A Survey of the Practice Patterns of Nurse Practitioners in Primary Health Care in Nova Scotia. January 31, 2010

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A Survey of the Practice Patterns of

Nurse Practitioners

in Primary Health Care

in Nova Scotia

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© 2010 College of Registered Nurses of Nova Scotia and Dalhousie University School of Nursing, Halifax, NS

Co-Principal Investigators:

Ruth Martin Misener, RN-NP, PhD (corresponding author) Associate Professor and Associate Director, Graduate Programs Dalhousie University School of Nursing

5869 University Ave, Halifax, Nova Scotia B3H 3J5 902-494-2250 (h)

902-494-3487 (f )

Ruth.martin-misener@dal.ca Teri Crawford, RN, MN Policy Advisor

College of Registered Nurses of Nova Scotia

Co-Investigators:

Alba DiCenso, RN, PhD

CHSRF/CIHR Chair in Advanced Practice Nursing (APN)

Director, Ontario Training Centre in Health Services & Policy Research Professor, Nursing and Clinical Epidemiology & Biostatistics

McMaster University

Noori Akhtar-Danesh, PhD

Associate Professor, Nursing and Clinical Epidemiology & Biostatistics McMaster University

Faith Donald, RN(EC), NP-PHC, PhD

Associate Professor, Daphne Cockwell School of Nursing Ryerson University

Denise Bryant-Lukosius, RN, CNS, PhD Assistant Professor, Nursing and Oncology McMaster University

Jointly Appointed to the Juravinski Cancer Centre Sharon Kaasalainen, RN, PhD

Assistant Professor, School of Nursing McMaster University

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Acknowledgements

Th is project was funded by the College of Registered Nurses of Nova Scotia and Dalhousie University School of Nursing Research Seed Funds. R. Martin- Misener was funded as a fellow by the Canadian Institutes of Health Research (CIHR) Strategic Training Initiative in Health Research, Transdisciplinary Understanding and Training on Research - Primary Health Care Program (TUTOR-PHC). We thank Karen Mahoney for her excellent staff support of this project and the experts who helped us establish the content validity of the questionnaire. We extend our particular gratitude to the nurse practitioners who took time from their busy schedules to participate in the study.

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Table of Contents

List of Tables ... ... 5 Executive Summary ... 6 Background ... 8 Methods ... 9 Results ... 9 Total Sample ... 9

NPs in Nova Scotia Providing Direct Care ...10

Demographics and Practice Settings ...10

Employment and Work Life ...12

Financial and Other Supports ...12

Practice Activities ... 13

Diagnosing and Prescribing ...13

Community Development Activities ...13

Collaboration, Consultation and Referral Activities ...14

Achievement of Expected Outcomes in NP Practice ...16

Contributions of the NP Role to Individuals, Organizations and the Health Care System ...16

Barriers and Facilitators to NP Practice ...17

Attrition from NP Practice ...17

Discussion ...18

Conclusion ...19

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List of Tables

Table 1: Demographic Characteristics of NPs Licensed in Nova Scotia as of May 2008 ...10

Table 2. Nova Scotia Practicing NPs’ Satisfaction with Supports ... 12

Table 3. Community Development Activities Reported by Nova Scotia NPs ... 14

Table 4: Frequency of Collaboration Methods Used By Nova Scotia NPs & Physicians ... 15

Table 5: Reasons Nova Scotia NPs Collaborate with Pharmacists ... 16

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Executive Summary

Regulated by the College of Registered Nurses of Nova Scotia (CRNNS), nurse practitioners (NPs) are a relatively new professional group, whose practice has continued to evolve in Nova Scotia since the fi rst NPs were licensed in 2002. Th e scope of practice for NPs in Nova Scotia was fi rst authorized by the Registered Nurses Act of 2001 and revised in 2006 to remove legislative barriers to NP practice. Standards of practice and competencies for NPs were initially established by CRNNS and have been updated periodically, most recently in 2009. Th e number of NP positions in the province has increased gradually, mostly through funding provided by the provincial government.

Th e purpose of this research was to examine the practice patterns of NPs in primary health care in Nova Scotia. A descriptive survey design was used to address the following research questions: 1) what are the characteristics of NPs, their practice models and settings? 2) what is the profi le of the practice population served by NPs and the types of services NPs provide? and, 3) what are the barriers and facilitators to NP role implementation? Data collection occurred during May and June 2008.

