Family Practice Nursing in Newfoundland and Labrador: Are Reported Roles Reflective of Professional Competencies for Registered Nurses in Primary Care?

BACKGROUND: Family practice nurses are Registered Nurses who work collaboratively in primary care and deliver a range of services. Professional competency statements have been developed to describe the skills and knowledge of family practice nurses as a distinct field.
PURPOSE: We conducted a secondary analysis of qualitative interview data to examine how family practice nurse roles/activities relate to recently developed professional competencies.
METHODS: Family physicians and family practice nurses in Newfoundland and Labrador (NL) participated in semi-structured interviews, during which they discussed roles/activities and scope of practice surrounding family practice nursing. For this secondary analysis, we used competency statements to inform thematic coding of the transcribed interviews.
RESULTS: For the initial study, a total of 8 participants (5 family practice nurses; 3 family physicians) were interviewed from diverse practices. All transcripts from the original study (n = 8) were included in the secondary analysis and analysed across 47 competencies encompassing 6 domains (Professionalism; Clinical Practice; Communication; Collaboration and Partnership; Quality Assurance, Evaluation and Research; Leadership). Roles/activities reported by participants were reflective of the competencies, but with substantial variation in expression.
CONCLUSIONS: Family practice nursing competency statements reflect the actual activities of family practice nurses in NL. The professional competencies can serve as a framework to examine contributions of family practice nurses and identify areas warranting further training. The use of competencies to explore family practice nurses' roles and activities can assist with optimizing scope of practice.

Background

Internationally, the nomenclature used to refer to Registered Nurses (RNs) who work in primary health care varies considerably. In Canada, there are three common nursing classifications: Nurse Practitioners, Registered Nurses, and Licensed Practical Nurses (known as Registered Practical Nurses in Ontario). RNs who work in primary care are most commonly known as family practice nurses, primary care nurses, and general practice nurses (herein referred to as family practice nurses). Baccalaureate-prepared RNs comprise 70% of the nursing workforce in primary health care/community health settings (Canadian Institute for Health Information, 2019). RNs have a wider scope of practice than Licensed Practical Nurses and a more limited scope of practice than Nurse Practitioners. RNs are able to work in primary health care without any additional training requirements beyond their Bachelor's degree. It is within the scope of practice of family practice nurses to deliver a broad range of health services, including but not limited to preventative screening, education, management of chronic diseases, pharmaceutical management, pediatric and women's care, and care coordination (Halcomb et al., 2016; Lukewich et al., 2020; Norful et al., 2017; Poitras et al., 2018; Poitras et al., 2018).

Review of Literature

Emerging literature on the effectiveness of family practice nursing shows that family practice nurses working as part of a collaborative team improve access, continuity, and quality of care, contribute to increased patient satisfaction, and improve cost effectiveness (Horrocks et al., 2002; Laurant et al., 2005; Smolowitz et al., 2015; Todd et al., 2007). Additionally, interdisciplinary teams that include family practice nurses are associated with improved outcomes for individuals with chronic diseases and are known to reduce the economic burden related to these health conditions (Aggarwal & Hutchison, 2012; Griffiths et al., 2010, 2011; Health Council of Canada, 2009; Lukewich et al., 2016).

