role DEFINITION, an essential element in PHCNP integration

The importance of appropriately and coherently defining the PHCNP’s role and scope of practice is, by far, the point most often made in the literature on the functioning of teams that include PHCNPs. Even when all members of a clinical team share the desire to develop a collaborative practice, it often happens that each, in fact, has a different idea of what the others’ roles are. This can be the sources of misunderstandings, conflicts, and ultimately of disenchantment with team practice. It is therefore essential that, using a consensual approach, teams establish the broad outlines of the members’ respective roles in the service offering and in patient management.

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Source et validiTy of these recommendations

The information presented here comes from two sources: 1) the results of a systematic review of the scientific literature on advanced nursing practice in primary care, and 2) the results of six case studies of settings that have integrated PHCNPs in three health regions of Quebec. Details of the methodologies used for each of these two research efforts are presented in the Methodology section. The analyses of the data produced in each of these two components were used to inform each other reciprocally. Thus, the data from the scientific literature were analyzed in relation to the various models of integrating PHCNP practice found in Quebec, while the empirical data were interpreted based on themes identified in the literature.

Many studies have analyzed the deployment of primary health care nurse practitioners in other provinces and countries. These studies all stress, with notable unanimity, the importance of defining each team member’s role clearly and explicitly. This emphasis on the importance of role definition appears to be largely the result of studies that examined obstacles to collaboration or to PHCNP integration. These studies provide convergent evidence that misunderstandings and conflicts around roles are frequent and significant barriers to PHCNP deployment and practice. From our analysis, there is solid and credible evidence to support the need for consensus on role definition in the clinical team. On the other hand, the evidence to support the more instrumental recommendations on how to create such a consensus is much less strong.

Clarifiying and formalizing team members' roles

The challenge of integrating a new professional role into a clinical team should not be underestimated. An analysis of the roles of PHCNPs, physicians, and nurses carried out jointly by Quebec’s Ministry of Health and Social Services and the Quebec Order of Nurses revealed considerable overlap in these professionals’ practices—a situation which is not unique to Quebec (Download in French only).
A first key step in analyzing this situation involves distinguishing between role clarity and the level of role formalization. When a role is clear and well-defined, it means there is consensus in the team about how patient management responsibilities are distributed, about each members’ skills, and about each profession’s scope of practice. The level of formalization describes the extent to which each person’s role is defined, in more or less detail, in written documents.

Several documents, legislative and otherwise, suggest that the role definition process should result in each person’s role being formalized in writing. However, we have found no strong empirical evidence in the literature to support the conclusion that role formalization is the sole or best way to support consensus around role definitions. Some authors argue that, to create such a consensus, formal role descriptions are essential. Conversely, other studies in the management arena have suggested that role formalization should be sufficiently flexible and malleable to allow team members’ practices to evolve. According to this approach, any excessive role formalization that attempts to set down in writing every possible situation and all interventions is probably counterproductive to collaboration.

It is impossible, from the available data, to determine exactly what the appropriate level of formalization should be. Each person’s role should be clear and consensual. It may be that the optimal level of formalization is a function of team size and that larger teams may require greater formalization.


The role definition process

While it is difficult to draw conclusions about the optimal level of formalization of professional roles, it is, on the other hand, very clear that setting up an effective process to define clearly each team member’s role is a key factor in optimizing practice.
As mentioned earlier, there is notable convergence in the literature around the importance of having clear and consensual role definitions. Similarly, our analysis of the cases studied suggests, in fact, that PHCNPs’ clinical practice was more effective in settings that implemented processes to discuss and exchange ideas about the professional roles of all primary care team members. These interactions resulted in a clear and shared vision of the PHCNP’s role and in the PHCNP’s autonomous exercise of that role in patient management.

Quebec’s regulatory framework requires that PHCNPs and their physician partners sign a partnership agreement, developed jointly by the nurses’ and physicians’ professional orders, whenever a PHCNP is hired (Download in French only). The content of each collaboration agreement depends on population needs, the different physicians’ preferences, clinic characteristics, regulations in effect, etc.; as such, it is not possible to determine the content of the agreement beforehand. Partnership agreements are not required everywhere in Canada, but the case of Quebec shows that this step presents an opportunity to discuss each professional’s role in detail. There are many useful documents to support this step, available in the Resources section .

The impact of a new professional’s arrival and of defining a new role in a clinical team should not be underestimated. An analysis of the respective roles of PHCNPs, physicians, and nurses revealed a potentially large overlap in these professionals’ practices. The international scientific literature on the definition of the PHCNP’s role in primary care teams shows that this situation is not unique to Quebec. Sibbald et al. (2006) proposed a typology for defining primary care roles. According to this typology, often taken up in the literature, a new professional’s role can be defined using four logics:

  • enhancement, which involves widening the field of practice or the competencies of a professional group;
  • substitution, which involves replacing one type of professional by another in the provision of certain services;
  • delegation, which involves allowing a subordinate professional to provide extended services, but under the supervision of another type of professional;
  • innovation, which involves establishing new types of services or creating new professional roles.

