Role Clarification Processes for Better Integration of Nurse Practitioners into Primary Healthcare Teams: A Multiple-Case Study

Abstract

Role clarity is a crucial issue for effective interprofessional collaboration. Poorly defined roles can become a source of conflict in clinical teams and reduce the effectiveness of care and services delivered to the population. Our objective in this paper is to outline processes for clarifying professional roles when a new role is introduced into clinical teams, that of the primary healthcare nurse practitioner (PHCNP). To support our empirical analysis we used the Canadian National Interprofessional Competency Framework, which defines the essential components for role clarification among professionals. A qualitative multiple-case study was conducted on six cases in which the PHCNP role was introduced into primary care teams. Data collection included 34 semistructured interviews with key informants involved in the implementation of the PHCNP role. Our results revealed that the best performing primary care teams were those that used a variety of organizational and individual strategies to carry out role clarification processes. From this study, we conclude that role clarification is both an organizational process to be developed and a competency that each member of the primary care team must mobilize to ensure effective interprofessional collaboration.

Full text

Research Article
Role Clarification Processes for Better Integration
of Nurse Practitioners into Primary Healthcare Teams:
A Multiple-Case Study
Isabelle Brault,1Kelley Kilpatrick,1Danielle D’Amour,1
Damien Contandriopoulos,1Véronique Chouinard,1Carl-Ardy Dubois,1
Mélanie Perroux,2and Marie-Dominique Beaulieu3
1Faculty of Nursing, University of Montreal, P.O. Box 6128, Centre-Ville Station, Montreal, QC, Canada H3C 3J7
2University of Montreal Public Health Research Institute, P.O. Box 6128, Centre-Ville Station, Montreal, QC, Canada H3C 3J7
3Department of Family Medicine and Emergency Medicine, University of Montreal, CRCHUM, Saint-Antoine Tower,
850 St. Denis Street, Room S03-284, Montreal, QC, Canada H2X 0A9
Correspondence should be addressed to Isabelle Brault; isabelle.brault@umontreal.ca
Received  July ; Revised  October ; Accepted  November ; Published  December 
Academic Editor: Karyn Holm
Copyright ©  Isabelle Brault et al. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Role clarity is a crucial issue for eective interprofessional collaboration. Poorly dened roles can become a source of conict
in clinical teams and reduce the eectiveness of care and services delivered to the population. Our objective in this paper is to
outline processes for clarifying professional roles when a new role is introduced into clinical teams, that of the primary healthcare
nurse practitioner (PHCNP). To support our empirical analysis we used the Canadian National Interprofessional Competency
Framework, which denes the essential components for role clarication among professionals. A qualitative multiple-case study
was conducted on six cases in which the PHCNP role was introduced into primary care teams. Data collection included 
semistructured interviews with key informants involved in the implementation of the PHCNP role. Our results revealed that the
best performing primary care teams were those that used a variety of organizational and individual strategies to carry out role
clarication processes. From this study, we conclude that role clarication is both an organizational process to be developed and a
competency that each member of the primary care team must mobilize to ensure eective interprofessional collaboration.
1. Introduction
High-performing primary care teams are one of the chief
characteristics of healthcare systems that are responsive to
population needs [,]. However, the optimal development
of such teams is a challenge for primary care systems. Opti-
mizing each professional’s scope of practice is one suggested
approach to reinforce team functioning and respond to
patients’ needs []. is is dicult, however, because changes
in professional roles can lead to power struggles []. When-
ever the nurse practitioner role has been introduced into
clinical teams, one of the greatest diculties encountered
has involved the clarication of professional roles []. Lack
of clarity about the nurse practitioner’s role has created
confusion and led to resistance to its integration [,].
Clarifying professional roles among members of a primary
care team can be an eective approach to mitigate power
struggles, facilitate the integration of new roles in teams, and
foster interprofessional collaboration.
In primary care practice, there is a great deal of role
overlap, specically with regard to the roles of physicians,
primary healthcare nurse practitioners (PHCNPs), registered
nurses,andotherprofessionalsontheclinicalteams.Clari-
fying professional roles can serve several purposes: dening
each person’s responsibilities, ensuring appropriate imple-
mentation of each professional’s role, optimizing professional
scopes of practice, and thereby ensuring ecient patient
management.