Although family practice nurses are the most common non-physician provider within interdisciplinary primary care teams across Canada (Ardal et al., 2007; Canadian Nurses Association [CNA], 2013, 2014; Horrocks et al., 2002; Keleher et al., 2009), their integration into primary health care systems varies across the country and uncertainty remains about the scope and depth of their competencies and roles/activities within a team. To address this, Norful et al. (2017) conducted a systematic review to synthesize literature related to RN roles within primary care. Eighteen studies from six countries (i.e., Australia, United States, Spain, Canada, New Zealand, South Africa) found that RNs contribute substantially to chronic disease management, care coordination, pharmaceutical management, and pediatric and women's health care (Norful et al., 2017). Furthermore, in 2019, the Canadian Family Practice Nurses Association developed a unique set of competencies (integrated knowledge, skills, judgement, and attributes) for family practice nurses. Forty-seven competencies are organized within six overarching domains: Professionalism, Clinical Practice, Communication, Collaboration and Partnership, Quality Assurance, Evaluation and Research, and Leadership (Lukewich et al., 2020). Each domain includes an expansive list of relevant competencies that family practice nurses should be able to enact within their primary care practice. Enactment of these competencies is shaped by the patient population of the practice, individual abilities, and unique circumstances and needs of the practice setting. These competency statements provide a framework from which to more closely examine nursing roles/activities within primary care and demonstrate the contributions of family practice nurses in real-life primary care environments. Moreover, the competencies represent a higher-level statement of family practice nurse contributions than specific roles and activities, and depict the potential for family practice nurses to undertake a broad scope of practice within primary care settings. In order to support the integration and utilization of these competencies, it is essential to map the current roles and activities of family practice nurses onto the developed competencies. That is, specific roles and activities are encompassed by each broad competency statement.

The objective of this study is to examine how family practice nurse activities in Newfoundland and Labrador (NL) relate to the recently developed national family practice nursing competency statements. We conduct a secondary analysis of qualitative interviews with family physicians and family practice nurses. The interviews were originally conducted by the study authors to examine the contributions of family practice nurses in primary care across NL in practices funded by fee-for-service and alternate payment plans (Mathews et al., 2020). The national competencies for family practice nurses examined in this present study were published after the original interview data were collected (Canadian Family Practice Nurses Association, 2019; Lukewich et al., 2020). The original study and results focused on the impact of funding structures on family practice nursing roles, and are published elsewhere (Mathews et al., 2020).

Methods

Sample

A detailed description of the methods, including how study participants were recruited for the original study, is published elsewhere (Mathews et al., 2020). Participants were family physicians and family practice nurses working in primary care settings in NL. Licensed Practical Nurses, Nurse Practitioners, and RNs working with specialist physicians were excluded from the study.

Design

In telephone interviews, we asked family practice nurses to describe their training and education, activities in primary care practices, and barriers/facilitators to enacting a full scope of practice. We asked family physicians to describe the roles and activities of the family practice nurses with whom they worked and any barriers/facilitators that may prevent them from optimizing the role of family practice nurses within their practice. Each interview was recorded and transcribed verbatim.

Analysis

For this secondary analysis, we used the competency statements as a guide to inform thematic coding of the transcripts. The interviews were originally conducted in 2018 and the competency statements were published in 2019. In 2020, we re-examined the interview transcripts to identify examples of roles and activities that were reflective of these developed competencies. To limit potential bias from our initial analysis, in the secondary analysis, we recoded the transcripts from scratch. We then met as a team to compare the coding of the transcripts line by line, and resolved disagreements until we reached consensus. These discussions assisted in enriching our understanding of how the competencies applied to the actual work of family practice nurses. We used NVIVO software to assist in the organization, management and coding of the data. This second coding differed in intent and approach from the first coding template that had been developed for the original study.

To ensure the rigor of our analysis, we kept transcripts and audio recordings, drafts of the coding template, coding disagreements and their resolutions. We use thick description and present illustrative quotes to support each competency statement (Berg, 1995; Creswell, 2014; Glaser & Strauss, 1967; Guest & MacQueen, 2012; Rowan & Huston, 1997).

Given the small pool of potential participants, we identified each participant with a unique study ID number and provide limited demographic information to protect confidentiality. We also edited quotations (as noted by square brackets) to obscure identifying information without changing the meaning of the quotation. We have preserved the local language customs and idiomatic expressions, which are unique to the province, in the quotations.

Ethics Statement

The NL Health Research Ethics Board and the four provincial regional health authorities approved the original study. Additional approval for a secondary analysis was not required.

Results

Sample Characteristics

In our original study (Mathews et al., 2020), eight interviews were conducted (five family practice nurses and three family physicians; six females and two males), ranging from 19–36 minutes in length. Participants worked in a variety of settings, including fee-for-service and globally-funded practices, and in both rural and urban communities.

