A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA - June 2012 Copyright by Esther Sangster-Gormley, 2012
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A SURVEY OF
NURSE
PRACTITIONER
PRACTICE
PATTERNS IN
BRITISH COLUMBIA
June 2012
© Copyright by Esther Sangster-Gormley, 2012
University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
Co-Principle Investigators
Esther Sangster-Gormley, RN, PhD (Corresponding Author)
Assistant Professor, School of Nursing
University of Victoria
PO Box 1700 STN CSC
Victoria, British Columbia V8W 2Y2
egorm@uvic.ca
Brenda Canitz, BA, BScN, MSc
Executive Director
Partnerships for Health
University of Victoria
Co-Investigators
Rita Schreiber, RN, PhD
Professor
University of Victoria
Elizabeth Borycki, RN, PhD
Assistant Professor
University of Victoria
Noreen Frisch, RN, PhD
Professor and Director, School of Nursing
University of Victoria
Linda Sawchenko, RN, MSHA, EXTRA Fellow
Interior Health Authority
Trail, British Columbia
Debbie McLachlan, RN, MN
Ministry of Health
Victoria, British Columbia
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
Karla Biagioni, BSc, MA
Ministry of Health
Victoria, British Columbia
Research Coordinator
April Feddema, BA
Research Assistant
Mindy Swamy, RN, MN
Acknowledgment
This project was funded by the Michael Smith Foundation for Health Research. We would also
like to thank the nurse practitioners who participated in this study.
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
Contents
LIST OF TABLES ........................................................................................................................ IV
LIST OF FIGURES ...................................................................................................................... IV
EXECUTIVE SUMMARY ............................................................................................................. 1
BACKGROUND............................................................................................................................. 3
METHODS ...................................................................................................................................... 4
FINDINGS ...................................................................................................................................... 5
Demographics ............................................................................................................................... 5
Financial and Other Supports ..................................................................................................... 9
Practice Activities ....................................................................................................................... 11
Diagnosing, Test Ordering, and Prescribing Patterns........................................................... 13
Encounter Reporting ................................................................................................................ 16
Nurse Practitioner Electronic Records Use .......................................................................... 17
Collaboration, Consultation, and Referral Activities ............................................................ 20
Collaboration with Family Physicians .................................................................................. 20
Collaboration with Specialist Physicians and Other Health Care Professionals ............ 20
Achievement of Expected Outcomes in NP Practice ............................................................. 22
Contributions of the NP Role to Individuals, Organizations and Healthcare System ..... 23
Facilitators and Barriers to NP Practice ................................................................................... 24
NPs Not Practicing in BC .......................................................................................................... 24
DISCUSSION ............................................................................................................................... 25
CONCLUSION ............................................................................................................................. 27
REFERENCES ............................................................................................................................... 28
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
LIST OF TABLES
Table 1. Employment Status ............................................................................................................ 5
Table 2. Practice Settings .................................................................................................................. 7
Table 3. Members of HealthCare Team Co-located with NP ..................................................... 8
Table 4. Patient Population .............................................................................................................. 9
Table 5. Satisfaction with Resources and Supports.................................................................... 10
Table 6. Direct Patient Care Activities ......................................................................................... 11
Table 7. Activities Other than Direct Patient Care ..................................................................... 12
Table 8. Frequency of Presenting Symptoms or Conditions .................................................... 14
Table 9. Patterns of Diagnostic Testing Ordered ........................................................................ 15
Table 10. Frequency of NP Diagnosis of Chronic Conditions .................................................. 15
Table 11. Frequency of NP Prescribing Pharmaceuticals .......................................................... 16
Table 12. EMR Functions and Use Patterns ................................................................................ 19
Table 13. Health Care Professionals with whom NPs Collaborate.......................................... 21
Table 14.Frequency and Reason for Collaboration .................................................................... 22
Table 15. NP's Perceived Contributions of Their Role............................................................... 23
Table 16. Facilitators and Barriers to NP Role Implementation ............................................... 24
LIST OF FIGURES
Figure 1. Geographic Distribution of NPs ..................................................................................... 6
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
EXECUTIVE SUMMARY
In British Columbia (BC), the first nurse practitioners (NPs) graduated and were hired into
regional health authorities beginning in 2005. Early expectations for the role included
increasing accessibility, expanding health care options and filling gaps in the BC healthcare
system. NPs were expected to provide safe, competent, and acceptable care to British
Columbians.
This survey was part of a larger study evaluating the integration of NPs in BC. The purpose of
this survey was to better understand how NPs in BC were practicing. Survey data was
collected from September 2011 through January 2012.
A total of 37 NPs returned the survey, 31 were practicing in BC and four were registered in
other provinces. All participants held a Masters of Nursing degree, the majority were female,
and their average age was 46. Participants had practiced as a registered nurse an average of 19
years before becoming an NP, the mean length of time as an NP was three years. The majority
of NPs were employed full-time by one of the regional health authorities, and were practicing
in rural settings, small towns and large metropolitan areas.
The majority of participants practice in community based settings where they were the only
NP in the practice. They provide care for a variety of populations such as First Nations,
homeless, seniors, and new immigrants. Most indicated they experience problems providing
care as a result of restrictive legislation that did not recognize NPs as authorized providers of
care.
