Are Canadian Nurse Practitioners here to stay?
Submitted by Yureve Govind, MD, MBA
The practice of medicine and nursing continues to evolve due to rapid changes in technology, knowledge, and health care needs. Many new areas of specialization have been developed, and the duties and roles of registered nurses have been expanded. These changes have enabled nurses with an advanced education and skills to function as independent or interdependent clinicians alongside physicians and other health care professionals (Worster et al., 2005). A Nurse Practitioner (NP) is a registered nurse with additional educational preparation and experience who possesses and demonstrates the competencies to autonomously diagnose, order, and interpret diagnostic tests, prescribe pharmaceuticals, and perform specific procedures within the legislated scope of practice (Edwards et al., 2011).
Nurse practitioners (NPs) were first introduced into the Canadian health care system almost 50 years ago. In 1967, the first educational program for NPs was started at Dalhousie University in Halifax, Nova Scotia. It was the 1972 Boudreau Report that made the implementation of the expanded role of the registered nurse (RN) a high priority in the Canadian health care system (Worster et al., 2005). In 1973, a joint statement by the Canadian Medical Association and Canadian Nurses Association outlined the role of the NP; however, during the 1980’s, NP educational programs across Canada had become obsolete. This was partially due to the NP role being faced with resistance by physicians and a missing public awareness regarding the role and difficulties in obtaining prescriptive authority for NPs. Educational programs for NPs did not resume until 1995 when Ontario offered a baccalaureate NP program for primary health care (Mildon, 2013). Despite the unfavorable landscape for NPs during this time, approximately 250 NPs continued to work in Ontario through the 1980’s into the early 1990’s; their duties were confined to community health centers and northern nursing stations (Worster et al., 2005).
According to the Canadian Institute of Health Information, the number of NPs in Canada has more than doubled from 2006 to 2010; there were 1,129 NPs in 2006 compared with 2,486 NPs in 2010 (Workforce, 2012). The integration of NPs into the Canadian health care system has been challenging, even though frameworks exist to guide the implementation of these roles (Sangster-Gormley, 2011). Today, the NP role continues to be promoted by task forces and government health care commissions as a valuable resource for the delivery of healthcare, especially when it comes to injury and disease prevention, community based care, and health promotion (Worster et al., 2005).
This paper outlines articles that take a closer look into the role of NPs in the Canadian health care system, and how their roles have evolved in response to an ever-changing health care environment.
1. Sangster-Gormley E; Martin-Misener R; Downe-Wamboldt B; Dicenso A. (2011). Factors affecting nurse practitioner role implementation in Canadian practice settings: an integrative review. Journal of Advanced Nursing, 67(6), 1178-90. doi: 10.1111/j.1365-2648.2010.05571.x.
This peer reviewed article focuses on analyzing specific literature about the Canadian experience with regards to nurse practitioner role implementation. This is accomplished by identifying influencing factors at the practice setting level that includes primary, acute, and long-term care. The authors specifically targeted this particular setting because it’s the main working environment where NPs primarily enact their role. Whilst conducting this integrative review, the authors were focused on creating an extensive understanding of NP role implementation so that future theories can be developed. This review was able to identify specific barriers and facilitators to role implementation such as involvement, acceptance, and intention. This source is particularly useful as it provides important information that can be used to develop strategies that could potentially enhance NP role implementation. The information presented in the article is objective as the authors present their own opinions that are not based on previous analyses. The reputability of the journal in which this review was published, including the qualifications of the authors, makes this review a reliable source of information.
2. Turin, R. (2015). Physical activity prescriptions in healthy populations: resources for Canadian nurse practitioners. The Nurse practitioner, 40(2), 45-54. doi: 10.1097/01.NPR.0000459731.77403.c1.
This literature review focuses on Canadian nurse practitioners and their role as primary health care providers in prescribing physical activity (PA) in order to promote active communities in Canada. The review suggests that this can be accomplished by the use of physical activity prescriptions (PAPs) and being able to identify Canadian PA resources for use in clinical application by NPs. Data suggests that the level of PA in Canada is increasing and over 80% of Canadian adults have physical activity levels below the recommended guidelines. The authors strongly believe that NPs are in an ideal position to make a significant difference in PA levels by utilizing various methods such as PA prescriptions (PAPs) and verbal counseling during the clinical encounter. This review paper is a useful source of information as it outlines significant barriers NPs face with PAPs such as a lack of knowledge about PAPs, time limitation, and patient disinterest. The authors strongly believe that solutions are needed to address these barriers so that techniques can be developed in order to help NPs motivate their patients. The author presents her own objective views within this review; her analysis is therefore original. The information outlined in this review is reliable as it is published in a reputable journal and there is an extensive reference list included.