Th e response rate to the survey was 71% (n=39 of 55 NPs surveyed). Of these, 28 were practicing NPs in Nova Scotia. Approximately half the sample was prepared at the graduate level and the remainder had diploma or baccalaureate education. Respondents were almost all female with a mean age of 47, a wide range of nursing backgrounds, an average of 24 years of nursing experience and 5 years of experience as an NP. Most NPs were employed full-time in either a community health centre or family practice offi ce in Nova Scotia.

Of the 28 NPs practicing in Nova Scotia, 25 provided direct care in primary health care settings. Most of the report is based on data from these respondents. Half of the NPs in Nova Scotia who were providing direct patient care practiced in settings with a population less than 10,000 and most (71%) provided health care services to patients across the lifespan.

Most of these 25 NPs were unionized (84%), had a job description (88%), and received an annual performance appraisal (56%). Less than half indicated physicians or health care professionals had been orientated to their role. However, most NPs indicated team members with whom they regularly worked understood their NP role fairly well.

Th e majority of NPs reported receiving fi nancial support (92%) and time off (88%) for continuing education. Full-time NPs (n=20) were remunerated, on average, for a 40 hour work week and reported working a weekly average of 5 unpaid hours of overtime. NPs were very satisfi ed with their practice supports but minimally satisfi ed with their salary.

In an average week, NPs reported spending 70% of their time on direct patient care; 28% of this time was spent on management and monitoring of chronic illness, 25% on wellness care and health promotion and 20% on episodic care for minor acute illness and injury. In the time NPs devote to direct patient care, they provided care for an average of 14 patients in an eight-hour day. All NPs reported that they diagnose diseases or conditions, order lab and diagnostic tests and prescribe medications. Besides time spent on direct patient care, most NPs (82%) reported performing community development activities. In addition, they indicated they perform administrative responsibilities, participate in team meetings, educate other learners, carry out management and leadership functions, and take part in professional development.

Th ose who had their collaborative practice agreement (CPA) approved through the CRNNS reported having more diffi culty with developing their CPA than those whose CPA was approved by their employer. However, both groups indicated the CPA had enabled other health care providers to have a better understanding about

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the NP role and was useful for establishing priorities, evaluating goals and or evaluating collaboration within their practice.

NPs reported a high level of satisfaction with their relationship with the physician with whom they collaborated most frequently; informally initiated discussions about patient care was the most common mechanism used to collaborate about patient care concerns. On a weekly basis, most NPs (58%) received patient referrals from their collaborating physicians for follow-up care. All NPs indicated they refer patients to specialist physicians. Most NPs (73%) reported that all specialists accepted their referrals. However, 23% reported that some specialists refused their referrals.

NPs perceived the main contributions of their role to be increased access to primary health care, improved quality of care, leadership and cost savings to the health care system. Th e top three identifi ed facilitators for NP practice were administrative/management support, a culture of teamwork and physician support. Th e top three barriers to NP practice were funding issues, scope of practice restrictions and resistance to role implementation. Th e results of this study provide a snapshot of the practice patterns of NPs in Nova Scotia prior to the May 2009 proclamation of the 2006 Registered Nurses Act. Having this profi le will provide a baseline from which to compare as the role of NPs continues to evolve. Th e results show that NPs in Nova Scotia are practicing to their full scope of practice and are satisfi ed with their practice supports and collaborative relationships. Some barriers persist to the full integration of the NP role.

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Background

Discussion about the nurse practitioner (NP) role in Nova Scotia began in 1995 when the Minister of Health convened and mandated the Nurse Clinical Working Group to explore the feasibility of introducing NPs into the Nova Scotia health care system (Nova Scotia Department of Health, 1996). Th e Working Group experienced challenging deliberations but eventually reached agreement on a role defi nition, competencies and education and recommended that Nova Scotia pilot the NP role (Hamilton, 2000; Nova Scotia Department of Health, 1996). Subsequently, NPs were introduced as one component of the Strengthening Primary Care Initiative supported through the federal Health Transition Fund (Nova Scotia Department of Health, 1998, 1999, 2004). An evaluation of the initiative concluded that patients accepted and were satisfi ed with the quality of care provided by NPs and that the addition of the NP had increased the emphasis on health promotion and illness prevention and improved chronic disease management (Graham, Sketris, Burge & Edwards, 2006; Nova Scotia Department of Health, 2004).

