Educational role of nurse practitioners in a family practice centre

Role clarification

Both senior residents (R2) and junior residents (R1) indicated that they were unclear about NPs’ scope of practice apart from the uniform agreement about the usefulness and importance of the NPs in facilitating team functioning. Senior residents understood that they were expected to learn about NPs’ scope of practice; however, many expressed frustration with this learning objective.

We function within a team environment but we don’t understand, like, the full information of each team player.

(R1)

One of the reasons we were told that we were going to be monitored by nurse practitioners in this clinic is so that we learn their scope of practice, but that’s really quite futile when it’s going to be different depending on which practitioner you are working with because they are all different.

(R2)

Residents recognized the value of working with NPs because of their specialized knowledge and skills.

[I]deally they shouldn’t be monitoring us but be there as resource if we need to ask them [a question].

(R2)

In another rotation … the nurse practitioners that are working there are specialized …. [T]hey have a different scope but they were very helpful and they did noon rounds and they did talks in education; they were great but they were specialized in that area.

(R2)

First-year residents tended to express more positive views and, in particular, noted NPs’ important role in team functioning.

I think they’re often more accessible than the physicians are sometimes … so if I knew more of their scope that would be helpful, but they’re very available and willing to help, which is nice and adds to [the] team.

(R1)

They also have a lot of knowledge about resources that are available in their area out in the community …. They can direct you in the right place to make things efficient as well.

(R1)

Nurse practitioners noted that there was no formal education about their scope of practice for residents and believed that learning it in the course of clinical work was more useful than presentations or written documentation. “You know we sort of expect them to absorb it in lots of ways as they go …. There’s so much to orientation … so they sort of learn slowly over time.” (NP)

Professional identity formation

Senior residents identified a need to become similar to the family physician teachers. They believed that NPs approached clinical problem solving differently than family physician teachers did and thought it was important that they learned to work in a similar manner to the family physicians. This resulted in some discomfort and, at times, actual avoidance of NPs in providing supervision of the day-to-day care of patients.

I generally would try to ask the physician since I’m trying to think like one and trying to angulate [sic] their scope.

(R2)

We are taught to think a certain way from, like, the beginning of medical school, through our clerkship, our residency; we’re taught to think the same way and the physician has probably been through the same education.

(R2)

Often the nurse practitioner answers more like following an algorithm. Like you do this, you do this, you do this, but the physician will provide more of an in-depth background explanation as to why you do these steps.

(R2)

I think why I feel a little bit more comfortable with a physician monitoring me, per se, is that it almost gives you a sense of you’re progressing towards where that physician is.

(R2)

Enhancing factors

Both junior and senior residents identified the expertise of NPs in a specific area, and found this expertise to be helpful to their education, as well as in team functioning and clinical care.

I felt that nurse practitioners were very good in counseling … they were excellent resources in that .... For the medical part, I wouldn’t go talk to them; I would go straight to the physician.

(R2)

I would like to tag along with … the ones with the wound care knowledge … one nurse that does the diabetic foot care so I would like to spend some time ... with them.

(R1)

The NPs indicated their awareness of the residents’ appreciation of their specific areas of expertise and explained that they worked to raise awareness of these areas. “We try and educate the residents … that we have specialities and to come to us ... to sort of double book.” (NP)

The more junior residents thought that the clinical teaching by NPs was very helpful, particularly because of their accessibility and the detailed nature of their teaching.

So much of our teaching is, like, just go and give it a shot ... that’s what a lot of the physicians, how they were trained. Sometimes a nurse practitioner [will] probably give you those details and for practical hints on things that would be helpful.

(R1)

Nurse practitioners viewed themselves as a safer and more approachable source of help for residents. “The residents if they’re in second year and they think ‘Oh I should know that but I can’t go to my supervising physician because they think I should know that.’ So you’re a little safer for them to come to.” (NP) One resident concurred with this view: I feel very comfortable approaching them because I found that their expectation from us is not that high as my staff …. [They are] more eager to help us, more compassionate, and so I feel comfortable with them.(R2)

Nurse practitioners also thought that their preparation as teachers was important and they believed they were well trained for this role. “We’ve had lots of opportunity for sort of faculty development and there’s also lots of opportunity for clinical knowledge and keeping up to date.” (NP)

Limiting factors

Nurse practitioners and residents identified a number of barriers to optimal education provision, including opportunity, time, training, and attitudes. Nurse practitioners perceived differing attitudes among physicians that influenced residents’ views of their role as teachers.

Some physicians are very comfortable with our role and then [with] others I can see that it’s not the case and it’s not as well supported.

(NP)

And I think that [physician’s degree of comfort with the educational role of NPs] does get reflected to the residents.

(NP)

Nurse practitioners also reported that their integral clinical role within the team meant that they were less available for educational activities.

We’re, you know, basically running the ship, meaning we’re not able to free up time.

(NP)

We don’t have quite as active a part in the resident evaluation as we could … logistically that would be a nightmare to try to pull us in [to resident behaviour science evaluations].

(NP)

There was a common belief among senior residents—who have less time to spend with each patient—that time was a barrier when being supervised by NPs, primarily because if the patient problem was outside the NP’s scope of practice, it became necessary to consult with a physician. They also expressed challenges with the broad and detailed nursing approach during the critical time of transitioning to shorter appointment bookings and experiencing new time pressures. “You are booked solid and you have patient after patient, and when you go back to review they want to talk about all things and you really don’t have time.” (R2)