3. Edwards N; Rowan M; Marck P; Grinspun D. (2011). Understanding whole systems change in health care: the case of nurse practitioners in Canada. Policy, politics & nursing practice, 12(1), 4-17. doi: 10.1177/1527154411403816.
This particular paper is a literature review that is based on a whole systems change approach, by analyzing the NP movement in terms of leverages, blockages, and system dynamics. The review focuses on understanding what else besides evidence is needed to ensure the success of desirable health systems innovations so that they take root and thrive. The authors believe that evidence of the effectiveness of NP services has not been adequate in terms of establishing a critical, sustainable mass of NPs within the Canadian health care system over the past five decades. The case of the NP movement in Canada was selected, as it provides an ideal opportunity to explore the nature of whole systems change within the Canadian health system by illustrating the innovation and change in nursing roles and practice over the past 50 years. This paper takes a different approach to other sources as it offers an explanation as to what factors are involved in shaping the uptake of NP services within Canada. This source proves to be really useful by providing the reader with unique information pertaining to socio-ecological perspectives that may be required in order to successfully integrate and sustain NP services within Canada. This review paper is a reliable source of information, as its been published in a reputable peer reviewed journal. The authors are experts in the field of nursing and health policy in Canada; biographies are included that outlines their qualifications and affiliations.
4. Stolee P; Hillier LM; Esbaugh J; Griffiths N; Borrie MJ. (2006). Examining the nurse practitioner role in long-term care: evaluation of a pilot project in Canada. Journal of Gerontological Nursing, 32(10), 28-36.
This paper outlines a primary research study that was conducted in order to examine the NP role in three long-term care facilities in Ontario, Canada. The authors looked specifically at factors that facilitate or impede the implementation of the NP role within these facilities. This paper uses surveying in order to obtain raw data; the staff and NPs were interviewed regarding their perception of the NP role. This is unique in comparison to other sources that have been outlined because NPs themselves have provided feedback in this study. The authors conducted this research with the belief that NPs play a significant role in improving the quality of care within long-term care facilities; this was confirmed by findings indicating a positive impact on practice activities conducted by NPs. This particular study also provides some insight into the factors that should be considered when introducing the NP role into a long-term care facility. The information in this paper is reliable as it includes the accompanying statistics that confirm the author’s suspicions and arguments. Additionally, all limitations of the study were disclosed.
5. Worster, A; Sarco, A; Thrasher, C; Fernandes, C; Chemeris, E. (2005). Understanding the role of nurse practitioners in Canada. Canadian Journal of Rural Medicine, 10(2), 89.
This paper is quite different in comparison to the literature reviews and primary studies – it takes more of an explanatory approach. It is believed that there is discordance in Canada regarding the NP role within health care settings; this limits the probability of NP certification and role implementation. As a result, the authors decided to publish this manuscript with the purpose of providing the reader with an explanation of the educational requirements, titles, legislation, clinical, and legal responsibilities of NPs in Canada. This was done with the intention of bringing awareness to the barriers preventing the effective integration of the NP role within health care settings. The authors strongly believe that NPs are capable of providing a wide variety of health services; therefore, by expanding the NP role during times of economic restraint and limited access to physicians, it would be the most viable option in meeting the gaps within the Canadian health care system. This source is quite useful as it provides a substantial amount of information regarding the medicolegal and regulatory issues that are faced by NPs in Canada. This paper was published in a reputable peer reviewed journal, therefore, can be considered to be a reliable source. Multiple authors from a variety of health professions have collaborated on this paper, therefore, it covers angles form several different perspectives.
8. Sangster-Gormley, E; Martin-Misener, R; Burge, F. (2013). A case study of nurse practitioner role implementation in primary care: what happens when new roles are introduced? BMC Nursing, 12, 1. doi: 10.1186/1472-6955-12-1.
The authors of this primary research study set out a goal of researching factors that influence NP role implementation while it is occurring. This was undertaken in order to better understand the process so that it could possibly be enhanced in the future. The review mainly focuses on three sensitizing concepts that influence role implementation: involvement, intention, and acceptance. The authors strongly believe that these concepts are interconnected and function simultaneously; NP role implementation becomes difficult without one or the other. This paper is an essential source as it enriches ones understanding of how clearly identified intentions for the NP role and the involvement of key stakeholders can influence the process of implementation and acceptance of the role. In comparison to the other sources, this review places an emphasis on the role of community stakeholders that either facilitate or prevent NP acceptance. The information presented is objective without bias from other literature sources. The authors are highly educated and hold qualifications within the nursing profession; all opinions are justified accordingly. In essence, this paper is a reputable source of information as is evidence by its publication in a well-known peer reviewed journal.