Th e scope of practice for NPs in Nova Scotia was fi rst authorized by the Registered Nurses Act of 2001 and revised in 2006. Standards of practice and competencies for NPs were established by the College of Registered Nurses of Nova Scotia (CRNNS) and have been updated periodically, most recently in 2009 (CRNNS,

2009a, 2009b). Th e Act protects the title of “nurse practitioner” through a licensing process and requires that NPs practice collaboratively with one or more physicians, although the specifi c requirements related to this collaborative relationship have changed over time. Prior to 2005, the CRNNS statutory Diagnostic and Th erapeutics Committee (D&T) approved the legislated formal collaborative practice agreements between NPs and their collaborating physicians, required for NPs to practice (CRNNS, 2001). More recently, employers are responsible for ensuring a collaborative practice relationship is in place for health care teams that include an NP (CRNNS, 2009c).

At the time of the data collection, NPs were authorized to do the following: 1) make a diagnosis identifying a disease, disorder or condition; 2) communicate the diagnosis to the client; 3) order and interpret approved screening and diagnostic tests; 4) select, recommend, prescribe and monitor the eff ectiveness of approved drugs and interventions; and, 5) perform approved procedures (Registered Nurses (RN) Act, 2001; CRNNS, 2004a, 2004b). Th e Registered Nurse Regulations (2001) specifi ed that NPs prescribe from a schedule of approved drugs, order laboratory and diagnostic tests and carry out procedures from an approved lists established by the D&T Committee. With the proclamation of the new RN Act in 2009, NPs’ prescribing privileges ceased being restricted to a list, enabling NPs to prescribe drugs based on their individual education, knowledge and competence (RN Act, 2006; CRNNS, 2009b, 2009d). Th ese privileges do not include the prescription of narcotics and other controlled or targeted drugs because federal law controls the prescriptive privileges for these drugs.

Th e number of NP positions in the province has increased gradually, mostly through funding provided by the provincial government. An interim provincial strategy and policy for NP implementation identifi ed ten criteria that proposals requesting funds for NP positions from the Department of Health had to address (Nova Scotia Department of Health, 2002). Th e policy stipulated that to be eligible for Department of Health funds, the NP’s employer could not be a physician and that physicians collaborating with NPs could not be remunerated solely on a fee-for-service basis.

Most models of NP practice identify that the primary focus of the NP role is to provide direct clinical services to individuals and families (Dontje, Corser, Kreulen & Teitelman, 2004; Dunphy & Winland-Brown, 1998; Shuler & Huebscher, 1998). Th e fi ndings from several studies support this. For example, research conducted with NPs in Ontario found that wellness care, diagnosis and treatment of minor acute illness, and monitoring of chronic illness were the principal activities performed by NPs (DiCenso, Paech & IBM Consulting

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Services, 2003; Sidani, Irvine & DiCenso, 2000; Way, Jones, Baskerville & Busing, 2001). Another study identifi ed 13 categories of NP practice activities: 1) patient assessment; 2) diagnosis and management; 3) ordering medication; 4) referral; 5) ordering diagnostic procedures; 6) implementing non-traditional therapies; 7) teaching; 8) performing technological procedures; 9) clinic operation; 10) community involvement; 11) continuing education; 12) research; and, 13) providing consultation (Holcomb, 2000). Th is study found that NPs spent most of their time in direct care activities with individuals and families and devoted little time to community involvement.

Little is known about the practice patterns of NPs in Nova Scotia. Th e purpose of this research was to examine the practice patterns of NPs in primary health care in Nova Scotia.

Methods

Th e conceptual framework for this study was the

P

articipatory, Evidence-based and

P

atient-focused

P

rocess for guiding the development, implementation and evaluation of

A

dvanced practice nursing (PEPPA). Th is framework provides a systematic approach to the implementation and study of NP roles (Bryant-Lukosius & DiCenso, 2004). A descriptive survey design was used to address the following research questions:

What are the characteristics of NPs, their practice models and settings? 1.

What is the profi le of the practice population served by NPs and the types of services NPs provide? 2.

What are the barriers and facilitators to NP role implementation? 3.

A questionnaire was designed based on the literature, existing surveys (Bryant-Lukosius et al., 2007; DiCenso, Paech & IBM Consulting Services, 2003; Kasasalainen, DiCenso, Donald & Staples, 2007; Sidani, Irvine & DiCenso, 2000) and the top 10 diff erential diagnoses reported for family medicine (Ponka & Kerlew, 2007). Th e questionnaire (available from the corresponding author) included closed and open-ended questions about NP demographics, practice setting descriptors, practice population descriptors and NPs’perceived scope of practice. An expert panel reviewed the questionnaire for content validity, clarity, comprehensiveness and relevance. Th e questionnaire was piloted with a small group of NPs (n=5) to determine relevance, clarity and ease of use of the questionnaire as well as to determine the completion time. All NPs (Primary Health Care) ever licensed with CRNNS were included regardless of residence or type of current practice. Th e names and addresses of all licensed NPs were obtained through CRNNS and the Nurse Practitioner Association of Nova Scotia (NPANS). Data collection occurred between May and June 2008. To increase response rates, the questionnaire was mailed three times at 10-day intervals and global emails were sent to the NP group requesting their completion of the survey (Edwards et al., 2002). A $5.00 gift certifi cate was included as a token of appreciation. Of the 59 surveys sent, 4 were returned address unknown, leaving a sample size of 55. Descriptive statistics and content analysis were used to analyze the data.

