two salaried physicians at centre, but none at 

satellite site. 

Community health centre - independent caseload 

but also works collaboratively with physicians. 

The satellite clinic does not have a RN - EC. The 

nurses there have independent caseloads, provide 

on-call coverage, and do medical evacuations to 

acute care facility. 

Broad referral base but limited with regard to 

specialists. No hospital admitting privileges. 

Clinical Co-ordinator. 

RN - EC certification required and a minimum of 

3 years clinical experience but not always 

followed. 


Budget for continuing education activities. NPs 

also do course work regularly. 


Scope of Practice Guidelines. As well as the 

Hospital Act and medical directives for nurses 

without EC preparation. 




Province 

Location 














Ontario 



Low income families with a high percent of 

seniors and immigrants. 

Clinics mostly operated by nurses. 

Physician on-site for clinics. 

Independent activities as per legislation. Nurse 

consults with physician for 5% of cases. 

No information. 

Works within a multi-disciplinary team. 



As required by licensing body. 






Province 

Location 











Ontario 





Three salaried physicians on-site. 

No independent caseload. Multi-disciplinary team 

approach at Centre. Collaborative practice with 

physicians and other health care providers. 

Initiates referrals to obstetricians and other health 

care providers. No hospital admitting privileges. 

Accountable to Executive Director. 






Expected to participate in external and internal 

continuing education activities on a regular basis. 






Province 

Location 














Ontario 



Inner city population - mixed age and ethnic group 

affiliation, the homeless, and low SES. 


One to two physicians on-site. 

Independent caseload as per scope of practice 

guidelines. Collaborative practice arrangement 

with physicians. 

Initiates referrals to a variety of providers (e.g., 

specialists, occupational therapists, etc.). No 

hospital admitting privileges. 

Physicians do most of the supervision. 



Wide-range of education opportunities available in 

area. No organization requirements - actual 

participation is individual-driven. 






Province 

Location 














Ontario 



General population. Priority groups include 

seniors who pose an isolation risk, the homeless, 

and persons with HIV and AIDS. 

Community health centre, as well as an off-site 

clinic for the homeless. 

Three physicians on-site. 

Shares caseload with physicians. Collaborative 

practice arrangement with physicians and other 


Not able to refer to specialists. No hospital 

admitting privileges. 

Accountable to Executive Co-ordinator. 

RN - EC certification required, and must have a 

minimal of 3 years prior experience, preferably in 

a community health centre. 


None specified, individually determined. A small 

budget to support continuing education activities. 






Province 

Location 














Manitoba 


Nurse Practitioner. 

Inner city - mix of low and middle income 

clientele. 

Physician operated clinic. 

Salaried physicians at site. 

No independent caseload. Unable to prescribe, 

order diagnostic tests or perform certain 

procedures. Shares responsibility with physician - 

reports assessment findings and confers on 

treatment plans. 

Most referrals are co-signed by the physician. 

No hospital admitting privileges or authority to 

order diagnostic tests. 

Clinical supervision by Medical Director. 

None specified. However, nurse working at the 

clinic does have Nurse Practitioner Certification. 


Self-directed but must engage in continuing 

education to maintain NP certification. 

Transfer of function or delegation agreement. 




Province 

Location 














Manitoba 



Inner city/ethnic mix, including aboriginals and 

working poor. 

Clinics. 

Four salaried physicians on-site. 

Manages an independent caseload, but is unable 

to prescribe or do testing without physicians cosigning. 

Collaborative practice arrangement with 

physicians. 

Initiates referrals but must be co-signed by 

physician. No hospital admitting privileges or 

authority to order diagnostic tests. 

Reports to physician on clinical matters, and to 

Director of Operations on administrative matters. 

Nurse Practitioner Certification. Prior clinical 

experience is preferred. 


Self-directed but must engage in continuing 

education to maintain NP certification. 

Delegated medical functions. 




Province 

Location 














Manitoba 


Registered Nurse. 

Inner city clientele. 

Physician operated clinic. 


Nurses in the clinics do not perform primary care 

functions (i.e., assess, diagnose or prescribe). 

The focus is restricted to prevention and 

promotion activities, and community development. 

N/A. 

N/A. 

N/A. 

N/A. 

N/A. 

N/A. 




Province 

Location 














Manitoba 



Inner city clientele. 

Resource centre and primary care clinic. 


Independent caseload and performs advanced 

practice roles. Unable to prescribe, but may order 

diagnostic tests with a physician co-signature. 

Collaborative practice arrangement with physician 

and other professionals. 

Initiates referrals to physiotherapist, chiropractor, 

and nutritionist. Physician must co-sign when 

referring to medical specialists. No hospital 


Immediate clinical supervisor and program 

manager. 

BN with several years experience working in 

under-serviced areas - recruitment/retention 

difficulties. 

Well-developed set of skills and abilities in 

performing primary care functions. 

Regular participation in inservice activities, 

relevant continuing medical education, and 

distance education courses. 

Delegated functions under the Collaborative 

Practice Guidelines developed between the 

physicians, nurse practitioners, and employer. 




Province 

Location 












Saskatchewan 

Site 1 (Northern - rural & remote) 

Primary Care Nurse. 

General population, excluding First Nations. 

Community health centres or nursing stations. 

Physicians not on-site; usually visits once per 

week. 

Nurses are often the only health care provider. 

Manages independent caseloads, and prescribes 

and dispenses medication through central 

pharmacy. Expected to consult with physician by 

telephone. 

Initiates referrals to available services (e.g., 

physicians, mental health workers, etc.). 

Immediate nursing supervisor. 

RN diploma or BN with hospital experience. 

Retention/recruitment difficulties. 

Minimal requirement of basic life support training. 



Regular inservice with visiting physician. Other 

continuing education opportunities are via 

telehealth, specialist inservice activities, and 

attending one conference annually. 

Delegated medical functions based on protocols 

negotiated between Medical Society, Nursing 

Association, Ministry of Health, & employers. 




Province 

Location 














Saskatchewan 




Community health centre and off-site clinics in 

other communities. 

Physicians present at health centre but not off-site 

clinics. 

Community health centre site: Balance between 

independent and collaborative functions. Consults 

with physicians directly or by telephone regarding 

clients. Manages an independent caseload, and 

prescribes and dispenses medication through 

central pharmacy. 

Initiates referrals to available services (e.g., 

physicians, mental health workers, occupational 

therapy, etc.) within particular project area. 

Physician supervises clinical functions. 

Completion of advanced clinical program at the 

Saskatchewan Institute of Applied Technology. 

Meet physician competency expectations with 

regard to the performance of each delegated 

function. 

Encouraged to participate in medical and nursing 

continuing education activities. 







Province 

Location 














Saskatchewan 






Collaborative practice re multi-disciplinary teams. 

Shared caseload among team members. PCN 

may assess, diagnose, and treat, as well as 

prescribe and dispense medications. 

Initiates referrals to other professionals (e.g., 

physiotherapy, etc.), however, medical referrals 

are done by physician. No hospital admitting 

privileges. 

Physician supervises clinical functions. The 

primary care nurse must also report to site 

manager. 


Saskatchewan Institute of Applied Technology 

(SIAT). Minimum of 2 years experience in 

primary health preferred. 

As per expected competencies following 

graduation from the SIAT program. 

Self-directed ongoing education to maintain 

acceptable level of competency in performing 

delegated functions. 

Transfer of functions - umbrella document 

negotiated between medicine, nursing, and 

pharmacy regulatory bodies. 




Province 

Location 














Saskatchewan 



General population, including Aboriginal people on 

and off reserves. 

Community health centre and off-site clinics in 

other communities. 

Salaried physicians on-site. 


health care providers. Degree of autonomous 

practice as per protocols. Some authority to 

prescribe and dispense medications. 

Initiates referrals to other professionals (e.g., 

physiotherapy, etc.), however, medical referrals 

are done by physician. No hospital admitting 

privileges. 

Physician supervises clinical functions. 


Saskatchewan Institute of Applied Technology. 

Expected competencies in-line with those of the 

SIAT program graduates. 

Self-directed but opportunities are provided to 

upgrade basic life-saving and trauma skills. 







Province 

Location 














Alberta 


Public Health Nurse. 

General population - predominance of 

Mennonites. 

Nurse-managed clinics. 

No physician on-site. 

Independent caseload. Initial assessment, 

diagnosis, and treatment - stabilizes patients for 

transfer to hospital via ambulance. 

Initiates referrals to physicians but not specialists. 

No hospital admitting privileges. 

Immediate nursing supervisor. 

BN with an advance practice certificate. 

Minimum of 3 to 5 years clinical experiences as a 

registered nurse. May obtain a special certificate 

for prescriptive authority. 

The advance practice certificate prepares nurses 

with the necessary skills and abilities to provide 

extended health services. Must demonstrate 

competency in delegated functions prior to 

independent work. 


Amended Public Health Act (1995) and 

accompanying regulations to cover extended 

practice. 




Province 

Location 














Alberta 


Registered Nurse - Expanded Practice (RN -EP). 

Under-served populations - homeless and clients 

with complex needs (e.g., mental health & 

addiction issues, etc.). 

Family Resource Centre and clinics on-site, as 

well as off-site at a shelter. 

Physician on-site. 

Works independently as per RN -EP scope of 

practice guidelines. Collaborative relations with 

other health care providers and consults with 

physicians as required. 

Initiates referrals to specialists but physicians 

must co-sign. No hospital admitting privileges. 

Medical Co-ordinator oversees clinical practice, 

and the Executive Director administrative 

matters. 

RN-EP certification. Minimum of 3 to 5 years 

clinical experiences as a registered nurse. May 

obtain a special certificate for prescriptive 

authority. 

As expected of graduates from a certificated 

outpost/primary health program. 

Self directed - invited to attend relevant continuing 

medical education activities. 



practice. 




Province 

Location 


Alberta 


Community Health Nurse. 

Client populations Non-reserve Aboriginal population in 3 

communities. 












Site clinics. 

No physician on-site; visits every 1 to 2 weeks 

and holds clinics. 

Independent caseload. Nurse is expected to 

practice autonomously but site has limited testing 

capabilities. Regular case-conferencing takes 

place between physician and nurse. Prescribes 

and dispenses medications as per Nursing 

Association Guidelines. 

Initiates referrals to physicians and other 

professionals, but not specialists. No hospital 

admitting privileges. No access to pharmacies 

and thus dispenses medication through formulary 

(i.e., in-house supply of drugs). 

Medical Co-ordinator oversees clinical practice, 

and the Executive Director administrative 

matters. 

Clinical experience in North with Medical Service 

Branch. May obtain a special certificate for 

prescriptive authority. 

Expected competencies following completion of 

the Medical Services Branch program. 

Internet access but no job specifications. 



practice. 




Province 

Location 
















Community Health Nurse (expanded role). 

First Nations on reserves. 