9. Reay, T; Patterson, E; Halma, L; Steed, W. (2006). Introducing a nurse practitioner: experiences in a rural Alberta family practice clinic. Canadian Journal of Rural Medicine, 11(2), 7.
This paper encompasses a primary research study that was conducted in order to report on the experiences of introducing a NP into a rural community-based clinic in Taber, Alberta. This case study is unique because it reports qualitative findings about the introduction of the NP role in relation to the experiences of several stakeholders including physicians, clinic staff, and community members. The opinions in the paper are objective, especially with analysis of the data. Due to their findings showing support for the NP role within this particular type of clinical setting, the authors argue that further investigation is warranted in order to integrate the NP role within primary health care in Canada. All limitations of the case study were disclosed, and the data was obtained by means of interviews and surveys; therefore, it can be considered as a reliable source of information.
10. Gould ON; Johnstone D; Wasylkiw L. (2007). Nurse practitioners in Canada: beginnings, benefits, and barriers. Journal of the American Academy of Nurse Practitioners, 19(4), 165-71. doi: 10.1111/j.1745-7599.2007.00210.x.
This particular paper involves a primary study that was carried out by investigating the experiences of NPs one year after they are introduced to a mostly rural Canadian province, New Brunswick. Like the other sources, this paper identifies many barriers to role implementation; however, a pioneering outlook of the NP profession in Canada mainly overshadows this. The authors had two main goals in mind that involved investigating NPs perceptions of acceptance and their work satisfaction levels within a rural setting. This study is unique as it focuses specifically on rural preventative care and the challenges that are faced by NPs when high expectations are placed on them, especially in areas where access to health care is minimal. The data source in this study is directly from the NPs by means of interviews. The authors performed a qualitative analysis on the data and presented their expert opinions. As a result, it can be inferred that this is a reliable source of information. The paper does take the stance of viewing the profession from an outsider’s perspective; for this reason, it is biased to an extent, as the authors are not from the nursing profession.
11. Thrasher C; Purc-Stephenson R. (2008). Patient satisfaction with nurse practitioner care in emergency departments in Canada. Journal of the American Academy of Nurse Practitioners, 20(5), 231-7. doi: 10.1111/j.1745-7599.2008.00312.x.
This paper involves a primary study that utilizes a psychometric survey in order to measure patient satisfaction with care delivered by NPs in emergency departments (EDs) in Canada. The authors believe that due to shortages of primary care physicians and a lack of round-the-clock physician availability, patients are increasingly seeking care in EDs for their primary care needs. At the time of this publication, NPs had just recently been introduced throughout EDs in Ontario, Canada; therefore, the authors were determined to examine how patients responded to care received from NPs in this setting. This particular paper is unique as it uses an alternative approach to gaging patient satisfaction levels by the use of principle component analysis and psychometric evaluation. This study primarily looked at patient attentiveness, comprehensive care, and role clarity. The results were positive in understanding the NP role overall, which confirms the authors arguments and is consistent with other previous studies. This source is unique due to the alternative survey methodology that is used in order to look specifically at satisfaction in response to the NP role – this differs from the previous sources discussed. The paper is published in a reputable peer reviewed journal and the authors are experts in the nursing field; this source can therefore be considered reliable. The author’s analysis and discussion of the findings is objective without bias. Overall, this is a good source as it looks at the ED setting in comparison to rural, or primary care environments.
12. Contandriopoulos, D; Brousselle, A; Dubois, C; Perroux, M; Beaulieu, M; Brault, I; Kilpatrick, K; D’Amour, D; Sansgter-Gormley, E. (2015). A process- based framework to guide nurse practitioners integration into primary healthcare teams: results from a logic analysis. BMC Health Services Research, 15(1), 78. doi: 10.12968/bjon.2013.22.2.74.
This paper looks at the challenges faced when integrating NPs into primary care teams in Quebec, Canada. The authors took an alternative approach to this study by differentiating their goals from previous literature; they relied on logic-analysis by conducting a realist review of prior literature, in addition to several qualitative case studies in primary health care teams around rural and urban Quebec. This paper is a great source of information as it provides the reader with practical recommendations to overcome barriers and enhance the facilitation of NP role integration. Additionally, the authors specifically identified themes that are essential to creating an integrative model for NPs within primary care settings. In essence, this paper presents information that is highly relevant in understanding NP role implementation and integration within primary care settings; this is especially relevant when using the process-based framework that encompasses existing and future knowledge regarding the NP role. The information presented in this paper can be considered reliable as the authors are highly qualified and it has been published in a reputable, peer-reviewed journal.
13. Bailey, P; Jones, L; Way, D. (2006). Family physician/nurse practitioner: stories of collaboration. Journal of Advanced Nursing, 53(4), 381-91. doi: 10.1111/j.1365-2648.2006.03734.x.