Hindawi Publishing Corporation
Nursing Research and Practice
Volume 2014, Article ID 170514, 9 pages
http://dx.doi.org/10.1155/2014/170514

Nursing Research and Practice
PHCNPs were introduced in Quebec in  to provide
health and wellness promotion and to treat patients requiring
follow-up for an acute common illness, chronic disease man-
agement, and pregnancy follow-up to  weeks of gestation.
In Quebec, PHCNPs are Master’s prepared registered nurses.
PHCNPs can order and interpret diagnostic tests, prescribe
medication and medical treatments, and perform specic
procedures within their legislated scope of practice []. e
focus of the PHCNP role is health promotion, disease pre-
vention, preventive care, diagnosis of acute minor illness and
injuries, and monitoring and management of stable chronic
conditions []. PHCNPs in Quebec have some restrictions on
their scope of practice, including their ability to establish a
primary diagnosis [].
Several researchers have explored collaboration between
physicians and nurses in primary care teams [], but, to our
knowledge, no study has specically examined the processes
by which professionals clarify their respective roles in these
teams. In this paper, our objective is to examine the processes
of role clarication among professionals in primary care
teamswhenanewroleisintroducedintotheteam,thatis,
the PHCNP. Specically, we want to understand the organiza-
tional and individual components that inuence the process
of professional role clarication. In the following section we
present the key elements of the Canadian National Interpro-
fessionalCompetencyFramework.
2. The Canadian National Interprofessional
Competency Framework
The Canadian National Interprofessional Competency Frame-
work was developed by the Canadian Interprofessional
Health Collaborative (CIHC) in . e CIHC is made
up of academics, researchers, health professionals, students,
and health organizations concerned with training for inter-
professional collaboration and the associated competencies.
is framework denes the competencies required for better
collaboration; it positions role clarication as one of the
fundamental competencies for optimizing interprofessional
collaboration []. is framework is relevant for two reasons.
First, it presents a shared vision of the competencies asso-
ciated with interprofessional collaboration. Second, it allows
us to link specic activities with the implementation of the
role clarication competency, to gain a better understanding
oftheprocessesinvolved.eCIHCframeworkandtherole
clarication competency are briey described below.
According to the CIHC [], interprofessional collabora-
tion is encompassed by six competency domains: () interpro-
fessional communication, which refers to eective, respon-
sible, and open communication within the interprofes-
sional team; () patient/client/family/community-centred
care, which examines the involvement of patients and their
families in care planning; () team functioning, which reects
the importance of knowing the mechanisms and princi-
ples underpinning eective team functioning; () collabo-
rativeleadership,whoseaimistofacilitateshareddecision-
making and develop a collaborative work climate by applying
the principles of consultation to decision-making; () inter-
professional conict resolution, which seeks to engage all
team members in identifying constructive solutions to any
conicts arising within the interprofessional team; and ()
role clarication, which is presented in greater detail in
the following paragraphs. ese competencies are mobilized
dierently depending on the practice context and the com-
plexity of clinical cases, as well as on the quality improvement
processes in place in the clinical settings.
Besides the competencies that underlie interprofessional
collaboration, the CIHC framework [] puts forward three
other components to be considered when interprofessional
teams work together: the complexity of clinical situations,
the practice context, and quality improvement. ese compo-
nents inuence the application of the competencies, as they
may determine the intensity of interprofessional collabora-
tion in clinical teams. e complexity of clinical situations
refers to those situations in which professionals collaborate.
ey cover a broad spectrum ranging from simple to com-
plex. In most cases, complex situations require the involve-
ment of many professionals. e practice context inuences
interprofessional collaboration. Indeed, depending on the
setting, care teams function dierently and adapt dierently
to the needs of patients and families. Quality improvement is
addressed more eectively using interprofessional collabora-
tion. All actors in the healthcare system must work together
to transform practices and to improve the quality of care and
services. ese three components (i.e., complexity of clinical
situations, practice context, and quality improvement) refer
essentially to elements of the organizational context in which
care is provided.