Nursing stations and health centres. 

No physicians on-site. 

Nurses carry an independent caseload, and are 

expected to practice autonomously (i.e., initial 

assessment, diagnosis, & treatment within 

defined scope). Expected to work collaboratively 

with physicians where possible. Consults with 

physicians via telephone as required. 

Initiates referrals to physicians. Must consult 

with physician for referrals to other health care 

providers. No hospital admitting privileges, must 

go through physician. 

Nurse-in-charge ´ Zone Nursing Officer ´ 

Regional Nursing Consultant. 

Bachelor of Nursing and/or completion of the 

Primary Care Clinical Nursing Program. 

Minimum of 1 year experience in acute care. 

Expected competencies following completion of 


Re-certification required every 2 years in 

delegated medical functions. 

Medical Services Branch Scope of Practice 

Guidelines. 




Province 

Location 

















General population. Special focus is on individuals 

with chronic illness. 





assessment, diagnosis, & treatment within a 

restricted scope of practice). No ability to order 

diagnostic tests or prescribe medications. Clients 

are linked with community resources, such as 

physicians. Nurses work in collaboration with 

clients and physicians. 

Initiates referrals to physiotherapy and 

occupational therapy. No hospital admitting 

privileges. 

Nurse Manager. 

Bachelor of Nursing is preferred. 

Basic nursing skills & abilities plus strong rapport 

with community. 

Participation in inservice opportunities. 

Nurses are not considered to be in expanded roles 

requiring legislation. 




Province 

Location 















Site 3 (rural, remote & urban) 

Registered Nurse - Nurse Practitioner. 

General population in small communities. 

Special focus on vulnerable populations (e.g., 

drug-users, frail elderly, street youth, young 

families, etc.) in urban areas. 

Health centres with nurse only and multidisciplinary 

type clinics. 

Physicians on-site, except for remote areas. 



assessment, diagnosis, & minor treatment). Also 

may prescribe medications, monitor chronic 

illness, and provide short-term in-patient care. 

Nurses work in collaboration with physicians who 

usually sign off charts. 

Refers patients when appropriate. Also stabilizes 

for medical evacuation in remote areas. 

Administrator who is usually a nurse. 

Basic nursing education. 

No core competencies identified to date. 

Self-directed. 

Protocols vary from centre to centre. Nurses 

practice within clinical guidelines. 




Province 

Location 
















Nurse Practitioner (unofficial). 

Mostly women; some family health and seniors. 

Multi-disciplinary clinics. 

Physicians on-site, except for remote areas. 

Nurses practice autonomously (i.e., first contact, 

initial assessment, diagnosis, & independent 

management). Unable to prescribe medications 

but can order limited diagnostic tests. Nurses 

work in collaboration with physicians and other 

team members (i.e., clinical pharmacist, 

nutritionist, counsellor, & dentist). 

Refers patients when appropriate, but must first 

consult with a team physician. 

Head physician for clinical issues, and Executive 

Director for other matters. 

Bachelor of Nursing with 2 years experience in a 

community setting. 

Competent to perform delegated primary care 

functions. 

None specified but encouraged to participate in 

available continuing medical education. 

Clinical guidelines/protocols in place; physicians 

have ultimate responsibility. 




Province 

Location 




Registered Nurse (Outpost Hospital Nurse). 

Client populations General population in small communities. Most 

sites have a high percentage of First Nations 

people. 












Outpost hospitals. 

No physicians on-site, but provide intermittent 

services. 

Nurses have independent caseloads, and are 


assessment, dx, minor treatment) and prescribe 

mads as per MSB guidelines. Also must 

collaborate with physicians and other providers 

during site visits. 

Consult with and refer to physicians and 

emergency department of referral hospital. 

Responsible for stabilization and medical 

evacuation of patients during emergencies. 

Unable to order diagnostic tests. 

Off-site manager. 

Basic nursing education with extra skills (e.g., 

suturing, intravenous initiation, physical 

assessment, etc.). Minimum of 5 years of general 

practice in adult medicine/ surgery, pediatrics, and 

obstetrics. 

Competent to perform physical assessments and 

identify need for referrals/consultations. 

CPR update & annual in-house inservices. 


Guidelines; and Red Cross Emergency Protocols. 




Province 

Location 




Registered Nurse (expanded role). 

Client populations Across the lifespan with most clientele under 60 

years of age. 






Health centre. 


Nurses practice autonomously (i.e., assessment, 

problem identification, & management) within 

approved protocols. Limited collaboration with 

physicians except as dictated by protocols. 

Refers patients to on-site physician, except on 

weekends when referrals go to the local hospital. 




Nurse manager on-site. 

Registered nurse with RN - First Call training. 

Minimum of 2 years emergency room experience. 



Assess, diagnose and manage care as outlined in 

protocols. 

Encourage to participate. 

Authorities and protocol Delegation of functions as per 10 protocols and 2 

standing orders covering such conditions as otitis 

media, urinary tract infection, 

lacerations/abrasions, minor thermal burns, among 

others. 




Health Canada 

Location 














Medical Services Branch (MSB) 

Sites (Northern remote lands - Federal 

jurisdiction) 


General population, primarily First Nations people 

on reserves. 

Nursing stations. 


Nurses are often the only health care provider, 

and work in advanced practice roles. Expected to 

consult with physician by telephone as required. 

Prescribes and dispenses medications as per 

scope of practice guidelines. 

No access to pharmacies and is therefore 

required to dispense medication through formulary 

(i.e., in-house supply of drugs). Stabilizes 

patients for medical evacuation. 

Nursing Supervisor and Practice Consultant. 

RN diploma and current registration with a 

regulatory body. Retention/recruitment 

difficulties. 

General nursing with knowledge of community 

health. Expected competencies re performance 

of primary care functions following completion of 


Expected to participate in “zone” conferences. 

MSB Scope of Practice Guidelines. 




Territory 

Location 














Nunavut/North West Territories 

Sites (rural & remote) 

Community Health Nurse. 

General population - mostly Inuit. 

Health centres. 

No physicians on-site, but are available for 

referrals and make monthly on-site visits. 


expected to practice autonomously (i.e., assess, 

diagnose, & treat within defined scope). 

Collaborative practice arrangements between 

nurses and physicians. Nurse consults with 

physicians via telephone as required, and 

prescribes medications as per North West 

territories Nursing Association (NWTRNA) 

Guidelines. 

Initiates referrals to physicians, as well as some 

specialists (e.g., psychiatrists, etc.). Possible to 

order some diagnostic tests. No direct hospital 


Nurse Manager ´ Director of Patient Services. 

Preference is to have nurses with community 

health, primary care, or outpost experience. 

Nurses with emergency/intensive care experience 

are also considered. Difficult to recruit and retain 

nurses. 

None specified at present but currently developing 

guidelines. 


MSB Scope of Practice Guidelines and 

NWTRNA Guidelines. 




Territory 

Location 














Yukon 

Sites (rural & remote) 


General population - cultural/ethnic mix. 

Nurse-managed clinics. 

The norm is not to have physicians on-site, with 

one or two exceptions. Physicians are available 

for referrals and visit sites every 2 to 3 weeks to 

hold a 1-day clinic. 


expected to practice autonomously (i.e., assess, 

diagnose, & treat within defined scope). Must 

work collaboratively with physicians, when 

possible, and consult with them via telephone as 

required. Prescribe medications as per MSB 

Guidelines. 

Initiates referrals to physicians and other 

providers but not medical specialists. Possible to 

order some diagnostic tests. No direct hospital 


Nursing Supervisors ´ Managers ´Director of 

Community Nursing Programs. 

Preference is to have nurses with a BN degree 

and graduates of recognized outpost or clinical 

skills programs. Minimum of 2 years experience 

in an acute care setting. 

Expected to be competent in performing 

recognized outpost or clinical skills. 

Required to attend annual 5-day conference for 

clinical updating. 


Guidelines. 



Supporting Document 2 

Evaluation of Nursing Practice Models in Primary 

Health Care Settings 

Principal Investigator: 

Christine Way, PhD 

Co-Investigators: 

Colleen Hanrahan, John Housser, & Madge Applin 

Date: January 12, 2000

TABLE OF CONTENTS 

Significance of the Problem 1 

Background 2 

Purpose and Research Questions 4 

Methodology 5 

Population/Sample 5 

Procedure 6 

Instruments 7 

Data Analysis 8 

Ethical Considerations 9 

References 10 

Appendix A: Summary of Research Study 12 

Appendix B: Consent Forms 14 

Appendix C: Interview Schedules 23 

Appendix D: Patient/Client Survey 28 

Appendix E: Observational Checklist 32 

Appendix F: Letter of Support 37 

i

There is an increasing trend in the health care sector to employ registered nurses to perform primary 

care functions in a variety of settings. Nurses working in advanced practice roles have come under the 

scrutiny of health care providers, researchers, and developers of public policy at different times over the past 

decades. Clinical and research data support the positive effects (e.g., increased availability of and accessibility 

to health services, delivery of quality care, achievement of health outcomes equal to or superior to physicians, 

decreased impact on physician workload, increased patient/client satisfaction, etc.) of nurses working in 

advanced or extended/ expanded roles (Brown & Grimes, 1995; Chambers & West, 1978; Feldman, Ventura, 

& Crosby, 1987; Reveley, 1998). However, it is less clear which nursing practice models provide the most 

effective and efficient care and, most importantly, how the environmental context facilitates or inhibits the 

performance of extended/expanded nursing roles. 

1 

Several studies have investigated the influence of clinical settings on the utilization of nurse 

practitioners (NPs) and, to a lesser degree, the job expectations and satisfaction of NPs. The most consistent 

barriers to or facilitators of role development and performance identified from the research literature were 

resistance/acceptance by other health care providers, especially physicians, efforts expended by the 

organization/agency to formalize the role (Crosby, Ventura, & Feldman, 1987; Hupcey, 1993; Reveley, 1998), 

and legal/legitimate status of the role (Reveley, 1998; Torn & McNichol, 1998). Additional aspects of the 

practice setting identified to influence role performance and NPs’ job satisfaction include the scope of patient 

care activities, degree of autonomous and independent practice, and sense of achievement/ accomplishment 

(Hupcey, 1993; Koelbel, Fuller, & Misener, 1991; Torn & McNichol, 1998; Tri, 1991). 

The current study is being undertaken at a time when there is a lack of consensus on what constitutes 

extended/expanded nursing practice roles in primary health care settings, as well as provincial/state variations 

on the degree to which these roles are legitimized through legislation. Further, within the Canadian health care 

system, a number of advanced practice roles have evolved and are being delivered in a variety of ways and 

guided by diverse protocols. The provision of quality care can be quite a challenge for any health care 

system, especially one operating under severe cost restraints. Given the current pervasive downsizing and 

restructuring initiatives in the health care sector, there is an increased urgency to document facilitators of and 

barriers to the full realization of extended/expanded nursing practice roles in different clinical settings. This 

kind of data base is needed to ensure the maximum utilization of scarce resources. 