Research Question Results

For the purposes of the secondary analysis, we re-examined all eight transcripts included in the original study across the full list of 47 professional competency statements. Table 1 lists the six competency domains and the corresponding statements, and highlights whether or not (i.e., yes/no) the competencies were described by roles and activities of family practice nurses in NL.

Table 1.

Complete List of Competency Statements and Whether or not They Were Identified in Qualitative Interviews as Part of Family Practice Nursing Roles in NL in 2018.

Domain	Statement Number	Competency Statement (Canadian Family Practice Nurses Association, 2019)	Identified by Participants
Professionalism	1.1	Practice in accordance with evidence-informed guidelines and policies relevant to primary care.	Yes
	1.2	Maintain a professional relationship and appropriate professional boundaries with patients across the lifespan and over time.	No
	1.3	Promote a culture of quality improvement and safety within primary care.	Yes
	1.4	Participate in professional development activities relevant to primary care.	Yes
	1.5	Contribute to capacity development of nursing in primary care through mentorship and teaching.	No
	1.6	Articulate the roles and contributions of nursing within primary care.	Yes
	1.7	Participate in the advancement of nursing in primary care.	Yes
	1.8	Advocate for nursing role optimization within interprofessional primary care practice.	Yes
Clinical Practice	2.1	Integrate the principles of primary health care as applied to primary care service delivery.	Yes
	2.2	Identify health and social care needs, preferences, and values of patients across the lifespan and over time.	Yes
	2.3	Apply strategies (e.g. motivational interviewing, stages of change) to support patient self-management.	Yes
	2.4	Address key determinants of health and health inequities within the primary care practice population.	Yes
	2.5	Deliver nursing care informed by the impact of colonialism and Indigenous ways of knowing within primary care practice.	No
	2.6	Report communicable diseases to public health as appropriate.	No
	2.7	Understand the needs of patients with complex health care conditions common in primary care.	Yes
	2.8	Manage physical, psychological, and social issues across the lifespan through the development of patient-centered health care plans.	Yes
	2.9	Provide anticipatory guidance and early intervention for patients across the lifespan and over time.	Yes
	2.10	Conduct assessment, monitoring, and evaluation of patient health care plans across the lifespan and over time.	Yes
	2.11	Integrate relevant research and evidence-informed practices into clinical decision making in primary care.	Yes
	2.12	Provide case management and coordination of care for patients with complex health needs to ensure optimal utilization of services and resources.	Yes
	2.13	Deliver primary care-based programs to support health promotion, disease prevention, and rehabilitation.	Yes
	2.14	Facilitate patient empowering approaches in the provision of primary care across the lifespan.	Yes
	2.15	Use information technology to support patient care in primary care practice.	Yes
	2.16	Educate patients on resources and tools for self-management of their health and well-being.	Yes
	2.17	Help patients navigate the healthcare system.	Yes
Communication	3.1	Utilize evidence-informed communication approaches with patients, families, and the broader community to support the achievement of patient-centered health-related goals.	No
	3.2	Build patient capacity in health literacy.	Yes
	3.3	Engage in respectful and supportive communication with members of the interprofessional primary care team.	Yes
	3.4	Exchange knowledge amongst interprofessional team members to promote excellence in primary care practice.	Yes
	3.5	Use communication strategies and tools (e.g. information technology) in a secure and confidential manner to effectively manage patient care with the interprofessional primary care team.	Yes
Collaboration and Partnership	4.1	Collaborate with organizations in health and non-health sectors to promote optimal health and well-being of patients in primary care.	Yes
	4.2	Understand the roles and responsibilities of regulated and unregulated health care workers involved in interprofessional primary care teams.	Yes
	4.3	Facilitate organizational practices that support continuity of care.	Yes
	4.4	Support transitions of care within and across health care settings to enhance patient outcomes.	Yes
	4.5	Engage in intra- and inter-sectoral communication and strategies that supports integrated care for patients with complex health and social needs.	Yes
Quality Assurance, Evaluation and Research	5.1	Participate in practice quality improvement initiatives, including accreditation activities.	Yes
	5.2	Collaborate with team members in primary care to address potential and/or actual risk, near misses, privacy breaches, and critical incident reviews.	No
	5.3	Understand quality performance indicators for primary care practice.	Yes
	5.4	Assist in developing policies and procedures to ensure they reflect both best practice and local context.	Yes
	5.5	Engage in research and evaluation activities relevant to primary care and the nursing role in primary care practice with academic institutions, community services, and other professionals.	Yes
	5.6	Participate in gathering, interpreting, and/or synthesizing of patient data to inform continuous quality improvement.	Yes
	5.7	Use clinical data and literature/studies to support program development/planning and a population health approach in primary care practice.	No
Leadership	6.1	Support leadership in the implementation of primary care initiatives.	No
	6.2	Advocate for the effective use of resources within interprofessional primary care practice.	Yes
	6.3	Share new knowledge with peers and colleagues to advance evidence-informed practice within primary care nursing.	Yes
	6.4	Advocate for healthy public policies and social justice relevant to patients and populations in primary care.	Yes
	6.5	Participate in coordination of the development and/or implementation of primary care-based programs to support health promotion, disease prevention, and rehabilitation.	Yes