Results

T

OTAL

S

AMPLE

Th irty-nine questionnaires were returned for a response rate of 71% (n=39 of 55 surveyed). Of these, 28 were practicing NPs in Nova Scotia and 25 of the 28 provided direct care in primary health care. Approximately half of the sample was prepared at the graduate level and the remainder had diploma or baccalaureate education. Respondents were almost all female, middle aged with a wide range of nursing backgrounds and had an average of 24 years of nursing experience and on average had been working as an NP for 5 years. Most NPs were employed full-time in either a community health centre or family practice offi ce in Nova Scotia. Table

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1 provides the complete demographics of all respondents. Th e remainder of the results is based on the data obtained from the 25 NPs currently providing direct care in Nova Scotia.

NP

SIN

N

OVA

S

COTIA

P

ROVIDING

D

IRECT

C

ARE

Demographics and Practice Settings

Half of the NPs in Nova Scotia were providing direct patient care in settings with a population less than 10,000. Most (92%) practiced in teams that included physicians and receptionists; 60% and 52% respectively indicated that they worked in teams that included a registered nurse and dietician. Fewer than 35% worked in teams containing other types of health care providers. Just over half (58%) worked in settings that used an electronic patient record.

When asked about the population for which they provided care, most respondents (71%) indicated they provided health care services to a population that spanned the lifespan; 46% reported their patient population was mainly Caucasian and 29% that it was mainly of low socioeconomic status.

Table 1: Demographic Characteristics of NPs Licensed in Nova Scotia as of May 2008

Variable Levels Practicing in NS

(n=28)

Not practicing as NP in NS (n= 11)

n % n %

Highest Education RN Diploma + NP 4 (14.3) 2 (18.2)

BScN/BN + NP 8 (28.6) 4 (36.4) Master’s + NP 12 (42.9) 4 (36.4) Doctorate + NP 1 (9.1) 1 (9.1) Other 3 (10.7) -Gender Female 27 (96.4) 11 (100) Male 1 (3.6)

-Mean/medium age (yrs) 46.96/46.0 46.36/47.0

Mean/medium yrs nursing experience 24.21/22.5 24.82/25.0

Mean/medium yrs NP experience* 5.09/4.0 4.40/5.0

Area of nursing before becoming NP** Primary Care 2 (7.1) 1 (9.1)

Long Term Care 1 (3.6)

-Public Health - - 2 (18.2) Education 1 (3.6) 2 (18.2) Outpost Nursing 6 (21.4) 1 (9.1) Critical Care 3 (10.7) 1 (9.1) Maternal Newborn 1 (3.6) -Mental Health - - -Government/Policy - - -Home Care 5 (17.9) -Administration 2 (7.1) -Medical Surgical - - 1 (9.1) Emergency 6 (21.4) 2 (18.2) Pediatrics - -

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-Variable Levels Practicing in NS (n=28) Not practicing as NP in NS (n= 11) n % n % NP license in NS Yes 28 (100) 9 (81.8) No - - 2 (18.2)

NP license elsewhere Yes 6 (21.4) 7 (63.6)

No 22 (78.6) 4 (36.4) Current practice PHC NP 24 (85.7) 6 (54.5) PHC NP and RN 3 (10.7) 1 (9.1) Specialty NP 1 (3.6) -RN - - 2 (18.2) Not NP or RN - - 2 (18.2)

Employment status** Full-time 23 (82.1) 6 (54.5)

Part-time 4 (14.3) 1 (9.1)

Permanent - - 7 (63.6)

Temporary - -

-Contract - -

-Other - -

-Current practice setting** Community Health Centre

13 (46.4) 3 (27.3)

Aboriginal Health Centre

1 (3.6)

-Family Practice Offi ce 14 (50) 1 (9.1)

Outpost Nursing - - 2 (18.2) Public Health - - 1 (9.1) Home Care - - -Emergency Depart. 1 (3.6) -Long-term Care 3 (10.7) -Dept. National Defence 1 (3.6) 1 (9.1) Ambulatory Clinic 1 (3.6) -University 2 (7.1) 1 (9.1) Hospital 1 (3.6) -Government 1 (3.6)