2.1. Role Clarication: An Interprofessional Collaboration
Competency. e CIHC framework describes the role clari-
cation competency as follows:
Learners/practitioners understand their own role
and the roles of those in other professions, and
use this knowledge appropriately to establish
and achieve patient/client/family and community
goals. [10] (page 12)
is competency is closely linked with the other ve
competency domains identied in the CIHC framework
and is aimed at supporting processes to optimize each
professional’s eld of practice. It is based on a detailed under-
standing of one’s own role and those of other professionals.
is competency, which is fundamental to interprofessional
collaboration, is dened by seven descriptors that identify
the relevant knowledge, attitudes, and values, which are
dynamic and constantly evolving []. ese role clarication
competency descriptors include the following:
() describing own role and that of others;
() recognizing and respecting the diversity of other
healthcare and social care roles, responsibilities, and
competencies;
() performing own roles in a culturally respectful way;
() communicating roles, knowledge, skills, and attitudes
using appropriate language;

Nursing Research and Practice 
T : Description of the cases.
eme Cases
Case  Case  Case  Case  Case  Case 
Location Urban Rural Rural Rural Urban Urban
Patient management
model: joint,
consultative, mixed∗
Mostly
consultative Mixed Consultative Mixed or
consultative Consultative Exclusively
consultative
Type of clientele
(socioeconomically,
geographically).
Large territory refers
to a geographical area
covering more than 
cities and hundreds of
miles
Varied client e l e ,
socioeconomi-
cally poor
Small, dense
territory
Clientele with
chronic illnesses
Large territory
Economically
disadvantaged
clientele
High birth rate
Large territory
Clientele with
chronic illnesses
Pediatric
clientele
Large territory
Clientele with
chronic
illnesses, socioe-
conomically
poor,
immigrants
Small, dense
territory
Home care
clientele (with
the exception of
palliative care)
Small, dense
territory
Type and number of
professionals working
closely with the
PHCNP
PHCNPs,
MDs,  RNs, 
nursing
assistant,  social
worker, 
psychologist, 
nutritionist, 
kinesiologist
PHCNPs,
MDs,  RNs, 
nursing
assistant, 
nutritionist
PHCNPs,
MDs,RNs,
nursing
assistants, 
social workers, 
occupational
therapist
PHCNPs,
MDs,  RN, 
nursing assistant
PHCNP,MD,
RN,nursing
assistant, 
pharmacist
PHCNP,
MDs,  RNs, 
social workers, 
occupational
therapists, 
physiotherapy
technicians
Patients seen by the
PHCNP on a daily
basis in the walk-in
clinic
Around –
patients/day - patients/day  patients/day Around 
patients/day
Around 
patients/day
Not applicable
PHCNP’s home
care caseload:
– patients
∗In the joint management model, a group of patients is managed jointly by the PHCNP and the physician partner. In the consultative management model, the
PHCNP and the physician each manage a dierent group of patients and the PHCNP consults the physician as needed for patients in the group the PHCNP is
following. e mixed model includes both joint and consultative patient management.
() accessing others’ skills and knowledge appropriately
through consultation;
() considering the roles of others in determining own
professional and interprofessional roles;
() integrating competencies/roles seamlessly into mod-
els of service delivery.
In order to better understand the role clarication pro-
cess, it is important to examine the components of the context
that inuence role clarication (complexity of clinical situa-
tions, practice context, and quality improvement) as well as
the seven descriptors of role clarication presented above.
3. Methods
3.1. Research Design. is descriptive multiple-case study []
was approved by the Research Ethics Board of the University
of Montreal. Case study design was recommended because
it allows for in-depth examination of events while taking
into account the larger context in which they occur []. e
CIHC Framework was used as a reference model to direct
data analysis []. Multiple-case study design is more robust
because using a framework allows the researcher to compare
and generalize ndings to other cases (i.e., analytic general-
ization) [].
3.2. Case Selection and Description. Each case was opera-
tionally dened [] as the primary healthcare setting where
the PHCNPs practiced. e cases were bounded by the limits
of service as determined by the PHCNP’s practice model
and reporting structure. We used purposeful sampling []
to identify cases that oered a broad picture of PHCNPs’
roles in the province of Quebec, Canada, where PHCNP role
implementation is recent. e cases were selected based on
their similarities and dierences in terms of geographic loca-
tion and time elapsed since implementation. We identied
six cases in four geographic regions of the province. Half
the cases were situated in predominantly rural catchment
areas. PHCNPs served patients in all age groups. Also, the
cases present a diversity of characteristics in terms of patient
management models, size of interprofessional teams, number
of professional sta, and number of patients seen by the
PHCNP. ese intercase variations provide a wealth of data
to better understand the phenomena under study []which
are the deployment of PHCNPs in primary care settings
and the associated role clarication processes. e patient
populations under PHCNP care included patients without
a regular physician, new immigrants, and refugees, among
others; conditions managed included chronic illnesses such
as diabetes or hypertension, mental health conditions, preg-
nancy, and routine acute health problems such as otitis. e
cases studied are described in Table .