Professionalism

The professionalism domain describes family practice nurses’ knowledge of guidelines and policies specific to primary health care; standards of integrity, patient safety; commitment to continued professional development and life-long learning, and an awareness of the unique contribution of family practice nursing to high quality primary health care.

In interviews, family practice nurses described how they stay current on clinical practice guidelines by attending continuing medical education events with family physicians: “so anytime there's a learning opportunity that arises, if it's CME events that Dr. [Name] goes to …, typically I go off to all the CME events. So I’m, you know, aware of the practice guidelines for the management of hypertension, for the management of hyperlipidemia” [T3] and “I get to take advantage of the educational stuff that's offered to the physicians. So if they have, you know, like drug reps come in or the professional developmental offered by the medical school and stuff like that, they’ll often include me, so I get to take advantage of that… And that's a huge benefit” [T8].

Family practice nurses also contribute to the education of medical students. A family physician made a point of bringing medical students along on home visits so that the students could watch the collaboration between family practice nurses and family physicians: “I bring medical students with me on house calls just to see how the two of us- because house calls are the other big part of what we do. And how we seamlessly move from my, my thing to her thing to my thing to her thing, you know? And we can finish each other's sentences in that regard, right? So I tell the medical students, ‘Come watch this, it's a thing of beauty,’ right?” [T3].

Primary health care represents an area where the role of nursing is expanding as patient needs change. As an example, a family practice nurse described how the nursing role has evolved to include more palliative care: “I think over the past years, our scope of practice has broadened and certainly one of the examples would be palliative care. I mean, when I came to [community] twenty years ago, virtually it was unheard of - of someone palliative and passing away at home, and now it's a very common practice. And that in itself is, you have to be very dedicated to the family and you know, to the patient themselves. That's an increase in your workload, having palliative patients” [T6]. Family practice nurses were also able to articulate the contribution of nursing to patient care: “I feel that I’m permitted in the setting that I am to practice to the full scope as a registered nurse and it's a very rewarding environment because of the fact that you see people through the lifespan, so you’re not just seeing them on one individual visit, you’re actually working with them, you know, long-term, so it's a very rewarding environment” [T2].

Clinical Practice

The competency statements in the clinical practice domain describe the attributes of the care provided by family practice nursing. The competency statements highlight that family practice nursing occurs over many visits and episodes of care, and throughout the patient's lifespan. Family practice nurses treat all ages and life stages: “So you see people from the age of newborn to the age of 101, I think, our oldest” [T7].