Significance of the Problem 

It has been postulated that registered nurses working in extended/expanded practice roles in primary 

health care settings provide more effective avenues for addressing consumers’ needs, enhancing health, and 

facilitating positive health outcomes than traditional medical programs. Extended/expanded roles are based 

on nursing practice models which provide basic health care services (e.g., assessment, diagnosis and 

treatment of episodic, acute and chronic illness and injury), as well as health promotion and maintenance 

activities, to all people at different stages of health and illness. It is also conjectured that higher quality care

will result when extended/ expanded nursing practice roles are implemented through a collaborative network 

of nurses, physicians, pharmacists, nutritionists, and physiotherapists, among others. 

2 

Within the Canadian context at the national, provincial and regional levels, important issues are being 

raised concerning the definition and role functions of nurses engaged in extended/expanded practice. The 

concepts of nurse practitioner, extended class, and expanded practice are used to identify nurses who perform 

clinical functions outside the traditional scope of nursing practice. Significantly, the nursing profession is 

struggling to define the boundaries/parameters of its practice while ensuring that its members are providing 

quality care that is supported by sound research. An integral component of this process are the efforts 

directed toward standardizing education programs that prepare nurses for extended/expanded practice roles. 

There is also a general desire by the nursing profession to ensure that its members receive recognition for and 

legitimization of the true scope of nursing roles and functions. 

During the initial stages of the current project, all relevant provincial/territorial legislation and 

regulations were reviewed and a cross country survey of key informants undertaken to document existing 

information on nursing practice models. Data were gathered from consultants at the nursing associations 

concerning the regulation of, as well as the policy and standards for, nursing practice in their jurisdictions. 

As well, representatives of select provincial/territorial Ministries of Health were contacted to augment/clarify 

information received from the nursing associations. Finally, administrative personnel from different 

agencies/organizations which employ nurses to work in extended/expanded practice roles were surveyed. 

The preliminary findings suggest that there are significant differences among the approaches used to deliver 

extended/expanded nursing services. Although there are a number of possible explanations for these 

disparate conditions, one significant factor influencing the enactment of nursing roles in each jurisdiction is 

the environmental context (i.e., legislative, regulatory, employing organization, nurse/physician relationships, 

etc.). 

A significant next step in the evaluation process is to explore health care providers’ and 

patients’/clients’ experiences with extended/expanded nursing practice in primary health care settings. The 

positives and negatives of different nursing practice models must be understood if health care providers are 

to achieve the best possible care outcomes in the short and long term, while doing so in a cost-effective 

manner. The primary objective of the current study is to identify aspects of nursing practice models which 

are most and least helpful in facilitating extended/expanded nursing practice. This objective can be achieved 

through a data collection approach which involves conducting interviews and participant observation sessions 

with those who are performing the extended/expanded role, interviewing collaborating physicians, and 

surveying patients/clients. 

Background 

Clinical and research findings suggest that settings which employ nurses in extended/expanded roles 

to provide primary care functions, along with prevention and health promotion services, are as effective as,

and in some cases superior to, traditional medical programs in achieving positive patients/clients health 

outcomes. A brief summary follows on select published articles that reported on the effectiveness of 

extended/expanded nursing practice, key aspects of the process of care, and factors present in clinical settings 

that may enhance or hinder role performance. 

3 

Feldman et al. (1987) conducted an analysis of 248 articles, published between 1963 and 1983, dealing 

with nurse practitioner (NP) effectiveness. Reviewers with expertise in the content area and in health care 

research design were selected to assist with the analysis. The findings indicated that nurse practitioners 

(NPs) provided cost effective care at an equal or higher quality level than physicians. Further, NPs improved 

health care access in rural areas and to underserved populations, and achieved better or equivalent health 

outcomes than physicians. Significantly, patient acceptance of and satisfaction with the care provided by NPs 

was high, especially with regard to interpersonal skills, provision of useful information, and promoting 

understanding of condition/illness. 

In a second article on NP effectiveness, Crosby et al. (1987) presented an overview of key study 

findings related to process and a discussion on areas requiring further research. With regard to process 

indicators, the authors noted that NPs were working predominately in ambulatory care settings and 

physicians’ offices. NPs were performing a wide-range of expanded nursing practice and physiciansubstitute 

activities, ranging from diagnoses through treatment to follow-up, but mainly for well clients or 

patients with chronic and mixed health problems. Full utilization of NPs skills and abilities was curtailed by 

restrictions imposed by the employing agency. Based on the studies foci and tentative findings due to 

methodological shortcomings, certain key areas were identified for further inquiry, including cost implications, 

uniqueness of the role, impact of the practice setting on effective care delivery, educational preparation 

requirements, short and long term impact on health outcomes, and factors that enhance or impede care 

delivery by Nps. 

In a meta-analysis of 38 well-designed studies on NPs performing primary care functions in 

community or hospital based ambulatory care settings, Brown and Grimes (1995) examined the effects of NP 

versus physicians on health outcomes. The analysis revealed that NPs outscored physicians on some process 

indicators (i.e., health promotion activities, time spent with patients, referrals/consultations, and diagnostic 

tests) but equalled physicians on others (i.e., quality of care, number of visits per patient, and number of drug 

prescriptions). NPs were more likely than physicians to achieve better clinical outcomes in certain areas (i.e., 

resolve pathological conditions, fewer hospital admissions, and receive greater patient satisfaction and 

compliance) but equalled physicians in others (i.e., patients’ functional status and emergency room use). The 

authors concluded that the research evidence suggests that NPs can manage common aliments and chronic, 

stable conditions as well as, or better than, physicians in a cost-effective manner. 

In a descriptive study, Courtney and Rice (1997) examined the process of care implemented by NPs 

during interactions with patients at a family practice clinic. Twenty NP-patient interactions were randomly 

selected for videotaping sessions. The data were coded with an observational rating tool - Nurse Practitioner

Rating Form - in three areas: activity (e.g., history, examinations, procedures, advice, consultation, etc.), 

content (i.e., somatic/psychosocial aspects of presenting problem, and somatic/ psychosocial aspects of health 

promotion), and global scales measuring provider communication and client participation. The findings 

indicated that the NPs averaged 18 minutes per visit with clients, with communication and interpersonal 

activities accounting for two thirds of the time. While NPs spent most of the time (61%) engaged in 

assessment activities (i.e, history taking and physical examination), an additional 29% of the time was spent 

with management activities (i.e., giving advice, facts, explanations, or demonstrations). Significantly, about 

90% of the NP’s attention was directed towards the physical aspect of the client’s problem and only 1% of 

the time on the physical or psychosocial aspects of health promotion. The authors stressed the need for more 

research to document the nature and content of primary care encounters in order to identify the most 

important aspects of effective primary care practice. 

4 

Moody, Smith, and Gleen (1999) investigated the client populations and practice patterns of a random 

sample of NPs (N = 44) working in primary care settings in Tennessee. The Nurse Practitioner Ambulatory 

Client Care Survey was used to collect data on 680 NP-client encounters during a one day period. Study 

findings indicated that most (81%) of the NPs’ clients had been seen previously by a provider in the same 

setting, with hypertension, ear and respiratory infections, and diabetes mellitus the most common medical 

diagnoses. Further, NP-client encounters averaged 17 minutes in duration, with teaching/counselling and 

writing prescriptions for antibiotics or analgesics the most frequently reported therapeutic interventions. 

In a descriptive study of a random sample of NPs (N = 80) working in Pennsylvania, Hupcey (1993) 

investigated key aspects of practice settings that helped or hindered role performance. Study findings 

indicated that most respondents held a masters of nursing degree (64%), worked in primary care or 

community clinic settings (51%), and had been employed in more than one position as a NP. With regard to 

factors that facilitated or hindered role performance, the most important were acceptance and support from 

other health care providers (i.e., physicians, coworkers, and other NPs), as well as the degree of 

independence enjoyed in the work setting. 

Purpose and Research Questions 

Despite the extensive research base supporting the positive effects of extended/expanded nursing 

practice, what is not so well-documented are those practice models that are capable of facilitating the greatest 

access to quality health care services and, thereby, promoting the best possible health outcomes for all levels 

of patient/clients. The purpose of the proposed study is to develop a greater understanding of health care 

providers’ and patients’/clients’ experiences with the extended/expanded nursing role in primary health care 

settings with similar and different nursing practice models. This study has the potential not only to increase 

our understanding of the positive and negative aspects of nursing practice models that are directing nurses 

performance of extended/expanded roles in primary health care settings but, most importantly, to build upon 

the identified strengths.

5 

The current study will address the following research questions: 

1. What are the experiences of registered nurses performing primary care functions in primary health 

care settings 

2. What are the experiences of physicians working with nurses in extended/ expanded practice roles 

3. What are the experiences of patient/clients receiving care from nurses working in extended/expanded 

practice roles 

4. What aspects of the practice setting enhance or hinder the practice patterns of nurse 

practitioners/regional nurses 

5. Which nursing practice models do nurse practitioners/regional nurses find the most/least helpful for 

addressing patient/client needs 

Methodology 

The proposed field study is designed to describe and evaluate nursing practice models operant in 

primary care settings where nurses function in extended/expanded roles. When the objective is to investigate 

complex and variant phenomena, multiple triangulation methods are recommended to enhance the reliability 

and validity of study findings. The proposed study design combines data, investigator and methodological 

triangulation. By using a flexible methodological approach, the rich data that emerges will provide meaningful 

insights into practice patterns that are perceived to be most and least helpful in facilitating movement towards 

positive health outcomes. 

Population and Sample 

The population of interest is physicians working with and nurses working in extended/expanded roles 

in primary health care settings in the provinces of Newfoundland, Ontario, and Saskatchewan. A second 

target population is patients/clients receiving care from nurses performing these roles at different provincial 

sites. The provinces selected for onsite data collection have either recognized, through legislation, the 

extended/expanded functions of registered nurses or have longstanding protocol agreements negotiated 

between medical and nursing regulatory bodies, agencies/organizations, and Ministries of Health. Three 

potential sites have been selected from each provincial jurisdiction that reflect similar, but slightly different, 

models of practice. 

The total population of physicians working with and nurses working in extended/expanded practice 

roles will be asked to participate in the study at each site. In addition, a purposive sample of patients/clients 

will be recruited for participation in the study during a scheduled visit to the centre/clinic when the 

interviewer/observer is present at the site for data collection. Because the objective of qualitative research 

is to obtain data that are comprehensive and insightful, the large volume of narrative data generated by 

different methods across different population groups will preclude enlisting a large number of participants.

Theoretical sampling will be used during data collection and analysis to assess the data’s representativeness 

(i.e., in accordance with the theoretical needs and direction of the research) and determine the final sample 

size (Sandelowski, 1995). 