Participants spend the majority of their time engaged in direct patient care activities. Most
often they manage and monitor chronic illnesses and mental health concerns, and provide
counseling and education. Participating NPs provide care for frail seniors in their homes or
residential care facilities, and practice in youth clinics and homeless shelters. They assess,
diagnose and manage a variety of acute and chronic conditions, order diagnostic tests and
prescribe medications.
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
When not providing direct patient care, non-clinical activities involve participating in team
meetings and educating others, such as NP and medical students. In the communities in which
they practice, participants engage in community outreach by facilitating health workshops,
presenting at nursing educational rounds, and liaising with other healthcare providers.
Most participants use an electronic health record or a hybrid record. Participants submit ICD 9
diagnostic codes and NP encounter codes to the MOH and/or their health authority employer.
They commented that there was inconsistency in how these codes were submitted because of a
lack of training in how to submit the codes.
NP participants perceived that they contribute to the healthcare system by increasing access to
care, managing chronic diseases, supporting other providers, and reducing the use of acute
and/or emergency departments. There remain barriers to implementing the NP role in BC.
These include inadequate support from administrators and physicians, and lack of
understanding of the role by others. In spite of this, facilitators of the role include supportive
team members, including physicians and the community, and personal initiative.
The results of this survey provide a snapshot of how NPs are practicing in BC as of January
2012. These findings provide a baseline for future comparison of role integration. As indicated
by these findings they are practicing in their legislative scope of practice in diverse
communities with people of all ages. Barriers to role integration exist and will need to be
considered as more NPs are hired throughout the Province.
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
BACKGROUND
The nurse practitioner (NP) role has existed in North America for more than 40 years (Mason,
Vaccaro, & Fessler, 2000), yet in British Columbia (BC) the role is new, having first been
introduced in 2005, less than 10 years ago. Although the role is new in BC, the Ministry of
Health’s (MOH) interest in the NP role can be traced back to the 1970s (Haines, 1993). This
early interest was not sustained; however, renewed efforts to implement the NP role began
again in 1997 with joint efforts of the MOH and the Registered Nurses of British Columbia
(RNABC1) to define the role for the BC context (RNABC, 1997). Between 2000 and 2005, the
MOH, partnering with the CRNBC and in consultation with other key stakeholders, developed
a regulatory and legislative framework to register NPs and define their practice. Legislation
establishing the NP title and scope of practice was proclaimed in 2005 (MOH, 2006). In 2005
the first NPs graduated and were soon registered by the CRNBC and hired into regional health
authorities. The defined NP scope of practice was intended to allow for a professional practice
model of autonomous NP practice, with minimal restrictions (CRNBC, 2006a; CRNBC, 2006b).
Because of this, NPs were expected to increase accessibility to acute, long-term, and primary
health care (PHC) services; expand health care options; and fill gaps in the BC healthcare
system (RNABC, 2004).
Expectations for the role in BC are similar to those in other provinces and in the United States.
From the inception of the role, NPs were expected to reduce the costs of healthcare, provide
high quality care (Nies et al., 1999; Sidani & Irvine, 1999), and increase access to healthcare
services (DiCenso et al., 2003; Fahey-Walsh, 2004; Ingersoll, McIntosh, & Williams, 2000).
The NP role has been evaluated more than any other role in healthcare, and researchers have
demonstrated that NPs provide safe, effective care; patients are satisfied with care provided by
NPs; patient health outcomes are improved; and NPs facilitate functioning of multidisciplinary
care teams (DiCenso et al., 2010; Horrocks, Anderson, & Salisbury, 2002; Newhouse, 2011).
This evidence supports the BC MOH’s expectation that NPs will provide safe, competent, and
acceptable care to British Columbians.
1 Now the College of Registered Nurses of British Columbia (CRNBC)
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
This report is based on the findings of a survey of NP practice patterns conducted from
September 2011 through January 2012. The survey was part of a larger study evaluating the
integration of NPs in the Province. The specific purpose of this survey was to gain an
understanding of how NPs in BC are practicing. We were interested in learning about the
populations for whom NPs provide care, the health conditions they most frequently diagnose
and treat, and their collaborative relationships; as well as, their use of electronic health records,
job satisfaction and other general aspects of their practice.
METHODS
We obtained permission to use a survey previously developed to assess NP practice patterns
in Nova Scotia (Martin-Misener et al., 2010). We modified the survey to reflect the BC context
and added questions about use of electronic records. We then pilot tested the survey with two
experienced NPs in the Province to determine clarity, appropriateness, and ease of use. Ethics
approval was obtained from the University of Victoria.
We used three recruitment strategies to ensure we obtained information from a wide range of
NPs practicing in BC. We did not have direct access to the names and addresses of registered
NPs, therefore we contacted CRBNC, who agreed to mail a researcher-prepared letter of
invitation to the 100 registered NPs who had previously consented in their registration
renewal application to be contacted for research purposes. The written invitations contained
an electronic link participants could use to access the questionnaire. For our second strategy,
we obtained permission from the BC Nurse Practitioners Association (BCNPA) to post a link
to the survey on their website. Finally, we emailed an invitational letter to 57 University of
Victoria NP alumni who had voluntarily given us their email addresses.