These logics are not mutually exclusive, but they can serve as guideposts for thinking about the process of redefining roles in a team. Further, as a general rule, role definition should enable all members of the team:

  • to practice to the full scope of their capacities;
  • to contribute efficiently and effectively to patient management according to each professional’s expertise;
  • to develop their own expertise and capacities and to facilitate this development process.

Our empirical data are consistent with the literature in showing that an essential factor in the role definition process is the identification of one or more project champions in the organization (see the Team Support section). In many settings, this role is given to a manager in the nursing department and sometimes it is delegated to a nurse consultant. As a matter of principle, it is imperative that all members of the team be involved in the role definition process and that the discussions be open and collegial. It is important that there be champions to support the implementation of the role definition process, as well as any role formalization (see the Team Support section). The presence of this “guardian of the PHCNP role” will help ensure the full scope of the PHCNP’s practice is respected. It is helpful to repeat periodically the interactive process of discussing team members’ roles, since those roles evolve over time. Along these lines, both the literature and our observations suggest that, in supportive settings, PHCNPs settle fully into their roles between 6 and 12 months of taking up their position. PHCNPs are also responsible for promoting their role among their peers, their team, and the entire organization.

In conclusion, there is no solid evidence as to which is better, a broad definition of roles that is flexible and informal or, at the other extreme, a very detailed definition. On the other hand, one key factor appears to be the existence of a clear consensus, shared by all members of the team, that allows everyone to know what their own role is, where it begins and ends, and how it fits with those of the other team members. It should not be assumed that such consensus will emerge on its own from everyday practice. The best way to establish roles that are clear and well understood is to provide the means to discuss them, to put them into practice, and to make adjustments using a collegial approach.

Questions to consider in order to develop a clear vision of the PHCNP’s role

  • Beyond the guidelines regarding the PHCNP’s role provided in various regulations, how does the setting envision the PHCNP’s role?
  • What concerns do the professionals have regarding their own roles?
  • Have meetings been planned to allow all team members (organization managers, physicians, PHCNPs, nurse clinicians, licensed practical nurses, clerical staff) to discuss each other’s roles?
  • Has a grid to clarify each member’s role been developed and discussed?
  • Has the PHCNP’s support to the development of team members’ practices (training sessions) been determined?

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For more information:

  • Clarin, O. A. (2007). Strategies to overcome barriers to effective nurse practitioner and physician collaboration. Journal for Nurse Practitioners, 3(8), 538-548
  • DiCenso, A., & Matthews, S. (2005). Report on the Integration of Primary Health Care Nurse Practitioners into the Province of Ontario Executive Summary. Toronto, ON: Ministry of Health and Long Term Care. (Download)
  • DiCenso, A., & Matthews, S. (2007). Report of the Nurse Practitioner Integration Task Team submitted to the Ontario Minister of Health and Long-Term Care. Toronto, ON: Ministry of Health and Long-Term Care. (Download)
  • Hoskins, R. (2011). Interprofessional working or role substitution? A discussion of the emerging roles in emergency care. J Adv Nurs, 68(8), 1894-1903.
  • Irvine, D., Sidani, S., Porter, H., O'Brien-Pallas, L., Simpson, B., McGillis Hall, L., et al. (2000). Organizational factors influencing nurse practitioners' role implementation in acute care settings. Canadian journal of nursing leadership, 13(3), 28-35.
  • Koren, I., Mian, O., & Rukholm, E. (2010). Integration of nurse practitioners into Ontario's primary health care system: variations across practice settings. Canadian Journal of Nursing Research, 42(2), 48-69.
  • Laurant, M., Reeves, D., Hermens, R., Braspenning, J., Grol, R., & Sibbald, B. (2005). Substitution of doctors by nurses in primary care. Cochrane Database of Systematic Reviews(2), 001271.
  • Lowe, G., Plummer, V., O'Brien, A. P., & Boyd, L. (2012). Time to clarify--the value of advanced practice nursing roles in health care. J Adv Nurs, 68(3), 677-685.
  • Martin-Misener, R. (2006). Defining a role for primary health care nurse practitioners in rural Nova Scotia. Canadian Journal of Nursing Research, 42(2), 30-47.
  • Sangster-Gormley, E. V. (2011). A case study of the process of nurse practitioner role implementation within a health authority in Bristish Columbia. Halifax, Nova Scotia: Ph.D. Thesis (Dalhousie University School of Nursing).
  • Sawchenko, L., Fulton, T., Gamroth, L., & Budgen, C. (2011). Awareness and acceptance of the nurse practitioner role in one BC health authority. Nurs Leadersh (Tor Ont), 24(4), 101-111.
  • Thille, P., & Rowan, M. S. (2008). The Role of Nurse Practitioners in the Delivery of Primary Health Care: A Literature Review: Health Canada.

Citing this document Project (2013). Information sheet on Role Definition. Role definition, an essential element in PHCNP integration. Montreal, December 2013.

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collaboration, Much more than substitution is at the heart of the primary care NP in practice model.