6 

Procedure 

Data collection will consist of a combination of interviews and participant observation sessions with 

nurses and physicians working at identified sites, as well as a survey of patients/clients accessing the 

resources at the centre/clinic. This phase, depending on the number of participating sites, is expected to 

require three to four weeks to complete. 

Nurses and physicians will be identified through consultation with personnel from 

management/administration. The contact person(s) will approach staff members to briefly explain the study, 

provide them with a summary sheet of the project (see Appendix A), and ascertain their willingness to be 

contacted by a member of the research team. Those who indicate an initial willingness to participate in the 

study will be contacted by a member of the research team during their regularly scheduled working hours. 

The study will be explained more fully and any questions/concerns addressed at this time. Interviews and/or 

participant observation sessions will be scheduled at a mutually agreed upon time. 

Health care provider group. Nurses and physicians will be asked to provide information on certain 

demographic variables (e.g., age, education, length of time in this type of practice, etc.) prior to the interview. 

In-depth, ethnographic interviews will be conducted with each physician working with and nurses working 

in extended/ expanded practice roles. Informed, written consent will be obtained prior to the beginning of the 

interview (see Appendix B). With participants’ permission, all interviews will be audio-taped. In-depth 

interviews will be conducted using a semi-structured interview schedule (see Appendix C). It is anticipated 

that interviews will take approximately 60 to 90 minutes. 

One or two participant observation sessions will also be scheduled with nurses working in 

extended/expanded practice roles while they perform normal centre/clinic activities. The observation sessions 

will be conducted on the same day of the interview and/or the following day depending on nurses’ 

centre/clinic responsibilities. Observational checklists will be used to collect data on each nurse-patient/client 

encounter (see Appendix E). 

Patient/clients. Patient/clients will be approached by an interviewer/observer during a regularly, 

scheduled centre/clinic visit. The rationale for the study will be explained to them and any questions/concerns 

addressed. If they indicate a willingness to participate, they will be given a copy of the survey instrument to 

complete at this time (see Appendix D). The survey questionnaires are designed so that patients/clients are 

able to fill out the questionnaires anonymously while waiting to see the nurse. Thus, informed, written consent 

is not required for this group of participants.

7 

Instruments 

The interviews/observations with health care providers are intended to elicit commentary on 

experiences and practice needs. Given the importance of the interview/observation processes in eliciting a 

rich data base in qualitative inquiries, training sessions will be conducted with each interviewer/observer prior 

to data collection. These sessions will be conducted by the principal investigator who has an extensive 

theoretical and experiential basis in qualitative research. The training sessions will emphasize the importance 

of paying attention to what is being conveyed by the verbal reports/observations, probing for clarifications of 

participants’ meanings, and being sensitive to emotional responses that may indicate participant discomfort 

and/or difficulty with certain topics/sessions. 

Interview Schedule. The interview schedule, developed for this study, was designed to explore key 

aspects of study participants’ experiences working in extended/expanded roles, or working with nurses 

performing extended/expanded practice roles (see Appendix B). Probes and question content comprising the 

interview schedule were based on relevant literature. Although interviews will be guided by the topics 

covered by the interview schedule, many additional questions may be generated by the thematic content 

emerging during each interview and the ongoing data analysis. 

It is important to note that because data collection and analysis occur simultaneously in qualitative 

studies, it is impossible to anticipate all possible questions and probes ahead of time. As well, some 

participants will be better informants than others (i.e., ability to recall and relate experiences). Thus, there 

will be variations in terms of the numbers of probes and questions required for a particular interview. 

Observation Checklist. Nurses working in extended/expanded practice roles will be asked to have 

a nurse observer present during centre/clinic activities. These sessions are designed to help the research 

team describe the protocols followed by nurses while making decisions about patient/client care requirements 

(see Appendix E). 

The observation data is intended to help the research team capture and describe the protocols 

followed by nurses while making decisions about patient/client care requirements. It is also anticipated that 

the observation data will augment the interview data obtained from the nurses and physicians (i.e, fill in the 

gaps and/or compliment the conceptual categories/properties emerging from the data). 

Patient/client survey. The survey questionnaires are designed to document patient/client 

experiences with nurses working in extended/expanded roles, as well as how satisfied they are with nurses 

in these roles. Item content is based on relevant information from the literature dealing with surveys of 

patients receiving care from nurses working in extended/expanded roles.

8 

Data Analysis 

The taped interviews will be transcribed verbatim and checked for accuracy. The constantcomparative 

method of analysis as defined by Glaser and Strauss (1967) will then be applied to each data set 

by a minimum of two raters/coders (the principal investigator and research assistants) working independently. 

Debriefing sessions will be held regularly to discuss major themes and to identify the conceptual categories 

and properties being generated by the initial joint coding and analysis. Because the consulting team is not only 

interested in the accuracy of the conceptual categories and their properties but also the weight and importance 

attached to them by study participants, each participant will be asked to review and confirm an interpretive 

summary of his/her transcript to achieve this objective. This step is necessary to understand the importance 

of each category and property for grasping the experiences of participants with the extended/expanded 

nursing role in their work setting. 

A structured coding system, which is based on categories depicted in provincial regulations and 

nursing associations/colleges standards for practice and competencies for nurse practitioners will be applied 

to the observation data sets. Each rater will be responsible for reviewing all data sets to locate incidents of 

relevant content for each specified category. Counts of the number of times key components are identified 

in the data will then be tabulated. 

As conceptual categories and conceptual properties of categories emerge that have equal applicability 

across interview and observational data sets, greater attention will be given to linking them into coherent 

entities or "theoretical constructs." At this stage in the analysis, all raters will be working together to collapse 

the categories into a parsimonious set reflective of participants' experiences with extended/expanded nursing 

practice, identify possible relations between and among major categories, and propose conceptual model (s) 

to capture identified relationships. Theoretical sampling will then be used to identify slices of data that could 

serve as incidents for the theoretical constructs, and confirm their explanatory and predictive power for 

capturing the process of extended/expanded nursing practice as performed under different nursing practice 

models. In order words, theoretical sampling will be used to help test the accuracy of the emerging 

substantive theory. 

Credibility. Credibility measures how vivid and faithful the description of the phenomena are and 

provides the standard for judging the truth value. Nurses working in extended/ expanded or health care 

providers working with nurses in these roles are considered the experts and therefore the most credible 

sources of information. A qualitative study is credible when the participants recognize the descriptions and 

interpretations of the experience as their own (Sandelowski, 1986). Therefore, an interpretive summary of 

the transcribed interview will be reviewed by each participant who will be asked to validate conclusions that 

have been drawn.

9 

Ethical Considerations 

Participants who meet the inclusion criteria and agree to be contacted will be approached by a 

member of the research team. The purpose, procedure, examples of interview questions, and voluntary 

nature of participation in the study will be presented to potential participants. Written, informed consent will 

be obtained immediately prior to commencing the formal interview by a member of the research team. 

Participants will be interviewed in a mutually agreed upon private place. 

Appropriate measures will be taken to ensure that confidentiality of all data is maintained. All tapes, 

transcripts, and observation checklists will be coded, and kept in a secure place. A log of names and 

matching codes will be stored in a locked filing cabinet, accessible only to members of the research team, and 

destroyed once the study is completed. Participants will also be informed that all information collected will 

be described in a manner that will prevent identification of the source, no direct benefits are anticipated, and 

they are free to withdraw from the study at any time.

10 

References 

American Nurses Association (1992, December). A meta analysis of process of care, clinical outcomes, and 

cost effectiveness of nurses in primary care roles: Nurse practitioners and nurse-midwives. 

Washington DC: Author. 

Brown, S. A. & Grimes, D. E. (1995). A meta analysis of nurse practitioners and nurse-midwives in primary 

care. Nursing Research, 44(6), 332-339. 

Brown, M. & Olshansky, E. (1998). Becoming a primary care nurse practitioner: 

Challenges of the initial year of practice. The Nurse Practitioner, 23(7), 46-64. 

Crosby, F., Ventura, M. R., & Feldman, M. J. (1987). Future research 

recommendations for establishing NP effectiveness. The Nurse Practitioner, 12(1), 75-76, 78-79. 

Chambers, L. & West, A. (1978). The St. John’s randomized trial of the family practice nurse: Health 

outcomes of patients. International Journal of Epidemiology, 7(2), 153-161. 

Chang, E., Daly, J., Hawkins, A., McGirr, J., Fielding, K., Hemmings, L., O’Donoghue., 

& Dennis, M. (1999). An evaluation of the nurse practitioner role in a major rural emergency 

department. Journal of Advanced Nursing, 30(1), 260-268. 

Courtney, R. & Rice, C. (1997). Investigation of nurse practitioner-patient interactions: Using the nurse 

practitioner rating scale. The Nurse practitioner, 22(2), 46-65. 

Feldman, M. J., Ventura, M. R., & Crosby, F. (1987). Studies of nurse practitioner effectiveness. Nursing 

Research, 36(5), 303-308. 

Glaser, B. & Strauss, A. (1967). The discovery of grounded theory. Chicago: Aldine Hansson, S. (1989). 

Dimensions of risk. Risk Analysis, 9, 107-112. 

Hicks, C. & Hennessy, D. (1997). The use of a customized training needs analysis tool for nurse practitioner 

development. Journal of Advanced Nursing, 26, 389-398. 

Hicks, C. & Hennessy, D. (1998). A triangulation approach to the identification of acute sector nurses’ 

training needs for formal nurse practitioner status. Journal of Advanced Nursing, 27, 117-131. 

Hupcey, J. E. (1993). Factors and work settings that may influence nurse practitioner practice. Nursing 

Outlook, 41, 181-185. 

Koelbel, P. W., Fuller, S. G., & Misener, T. R. (1991). Job satisfaction of nurse 

practitioners: An analysis using Herzberg’s theory. The Nurse Practitioner, 16(4), 43-56. 

Larrabee, J. H., Ferri, J. A., & Hartig, M. T. (1997). Patient satisfaction with nurse 

practitioner care in primary care. Journal of Nursing Care Quality, 11(5), 9-14. 

Martin, P. D. & Hutchinson, S. A. (1997). Negotiating symbolic space: Strategies to

11 

increase NP status and value. The Nurse Practitioner, 22(1), 89-102. 

Moody, N. B., Smith, P. L., & Glenn, L. L. (1997). Client characteristics and practice patterns of nurse 

practitioners and physicians. The Nurse Practitioner, 24(3), 94-103. 

Reveley, S. (1998). The role of the triage nurse practitioner in general medical practice: an analysis of the 

role. Journal of Advanced Nursing, 28(3), 584-591. 

Sandelowski, M. (1986). The problem of rigor in qualitative research. Advances in Nursing Science, 8, 

27-36. 