Nursing Research and Practice
T : Number of participants interviewed by profession and by case.
Participants Case  Case  Case  Case  Case  Case  Total
PHCNP∗ 
Physician partner       
Management team member       
Other interprofessional team member  
Nurse and charge nurse     
Total       
∗PHCNP: primary healthcare nurse practitioner; management team includes nurse and program managers and clinical nurse specialists.
3.3. Data Collection and Participants. Data were collected
from May  to October . We conducted  individ-
ual interviews:  nurse managers or nursing directors, 
intraprofessional (i.e., within nursing) team members, seven
physician partners, and one interprofessional (outside nurs-
ing) team member (Tab l e  ). In each setting, we interviewed
the key actors directly involved in the PHCNP integration
processes, who were mainly PHCNPs, physician partners,
and nurse managers. In only one case was a professional other
than a nurse involved in the implementation of the new
PHCNP role in the primary care team.
We used semistructured interview guides [], which
we adapted according to the professional’s role (e.g., nurse
manager, physician, PHCNP, and registered nurse). Initial
questions and themes were identied from the literature
andincludedquestionsaboutthepreparationofthework
setting, implementation of the PHCNP role, their vision for
the PHCNP role and that of the team, the activities comprised
in the PHCNP role, how activities were shared between
PHCNPs and other team members, and collaboration within
the team []. e interviewer’s questions were exible to allow
exploration of emerging themes as the interviews unfolded
[]. Interviews were generally audio-recorded with partic-
ipants’ permission and transcribed. For those not audio-
recorded, summary notes were prepared. Interviews lasted
between  and  minutes.
3.4. Data Analysis. e overall aim of the analysis was to
understand how roles were claried among team members.
e interviews were analyzed within the context of the case,
and then the ndings from each case were compared. All the
interviews were read several times by dierent members of
the research team “to obtain a sense of the whole” (page )
[]. Each site was given a unique identifying code number to
facilitate retrieval []. An overall summary of each case was
developed by the research team member responsible for the
case to identify key themes.
3.4.1. Phase One: Within-Case Analysis. e qualitative data
was analyzed using qualitative content analysis [], dened
by Hsieh and Shannon as the “subjective interpretation of
the content of text data through the systematic classication
process of coding and identifying themes or patterns” (page
) []. We used the approach described by Miles and
Huberman [] to organize and synthesize the collected data.
Matrices were used to display the data and identify patterns
[].
To gain a better understanding of the role clarication
process [,], our analysis was supported by the descriptors
oftheCIHCroleclaricationcompetency.Wesoughtto
populatetherolecompetenciesframework[,]. No
additional codes were created. Langley argued that, to under-
stand processes, it is essential to “document as completely as
possiblethesequenceofevents”(page)[]. We identied
instances where participants described how activities or
perceptions had changed over time. Subsequent to this step,
we explored similarities and dierences in processes within
and across the cases [].
3.4.2. Phase Two: Cross-Case Analysis. In phase two, we pro-
ceeded to the overall analysis across the six cases []. We
used inductive and deductive approaches [] to understand
how roles were claried. Similarities and dierences in role
clarication were identied across cases. To identify patterns
across the cases, we developed a matrix of the themes and
concepts identied in the within-case analysis []. We used
pattern-matching to understand how the cases t within the
CIHC framework [].
3.5. Rigour. We used several strategies to ensure the quality of
the case studies []. We collected data from dierent sources
(PHCNPs, physician partners, and nurse managers) and from
rural and urban regions of the province. Patterns in the data
were identied by using the concepts of the CIHC framework.
We compared the ndings across the cases to understand
how the process of role clarication occurred []. Case
study methodology uses analytic generalization to generalize
ndings to a broader theory []. e explicit description of
the methodological approach is intended to facilitate repro-
duction of the study. However, any application of the results
must take into consideration the particular features of other
contexts []. In this study, the identication and selection
of multiple cases allowed us to identify similarities and
dierences across the cases for anticipated reasons, thereby
strengthening the conclusions []. rough the interviews,
we were able to gather information on the dierent concepts
associated with the study, and we conducted interviews until
we reached the point of data saturation, when information
provided in new interviews was redundant []. e results
were validated with the participants in the majority of the case
settings.