Primary health care includes health promotion and education, routine screening and preventative services, diagnosis and management of acute and chronic conditions, and end-of-life care (Starfield, 2005). Not surprisingly, family practice nurses play an integral role in providing preventative care and patient education. A family practice nurse described her role in the care of patients: “So I come in, I start seeing patients, and typically the patients range from chronic disease management to prenatal visits, to Pap smears, hypertension management. It's pretty well everything across the span that would encompass any preventative measures and any chronic disease” [T2]. A family physician described the important role that family practice nurses play in empowering patients about their sexual health and well-being: “Because she [the family practice nurse] spends 30 min talking to all my young ladies who start birth control pills. She talks to them about how to take the pill, about how the pill works, the side effects, but she also talks to them about sexually transmitted infections, and what's out there, and how they can prevent, protect themselves. And you know, that's the whole thing including, you know, the oral sex and the HPV and all that kind of stuff, right? Because I really believe knowledge is power, so we try to get that information over, so she's able to do that” [T1].

Two family practice nurses independently described how they support patient self-management: “It could be also diabetic teaching, including diet compliance, teaching them how to do glucometer checks and self-administering insulin” [T5], and “We also provide diabetic education here too, …[if] their HbA1c's are elevated, then I would sit down with them and talk about their diet, you know, review their insulin, what they’ve been taking, the importance of exercise, just the basic nursing, just the basic diabetic education” [T7]. Another family practice nurse described how she provides patients with anticipatory guidance: “For sure, because like, with all our COPD patients…I work with these patients with action plans… so that they don’t land in the hospital. If they have a COPD exacerbation, they have an automatic walk-in service, but they also have an action plan so if it happens on the weekend they know what to do…” [T2].

Family practice nurses are expected to be able to coordinate care and manage patients with complex health needs to ensure optimal care and resource utilization. Family physicians noted that in their practices, the family practice nurse took a key role in the ongoing assessment, monitoring, and evaluation of patients: “[the family practice nurses] coordinate certain programs, so certainly our cancer patients they’re following up on, our diabetics they’re following up on them” [T10], and in one example, going so far as to establish a new follow-up program: “And our registered nurse actually has now developed a hepatitis C program… Because what we were finding was that there was a delay in people getting treatments, delayed in getting your second lot of blood work, delayed in identifying those that needed treatment and who didn’t. And the registered nurse has actually been a very important person in calling, following up on getting me to order a second blood work. So monitoring and triaging those that we know have had their initial hepatitis C blood work has been positive” [T1].

As outlined in the competency statements, family practice nurses are expected to integrate the principles of primary health care in the care they deliver. They are expected to incorporate a patient-centred approach that reflects an understanding of patients’ health and disease care in the context of patients’ individual experiences. As a family practice nurse noted, addressing determinants of health is an important aspect of care: “…especially in a low socioeconomic population, I think everybody really needs to have the same train of thoughts and, you know, and ideas about how to care for the clients. And you know, just the whole bias [towards] a lower …socioeconomic groups and all - that just gotta go. And you’re just caring for the client, right?” [T5].

Family practice nurses also help patients navigate the healthcare system. As an example, a family practice nurse noted how she is able to access members of her clinics interdisciplinary team to help patients obtain mental health services: “…sometimes through the course of my nursing visits, people have multiple problems, it could be a mental health problem, and then I’m certainly able to access [resources] through [the team psychologist]…. People find it hard to navigate the system. But just a simple email or you know, I can obtain a number then from [the psychologist]” [T6].

Family practice nurses are not only expected to engage in ongoing professional development, but also to integrate relevant research and evidence into their clinical decision making and care. One family practice nurse described how she ensured that her clinical care incorporated the latest best practices: “I rely on my experience, my intuition, reading research, new articles, keeping up on new procedures to further my knowledge. I would research, if I wasn’t familiar with a procedure I would have to do, and I would also consult like, our clinical nurse coordinator to help with anything that I would be unfamiliar with” [T6].