Sandelowski, M. (1995). Focus on qualitative methods: Sample size in qualitative research. Research in 

Nursing and Health, 18, 179-183. 

Torn, A. & McNichol, E. (1998). A qualitative study utilizing a focus group to explore the role and concept 

of the nurse practitioner. Journal of Advanced Nursing, 27, 117-131. 

Tri, D. L. (1991). The relationships between primary health care practitioners job satisfaction and 

characteristics of their practice settings. The Nurse Practitioner, 16(5), 46-55.

Appendix A: Summary of Research Study 

12

13 

Brief Overview of Research Study 

Title: 

Investigators: 

Evaluation of Nursing Practice Models in Primary Health Care Settings 

Dr. Christine Way, Colleen Hanrahan, & John Housser (Institute for the 

Advancement of Public Policy) 

Madge Applin (Centre for Nursing Studies) 

Study Objectives: 

1. To describe the experiences of nurses performing primary care functions in variant primary health care 

settings. 

2. To describe the experiences of physicians working with and patient/clients receiving care from nurses 

in extended/expanded practice roles. 

3. To develop a greater understanding of how different nursing practice models work to address 

patient/client needs. 

4. To identify relevant information which may help strengthen public policy directed towards the maximum 

utilization of human health resources. 

Brief Description of the Study: The proposed study will use a grounded theory method during data collection 

and analysis to generate conceptual models of extended/expanded nursing practice in different primary health 

care settings. A purposive sample of health care providers (i.e., nurses and physicians) and centre/clinic 

patients/clients will be recruited for participation in the study. 

Health care providers will be asked to participate in one face-to-face interview. The interview will elicit 

commentary on experiences and practice needs. Each participant will be asked to review and confirm an 

interpretive summary of the main points addressed in his/her interview. As well, nurses working in 

extended/expanded practice roles will be asked to have a nurse observer present during normal centre/clinic 

activities. These sessions are designed to help the research team capture and describe the protocols followed 

by nurses while making decisions about patient/client care requirements. 

The research team is also interested in documenting patient/client experiences with nurses working in 

extended/expanded roles, as well as how satisfied they are with nurses in these roles. The survey questionnaires 

are designed so that patients/clients are able to fill out the questionnaires anonymously during a scheduled visit 

to the centre/clinic. 

Procedure for Obtaining Consent: It is requested that administrative personnel at the centres/clinics will 

inform nurses and physicians about the study and seek permission for the research team to initiate contact with 

them. Those expressing an interest in participating in the study will be contacted by a member of the research 

team and have the study explained to them more fully and any questions/concerns addressed at this time. 

Informed, written consent will be obtained prior to data collection.

Appendix B: Informed Consent 

14

15 

INSTITUTE FOR THE ADVANCEMENT OF PUBLIC POLICY (INSTITUTE) 

AND 

CENTRE FOR NURSING STUDIES (CNS) OF THE HCCSJ 

Consent To Participate In Health Care Research: Nurses 

TITLE: 

INVESTIGATOR(S): 

SPONSOR: 

Evaluation of Registered Nursing Practice Models in Primary Health Care 

Settings 

Dr. Christine Way, Colleen Hanrahan, & John Housser (Institute); Madge 

Applin (CNS) 


You have been asked to participate in a research study. Participation in this study is entirely voluntary. You may 

decide not to participate or may withdraw from the study at any time. 

Information obtained from you or about you during this study, which could identify you, will be kept confidential 

by the investigators. The principal investigator will be available during the study at all times should you have any 

problems or questions. 

Administrators, clinical supervisors, or any other person involved with your organization will not have 

access to your taped interviews or any other information that could potentially identify you as a source. 

Purpose of study: The purpose of this study is to develop a greater understanding of registered nurses’ 

experiences with the extended/expanded nursing role in primary health care settings. The study has the potential 

to increase our understanding of the most and least important aspects of this role, and provide useful information 

on which nursing models are most useful for addressing patient/client needs. 

Description of procedures: You are being asked to participate in one interview and one to two participant 

observation sessions which will take place in the work setting at a time that is convenient for you. You will be 

given copies of the interview schedule and observational checklist prior to your participation in any of the 

sessions. 

Interviews will be audiotaped (with your permission). The tape will be transcribed word for word, and will be 

used solely to help the interviewer recall the details of your conversation. During the interview you will be asked 

to reflect upon and describe your experiences with the extended/expanded role within your work setting. Within 

a two to three week period, you will be given a summary of the interview and asked to confirm whether or not 

it accurately reflects your experiences. You will also be given an opportunity to provide any additional 

information at this time. 

The observation sessions will be conducted on the same day of the interview and/or the following day. We are 

particularly interested in documenting the protocols that you would normally follow while making decisions about 

patient/client care requirements. In particular, the nurse observer will be looking for examples of the kinds of 

diagnostic procedures that you access and treatment plans that you prescribe, how you apply decision-making 

Participant Initials_________Page 15

approaches while administering care, and how you relate to and consult with others in the clinical setting. It is 

important for you to remember that these sessions are being conducted for the sole purpose of 

developing a descriptive profile of what and how primary care functions are being performed within 

different nursing practice models operant in primary health care settings. 

Duration of participant’s involvement: The interview will take approximately 60 to 90 minutes to complete. 

It is anticipated that the participant observation sessions may vary from 4 to 6 hours. 

Possible risks, discomforts, or inconveniences: There are no expected risks from participating in this study. 

You may refuse to answer any questions which make you feel uncomfortable and ask to terminate the interview 

at any time. All information that you provide will be kept strictly confidential, secured in a locked file, and 

accessible only to members of the research team. 

Benefits which the participant may receive: You will not benefit directly from participating in this study. 

However, the information that you provide may help identify the changes required in the health care system to 

facilitate nursing’s role in primary health care. 

Liability statement: Your signature indicates your consent and that you have understood the information 

regarding the research study. In no way does this waive your legal rights nor release the investigators or involved 

agencies from their legal and professional responsibilities. 

Any other relevant information: Findings of this study will be available to you and your participating 

organization. Findings may be published, but neither you nor your organization will be identified. The 

investigators will be available throughout the study to address any questions or concerns. 

16 


17 

Signature Page 

Title of Project: Evaluation of Nursing Practice Models in Primary Health Care Settings 

Name of Principal Investigator: Dr. Christine Way 

To be signed by participant 

I, , the undersigned, agree to my participation in the 

research 

study described above. 

Any questions have been answered and I understand what is involved in the study. I realize that 

participation is voluntary and that there is no guarantee that I will benefit from my involvement. 

I acknowledge that a copy of this form has been given to me. 

(Signature of Participant) 

(Date) 

(Signature of Witness) (Date) 

To be signed by interviewer/observer 

To the best of my ability I have fully explained the nature of this research study. I have invited questions 

and provided answers. I believe that the participant fully understands the implications and voluntary nature 

of the study. 

(Signature of Interviewer) 

(Date) 

Phone Number 

Consent for audiotaping during interviews 


(Date) 

(Signature of Witness) 

(Date)

18 

INSTITUTE FOR THE ADVANCEMENT OF PUBLIC POLICY (INSTITUTE) 

AND 

CENTRE FOR NURSING STUDIES (CNS) OF THE HCCSJ 

Consent To Participate In Health Care Research: Physicians 

TITLE: 

INVESTIGATOR(S): 

SPONSOR: 

Evaluation of Registered Nursing Practice Models in Primary Health Care 

Settings 

Christine Way, Colleen Hanrahan, & John Housser (Institute); Madge Applin 

(CNS) 


You have been asked to participate in a research study. Participation in this study is entirely voluntary. You may 

decide not to participate or may withdraw from the study at any time. 

Information obtained from you or about you during this study, which could identify you, will be kept confidential 

by the investigators. The principal investigator will be available during the study at all times should you have any 

problems or questions. 

Administrators, clinical supervisors, or any other person involved with your organization will not have 

access to your taped interviews or any other information that could potentially identify you as a source. 

Purpose of study: The purpose of this study is to develop a greater understanding of physicians’ experiences 

with nurses performing primary care functions in primary health care settings. The study has the potential to 

increase our understanding of the most and least important aspects of this role, and provide useful information 

on which practice models are most useful for addressing patient/client needs. 

Description of procedures: You are being asked to participate in one interview which will take place in the 

work setting at a time that is convenient for you. You will be given a copy of the interview schedule to review 

prior to your participation in the study. Interviews will be audiotaped (with your permission). The tape will be 

transcribed word for word, and will be used solely to help the interviewer recall the details of your conversation. 

During the interview you will be asked to reflect upon and describe your experiences with nurses working in an 

extended/expanded role within your work setting. Within a two to three week period, you will be given a 

summary of the interview and asked to confirm whether or not it accurately reflects your experiences. You will 

also be given an opportunity to provide any additional information at this time. 


Duration of participant’s involvement: The interview will take approximately 60 to 90 minutes to complete. 

Possible risks, discomforts, or inconveniences: There are no expected risks from participating in this study. 

You may refuse to answer any questions which make you feel uncomfortable and ask to terminate the interview 

at any time. All information that you provide will be kept strictly confidential, secured in a locked file, and 

accessible only to members of the research team. 

Benefits which the participant may receive: You will not benefit directly from participating in this study. 

However, the information that you provide may help identify the changes required in the health care system to 

facilitate nursing’s role in primary health care. 

Liability statement: Your signature indicates your consent and that you have understood the information 

regarding the research study. In no way does this waive your legal rights nor release the investigators or involved 

agencies from their legal and professional responsibilities. 

Any other relevant information: Findings of this study will be available to you and your participating 

organization. Findings may be published, but neither you nor your organization will be identified. The 

investigators will be available throughout the study to address any questions or concerns. 

19 


20 

Signature Page 

Title of Project: Evaluation of Nursing Practice Models in Primary Health Care Settings 

Name of Principal Investigator: Dr. Christine Way 

To be signed by participant 

I, , the undersigned, agree to my participation in the 

research 

study described above. 

Any questions have been answered and I understand what is involved in the study. I realize that 

participation is voluntary and that there is no guarantee that I will benefit from my involvement. 

I acknowledge that a copy of this form has been given to me. 


(Date) 

(Signature of Witness) (Date) 

To be signed by interviewer 

To the best of my ability I have fully explained the nature of this research study. I have invited questions 

and provided answers. I believe that the participant fully understands the implications and voluntary nature 

of the study. 

(Signature of Interviewer) 

(Date) 

Phone Number 

Consent for audiotaping during interviews 


(Date) 

(Signature of Witness) 

(Date)

Appendix C: Interview Schedules 

21

22 

Interview Schedule: Nurses 

Interview Script 

We are interested in your experiences with performing primary care functions within this setting from when you 

first started up to now. We would like for you to take some time to reflect upon these experiences and share 

with us your perceptions of the nursing role as it is being implemented here. You can share any thoughts, 

feelings, and ideas about your experiences. Feel free to talk about whatever comes to mind. 