A total of 37 NPs returned the questionnaire. Three surveys were incomplete and were
excluded from analysis. Three NPs were not practicing in BC and completed only
demographic information and questions related to why they were not practicing in BC.
Therefore, most data from this report is based on 31 responses.
We cannot calculate an exact return rate because we are unaware of the number of NPs
viewing the BCNPA website. Not all participants answered all questions, therefore for the
purpose of clarity we provide the number responding to the question along with percentage
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
when appropriate. Given the multiple recruitment strategies used, the return rate was low,
however, because this is the first study of its kind in BC, the results are informative.
FINDINGS
Demographics
All participants held a Masters of Nursing degree, 85 % (n=34) were female, and the average
age was 46 years (range 28-60 years). Participants practiced an average of 19 years as a
registered nurse (RN) before becoming an NP indicating that NPs returned to pursue a
graduate degree in nursing as highly experienced RNs. The mean length of time participants
had practiced as an NP was 3 years. Eighty seven percent (n=27) were registered as family
NPs, and 13% as adult or pediatric NPs (n=4). Most NPs (n=31) were currently practicing as an
NP in BC, but three were not registered in BC. We asked participants if they were registered in
another province, four indicated they were registered outside of BC; one in the Northwest
Territories, two in Alberta, and one in Ontario.
The majority of the 31 participants (68%; n=21) held permanent full-time positions, and 26%
(n=9) were in part-time positions. Nineteen percent of 31 NPs (n=6) practiced in dual roles, for
example, RN/NP, part-time as an NP and casual as an RN, or clinical nurse specialist/NP. One
participant was employed primarily as an RN and practiced less than 8 hours per week as an
NP. The majority of participants were employed by one of the six regional health authorities.
In Table 1 we summarize participants’ employment status.
Table 1. Employment Status
Perm FT
Perm PT
Temp FT
N=31
Temp PT
Locum
0 5 10 15 20 25
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
Participants were geographically dispersed in the Province, practicing in rural settings, small
towns, and large metropolitan areas. Figure 1 is a display of their location based on population
density.
Figure 1. Geographic Distribution of NPs
16% n=31
Towns
< 10K 65%
19%
Towns Metropolitan area
10K-100K population
>100,000
Twenty NPs practiced in municipalities with populations more than 100,000; six practiced in
towns of populations between 10,000 and 100,000; and five were in towns of less than 10,000
people. We compared these percentages to the population distribution of British Columbians,
because we expected that NPs would be uniformly distributed and represented in the same
percentages as the rest of the population. However, according to the 2011 BCStats population
estimates, 72% of British Columbians live in metropolitan areas with populations more than
100,000; 15% live in towns between 10,000 and 100,000; and 13% live in towns of less than
10,000. Therefore, although this finding may be an artifact of the small sample size, it appears
that 7% more NPs than expected are working outside of the large metropolitan areas.
Participants practiced in a variety of healthcare settings, primarily in community based
settings (69%). Table 2 is a summary of practice settings in which NPs were employed. Six NPs
were employed in private settings such as physician offices or private organizations.
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
Table 2. Practice Settings
Practice Settings* n =31 %
Community/Primary Health Care Centre 15 48%
Ambulatory Clinic/Outpatient Department 9 29%
Other 8 24%
Physician Office 7 23%
Long-term Care Facility/Residential Care 5 16%
Hospital - in patients 3 12%
Home Care 2 6%
Aboriginal Health Centre 2 6%
Outpost Nursing Health Centre 1 3%
Public Health 1 3%
*Multiple responses allowed
“Other” settings included Hospice, mental health and addictions centres, and homeless
shelters. Thirty nine percent (n=12) of NP participants were employed in ambulatory clinics
and hospital in-patient settings. With the exception of one setting where 3 NPs were
employed, in most settings there was only one NP. NPs practiced in settings where other team
members were co-located. Most often co-located team members were physicians (87%),
registered nurses (77%), and/or medical office assistants (77%). Table 3 includes all team
members co-located with NPs. In addition to those listed in Table 3, there were respiratory
therapists, mental health workers and spiritual care coordinators.
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
Table 3. Members of HealthCare Team Co-located with NP
Team Member* n = 31 %
Physician(s) 27 87%
Registered Nurse(s) 24 77%
Medical Office Assistant(s)/Receptionist(s) 24 77%
Dietician(s) 14 45%
Social Worker(s) 12 39%
Pharmacist(s) 11 35%
Licensed Practice Nurse(s) 10 32%
Physiotherapist(s) 10 32%
Occupational Therapist(s) 7 23%
Paramedic(s) 2 6%
Midwife(s) 1 3%
Chiropractor(s) 1 3%
*Multiple responses allowed
Patient Populations Served
We asked NPs to identify the patient populations that were the focus of their practice. Table 4
is a summary of the populations for whom NPs provided care.