This paper presents the experiences of nurse practitioners and family physicians working in collaboration at four primary care facilities in rural Canada. The study was conducted in order to examine the impact of educational interventions on interprofessional practice, especially with regards to role expectations. As with other previous studies, there are several overlapping themes in this particular paper. This is evidenced by issues related to role clarity and trust, the scope of practice, and differences in perceptions regarding collaborative practice. This paper is unique in that it presents issues that are highly apparent with implementation of the NP role, especially when it comes to collaborating with physicians. The authors were able to identify that NPs and family physicians were unable to collaborate effectively in the primary care setting as a result of being unaware of role expectations, especially with regards to NPs. The paper therefore looks specifically at educational strategies that are related to improving role expectations so that better collaborative partnerships can be developed between NPs and physicians in general. The data in this paper was obtained by interviews with NPs and physicians directly; a narrative analysis was performed. It can be inferred that this feedback is reliable as the data was obtained over two sets of interviews. This study represents a great source of information outlining collaborative roles between NPs and physicians in health care. The authors were objective in their analysis and provided justifications regarding their expert opinions.
As can be seen from the previously discussed articles, the NP role has continued to evolve over time since its inception in Canada. This is primarily due to barriers that make implementation of the NP role quite challenging. Increasing awareness through education and establishing role clarity has helped to integrate NP services into various health care settings. This is a step in the right direction in terms of providing affordable, quality care to patients in a time where access to primary health care in Canada is a necessity.
Bailey, P; Jones, L; Way, D. (2006). Family physician/nurse practitioner: stories of collaboration. Journal of Advanced Nursing, 53(4), 381-91. doi: 10.1111/j.1365-2648.2006.03734.x.
Contandriopoulos, D; Brousselle, A; Dubois, C; Perroux, M; Beaulieu, M; Brault, I; Kilpatrick, K; D’Amour, D; Sansgter-Gormley, E. (2015). A process- based framework to guide nurse practitioners integration into primary healthcare teams: results from a logic analysis. BMC Health Services Research, 15(1), 78. doi: 10.12968/bjon.2013.22.2.74.
Edwards N; Rowan M; Marck P; Grinspun D. (2011). Understanding whole systems change in health care: the case of nurse practitioners in Canada. Policy, politics & nursing practice, 12(1), 4-17. doi: 10.1177/1527154411403816.
Gould ON; Johnstone D; Wasylkiw L. (2007). Nurse practitioners in Canada: beginnings, benefits, and barriers. Journal of the American Academy of Nurse Practitioners, 19(4), 165-71. doi: 10.1111/j.1745-7599.2007.00210.x.
Mildon B. (2013). Nursing in Canada: roles, resurgence and resolve. British Journal of Nursing, 22(2), 74. doi: 10.12968/bjon.2013.22.2.74.
Reay, T; Patterson, E; Halma, L; Steed, W. (2006). Introducing a nurse practitioner: experiences in a rural Alberta family practice clinic. Canadian Journal of Rural Medicine, 11(2), 7.
Sangster-Gormley E; Martin-Misener R; Downe-Wamboldt B; Dicenso A. (2011). Factors affecting nurse practitioner role implementation in Canadian practice settings: an integrative review. Journal of Advanced Nursing, 67(6), 1178-90. doi: 10.1111/j.1365-2648.2010.05571.x.
Sangster-Gormley, E; Martin-Misener, R; Burge, F. (2013). A case study of nurse practitioner role implementation in primary care: what happens when new roles are introduced? BMC Nursing, 12, 1. doi: 10.1186/1472-6955-12-1.
Stolee P; Hillier LM; Esbaugh J; Griffiths N; Borrie MJ. (2006). Examining the nurse practitioner role in long-term care: evaluation of a pilot project in Canada. Journal of Gerontological Nursing, 32(10), 28-36.
Thrasher C; Purc-Stephenson R. (2008). Patient satisfaction with nurse practitioner care in emergency departments in Canada. Journal of the American Academy of Nurse Practitioners, 20(5), 231-7. doi: 10.1111/j.1745-7599.2008.00312.x.
Turin, R. (2015). Physical activity prescriptions in healthy populations: resources for Canadian nurse practitioners. The Nurse practitioner, 40(2), 45-54. doi: 10.1097/01.NPR.0000459731.77403.c1.
Workforce (WORLD IN BRIEF) (2012). Nursing Standard 26.23. Nursing Resource Center, 10(1), 10.
Worster, A; Sarco, A; Thrasher, C; Fernandes, C; Chemeris, E. (2005). Understanding the role of nurse practitioners in Canada. Canadian Journal of Rural Medicine, 10(2), 89.