Family practice nurses are expected to use technology effectively to support patient care. In many cases, family practice nurses use electronic medical records (EMR) to track patients’ lab results or note upcoming tests. Technology is used to document care, communicate with other team members, and support quality improvement in the practice. A family physician noted that the family practice nurse played a key role in keeping EMRs up-to-date: “All the A1Cs for example are taken by [the family practice nurses] and inputted into the care plan of the electronic medical records… all the mammograms that come through, all the PAPs, all the primary preventative targets that we look at. Any of those results that come in, again, they take them, they input them into the EMR and say, ‘next mammogram is due on such and such a date’ and things like that” [T1].

Communication

The communication domain refers to the exchange of information with patients as well as other members of the team. It includes supporting patients to realize patient-centred health goals and build health literacy. Participants described a variety of ways in which they communicated to further team work and adopt an inter-professional approach to care: “We meet as a staff, a clinic staff. So that we actually try to share some of the work… that we have in common… We also have what's called a case conference where we meet to discuss those patients that we do have in common and even the ones we don’t have in common, we’re seeking the input of the nurses, where they can give their input” [T4]. A family practice nurse noted that team-based communication provides mutual support to all members of the team: “…we’ll get together and just discuss mutual clients and … if a certain situation came up in any of our practices that we had further questions about or wanted some extra advice on. And for the most part, the clients are mutual so it's great that we can all kind of work together and you know, are all on the same, the same page with our clients” [T5].

Family practice nurses are also resources to other primary care providers. For example, a physician commented that “…people come to her [family practice nurse] and pick her brain about diabetes…because she is exceedingly knowledgeable. I would suggest to you, you’ll have a hard time finding a physician in [region] who knows more about type 2 diabetes than she does” [T3].

As noted above, the ability to use information technology in a secure and confidential manner is an expected competency of family practice nurses. A family physician described an example of family practice nurses’ use of technology: “We have eHealth NL that is within our EMR, so they [family practice nurses] actually go into the pharmacy network, kind of confirm what the list was so that when I go in, and I’m going to be renewing medications and everything, those medication checks have already been done, you know?” [T1] and “I mean the communication throughout the day, through the EMR, we have a messaging system” [T1].

Collaboration and Partnership

The collaboration and partnership competency domain relates to activities that family practice nurses engage in with other health professionals, both within their own clinic or practice and across the health care system. It also refers to joint efforts with other organizations outside the traditional health sector, including community and non-government organizations. As one family practice nurse noted, collaboration includes shared approaches with other health professionals to provide community supports for patients: “If I see a client that, you know, a mom is going through post-partum depression or struggling with addictions, I’m able to speak with [the mental health worker] to get some feedback from him. He can offer me some community supports for the clients or the mothers. And sometimes if, you know, they’re in a very desperate situation or crisis, you know, [he] can see them. Because there's such a wait list right now for mental health and addictions services and sometimes he can kind of, speed things up for the clients of the clinic. … it's pretty much the same as I would for the physicians, I would bounce information off them, to get their advice on resources I could offer or advice to offer for the clients…” [T5].

A collaborative approach, such as shared care arrangements, is important for fostering continuity of patients’ care. A family practice nurse noted an example of a palliative care patient: “So sometimes if we have a palliative patient, [collaboration] is very helpful then. I may go and do a visit one day and then the physician may go the next day and we kind of liaise and collaborate together of our approach and then how the patient is coping” [T6]. Collaboration is also important for facilitating smooth patient transitions between health care settings: “So it's post-op [operative] care following surgeries. It could be someone having chemo in the community. It could be someone requiring home IV therapy. Palliative care has been a big part coming on line now the past couple of years and people are tending to palliate and pass away at home…which would be a planned death… and of course suture and staple removal. Wound care is a big thing…” [T6].

Some family practice nurses, depending on the nature and funding of their position, may also engage in inter-sectoral collaboration and work with other community-based organizations to reach vulnerable patients. One family practice nurse said, “I try at least once a week to get into the schools and also [the women's shelter]…, so I try to get in there at least once, once a week, you know, or even every second week. Just to do some talks with the moms there. I try to make my services very accessible. I do vaccinations there as well just because moms have transportation issues” [T5].