Nursing Research and Practice 
4. Results
e results are presented here in reference to the Canadian
National Interprofessional Competency Framework. First,
we present the empirical results with respect to the three
organizational components that inuence interprofessional
collaboration: the practice context, the complexity of clinical
situations, and quality improvement. is initial step is help-
ful in understanding how these elements inuenced role
clarication.Wethenlookspecicallyattheroleclarication
competency and present our results in relation to the seven
descriptors of this competency in order to better understand
howthiscompetencywasmobilizedinthedierentsettings
studied.
4.1.ePracticeContext. Our empirical data showed that,
with respect to practice context, clarication of the PHCNP’s
role was based on two elements: an analysis of unmet patients’
needs and the legislative framework governing PHCNP prac-
tice in Quebec. Accessibility to healthcare and services was
thekeyelementthatemergedfromtheanalysisofpatients’
needs. In the high-performing settings, this needs analysis
preceded the arrival of the PHCNP and helped clarify the
PHCNP’sroleintheprimarycareteam:
Here in our organization, we met with the director
of nursing to determine which would be the most
appropriate sectors to receive a PHCNP, and what
roles she might take on, while also taking into
account the regulations of the regional health
agency. (Clinical nurse specialist)
e analysis of patients’ needs and the clarication of the
PHCNP’s role in the team were directly based on knowledge
of the legislative framework governing PHCNP practice, in
which the scope of the PHCNP role, prescribing activities,
and eligible practice settings are dened. Settings that were
less knowledgeable about the PHCNP’s scope of practice
encountered problems in assigning patients to the PHCNP.
For example, if the assigned patients had complex needs that
could not be entirely addressed within the PHCNP’s scope
of practice, this inhibited the autonomy of the PHCNP’s role.
e high-performing settings used the legislative framework
tonegotiatethePHCNP’srolewiththedierentmembers
of the primary care team, such as, among other things, to
conrm with pharmacists and radiologists the PHCNP’s right
to prescribe in that setting.
us, the practice context refers to the local context
of care and services for each of the settings studied. e
legislativecontextalsoinuencedroleclarication,asit
helped dene the dierent practitioners’ scope of practice
(e.g., pharmacist and radiologist).
4.2. e Complexity of Clinical Situations. Clinical complex-
ity refers to the broad spectrum of situations encountered
by PHCNPs and primary care teams, ranging from simple
to complex. e complexity of clinical situations creates
opportunities for interaction among the dierent members
of the primary care team. Most of the settings had instituted
formal occasions for interaction through team meetings.
Such meetings fostered role clarication among team mem-
bers and primarily between the PHCNP and the physician
pa rtner. However, in s ome s ett ings, physi cians me t onl y
among themselves and discussed the PHCNP’s practice and
how the PHCNP could be more eective and better used:
IthinkeachFMG[familymedicinegroup]will
develop, to some extent, its own modus operandi
with the nurse practitioner regarding what they
wanthertodoforchronicillnessmanagement.
(Physician partner)
In another setting, meetings were held to clarify roles in
relation to the preferences and interests of the PHCNP:
I sat down with the PHCNP to talk with her about
her preferences, her wishes, what she hoped to
do in coming to work at our clinic, because the
needs are so great that we have to make choices.