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
Table 4. Patient Population
Population* n =31 %
Mainly adults 13 42%
All ages across the lifespan 9 29%
Patients with one specific condition 7 23%
Homeless/street involved patients 6 19%
Other 6 19%
First Nations or Inuit 5 16%
Mainly seniors 4 13%
Newcomers (immigrants) to Canada 3 10%
Mainly children or youth 3 10%
Mainly Women 2 6%
*Multiple responses allowed
As demonstrated above, NPs worked with a variety of populations such as First Nations,
homeless, seniors, and new immigrants. Other populations included people with HIV/AIDs,
those with end-stage renal disease, cardiovascular disease, mental health and addictions
issues, and children in foster care. These populations align with those identified by the MOH
as high needs populations.
Financial and Other Supports
Fifty eight percent of NPs (n=18) indicated that they work more than 40 hours per week.
Thirteen out of 17 participants indicated they worked 10 hours or less per week overtime
(range 2-10 hours), and that they were not financially compensated for these extra hours. On
average, the annual salary of NPs who were employed full-time was $97,698. Fifty-four
percent of NPs employed full-time indicated they were satisfied with their salary however,
23% were either dissatisfied or very dissatisfied with their salary. Of the NPs employed part-
time, 56% were satisfied with their salary and 33% were dissatisfied or very dissatisfied.
Further studies will be necessary to determine reasons for these responses. NPs were asked to
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
rate their satisfaction with resources and supports provided by their employer on a scale of 1
to 6, where 1 represents “not satisfied” and 6 represents “very satisfied”. Table 5 is a list of
resources and supports and NPs’ level of satisfaction.
Table 5. Satisfaction with Resources and Supports
Resources and Supports Mean
(n=28)
Information support (Internet, digital library, online guidelines, decision support 4.8
systems)
Support from other health care providers in your setting (RNs, etc.) 4.8
Clinical examination space 4.6
Technology (fax, telephone, computer, pager, mobile phone etc) 4.5
Office space 4.4
Support from your physician colleagues 4.2
Technology support 4.2
Support from your direct supervisor 4.1
Clerical support 4
Orientation to the electronic medical/electronic health record 3.8
Telemedicine/Telehealth support, e.g. video equipment 3.8
Employer policies that support full implementation of the NP role 3.6
Orientation to your practice setting 3.6
Orientation to the expectations of your employer 3.5
Policies of CRNBC, e.g. QA, Continuing Competence, etc. 3.4
Data management support e.g. access to databases, analysts, statisticians 3.3
BC Ministry of Health requirements, e.g. forms, encounter codes, legislation, etc. 2.7
Ninety-seven percent (n=30) of NPs indicated they experienced problems providing patient
care as a result of restrictive legislation that does not recognize NPs as authorized providers or
allow them to complete and sign various forms. These forms include such things as driver’s
license physicals, Worksafe BC, ICBC, various Revenue Canada forms, and long term
disability claims. Legislation that will ameliorate these restrictions has been passed and is
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
expected to be proclaimed later in 2012. NPs also indicated that their inability to prescribe
controlled substances for patients with pain and some mental health conditions was a barrier
to practice. At the time of this report, the draft regulations enabling NPs to prescribe controlled
substances are posted on the Health Canada website for feedback.
Practice Activities
NPs are involved in a variety of clinical and non-clinical practice activities. Participants were
asked to estimate the number of hours per week they spend providing various patient care
activities. Table 6 is a list of the patient care activities and the approximate number of hours
per week they engaged in the activity. Because of the multidimensional practice of NPs, the
data may reflect work hours counted in two or more categories simultaneously.
Table 6. Direct Patient Care Activities
Patient Care Activity Hours/week Number of
Mean participants
Management and monitoring of chronic illness, e.g. 12.98 30
stable angina, diabetes, hypertension, asthma
Health counseling/education 10.45 31
Management and monitoring of mental health 7.93 30
concerns, e.g. depression, anxiety, stress
Wellness care/health prevention, e.g. breast & 7.46 29
cervical screening, immunization, lifestyle &
behaviour changes
Episodic care for minor acute illness/injury, e.g. 5.81 30
colds, flu, sore throat, ankle sprain
Episodic care for major acute illness or surgery, e.g. 4.91 26
unstable angina, acute abdominal pain, post-op care
Health promotion, e.g. community development, 2.76 24
policies affecting social determinants of health
Palliative care 1.08 28
Community outreach 0.53 20
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
Community outreach included making home visit, providing a youth clinic, and providing
care in a homeless shelter. Table 7 is a list of the average number of hours spent by NPs
performing non-direct care activities.
Table 7. Activities Other than Direct Patient Care
Activity Hours/week Number of
Mean participants
Management/leadership (including development of 3.03 25
policies, programs, etc)
Team meetings related to patient care 2.83 31
Providing education/training to other learners 2.69 29
Personal professional development 2.16 29
Community development/outreach 1.43 26
Research 0.62 26
From Table 6 and 7 it is clear that NP participants spend the majority of their time in direct
care activities. The majority of their non-direct activities involves working with others, for
example team meetings, management or leadership, and educating and training learners, such
as NP and medical students.
The CRNBC competencies include an expectation that NPs will engage in community outreach
activities. Only 11 of 31 (35%) of participants reported that they perform community outreach
as part of their practice. Examples of these activities include setting up and facilitating health
workshops, presenting at nursing education rounds, liaising with other healthcare providers,
and lobbying for health related programs.