An important element of collaboration is understanding the roles and professional scopes of practice of other health care providers. In some practices, this understanding was established through general knowledge of professional regulations: “… I have my own scope [defined by the nursing regulator]. I don’t go beyond that scope and… everybody knows what their role is in regards to patient care … there's kind of an understanding without saying it” [T5]. In another clinic, a family physician used medical directives to provide clarity: “We’re working together every day so, being you know, they work autonomously under their license. There are some things where there may be a bit of a grey zone, I protect them with medical directives” [T1]. In addition, participants noted that a shared understanding of areas of expertise and care responsibilities across different health care providers also facilitates patient care. For example, in describing potential overlap with public health nurses, a family practice nurse said: “like a Public Health Nurse…would be vaccines, and they do post-natal checks. So we would focus more on the med-surge part of seeing a child and same with adults” [T6]. Similarly, a family physician recalled an example of when a public health nurse, rather than a family practice nurse, would be relied upon to provide care: “Or we suspect head lice. Our public health nurse is the expert… I wouldn’t think of managing that without the public health nurse because that's, that's her thing” [T3].

Quality Assurance, Evaluation and Research

Family practice nurses are also expected to contribute to quality assurance, evaluation and research activities. As noted by one family physician, the family practice nurses in the practice have played a key role in improving preventative care: “So they have a really pivotal role in tracking and noting when things such as colorectal cancer screening, breast screening, PAP screening, vaccinations. What I call the key preventative targets of what family practice should be targeting” [T1], and, as described above in the example of the Hepatitis C follow-up program under the Clinical Practice domain, instituting procedures to ensure best practices in the local context that are essential to primary health care: “…whatever that benchmark is that you aim for in primary care to achieve when it comes to preventative screening, we’ve always surpassed that. And I’ve always said you know, we’ve been able to meet it and surpass it only because we have nursing on our team” [T1].

While study participants were able to identify the contribution of family practice nurses to quality assurance activities, only one family practice nurse identified research as an expectation of her role. Based at an academically-affiliated clinic, she said, “the director is a faculty member so he kind of expects everybody to do research and partake in research” [T8].

Leadership

The leadership competency statements relate to leadership at the societal or health system level (by advocating for primary care reform and social justice) as well as at the individual clinic or team level (by providing guidance, direction, and sharing knowledge). The expression of leadership varies by the nature of the family practice nurse's appointment, the type of clinic, and clinic funding model. When describing specific components of her role, a family practice nurse at an academically-affiliated centre noted that: “we’ve been lobbying so long, but we’re really starting to re-evaluate the programs that we do and to make them leaner and to…evaluate programs to see … the long-term outcomes… Is it beneficial or should we be putting more of our resources…Or getting in to do more work with the schools, for example, right? With the youth. … the more that we can lobby with the government and what not to get some more money into, into public health programs, I think they would see the long-term outcomes when it comes to cost and the health of the population as a whole” [T5]. The same nurse described working within a team to provide colleagues with evidence-informed practice: “Some physicians even ask me to watch them, because that's not a big part of their scope, is vaccinations and inoculations. So they might even ask me to watch them give a vaccine or you know… breast feeding…. A lot of the school health, a lot of the communicable disease. That's kind of the main things they might look for some advice from me” [T5]. Family practice nurses can also bring new skills and knowledge to a team to support or expand prevention and health promotion programs: “[The family practice nurse] identified that she wanted to become an advance foot care nurse, because foot care is something that we probably could have better service in our community” [T1].

Discussion

Our secondary analysis of qualitative interview data found that family practice nursing competency statements reflect the activities and capacities of family practice nurses in NL. For the newly developed competency statements to serve as a foundation in the development of primary care nursing, it is imperative that primary health care providers, including family practice nurses themselves, see the activities and capabilities of family practice nurses reflected in the competency statements. Moreover, it is important to recognize that, in many instances, a single activity relates to multiple competency domains. For example, the provision of health education or a preventative service may relate to the Clinical Practice, Communication, and Collaboration and Partnership domains and draw upon the knowledge, skills, and expertise associated with each individual domain.