-Principal focus of practicing NPs*** Direct care as PHC NP 25 (89.3) 6 (54.5) Direct care as specialty NP 1 (3.6) -Education of NP students 2 (7.1) 1 (9.1) Note: * 5 missing responses for NPs practicing in NS and 6 for NPs not practicing in NS

** multiple responses permitted

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Employment and Work Life

Most of the 25 NPs providing direct care in Nova Scotia were unionized (84%). Almost all (88%) indicated they had a job description and 35% reported the job description was developed by their employer. Others indicated that their job description had been developed either by themselves or another NP (26%) or collaboratively with other members of the health team (13%); 26% were not aware how it had been developed. Forty percent of NPs indicated physicians had been orientated to their role; 36% reported that other health care professionals received information about their role.

Most NPs reported that they receive an annual performance appraisal (56%); however, 36% did not and two did not complete the question. Of the 14 who indicated they received an appraisal, 12 indicated that they completed a self assessment; 10 indicated they received written feedback from a manager; 8 indicated they received written feedback from team members; and 7 indicated they received written feedback from a physician. Most (n=12) reported that their appraisal process did not include feedback from patients or other NPs. Six NPs reported that a chart audit was included as a component of the appraisal process.

Financial and Other Supports

Th e majority of NPs reported receiving fi nancial support (92%) and time off (88%) for continuing education. Full-time NPs (n=20) were remunerated, on average, for a 40 hour work-week and part-time NPs (n=5) worked an average of 14 hours. Annual salaries for full-time NPs ranged from $69,000 to $88,000. Full-time NPs reported working a weekly average of 5 unpaid hours of overtime. When asked how satisfi ed they were with their salary, where a score of 1 represented very satisfi ed and 5 was very dissatisfi ed, the mean score was 2.8 for Nova Scotia NPs. For NPs practicing in other provinces and territories the mean score was 2.5.

NPs’ satisfaction (a score of 1 represented very dissatisfi ed and 6 very satisfi ed) with other practice supports was generally high as outlined in Table 2. Nova Scotia NPs rated data management support lower than NPs practicing in other provinces/territories. On the other hand, Nova Scotia NPs gave higher scores to employer policies and expectations than NPs practicing in other provinces/territories.

Table 2. Nova Scotia Practicing NPs’ Satisfaction with Supports

Variable Mean Median

Offi ce space 5.0 5.0

Clinical exam space 5.2 5.0

Communication technology 5.3 5.0

Clerical support 5.0 5.0

Computer support 4.4 4.0

Data management support 3.4 3.0

Employer policies supporting role implementation 5.0 5.0

Orientation to practice setting 4.8 5.0

Orientation to expectations of employer 5.7 5.0

Support from other health care providers 5.3 5.0

Support from direct supervisor 5.3 5.0

Policies of Nova Scotia Department of Health 3.6 4.0

Policies of College of Registered Nurses of Nova Scotia 4.8 5.0 Note: a score of 1 represented very dissatisfi ed and 6 very satisfi ed

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Practice Activities

In an average week, NPs reported spending 70% of their time on direct patient care. Breaking this down further, they reported spending 28% of direct patient care on management and monitoring of chronic illness, 25% on wellness care and health promotion, 20% on episodic care for minor acute illness and injury and 12% on the management and monitoring of mental health concerns. On average, they spend almost 10% of their time on community outreach and very little time on providing episodic care for major acute illness (3%) or palliative care (2.5%). None of the NPs provided on-call services.

On average, NPs provide consultation to 14 patients in an eight-hour work day. Th e principal ways patients were assigned to an NP’s care was by patients booking their own appointments directly (52%) or through receptionist assignment (21%). Very few (4%) reported that patient assignment to the NP occurred only when the physician was unavailable.

Th e majority of NPs (85%) conduct one to fi ve home visits per month. All responded that the reason for the home visits is to provide health care to older adults. Other patient health concerns for which NPs did home visits included mobility problems (73%), immobility (53%) and palliative care (47%). Almost half of the NPs (43%) reported that they provide primary care to residents living in nursing homes.

Diagnosing and Prescribing

All NPs reported that they diagnose diseases or conditions, order lab and diagnostic tests and prescribe medications. NPs indicated that they are required to diagnose a wide variety of symptoms on at least a weekly basis, for example, acute cough, low back pain, fever, fatigue, headache, chronic cough, depression/anxiety, musculoskeletal pain, skin conditions and menstrual irregularities. Other presenting symptoms that they

encountered less often (every 1-3 months) were acute and chronic abdominal pain, recurrent chest pain, vertigo/ dizziness, acute and chronic dyspnea and local edema.