Examples of Probes/Questions to Facilitate the Interview 

1. Could you think back to when you first started working at this centre/clinic as a nurse working in an 

extended/expanded practice role and describe what it was like for you then 

2. Thinking back to the time before you started working in an extended/expanded role, could you describe 

any changes that you have experienced in your nursing practice (Probes: How has it affected 

relationships with other health care providers - physicians, nurses, social workers, therapists, 

specialists, etc Have you experienced greater feelings of autonomy/independence in your 

practice Do you feel confident about this type of practice and your ability to manage 

independent caseloads How do you feel about your ability to work collaboratively with 

physicians Etc.) 

3. How has the extended/expanded practice role affected your relationships with patients (Probes: How 

have patients responded to you in this role Do you think that patients understand how this 

type of nursing care differs from what they receive from other nurses) 

4. How do you feel about your primary care role in general What are some of the positives Negatives 

5. Could you think about a typical work day or work week and describe your role as a nurse working in 

primary care Reflecting upon what you typically do as a nurse working in an extended/expanded role, 

what do you consider to be the most important aspects of this role What are the most and least 

rewarding aspects of this role (Probes: Are you able to identify any particular experiences that 

left you feeling good/bad about things/yourself Can you recall a significant event that 

reinforced/diminished your confidence about how well prepared you were to deal with patient 

problems/needs in a comprehensive manner) 

6. How would you rate the overall health care services that you provide at this centre/clinic Are there 

particular aspects of these services that could be improved What measures would you like to see 

implemented/changed that could potentially improve the quality of these services (Probes, if not 

mentioned: Access to community resources, such as diagnostic facilities, specialists, and 

hospitals; restrictions on prescriptive authority; interpersonal relations with other health care 

providers both within and outside the centre/clinic; access to specialized technologies such 

as the Internet and telemedicine/ teleconferencing; etc.). 

7. What do you find particularly challenging about this role Do you feel from time to time that you could 

benefit from having additional knowledge and skills If so, how would you like to see this happen 

(Probes: What about continuing education opportunities Regular contact with other nurses 

performing a similar role)

23 

8. How has this role changed the way you look at nursing, as well as medical, practice 

9. How would you envision an ideal extended/expanded practice role What strategies and/or changes 

would be required in the health care delivery system to make this type of role possible 

10. Are there any other comments or thoughts that you would like to share with us about how you are 

experiencing the primary care role in this setting

24 

Interview Schedule: Physicians 

Interview Script 

We are interested in your experiences with nurses performing primary care functions in this setting. We would 

like for you to take some time to reflect upon these experiences and share with us your perceptions of the nursing 

role as it is being implemented here. You can share any thoughts, feelings, and ideas about your experiences. 

Feel free to talk about whatever comes to mind. 

Examples of Probes/Questions to Facilitate the Interview 

1. Could you think back to when nurses first started working at this centre/clinic in an extended/expanded 

practice role and describe what your thoughts/feelings were like then 

2. Thinking back to the time before you started working with nurses in extended/ expanded roles, could you 

describe any changes that you have experienced in your practice (Probes: How has it affected 

relationships with nurses and/or other health care providers Do you feel confident about 

nurses working in extended/expanded roles and their ability to manage independent 

caseloads How do you feel about their ability to work collaboratively with physicians Etc.) 

3. From your perspective, how has the extended/expanded practice role affected nurses’ relationships with 

patients (Probes: How have patients responded to nurses in this role Do you think that 

patients understand how this type of nursing care differs from what they receive from 

physicians and/or other nurses) 

4. How do you feel about nurses assuming primary care roles in general What are some of the positives 

Negatives 

5. Reflecting upon what nurses typically do while working in extended/expanded roles, what do you 

consider to be the most important aspects of this role What are the most and least helpful aspects of 

this role (Probes: Can you recall a significant event that reinforced/diminished your confidence 

about how well prepared nurses were to deal with patient problems/needs in a comprehensive 

manner If so, could you elaborate on this) 

6. How would you rate the overall health care services that nurses working in extended/expanded roles 

provide at this centre/clinic Are there particular aspects of these services that could be improved 

What measures would you like to see implemented/changed that could potentially improve the quality 

of these services (Probe s, if not mentioned: Access to community resources, such as 

diagnostic facilities, specialists, and hospitals; restrictions on prescriptive authority; 

interpersonal relations with other health care providers both within and outside the 

centre/clinic; access to specialized technologies such as the Internet and 

telemedicine/teleconferencing; etc.). 

7. What do you find particularly challenging about the extended/expanded practice role for nursing Do 

you feel that nurses working in primary care roles could benefit from having additional knowledge and 

skills If so, how would you like to see this happen (Probes: What about continuing education 

opportunities Basic education preparation Etc.)

25 

8. How has this role changed the way you look at nursing, as well as medical, practice 

9. Ideally, how would you like to see nurses implementing primary care roles What strategies and/or 

changes would be required in the health care delivery system to make this possible 

10. Are there any other comments or thoughts that you would like to share with us about how you are 

experiencing nurses who are performing primary care roles in this setting

Appendix D: Patient/Client Survey 

26

27 

Patient/Client Survey 

Part I: Centre/Clinic Experiences 

We are particularly interested in your experiences with the nurse practitioner (NP)/regional nurse during 

centre/clinic visits. Please provide estimates on each of the following items: 

1. Is this appointment for a new or 

ongoing condition/disease or a 

regular checkup 

2. Average wait time for appointments 

with the NP/regional nurse: 

3. Approximate number of visits over 

the past year with the NP/regional 

nurse: 

4. Number of times NP/regional nurse 

referred you to see other health care 

providers (e.g., physicians, community 

health nurses, physiotherapists, 

dieticians, etc.) (specify provider): 

5. Number of times you were referred 

to see the NP/regional nurse by 

another health care provider 

(specify provider): 

6. Number of times the NP/regional 

nurse renewed a drug prescription 

for you: 


nurse ordered a new drug 

for you: 

New____Ongoing____Checkup____ 

____________________________ 

____________________________ 

____________________________ 

____________________________ 

____________________________ 

____________________________ 

____________________________ 

____________________________ 

____________________________ 

____________________________

Use the following scale to rate the listed activities. Please circle the number that best reflects your 

experiences with the regional nurse/nurse practitioner. 

1. How often did the nurse do a physical examination 

1 2 3 4 5 

Never Rarely Sometimes Often Almost Always 

28 

2. How often did the nurse give you guidance or advice about how to best take care of yourself 

1 2 3 4 5 


3. How often did the nurse write a drug prescription for you 

1 2 3 4 5 


4. How often did the nurse order blood tests for you 

1 2 3 4 5 


5. How often did the nurse order x-rays for you 

1 2 3 4 5 


6. How often did you visit the nurse for a follow-up appointment for a chronic condition/disease 

1 2 3 4 5 

Never Rarely Sometimes Often Almost Always

29 

Part II: Satisfaction 

We are interested in your overall satisfaction with regional nurses/nurse practitioners within your area. Please circle 

the number that best describes your position. 

Please use the following scale to rate your degree of agreement/disagreement with each statement: 

1 

Strongly 

Disagree 

2 

Moderately 

Disagree 

3 

Slightly 

Disagree 

4 

Neutral 

5 

Slightly 

Agree 

6 

Moderately 

Agree 

7 

Strongly 

Agree 

General Satisfaction Strongly Strongly 

Disagree 

Agree 

1. Generally speaking, I am very satisfied with the 

care received from regional nurses/nurse 

practitioners at the health centre/clinic. 

2. I am generally satisfied with the information 

given to me about my illness by regional 

nurses/nurse practitioners. 

3. I am generally satisfied with the amount of time 

that I spend waiting to see a regional 

nurse/nurse practitioner on any given visit to the 

health centre/clinic. 

4. I am satisfied that regional nurses/ nurse 

practitioners have the necessary knowledge 

and abilities to know how to treat me when I 

become ill. 

1 2 3 4 5 6 7 

1 2 3 4 5 6 7 

1 2 3 4 5 6 7 

1 2 3 4 5 6 7 

5. I am generally satisfied with the follow-up care 

provided by regional nurses/nurse practitioners. 

6. Generally speaking, I am satisfied with the 

time spent by the regional nurse/ nurse 

practitioner to help me understand my illness 

and treatment requirements. 

1 2 3 4 5 6 7 

1 2 3 4 5 6 7 

Thank you for taking the time to fill out this questionnaire.

APPENDIX E: OBSERVATION CHECKLIST 

30

31 

CODE #_______ 

OBSERVATION TIME_______ 

Specialized Body of Knowledge 

INDICATORS 

OBSERVED RECORDED EXAMPLES 

Where Possible 

Yes No Yes No 

1.1 Institutes measures to gather 

needed information (e.g., 

conducts physical/ 

psychological exams, orders 

dx tests, reviews 

manuals/textbooks, consults 

with other health care 

providers, etc.). 

1.2 Shares knowledge with 

clients about their 

illness/condition (i.e., gives 

factual information on results 

of physical/ psychological 

exams and/or diagnostic 

tests). 

1.3 Justifies clinical decisions 

with reference to knowledge 

or theory (i.e., provides 

rationale for factual 

information or advice given to 

patient/ client). 

1.4 Presents an informed view of 

the extended/ expanded 

nursing role to 

patients/clients. 

1.5 Demonstrates appropriate 

use of therapeutic 

communication vs social 

interaction with 

patients/clients.

32 

CODE #_______ 

OBSERVATION TIME_______ 

Assessment and Management Activities 

INDICATORS 

OBSERVED 

Nature of 

Activity 

EXAMPLES 


Yes No New Old 

Assessment 

2.1 Takes patient/client health 

history. 

2.2 Reviews previous/ current 

treatment plans for 

patient/client. 

2.3 Performs physical 

examination of patient/client. 

2.4 Conducts psychological & 

social assessments of 


2.5 Makes tentative/ definitive 

decisions about patient/client 

health problem (s). 

Management 

2.6 Diagnostic decisions: 

- laboratory tests 

- cultures 

- x-rays 

- consults with GP 

- other (specify) 

2.6 Treatment decisions: 

- performs minor procedures 

(e.g., suturing, suture 

removal, wound cleansing, 

etc.) 

- prescribes medications 

- provides teaching/ 

counselling 

- initiates referrals to other 

health care providers 

(specify)

33 

CODE #_______ 

OBSERVATION TIME________ 

Application of Knowledge 

INDICATORS 



Yes No Yes No 

3.1 Searches for information 

from a variety of sources 

using skills of observation, 

communication and physical 

assessment. 

3.2 Distinguishes between 

relevant and irrelevant 

information when diagnosing, 

reporting or evaluating. 

3.3 States nursing diagnoses in a 

standardized format based on 

verifiable information. 

3.4 Designs care plans to address 

nursing diagnoses. 