Characteristics of NP Practices
The survey included the question “How many patients are on your roster of patients?” The
mean number of patients rostered to full-time NPs was 334 and they saw a mean of 14 patients
in an eight-hour work day. Participants commented that their patient roster changed
frequently because patients died within a few months of being admitted to the practice and/or
the population for which they cared was transient. Other comments indicated that patients
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
were rostered to the clinic and not to individual providers; NPs co-managed patients with
physicians in the setting; they provided care to homebound frail elderly; or they practiced in
an acute care setting. Forty-eight percent of participants made home visits; commonly cited
reasons for home visits were to provide care to elderly patients or those with mobility
problems, and to provide palliative care. NP participants (50%; n=15) refer patients to
residential care and 17% (n=5) provide primary care to those living in residential care. Seventy
percent had no locum replacement when they were away from their practice. The majority of
NPs (87% n=27) were not on-call. Patients were assigned to the care of NPs in a variety of
ways, either by having patients book their appointments directly with the NP (32%), based on
need or triage (29%), or were assigned by the medical office assistant (10%). Only 3% of NPs
saw patients when the physician was not available.
Diagnosing, Test Ordering, and Prescribing Patterns
All participating NPs reported that they diagnose, prescribe, and order diagnostic tests on a
routine basis. The frequencies with which these occur are presented below. Table 8 is a
summary of the frequency with which they diagnosed patients with common acute symptoms
or conditions.
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
Table 8. Frequency of Presenting Symptoms or Conditions
0 5 10 15 20 25 30 35
Depression/anxiety
Fatigue
Infections
Skin disorders
MSK pain or injury
Acute Cough
Localized edema
Chronic Dyspnea
Low Back Pain
Daily
Vertigo or dizziness
Weekly
Generalized edema
Fever Monthly
Chronic Cough
Acute Dyspnea
Post op/post procedural follow-up
Headache
Prenatal care/GYN
Recurrent chest pain
Chronic Abdominal Pain
Acute chest pain
Acute Abdominal Pain
As indicated in Table 8, depression/anxiety, fatigue, skin disorders and headache are the most
frequently seen presenting symptoms. All common conditions included in Table 8 are those
that would be expected in any primary care setting.
Table 9 is a summary of the frequency with which NPs order laboratory tests and diagnostic
imaging studies.
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
Table 9. Patterns of Diagnostic Testing Ordered
Biochemistry
Microbiology
Hematology/blood bank
X-rays
Electrocardiograms
Cytology/pathology Weekly
Montly
Pelvic/abdominal ultrasounds
CT scans
Bone density
Virology
Immunology
0 5 10 15 20 25 30
The range of NPs’ ordering of diagnostic testing is consistent with primary care practice, and is
within the NP scope of practice.
On average, 70% of patients seen by NPs have more than one chronic condition. Table 10
demonstrates the frequency of common chronic disease diagnosed by NPs. This also
demonstrates that NPs diagnose conditions associated with high use of the health care system.
Table 10. Frequency of NP Diagnosis of Chronic Conditions
Depression
Renal disease
Daily
Hypertension
Weekly
Congestive heart failure Monthly
Type 2 diabetes
0 10 20 30
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NPs’ scope of practice includes prescribing a wide range of pharmacotherapeutics. Table 11 is
a display of the frequency with which NPs prescribe various classes of pharmaceuticals. NPs
often prescribe classes of drugs to treat GI complaints, cardiovascular conditions, and
infections.
Table 11. Frequency of NP Prescribing Pharmaceuticals
0 5 10 15 20 25 30
Cardiovascular agents
Skin & mucus membrane agents
Vitamins
Gastrointestinal agents
Antiinfectives
Antihyperglycemics
Contraceptives
Daily
Electrolyte, caloric, & water balace agents
Weekly
Antihistamines
Monthly
Hormones and synthetic substitutes
Blood formers and coagulators
Vaccines/immunizations
Antitussives, expectorants, and mucolytics
EENT preparations
Autonomic drugs
Central nervous agents
Smooth muscle relaxants
Encounter Reporting
In BC there are two ways in which data on NP practice are recorded: ICD 9/10 and encounter
codes. Nineteen of 29 (66%) NP participants reported that they submit ICD 9 or ICD 10
diagnostic codes. Five of 30 (17%) NPs submit them to the BC Ministry of Health, while 9 of 30
(30%) submit them to their local health authority. Eight of 30 NPs (27%) were unsure of where
the codes were sent. Twenty-seven percent of NPs did not use ICD 9 or ICD 10 codes.
Encounter codes were originally developed by the BC MOH specifically to collect data on NPs’
practice activities. Fifty-eight percent (n=18 of 31) of NPs reported they submitted encounter
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
codes. Seventeen percent (n=5 of 30) submit them to the BC MOH, 30% (n=9 of 30) submit
them to their local health authority and 17% (n=5 of 30) were unsure of where the codes were
submitted. Thirty-seven percent of NPs (n=11 of 30) reported they did not use encounter codes.