Eighty percent or more of NPs indicated they ordered biochemistry, microbiology, hematology and cytology/ pathology lab tests and x-rays on a weekly basis. Between 50 and 70% reported ordering pelvic and abdominal ultrasounds and CT scans weekly.

Almost 60% of NPs indicated they prescribe 11 diff erent types of drugs on a weekly basis; these included antimicrobial, cardiac/anti-hypertensive, hormonal, anti-infl ammatory, asthma-COPD, topical, serum lipid reducing, antidepressant, anti-diabetic, gastro-intestinal and immunizing agents. On the other hand, 73% indicated they hardly ever prescribe or administer emergency drugs.

Community Development Activities

Most NPs (82%) reported performing community development activities, most commonly collaborating with communities to plan and implement health programs and speaking to community groups or organizations on health related topics. Table 3 outlines the various types of community development activities NPs reported performing.

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Table 3. Community Development Activities Reported by Nova Scotia NPs

Activities Number of NPs

Collaborate with communities to plan and implement health programs 12 Speak to community groups/organizations on health related topics 9

Serve as a member for community organizations 5

Staff development/including interprofessional 5

Develop linkages with other sectors such as education, transportation 3

Organize community education 3

Educate community regarding role of health care providers 3 Collaborate with communities to develop healthy public policy 2 Advocate with and/or for vulnerable populations in the community 2

Collaboration, Consultation and Referral Activities

Th e majority of NPs (63%) indicated their collaborative practice agreement (CPA) was approved by the CRNNS Diagnostic and Th erapeutics Committee; the remainder reported obtaining employer approval. NPs were asked to rate the diffi culty they experienced during the development of the CPA using a 5 point scale where 1 was “very diffi cult” and 5 was “very easy”. Th ey rated the extent to which they perceived the CPA had enabled other team members to understand their role using a similar scale. Th ose who had their CPA approved through the CRNNS reported having more diffi culty with developing their CPA (mean 2.27) than those whose CPA was approved by their employer (mean 3.13). However, both groups indicated the CPA had enabled a better understanding about the NP role with other health care providers (mean 4.29 and 3.88). Fifty percent also indicated their CPA was useful for establishing priorities, evaluating goals or evaluating collaboration within their practice.

Collaboration with Family Physicians

Fifty percent of NPs in Nova Scotia collaborate formally with one or two physicians and the others with three or four physicians. Most (72%) collaborate with the same physician(s) for community and offi ce practice activities. Sixty percent indicate their practice is co-located with that of their collaborating physician. Th e remaining NPs were either located in the same community but in a diff erent building than their collaborating physician, or were in an entirely diff erent community. Using a fi ve point scale where a score of one was “not satisfi ed” and fi ve was “totally satisfi ed” NPs’ mean rating of satisfaction with their relationship with the physician with whom they collaborate most was 4.71.

Informally initiated discussions about patient care was the most common mechanism NPs indicated using to collaborate with physicians about patient care concerns (Table 4); these discussions were initiated almost as often by physicians as NPs. NPs (35%) reported, that on a weekly basis, they refer patients to their collaborating physician because the patients’ needs fall outside of their scope of practice, however, more of them (58%)

received patient referrals from their collaborating physicians for follow-up. Other reasons cited for collaboration included discussing matters related to the collaborative practice or addressing issues related to the health

of the community. NPs indicated that they also collaborate with physicians, with whom they do not have a formal collaborative relationship; most commonly, this was to send a written report about care provided to the physician’s patient.

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Table 4: Frequency of Collaboration Methods Used By Nova Scotia NPs & Physicians

Weekly Monthly Every 3 mos

Hardly ever

n % n % n % n %

NP initiates informal:

-face-to-face discussions re patient care 20 (83.0) 3 (12.5) 1 (4.0) --telephone discussions re patient care 9 (37.5) 5 (21.0) - - 10 (42.0) MD initiates informal:

-face-to-face discussions re patient care 16 (67.0) 5 (21.0) - - 3 (12.5) -telephone discussions re patient care 4 (17.0) 4 (17.0) - - 16 (67.0) On regular basis MD and NP:

-meet face to face re patient care concerns* 6 (26.0) 7 (30.0) - - 10 (43.5) -talk by telephone re patient care concerns* 3 (13.0) - - - - 20 (87.0) Patients referred by:

-NP to MD as patient needs outside NP’s scope of practice**

8 (35.0) 10 (43.5) - - 4 (17.5) -MD to NP for specifi c follow up 14 (58.0) 6 (25.0) 3 (12.5) 1 (4.2) NP & MD communicate about emerging health

issues in the community

11 (46.0) 8 (33.0) 2 (8.0) 3 (12.5) NP & MD jointly:

-address issues aff ecting health of community* 9 (31.0) 8 (35.0) 2 (9.0) 4 (16.0) -plan to optimize systems in practice to carry out

specifi c activities

8 (33.0) 9 (37.5) 1

(4.0) 6 (24.0) -plan for changes in organization of practice* 8 (35.0) 8 (35.0) 4 (17.0) 3 (13.0) Note: 1 response missing for all variables except those with asterisk* which are missing 2 and ** which are missing 3.

Collaboration with Physician Specialists

All NPs indicated they refer patients to specialist physicians. When asked to identify the process they use for making a referral to a physician specialist, all NPs indicated they write the consult note and sign it themselves. Most NPs (73%) reported that the specialists they refer to accepted their referrals. However, 23% reported that some specialists had refused their referrals.

Collaboration with Pharmacists

Of the 23 NPs (2 did not respond) who responded to this item, most indicated that they collaborate with several pharmacists from two or more diff erent pharmacies (65%), the remainder with the pharmacist(s) in one specifi c pharmacy. Th e most common reason NPs collaborated with pharmacists was to determine third party payer insurance coverage and to discuss specifi c aspects of particular drugs for their patients (Table 5).

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Table 5: Reasons Nova Scotia NPs Collaborate with Pharmacists

Variable Responses n %

Discuss:

selection of a medication Yes 19 (79)

No 5 (21)

medication dose Yes 17 (71)

No 7 (29)

medication interactions Yes 19 (79)

No 5 (21)

medication contraindications Yes 15 (62.5)

No 9 (37.5)

Drug Monitoring Program Yes 6 (25)

No 18 (75)

Validate the evidence for prescribing a specifi c drug Yes 5 (21)

No 19 (79)

Determine third party coverage (e.g. Pharmacare, Blue Cross) Yes 20 (83)

No 4 (17)

Jointly off er community education Yes 9 (37.5)

No 15 (62.5)

Note: 1 response missing for all variables

Collaboration with Other Team Members and Programs

Using a fi ve point scale, where a score of 1 was “poor understanding” and 5 was “excellent understanding,” NPs’ mean ratings of how well team members with whom they regularly worked understood their NP role was 4.13. NPs indicated they refer patients to a wide variety of health care providers, (e.g., dieticians, mental health workers, social workers, and physiotherapists) and health programs (e.g., mental health services, diabetes program, addictions services, public health and community based self-help programs). Fifty percent or more of NPs receive patient referrals from public health, other physicians and other NPs.

Achievement of Expected Outcomes in NP Practice

Th e majority of NPs (64%) indicated they were not expected to achieve specifi c health outcomes in their

employment settings. Of those who reported that they were expected to achieve outcomes, 13 provided narrative comments specifying the outcomes they were expected to achieve; these were to increase cervical screening by conducting clinics in various communities, reduce wait times, reduce/control/manage chronic disease, and adhere to clinical practice guidelines. Half of NPs indicated they collect data for use in process or outcome evaluation of their role as an NP.

Contributions of the NP Role to Individuals, Organizations and the Health Care System

NPs perceived that the main contributions of their role to the care of patients and families were increased access, quality of care, health promotion and patient education. Th ey perceived their contributions to the organization in which they worked were leadership, teamwork and staff education and their contributions to the health care system were cost savings and pioneering a new health care provider role (Table 6).

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Table 6: NPs’ Perceived Contributions of their Role

Contributions to Patients and Families Number of Comments

Increase in access 46

Increase in quality of care 43

- Holistic compassionate care (22) - Management of chronic conditions (9) - More time spent with patient (8) - Continuity of care (4)

Increase in health promotion 20

Increase in patient education 14

Contributions to Employing Organizations

Leadership 27

Teamwork 9

Staff education 5

Contributions to the Health System

Cost saving 11

Pioneering/advancing a new health care role 8

Barriers and Facilitators to NP Practice

Th e top three identifi ed facilitators for NP practice were administrative/management support, a culture of teamwork and physician support. Th e top three barriers to NP practice were funding issues, scope of practice restrictions and resistance to role implementation.