3.5 Sets priorities when planning 

and giving care. 

3.6 Performs planned 

interventions in accordance 

with policies, procedures or 

care standards. 

3.7 Evaluates client's response to 

interventions and revise them 

as necessary. 

3.8 Documents timely and 

accurately reports of relevant 

observations, including 

conclusions drawn from time. 

3.9 Initiates, maintains and 

concludes a professional 

relationship.

34 

CODE #________ 

OBSERVATION TIME________ 

Collaboration with Health Care Team 

INDICATORS 



Yes No Yes No 

4.1 Communicates and consults 

with other members of the 

health care team about the 

client's care. 

4.2 Exercises judgement in 

providing nursing services and 

in assuming or performing 

delegated functions. 

4.3 Coordinates activities of 

others providing health care 

to the client. 

4.4 Delegates tasks to, and 

supervises members of the 

nursing team. 

4.5 Participates in, and 

encourages total quality 

management. 

4.6 Explains health care services 

to clients and others.

Appendix F: Letter of Support 

35

Supporting Document 3 (SD3) 

Reports of Results and Analyses of On-Site Data Collection 


Submitted to: 

F/P/T Advisory Committee on Health Human Resources 

March 30, 2001 






1. Physicians’ Perceptions of Extended/Expanded Nursing Roles ........................ 1 

Christine Way, PhD. 

2. Nurses’ Perceptions of Extended/Expanded Nursing Roles ..........................25 

Christine Way, PhD. 

3. Nurse Practitioners’ Practice and Patients Perceptions’ of Nurse 

Practitioners in Ontario, Saskatchewan, and Newfoundland ..........................53 

Christine Way, PhD., Joanne Simms, NP and Marcy Greene, NP

Physicians’ Perceptions of Extended/Expanded Nursing Roles 

Prepared by: Christine Way, PhD 

September 15, 2000

Physicians’ Perceptions of Extended/Expanded Nursing Roles 

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. 


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. 

2

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 

3

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 

1. “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”. 

2. “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”. 

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

4

4. “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”. 

5. “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”. 

6. “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”. 

7. “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”. 

8. “I don’t think they are coming out with enough practical and hands on experience. . . .Perhaps 

more on-site training with the course”. 

9. “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 experiential 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. 

5

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 

1. “Gradually they were getting better and better. Now, they are much better, they don’t consult us 

that much like they used to”. 

2. "They matured well and fast". 

3. “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”. 

4. “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”. 

5. “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”. 

6. “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”. 

7. “[Primary care nurse] is very confident. [Another primary care nurse] is probably the least 

confident of the bunch and it goes with experience”. 

8. “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”. 

6

9. “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”. 

10. “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 

1. “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”. 

2. “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”. 

3. “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. 

7


1. “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”. 

2. “I usually encourage her to attend CME [continuing medical education] things. . . .We are sharing 

the same clientele. . . . and we need upgrading”. 

3. “Anybody who is a provider in the health care system, whether primary, secondary or tertiary, 

needs continuing medical education”. 

4. “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”. 

5. “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”. 

6. “I think it is really important that they work with the physicians that they are going to be working 

with after they graduate”. 

7. “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 

8

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 

9

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. 


1. “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”. 

2. “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”. 

3. “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”. 

4. “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”. 

5. “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. 

6. “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.” 

7. “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”. 

8. “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”. 

10

9. “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”. 

10. “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”. 

11. “[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”. 

12. “They are being pushed into a role [on-call without physician back-up] in which, I wonder if 

they are being fully trained for”. 

13. “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”. 

14. “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”. 

15. “Many times they consult with us about something and we basically give them advice. So, we do 

work collaboratively”. 

16. “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”. 

17. “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”. 

11

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 inbetween 

weekly visits or alternating weekend on-call coverage. 

Illustrative Quotes: Positives 

1. “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”. 

12

2. “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”. 

3. “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”. 

4. “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”. 

5. “I never ever found that stuff [the pre-obstetrical visits, prenatal visits, and obstetrical followup] 

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”. 

6. “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.” 

7. “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”. 

8. “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”. 

9. “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”. 

10. “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”. 

11. “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”. 

12. “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”. 

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

complicated cases”. 

13

14. 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 

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

2. “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”. 

3. “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”. 

4. “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”. 

5. “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”. 

14

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 

1. “Some people think they are physicians”. 

15

2. “In many cases, it’s the other doctor”. 

3. “I am not sure if patients know there is a limitation of scope, especially with regards to medications 

(i.e., methotrexate)”. 

4. “Patients are confused”. 

5. “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”. 

6. “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”. 

7. “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”. 

8. “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”. 

9. “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”. 

10. “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 

1. “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”. 

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

3. “When it comes to women’s issues, they prefer a female”. 

16

4. “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”. 

5. “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”. 

6. “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”. 

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

in that regard”. 

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

nurse”. 

9. “Especially if the nurse practitioner consults with the physician, that reinforces in the patients mind 

that they need different care or a different provider”. 

10. “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”. 

11. “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”. 

12. “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 

1. “Patients are generally pleased. . . .and she [NP] has a nice personality. . .and takes good care 

of each person”. 

2. “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”. 

17

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

problems”. 

4. “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. 

18

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 

1. “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”. 

2. “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”. 

3. “I think that it has been positive with the nurse practitioners here, It has been an efficient way to 

utilize clinical resources”. 

19

4. “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”. 

5. “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”. 

6. “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 

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

2. “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”. 

3. “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”. 

4. “I’m not sure it [collaborative practice between physicians and nurses in extended/expanded 

roles] is any less expensive”. 

5. “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”. 

6. “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”. 

20

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. 


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

2. “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”. 


1. “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. 

2. “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 Quality 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 

21

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. 


1. “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”. 

2. “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”. 

3. “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”. 

4. “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”. 

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

patients”. 

6. “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”. 

22

7. “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”. 

8. “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”. 

9. “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”. 

10. “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”. 

11. “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”. 

12. “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”. 


1. “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”. 

2. “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”. 

23

3. “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. 


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

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

3. “Sometimes a person sees a nurse practitioner, then the physician, and then the nurse practitioner. 

You don’t get to know the patient”. 

4. “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”. 

5. “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”. 

24

Nurses’ Perceptions of Extended/Expanded Nursing Roles 

Prepared by: Christine Way, PhD 

September 15, 2000 

25

Nurses’ Perceptions of Extended/Expanded Nursing Roles 

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 subthemes 

that emerged from the data analysis. 


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 

26

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. 

27

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. 


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

2. “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”. 

28

3. “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”. 

4. “I would have liked to have seen more clinical”. 

5. “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”. 

6. “It was very. . . intimidating”. 

7. “It’s like starting over completely again. The confidence and stuff was gone completely”. 

8. “It was a new job and it was a new experience. A lot of people didn’t know what we were 

about”. 

9. “When I first started. . . .I had to basically relearn a lot of the practical work”. 

10. “It’s quite overwhelming when you first start, very overwhelming. And you are wondering am I 

not smart enough for this”. 

11. “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 an experiential 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. 

29


1. “As time goes on and the more you do, the more comfortable you become”. 

2. "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". 

3. “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”. 

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

5. “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”. 

6. “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”. 

7. “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”. 

8. “I didn’t come into the role with a set of skills. I moved step by step to where I am today”. 

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

thing”. 

10. “The patients that I can manage independently with confidence have come from having done that 

same type of case a few times”. 

11. “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”. 

30

12. “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”. 

13. “As you get more experience, the more confident you feel”. 

14. “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”. 

15. “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”. 

16. “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”. 

17. “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 Recommendations 

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 

31

participants felt that additional knowledge of pathophysiology and pharmacology would facilitate discussion 

of the disease process with clients. 


1. "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." 

2. “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”. 

3. “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”. 

4. “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”. 

5. “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”. 

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

practitioners”. 

7. “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”. 

8. “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”. 

9. “I think everyone needs to be masters prepared”. 

32

10. “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”. 

11. “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 

33

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. 


1. “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”. 

2. “Absolutely no problem [working independently within scope of practice]”. 

3. “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”. 

4. “It has always been my practice to function independently and autonomously”. 

5. “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”. 

34

6. “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”. 

7. “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”. 

8. “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.” 

9. “For me that’s the role advantage, looking at nursing in the broader perspective rather than 

medicine”. 

10. “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’”. 

11. “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”. 

12. “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”. 

13. “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”. 

14. “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”. 

15. “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”. 

35

16. “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. 


1. “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”. 

2. “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”. 

3. “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”. 

36

4. “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”. 

5. “There’s some independence and then there has to be a collaborative practice due to the nature 

of our work”. 

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

7. “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”. 

8. “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”. 

9. “If I’m dealing with any client independently I do the assessment, and if we run into a complication 

consult with the physician”. 

10. “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’”. 

11. “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”. 

12. “We refer to each other, we help each other.” 

13. “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”. 

14. “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 

37

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”. 

15. “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.” 

16. “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”. 

17. “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”. 

18. “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”. 

19. “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”. 

20. “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 

38

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. 


1. “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]”. 

2. “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”. 

3. “I don’t feel isolated down there [outreach clinics] because the contact [with physicians] is 

always there”. 

4. “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”. 

5. “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”. 

6. “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”. 

7. “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”. 

8. “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”. 

39

9. “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”. 

10. “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”. 

11. “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’”. 

12. “I think one of the things that has made our particular project so successful was the collaborative 

model that we choose”. 

13. “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”. 

14. “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 

40

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 

1. “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’”. 

2. “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”. 

3. “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’”. 

4. “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". 

5. “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”. 

6. “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”. 

7. “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”. 

41

8. “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”. 

9. “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”. 

10. “They know I am a nurse, they do know that”. 

11. “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’”. 

12. “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 

1. “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”. 

2. “One of the big things clients will say is I would rather come and see you because I know you are 

going to stay”. 

3. “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”. 

4. “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”. 

5. “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”. 

6. “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 ½ 

hour of your time rather than 5 minutes in and out. You just don’t check my blood pressure and 

42

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”. 

7. “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”. 

8. “They [patients] have been very accepting”. 

9. “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”. 

10. “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”. 

11. “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”. 

12. “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”. 

13. “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”. 

14. “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”. 

15. “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”. 

43

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. 

44

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. 


1. “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”. 

2. “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”. 

3. “We have had some very supportive physicians from here. Physicians that didn’t even know what 

nurse practitioners were but they wanted to learn”. 

4. “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”. 

5. “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”. 

6. “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”. 

7. “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”. 

45

8. “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”. 

9. “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”. 

10. “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”. 

11. “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”. 


1. “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”. 

2. “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’”. 

3. “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”. 

4. “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”. 

5. “If I worked a weekend with the salaried physician there was no problem. . . . When it was a feefor-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”. 

46

6. “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”. 

7. “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”. 

8. “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 

47

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. 