(Physician partner)
e complexity of clinical situations is an issue to be
considered when new PHCNPs are introduced and when the
PHCNP’s caseload is created. Our analysis showed that when
clinical situations were at the high end of the spectrum in
terms of complexity, PHCNPs needed to consult physician
partners more oen. In settings that implemented a system
in which nursing assistants collected preliminary patient data
to assign patients by level of complexity (two cases in six),
thenumberofconsultationsbetweenPHCNPsandphysician
partners was greatly reduced. is initial screening made it
possibleforPHCNPstotargetpatientswhosefullrangeof
healthcare consultation needs they could manage:
...the added value of a PHCNP is that she rarely
needs to consult the physician partner; that’s when
it becomes worthwhile. (PHCNP)
4.3. Quality Improvement in Care and Services. Integrating
a new member into the primary care team can create
opportunities to improve the quality of care and services. e
introduction of a PHCNP led to a renewed vision of nursing
in primary care in which the roles of the dierent types of
nurses could be optimized:
...it’s having a vision for nursing practice, saying,
whatrolesshouldwebegivingtoeachofthese
dierentjobcategoriesinnursing?So,nottothink
only about the PHCNP, and where we should put
her, but to ask what role she should play in relation
totheroleoftheregisterednurse,theroleofthe
sta nurse. But for me, that’s always what I’m
thinking about, because I also have a mandate, an
organizational responsibility, which is to optimize
care, or to set care priorities. (Nursing coordina-
tor)
Having clearly dened roles in primary care teams also
makesitpossiblefornewprofessionalprojectstoemerge.
Some settings had implemented special projects led by

Nursing Research and Practice
the PHCNPs. ese projects helped to promote the PHCNP’s
role in the team and to underscore the specicity of that role
and how it diered from the physician’s role. Our data showed
that this type of project had positive impacts on the clinic’s
overall performance:
First,westartedbymeetingthem[PHCNPs].It’sa
little simplistic to say. en to ...learn from them
what were their abilities, their limitations, and ...
their wishes to ...Not their wishes, but what they
wanted to do as work, and what they were able to
do as work. (Physician partner)
4.4. Role Clarication Competency Descriptors. As men-
tioned earlier, the Canadian National Interprofessional Com-
petency Framework presents seven descriptors for the role
clarication competency. e analysis of our data provided
a better understanding of how the descriptors of this com-
petency were manifested in the primary care teams. In this
section we present our empirical results in relation to these
descriptors.
(1) Describing Own Role and at of Others.Roleclarication
in a primary care team requires a detailed understanding
of one’s own professional role and those of others. In most
teams, the arrival of a PHCNP meant integrating a new
professional role into the team. PHCNPs have a key respon-
sibility for clarifying their role within primary care teams.
e majority of our respondents said PHCNPs were the best
persons to explain their own role to other team members.
However, PHCNPs could also nd themselves in a vulnerable
position if their role in the team is a new one and might need
the support of resource persons in the setting to support role
clarication. Such support from a resource person is crucial
to communicate the role optimally and to ensure it is well
understood by all the team members. Several respondents
estimatedthatittookaboutsixmonthsforPHCNPstosettle
intotheirroleanduptoayearforalldimensionsofthatroleto
be fully integrated. According to one PHCNP and a physician,
... you have to build up trust, a new role ...
And no one knows the role better than we do.
e guidelines, physicians, they have an idea of
the role, but ... I had to tell them, “okay, I’ve
come to see you [physician] because I think the
patientneedsthisdrug,butIcannotprescribeit.”
(PHCNP)
Ah!OK.Youknowheneedsitbutyoucannot
prescribe it? OK. (Physician partner)
Nevertheless, once the PHCNPs had settled fully into
their role, some respondents were very satised with their
practice:
...I was pleasantly surprised by their—how could
I say it?—their capacity for work and for man-
aging interprofessional care plans. So I quickly
accepted this principle and this form of team.
(Physician partner)
(2) Recognizing and Respecting the Diversity of Other Health-
care and Social Care Roles, Responsibilities, and Competencies.
Role diversity refers to all the dimensions associated with a
professional role and its responsibilities and competencies.
e diversity of the PHCNP’s role is not very widely recog-
nized in primary care teams. Sometimes roles are dierenti-
ated uniquely on the time allocated for patient consultations,
which varies from one professional to another. As this resp on-
dent pointed out,
e PHCNP’s consultation will be more compre-
hensive. Physicians know that, in her role, the
PHCNP can take more time for consultations with
patients. Also, the nursing dimension of the role
makes the dierence in terms of teaching. (Clinical
nurse specialist)
Another respondent sees the diversity of the role in a
positive light and respects the dierence:
I don’t have any genograms in my patients’ charts.
e PHCNP does, and for her it’s a value, which
Irespect.Butatthesametime,forusdoctors,we
need to respect the fact that the PHCNP won’t be
doing things exactly the same way we do them.