A

TTRITION FROM

NP P

RACTICE

Four respondents indicated they were not practicing in an NP role; two had previously practiced as an NP and cited their reasons for leaving NP practice as being unable to fi nd permanent employment as an NP and inadequate physician support. One respondent had never practiced as an NP and indicated this was due to three reasons: family factors, employment opportunities for NPs in Nova Scotia being too far from home, and being unable to relocate for employment. When asked if they were interested in completing an NP re-entry program, two of the respondents indicated they had no interest in such a program and the other two did not respond to the question.

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Discussion

Th is study examined the practice patterns of NPs in primary health care in Nova Scotia. Th e 71% response rate suggests the results are probably representative of NPs working in primary health care. However, as with all surveys, a limitation of the study is that it relies on self-report data.

Th e results show that NPs in Nova Scotia are practicing to their full scope of practice. Th e amount of time they spend on individual focused activities and the amount of patient consultations per day is consistent with other studies (DiCenso, Paech & IBM Corporation, 2003; Sidani, Irvine & DiCenso, 2000; van Soeren, Hurlock-Chorostecki, Goodwin & Baker, 2009). Th e top 10 diff erential diagnosis in Nova Scotia NPs’ practice are similar but not identical to those reported for family medicine (Ponka & Kerlew, 2007). Cough, low back pain, fever, fatigue and headache were encountered by both types of practitioners. Whereas Nova Scotia NPs encountered depression/anxiety, musculoskeletal pain, skin conditions and menstrual irregularities, Ponka and Kerlew (2007) found the other diagnoses encountered in family medicine were dyspnea, generalized abdominal pain, vertigo, chest pain and edema. More research is needed to explore whether these diff erences are seen across a larger population of NPs. In addition to the offi ce-based primary care services NPs provide they conduct home visits, provide services in nursing homes and devote almost 10% of their time to community development, which is more than what has been reported in other studies (Holcomb, 2000).

NPs perceive their contribution to the care of patients and families to be an increased access to primary health care, improved quality of care, and increased health promotion and education. Th ey perceive their contribution to employers to be leadership, teamwork, and staff education and to the health system as cost saving and pioneering/advancing a new health care role. Although most NPs indicated that they collect data for use in process or outcome evaluation of their role as an NP, very few NPs were expected to achieve specifi c outcomes for their practice. Th is is likely to change as governments become increasingly focused on health outcomes and cost eff ective health care.

Th e results indicate that the majority of NPs work in full-time positions of 40 hours per week. However, NPs also indicated that, on average, they work 5 hours of unpaid overtime per week. Subtracting four weeks of vacation, NPs may be working an average of 240 hours of unpaid overtime per year. Th e collective bargaining agreement in Nova Scotia provides NPs with fi ve days (40 hours) off in lieu of overtime. Th is may be one of the reasons that NPs are only minimally satisfi ed with their remuneration and, if unaddressed, could negatively aff ect recruitment and retention.

Consistent with a recent national study of NPs in Canada (LaMarche & Tullai-McGuinness, 2009), most NPs are satisfi ed with their collaboration with their collaborating physician(s) and employer supports. Moreover, the extent of bilateral collaboration that is occurring between Nova Scotia NPs and their collaborating physician is indicative of eff ective teamwork (Way, Jones, Baskerville & Busing, 2001). Th e NPs in this study reported that the previous CRNNS requirement for the process of developing CPAs was diffi cult but that the CPA had furthered the development of role clarity among the physicians and other team members in their practice. Future research is needed to determine the benefi ts and disadvantages of CPAs, specifi cally their eff ect on NP autonomy and role integration. In addition, NPs’ relationships with other medical and health care professionals are largely positive. NPs regularly refer their patients to other health professionals and health programs and most refer patients to medical specialists without diffi culty. However, almost 25% of NPs had referral requests refused by at least one medical specialist. Th e reasons why such refusals are occurring should be explored to identify issues requiring intervention. Th is study did not determine if the problem is geographically specifi c or diff use.

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Th e top three facilitators to NP practice in this study were administrative/management support, a culture of teamwork and physician support and the top three barriers were funding issues, scope of practice restrictions and resistance to role implementation. Th ese fi ndings are consistent with surveys done on employment and practice trends conducted by CRNNS (2007, 2008) and with other Canadian studies (Bryant-Lukosius et al., 2007; DiCenso et al., 2003).

Conclusion

In conclusion, the results of this study provide a snapshot of the practice patterns of NPs in Nova Scotia prior to the May 2009 proclamation of the 2006 Registered Nurses Act. Having this profi le will provide a baseline from which to compare as the role of NPs continues to evolve. Th e fi ndings suggest that NPs in Nova Scotia are practicing to their full scope of practice and are satisfi ed with their practice supports and collaborative relationships. Some barriers persist to the full integration of the NP role.

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Figure

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References