In their comments about the use of encounter codes and the process for submitting them, NPs
expressed a lack of understanding about the reason for submitting codes, the submission
process was time consuming or cumbersome, and that the codes did not adequately reflect
their practice. They also indicated a lack of training for using the codes, technical support,
submission programs, and a standardized system for submission in their organization. NP
encounter codes are unique to BC.
Nurse Practitioner Electronic Records Use
We asked NPs to indicate if their record keeping system was: (a) paper based; (b) hybrid,
(where part of the patient record is electronic and part of it is paper based); or (c) a fully
electronic record, as in the case of a full electronic medical record (Borycki et al., 2009; Urowitz
et al., 2008). Twenty eight NPs responded to this question. Eighteen percent (n=6) of
participants used paper charts, 64% (n=17) used hybrid records (Borycki et al., 2009), and 18%
(n=6) used full electronic records. Eighty-two percent of NPs who responded to the question
were using hybrid or full electronic records. These data are consistent with prior North
American research that suggests most health professionals use a hybrid electronic record and
that in Canada 50% of Canadians have at least one component of an electronic record (Canada
Health Infoway, 2011; DeRoches et al., 2008; Jha et al., 2009)
NPs are using a wide range of electronic records. Twenty-six percent (n=6) of NPs are using
Physician Information Technology Office (PITO) qualified electronic medical records (EMRs).
Financial and implementation support is provided for PITO electronic record products used
by physicians and NPs in the province (PITO, 2009). Some NP’s use PITO Qualified EMRs
such as Intrahealth (4%; n=1), MedAccess (4%; n=1), Osler Systems (9%; n=2) and Wolf (9%;
n=2) (which is a Telus product) (PITO, 2009; Telus, 2012), while other NP’s are using other
EMR software products. Some NPs are using electronic patient records (EPRs) such as Cerner
(4%; n=1) and Meditech (9%; n=2). The type of electronic record used may vary by type of
organization and care setting where NPs practice (e.g. hospital, community, clinic, physician
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
office). For example, EMRs are used by NPs working in physician office settings, and EPRs are
used by NPs who work in hospital-based settings.
Sixty-three percent (n=17) of NP participants using an electronic record were either very
satisfied or somewhat satisfied with the system they used. However, 20% (n=5) were very
dissatisfied and 16% (n=4) were only somewhat dissatisfied with their electronic record. There
is a need to understand the underlying reasons for NPs’ dissatisfaction with electronic records.
At this time we can only speculate that underlying reasons may include poor electronic record
design or the inability of the electronic record to fully support NP practice requirements.
Further research is needed to understand the underlying reasons for this dissatisfaction.
Participants who use electronic records use varying electronic record functions. How, and to
what extent, NPs use their electronic record also varied. Table 12 is an outline of the functions
of EMRs in use and the extent to which they are used by participants. For example, NP’s were
most likely to store patient demographic information (64% - use most or all of the time, use
sometimes; 16/31), record their clinical notes (58%; 14/28), view laboratory (54%; 13/27) and
radiology test (35%; 8/25) results, and keep patient medication lists in their electronic records
(54%; 13/25). They were least likely to use electronic records for public health reporting (0%),
sending prescriptions electronically to a pharmacy (5%; 1/22), using electronic record
reminders for guidelines based interventions and/or generating screening lists (21%; 5/26) or
reports about the patient populations they serve (21%; 5/24). Electronic records were being
used to support individual patient encounters and are only beginning to be used to manage
patient health at a practice based level.
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
Table 12. EMR Functions and Use Patterns
Patient demographics
Clinical notes
Electronic lists of what medications each
patient takes
Viewing laboratory results
Use most or all of the
Orders for prescriptions time
Patient problem lists Use sometimes
Viewing radiology results
Do not use
Orders for radiology tests
Reminders for guideline-based interventions
and/or screening lists No or unsure if
available
Orders for laboratory tests
Warnings for drug interactions
Reports can be compiled so that I know more
information about my patients
Reports can be compiled on the patient
population my practice site services
Prescriptions send electronically to pharmacy
Public health reporting
0 5 10 15 20 25
Most NP participants rated their electronic records as having a positive impact on the quality
and efficiency of their work. In particular, 70% (16/23) of participants felt the electronic record
had a positive effect on their communication with others, and that it had a positive effect on
their timely access to medical records; 59% (13/21) felt it improved their practice patterns.
NPs indicated electronic records improved the consistency of communication between
practitioners, the legibility of patients’ information, remote access or access from another site,
follow up and reminders, and ease of refilling prescriptions. Challenges described included
slow computers and technical failures, lost or difficult to access data when hybrid electronic
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
records were used and missing or suboptimal electronic record features that would allow for
better support of NP practice.
Collaboration, Consultation, and Referral Activities
Collaboration with Family Physicians
Seventy-four percent (n=23) of participants worked in a direct relationship with one or more
physicians; 68% (n=21) were satisfied or totally satisfied with their relationship with the
physicians with whom they most often collaborated. Comments from NPs indicated that in
some situations there was a lack of physicians’ understanding of the NP role, which could lead
to NPs dissatisfaction with the relationship.