1. “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”. 

2. “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”. 

3. “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”. 

4. “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”. 

5. “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”. 

6. “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”. 

7. “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 

48

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”. 

8. “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”. 

9. “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”. 

10. “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”. 

11. “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”. 


1. “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. 

2. “When you are seeing people and you have to see them fairly quickly, I often feel that I’ve missed 

something”. 

3. “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”. 

4. “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”. 

5. “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”. 

49

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. 


1. “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”. 

2. “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”. 

3. “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”. 

50

4. “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”. 

5. “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”. 

6. “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”. 

7. “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”. 

8. “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”. 

9. “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 costeffective”. 

10. “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”. 

11. “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”. 

12. “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”. 

13. “I don’t feel that we got enough positive kind of advertising”. 

51

14. “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”. 

15. “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”. 

16. “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”. 

17. “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”. 

18. “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”. 

19. “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”. 

20. “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”. 

52

53 

Nurse Practitioners’ Practice and Patients Perceptions’ of Nurse 

Practitioners in Ontario, Saskatchewan, and Newfoundland 

Prepared by: 

Christine Way, PhD., Joanne Simms, NP and Marcy Greene, NP 

August 1, 2000 

I.

54 

II. 

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%).

55 

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 oneway 

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,

56 

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.

57 

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. 

II. 

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%

eing completed in less than 15 minutes. There were no statistically significant differences observed across 

sites for any of the demographic variables. 

58 

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.

59 

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

60 

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,

61 

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.

62 

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.

63 

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 selfexamination, 

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 nonjudgmental 

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.

64 

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 selfmonitoring 

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.

65 

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 .

Appendix G - 1: Patient Survey Instrument 

66

67 

Patient/Client Survey 

Part I: Centre/Clinic Experiences 

We are particularly interested in your experiences with the nurse practitioner (NP)/ regional nurse during 

centre/clinic visits. Please provide estimates on each of the following items: 

1. Is this appointment for a new or 

ongoing condition/disease or a 

regular checkup 

2. Average wait time for appointments 

with the NP/regional nurse: 

3. Approximate number of visits over 

the past year with the NP/regional 

nurse: 

4. Number of times NP/regional nurse 

referred you to see other health care 

providers (e.g., physicians, community 

health nurses, physiotherapists, 

dieticians, etc.) (specify provider): 

5. Number of times you were referred 

to see the NP/regional nurse by 

another health care provider 

(specify provider): 


nurse renewed a drug prescription 

for you: 


nurse ordered a new drug 

for you: 

New____Ongoing____Checkup____ 

____________________________ 

____________________________ 

____________________________ 

____________________________ 

____________________________ 

____________________________ 

____________________________ 

____________________________ 

____________________________ 

____________________________

Use the following scale to rate the listed activities. Please circle the number that best reflects your 

experiences with the regional nurse/nurse practitioner. 

68 

1. How often did the nurse do a physical examination 

1 2 3 4 5 


2. How often did the nurse give you guidance or advice about how to best take care of yourself 

1 2 3 4 5 


3. How often did the nurse write a drug prescription for you 

1 2 3 4 5 


4. How often did the nurse order blood tests for you 

1 2 3 4 5 


5. How often did the nurse order x-rays for you 

1 2 3 4 5 


6. How often did you visit the nurse for a follow-up appointment for a chronic condition/disease 

1 2 3 4 5 

Never Rarely Sometimes Often Almost Always

69 

Part II: Satisfaction 

In this section of the questionnaire we are interested in your overall satisfaction with regional nurses/nurse 

practitioners within your area. Please circle the number that best describes your position. 

Please use the following scale to rate your degree of agreement/disagreement with each statement: 

1 

Strongly 

Disagree 

2 

Moderately 

Disagree 

3 

Slightly 

Disagree 

4 

Neutral 

5 

Slightly 

Agree 

6 

Moderately 

Agree 

7 

Strongly 

Agree 

General Satisfaction Strongly Strongly 

Disagree 

Agree 

3. Generally speaking, I am very satisfied with 

the care received from regional nurses/nurse 

practitioners at the health centre/clinic. 

4. I am generally satisfied with the information 

given to me about my illness by regional 

nurses/nurse practitioners. 

5. I am generally satisfied with the amount of 

time that I spend waiting to see a regional 

nurse/nurse practitioner on any given visit to 

the health centre/clinic. 

6. I am satisfied that regional nurses/nurse 

practitioners have the necessary knowledge 

and abilities to know how to treat me when I 

become ill. 

7. I am generally satisfied with the follow-up care 

provided by regional nurses/nurse 

practitioners. 

8. Generally speaking, I am satisfied with the 

time spent by the regional nurse/ nurse 

practitioner to help me understand my illness 

and treatment requirements. 

1 2 3 4 5 6 7 

1 2 3 4 5 6 7 

1 2 3 4 5 6 7 

1 2 3 4 5 6 7 

1 2 3 4 5 6 7 

1 2 3 4 5 6 7

Thank you for taking the time to fill out this questionnaire. 

70

Appendix G - 2: Observation Checklist 

71

73 

CODE #_______OBSERVATION TIME_______ 

Specialized Body of Knowledge 

INDICATORS 



Yes No Yes No 

1.1 Institutes measures to gather 

needed information (e.g., 

conducts physical/ 

psychological exams, orders 

dx tests, reviews 

manuals/textbooks, consults 

with other health care 

providers, etc.). 

1.2 Shares knowledge with 

clients about their 

illness/condition (i.e., gives 

factual information on results 

of physical/ psychological 

exams and/or diagnostic 

tests). 

1.3 Justifies clinical decisions 

with reference to knowledge 

or theory (i.e., provides 

rationale for factual 

information or advice given to 

patient/ client). 

1.4 Presents an informed view of 

the extended/ expanded 

nursing role to 

patients/clients. 

1.5 Demonstrates appropriate 

use of therapeutic 

communication vs social 

interaction with 

patients/clients.

74 

CODE #_______OBSERVATION TIME_______ 

Assessment and Management Activities 

INDICATORS 

OBSERVED 

Nature of 

Activity 

EXAMPLES 


Yes No New Old 

Assessment 

2.1 Takes patient/client health 

history. 

2.2 Reviews previous/ current 

treatment plans for 


2.3 Performs physical 

examination of patient/client. 

2.4 Conducts psychological & 

social assessments of 


2.5 Makes tentative/ definitive 

decisions about patient/client 

health problem (s). 

Management 

2.6 Diagnostic decisions: 

- laboratory tests 

- cultures 

- x-rays 

- consults with GP 

- other (specify) 

2.6 Treatment decisions: 

- performs minor procedures 

(e.g., suturing, suture 

removal, wound cleansing, 

etc.) 

- prescribes medications 

- provides teaching/ 

counselling 

- initiates referrals to other 

health care providers 

(specify)

75 

CODE #_______OBSERVATION TIME________ 

Application of Knowledge 

INDICATORS 



Yes No Yes No 

3.1 Searches for information 

from a variety of sources 

using skills of observation, 

communication and physical 

assessment. 

3.2 Distinguishes between 

relevant and irrelevant 

information when diagnosing, 

reporting or evaluating. 

3.3 States diagnoses in a 

standardized format based on 

verifiable information. 

3.4 Designs care plans to address 

diagnoses. 

3.5 Sets priorities when planning 

and giving care. 

3.6 Performs planned 

interventions in accordance 

with policies, procedures or 

care standards. 

3.7 Evaluates client's response to 

interventions and revise them 

as necessary. 

3.8 Documents timely and 

accurately reports of relevant 

observations, including 

conclusions drawn from time. 

3.9 Initiates, maintains and 

concludes a professional 

relationship.

76 

CODE #________OBSERVATION TIME________ 

Collaboration with Health Care Team 

INDICATORS 



Yes No Yes No 

4.1 Communicates and consults 

with other members of the 

health care team about the 

client's care. 

4.2 Exercises judgement in 

providing nursing services and 

in assuming or performing 

specified functions. 

4.3 Coordinates activities of 

others providing health care 

to the client. 

4.4 Delegates tasks to, and 

supervises members of the 

nursing team. 

4.5 Participates in, and 

encourages total quality 

management. 

4.6 Explains health care services 

to clients and others.

Dissemination 



A Project of the Advisory Committee on Health Human Resources 

Funded by the Health Transition Fund Secretariat 

Project Identifier - NA 321 

Project Consultants: 


The Institute for the Advancement of Public Policy, Inc. 

March 23, 2001 





Supporting Document 4 

Dissemination Plan 

Dissemination of the research will be undertaken by the Centre for Nursing Studies, Health Corporation 

of St. John’s. The main report and all supporting documents will be posted on the web-site of the Centre 

for Nursing Studies at www.cns.nf.ca 

The following groups will be advised of the availability of the report at the web site. 

Government 

< Advisory Committee on Health Human Resources 

< Health Canada 

< Provincial/Territorial Ministers and Deputy Ministers of Health 

Nursing Organizations 

< Provincial/Territorial Nursing Associations 

< Canadian Nurses Association 

< Provincial/Territorial Nurses Unions 

< Canadian Federation of Nurses Unions 

< International Council of Nurses 

Educational Institutions 

< Canadian Faculties/Schools of Nursing 

< Canadian Faculties/Schools of Medicine 

< Canadian Faculties/Schools of Pharmacy 

Other Organizations 

< World Health Organization 

< Consumers Association of Canada 

< HEAL (Lobby Group) 

< Canadian Medical Association 

< Provincial/Territorial Medical Associations 

< Canadian Society of Rural Physicians 

< College of Family Physicians of Canada 

< Provincial/Territorial Pharmacy Associations 

< Canadian Alliance of Community Health Centres 

The Centre for Nursing Studies will endeavour to make presentations of the findings of the research at the 

following events:

Conferences 

< Ontario Association of Community Health Centres, Toronto, June 3, 2000 

< National Conference for Nurse Practitioners, Nov.8-11- Washington, D.C. 

< Association of Registered Nurses, Newfoundland and Labrador, 2001 

< Association of Registered Nurses, Ontario, 2001 

< Association of Registered Nurses, Saskatchewan, 2001 

< Opportunities to present will be pursued based on calls for abstracts. 

The Centre for Nursing Studies will endeavour to publish findings of the research through the following 

newsletters and journals: 

Newsletters 

< Provincial/Territorial Nursing Associations’ Newsletters 

< CAUSN Newsletter 

Journals 

< The Canadian Nurse 

< The Canadian Journal of Nursing Research 

< Journal of Nursing Education 

< Journal of Advanced Nursing 

< Nursing Research 

< Nursing Outlook 

< Nurse Educator 

< The Nurse Practitioner 

< Canadian Medical Association Journal 

< Canadian Journal of Public Health 

< Canadian Journal of Nursing Administration

Health Transition Fund Final Report - Projects Listed By Subject Area

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