Our study adopts a novel approach to illustrate how professional competencies can serve to describe the roles and contributions of family practices nurses. Previous studies in this area have focused on characterizing the roles and activities of family practice nursing in terms of their clinical activities and areas of expertise. These studies have documented family practice nurses’ activities in relation to global assessment, episodic and preventative care, health promotion, chronic disease management, pharmaceutical management, paediatric and women's health, case management, care coordination, collaboration, and practice organization (CNA, 2011, 2013; Lukewich et al., 2014, 2018, 2020; Norful et al., 2017; Oandasan et al., 2010; Poitras et al., 2018; Poitras et al., 2018; Smolowitz et al., 2015). The competency statements also recognize family practice nurses’ capacities in communication, collaboration and quality assurance, surveillance and research activities, as well as their broader involvement in addressing health inequities and social determinants of health. Not surprisingly, participants in our study were able to readily identify examples of family practice nurses enacting the clinical competency domains, but provided fewer examples related to the quality assurance, evaluation and research, and leadership domains. In this light, the competency statements provide a blueprint to optimize the role of family practice nurses within their current scopes of practice.

We found substantial variation in the expression of professional competencies among the participants in our study. Our original study found that the funding model under which family practice nurses work in NL influences the nature and scope of their role (Mathews et al., 2020). Across Canada, provinces use a variety of funding models to finance family practice nurses, including global funding, capitation, and enhanced fee-for-service. Research has consistently shown that funding models influence the work of family practice nurses, including the range of their activities, and their relative autonomy (Wranik et al., 2017, 2019). Family practice nurses employed in traditional fee-for-service practice tended to engage in a narrower set of activities that were directly linked to billable clinical procedures (Mathews et al., 2020; Merrick et al., 2015; Pearce et al., 2011; Pullon et al., 2009) and/or medical directives (Mathews et al., 2020; Norful et al., 2017; Pearce et al., 2011; Poitras et al., 2018; Poitras et al., 2018). In addition, our original study demonstrated that in globally-funded clinics, family practice nurses tend to work with greater autonomy, in greater collaboration with community organizations, and in activities targeting broader social determinants of health (Mathews et al., 2020).

Strengths and Limitations

This study used a secondary analysis of qualitative interviews. While it allows us to examine portrayals of family practice nurses without the potential influence of confirmation bias and leading questions related to specific competencies, it does not allow us to probe answers. Likewise, a secondary analysis does not allow us to tailor recruitment towards achieving saturation of main themes or maximum variation sampling, which are traditional strengths of qualitative interviews. The study examines a small number of family practice nurses in a province where family practice nursing is still in its early stages, so findings may not be transferable to other jurisdictions in Canada. We recommend replicating our study in other jurisdictions in Canada to develop a more complete understanding of how competency statements reflect and inform the roles and activities of family practice nurses, and vice versa.

Implications for Practice

As family practice nursing becomes increasingly recognized as a distinct discipline within the nursing profession, the integration of professional competencies is needed to underline the specific skills and training required to optimize family practice nursing (Akeroyd et al., 2009; Merrick et al., 2015; Oandasan et al., 2010; Oelke et al., 2014; Poitras et al., 2018; Poitras et al., 2018). Historically, RNs had limited exposure to family practice in their formal training, and most nurses who worked in family practices did not have prior experience in primary care settings (Al Sayah et al., 2014). Given the lack of formal experience in family practice nursing, the training and skill sets of family practice nurses have been driven by their roles in the specific clinic in which they practice. As the training of family practice nurses becomes more formalized, a better understanding of how actual practice relates to competency domains will ensure that training policy and programs produce graduates who are able to enact expected activities, roles, and professional standards.

Conclusions

Family physicians and family practice nurses both expressed a wide range of activities and roles performed by family practice nurses in NL, demonstrating that recently developed professional competency statements are reflective of actual activities and capacities of family practice nurses. The competency statements help to identify and unify training needs of these nurses. The professional competencies provide a framework with which to understand how family practice nurses contribute to primary health care and how their roles can be optimized within their existing scope of practice.