Collaboration with Specialist Physicians and Other Health Care Professionals
The majority of NPs referred patients to specialist physicians and to a variety of other health
care professionals. Overall, NPs indicated other team members understood their role. NPs
indicated that specialist physicians sometimes would not accept their referrals. The most
common reason given for this was specialists’ lack of understanding of the NP role. NPs in BC
also refer patients to an array of health programs including diabetes programs, home care,
mental health and addiction services, and community based self-help programs. Table 13 is a
display of the types of health care professionals to whom NPs referred patients.
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
Table 13. Health Care Professionals with whom NPs Collaborate
Specialist Physicians
Physiotherapists
Dieticians
Mental Health Workers
Social Workers
Pharmacists
Other NPs
Refer
Home Care Nurses
Do not refer
Public Health Nurses
Occupational Therapists
Family Physicians
Midwives
Chiropractors
Family Practice Nurses
0% 20% 40% 60% 80% 100%
NPs received referrals from other health team members; over 40% of participants received
referrals from family physicians, specialist physicians, other NPs, public health nurses, and
home care and mental health care staff. On a daily basis, 39% (n=12) of participants initiated
informal face-to-face discussions of patient care concerns with physicians and 42% (n=13) met
with other health care providers to discuss patient concerns. Table 14 is a representation of the
frequency with which NPs collaborated with other health team members along with the
reasons for collaborating.
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
Table 14.Frequency and Reason for Collaboration
I meet face-to-face on a regular basis to discuss patient
care concerns with other health providers
I initiate informal face-to-face discussions of patient care
concerns with MDs
I communicate about emerging health issues in the
community with other health care providers
I initiate informal telephone discussions re patient care Daily
concerns with MDs
We jointly plan how to address or optimize systems in our Weekly
practice to care out specific activities
We jointly plan for changes in the organization of the Monthly
practice
We participate in the same continuing education
opportunities
We jointly plan strategies to address issues affecting the
health of the community
We conduct research together
0 10 20 30
Achievement of Expected Outcomes in NP Practice
The majority of NP participants (18/31) indicated there were specific health outcomes they
were expected to achieve, and they spoke of these in their narrative comments. Examples of
expected outcomes included reduction in the number of patient visits to the emergency
department, reduced hospitalization of residents in long-term care, follow-up care of patients
in the home after hospitalization, and chronic disease management. However, 42% (13/31)
indicated there were no specific outcomes they were expected to meet.
We also asked NPs to indicate if they collected data to evaluate their role, and 52% (16/31)
indicated they do not collect data to aide with the evaluation of their role. Of those who
collected data, 12 participants provided narrative comments describing the types of data
collected for evaluation. Descriptors of data were very general; examples of types of responses
included patient satisfaction surveys, client surveys, access to care and encounter codes and
ICD-9 codes. Several NPs indicated they personally captured these data.
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
Contributions of the NP Role to Individuals, Organizations and
Healthcare System
We asked NPs to tell us the three most important contributions they made to patients and
families, the organization in which they worked, and to the healthcare system. NPs perceived
their major contributions to patients and families were access to care, time, health education
and chronic disease management. They perceived their contributions to the organization in
which they worked were supporting others and providing leadership. Perceived contributions
to the healthcare system were providing access to care and cost savings (Table 15).
Table 15. NPs’ Perceived Contributions of Their Role
Contributions to Patients and Families Contributions to Employing Organization
Increased access to care Supporting others
Being available Family physicians
Phone access Specialist physicians
Consistency of care Education of staff
Spending time with patients Clinical support for RNs
Listening Leadership
Clarifying inquiries Team building
Addressing complex health needs Knowledge sharing
Health education Contributions to Healthcare System
Supportive counseling Increased access to care
Empowering patients to Providing care for
understand and manage their underserved/marginalized/vulnerab
health le populations
Preventive health teaching Cost savings
Chronic disease management Reduced of hospitalizations/length
Symptom management of stay
Routine monitoring Preventing/reduced visits to
Patient participation emergency department
Provide support to patient Preventing complications
Medication management
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
Facilitators and Barriers to NP Practice
NP participants identified several barriers and facilitators to role implementation (Table 16).
Support from others was the most frequently mentioned facilitator. Specifically, NPs identified
that support from collaborating physicians as very important. Support from their employer
and the local community were also viewed as facilitative. Several NPs mentioned the success
and hard work of other NPs in their practice environments and across the province as being
instrumental to their own success. Finally, participants identified that personal attributes,
passion, and hard work by the NP him/herself facilitated the implementation of their roles.
Table 16. Facilitators and Barriers to NP Role Implementation
Facilitators of NP Role Implementation Barriers to NP Role Implementation
Physician support Inadequate support from
Leadership vision and administrators
commitment Lack of understanding of the NP
Supportive team role
Community support Restrictive legislation
Personal initiative Lack of funding
Understanding of role Fee for service funding
Having an NP mentor Inadequate physician support
NPs also identified barriers to implementation of their role. The main hindrance identified was
the lack of knowledge or understanding of the NP role by managers, physicians and other
staff. NPs also identified lack of managerial support and support from physicians as barriers
to role implementation. In addition, they identified legislative barriers and funding issues as
barriers.
NPs Not Practicing in BC
A number of participants (7 of 34) were currently underemployed or not employed as NPs in
BC. Three participants were not employed as an NP and four worked part-time as an NP and
part-time as an RN. In their comments, participants sited the reasons for not having an NP
position included lack of full-time NP employment opportunities, family factors such as
spouse unable to find work where an NP vacancy was posted, and limitations imposed by the
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
employer. Some participants described travelling to remote areas to piece together work as
NPs, for example working for a month in a northern clinic. Participants described
underemployment as working part-time hours as an NP, or in contract or temporary positions
due to a lack of permanent, full-time or local positions. Others worked as RNs to supplement
their limited NP hours.
DISCUSSION
This survey is the first of its kind in BC to examine the practice patterns of NPs. We
acknowledge that our return rate was low, with only 37 NPs responding, however the results
are informative. We also acknowledge that these findings are based on self-reported data,
which is a limitation of all surveys.
The results of this study illustrate that NPs in BC are masters prepared and were experienced
RNs prior to becoming an NP. The majority of our participants were employed full-time as
NPs, however several were employed part-time or practiced in two different roles (e.g. NP and
RN), and a small number were not employed as an NP in BC. Regional health authorities are
the primary employer of NPs, where they are located in diverse geographic locations and
practice in community/primary care settings. NPs care for people of all ages and with a variety
of populations including First Nations, seniors, people who are homeless, people with mental
health and addictions issues, and government assisted refugees. These findings are consistent
with the MOH’s initial expectations that NPs would complement traditional physician
services, practice in smaller communities (MOHS, 2003) and increase access to care (CRNBC,
2006a).
NP participants are practicing to their current legislated scope of practice, but are unable to
complete various governmental forms or prescribe controlled substances until pending
legislative changes are enacted. NP participants spend the majority of their time providing
direct patient care. Direct care activities include managing chronic diseases and mental health
issues; providing episodic care; health promotion, disease and injury prevention; and health
education. They also provide community based care that includes home visits, running youth
clinics, and providing primary care in homeless shelters. These activities are similar to practice
activities of NPs in Ontario (van Soeren, Hurlock-Chorostecki, Goodwin, & Baker, 2009) and
Nova Scotia (Martin-Misener et al., 2010). Gardner et al. (2010) also found that NPs practicing
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
in Australia spent the majority of their time in direct care activities. The most frequent
presenting symptoms or conditions of patients encountered by NPs were depression and/or
anxiety, skin conditions, and acute cough. Again, this is similar to findings from Nova Scotia
(Martin-Misener et al., 2010). Participants’ non-clinical activities involved teaching others, for
example medical and NP students; leadership activities; and community development.
NP participants had a direct working relationship with one or more physicians and they were
satisfied with the relationship. They most often consulted with and referred to physicians,
particularly specialists. NPs also consulted and referred to a variety of other providers,
especially pharmacists and dieticians. Most often NPs initiated either a face-to-face or
telephone contact with a physician to discuss a patient care concern.
NP participants submitted ICD-9 diagnostic codes and NP encounter codes to the MOH
and/or the health authorities, however there were some who did submit either. Their reasons
for not submitting included a lack of understanding of how to submit and a lack of training or
technical support on use of the codes. NPs were using a range of electronic records (i.e. EMRs
and EPRs). They used the electronic record to view laboratory and diagnostic imaging results
and to enter patient demographic information and their clinical notes. Many participants used
paper only charts or a hybrid of paper and electronic health records. Electronic record
adoption among NPs who responded to the survey was high. According to Rogers’
Innovation Diffusion Theory, NPs in this survey are in the late majority phase for adopting
this technology (Rogers, 2003). NPs have adopted electronic records more fully than
physicians in BC, where approximately 60% of physicians are using an EMR (Smith, 2011)
versus 82% of NPs. Fewer NPs use their records to generate reports about the patient
population they are managing or for public health reporting. Future research should involve
learning about how electronic records can be better designed and modified to support NP’s
practice.
Participants identified the contributions they make to patients and families were increased
access to care, spending time with patients, and chronic disease management. Their
contributions to their employing organization were supporting other providers and providing
leadership. At the healthcare systems level, NPs’ perceived contributions were access to care
and cost savings. However, few participants collect data that would substantiate these
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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA
contributions, and few identified specific outcomes they were expected to achieve. In spite of
this, these findings are similar to those in Nova Scotia (Martin-Misener, 2010).
NPs identified several factors that facilitated NP role implementation, including physician,
management and team support for the role; understanding of the role by others with whom
they worked; having a mentor; and personal initiatives. Barriers to role implementation were
also identified, including inadequate support for the role from administrators and physicians;
restrictive legislation; and lack of funding. These findings are similar to those identified by
Sangster-Gormley et al. (2011) in their integrative review of factors affecting NP role
implementation.
CONCLUSION
This survey is a preliminary overview of NP practice patterns in BC and can be used as a
baseline for future comparison as the role evolves. Participants are practicing to their currently
regulated scope of practice, however legislative limitations and inadequate availability of full-
time employment present ongoing challenges for NP role implementation. Although
facilitators exist, there are barriers to role implementation that will need to be addressed as
new NP positions are created.
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