(Physician partner)
(3)PerformingOwnRolesinaCulturallyRespectfulWay.is
competency indicator can take various forms: rst, as respect
for the cultures of the dierent professionals in the teams
and then as respect for the culture and values of patients and
families followed by the primary care teams. Several PHCNPs
in our cases worked with recent immigrants from other
countries, refugees, and vulnerable and impoverished groups.
e PHCNPs described how they incorporated culturally
adapted strategies in their diabetes teaching activities.
As an illustration of this competence, in the less well
performing settings, professionals in the same discipline, for
example, the PHCNPs and nurses, tended to stick together for
mutual support. ese alliances occurred more frequently in
settings where there was less collaboration with physicians,
and they were a source of comfort and support for the
PHCNPs.
(4) Communicating Roles, Knowledge, Skills, and Attitudes
Using Appropriate Language. Our data showed that mem-
bers of primary care teams used several dierent means to
communicate their roles, knowledge, abilities, and attitudes
in appropriate language. In some of the settings studied, the
PHCNP’srolewasexplainedtotheprimarycareteamina
presentation made by the nursing director and the PHCNP
together, in which they were able to respond to various
questions from the team members.
In most of the settings, care team members primarily
used informal communication to discuss professional roles.
Setting size also inuenced the type of communication used.
Settings with fewer professionals tended to opt for informal
communication, whereas settings with larger teams tended to
schedule formal sessions for communication. In our study,
the better performing settings were those where there was

Nursing Research and Practice 
ongoing communication, formal and informal, among the
members, in which they were able to discuss grey areas and
each person’s capacities.
One setting formalized the process of role clarication by
developing a matrix of all team members’ roles. is matrix
was a tool for discussing areas of overlap among the profes-
sionals and enabled team members to clarify each person’s
expertise. As one PHCNP reported,
So, at that moment, the roles were well dened; it
helped. I think that, for sure, it doesn’t solve all the
problems. Having it on paper, you can refer to it,
it’s useful, but aerward, it’s mostly in talking with
people. (PHCNP)
e settings that used only documents prepared by the
professional nursing and medical associations to clarify roles
said these were insucient and that interactions with other
members of the team were essential.
(5) Accessing Others’ Skills and Knowledge Appropriately
through Consultation. We identied two types of patient man-
agement models in the cases: the joint management model
and the consultative management model. In the joint man-
agement model, a group of patients is followed jointly by
both the PHCNP and a physician partner. In the consultative
management model, they each manage their own group of
patients, and the PHCNP consults the physician as needed for
the patients she is following. e consultative model was used
in the majority of settings studied. is patient management
model fosters consultations between the physician partner
and the PHCNP and requires that time be set aside for such
exchanges, as pointed out by this PHCNP:
We planned specic times when we could meet:
early in the morning, at lunch time, and at the end
oftheday.esewereourtimeswhenwetalked
about cases. (PHCNP)
is type of consultation did occur not only between
physicians and PHCNPs, but also between nurses and other
teammembers.However,ourdatarevealedthattheinformal
nature of the consultations sometimes made the PHCNPs
uneasy, as they worried about bothering their colleagues,
specically physicians, and disrupting their work.
(6) Considering the Roles of Others in Determining Own
Professional and Interprofessional Roles.Inprimarycare,
PHCNPs work closely with physician partners to establish
their place and their complementary role in the team. is
involves identifying what is unique about the PHCNP’s
role and what elements of the role are shared with other
professionals, that is, certain tasks that can also be performed
by other professionals or competencies that can be shared
bymorethanonememberoftheteam.Accordingtoone
physician, the sharing of clienteles raises issues about the
physicians’ medical role:
We’re only going to have the complicated cases,
thecasesnoonewants.Ourmorestable,easier
cases will be given to others. So there’s a sort of
reassessment happening among the professionals,
particularly with respect to the PHCNPs’ role.
(Physician partner)
For the nurses, the arrival of the PHCNP provoked
some apprehension. Some of them had developed expertise
in managing patients with diabetes and were worried they
would lose that role when the PHCNP arrived. Other nurses
saw the PHCNP’s arrival as an opportunity to ensure better
management of their clienteles and as providing an additional
resource to which they could refer patients as needed.
According to one PHCNP, recognizing and maintaining the
expertise of registered nurses was a key element in dening
the PHCNP’s own role:
e registered nurses have expertise in adjusting
insulin and in the very hands-on management of
hypertension. Knowing this from the start made it
possible for them to keep their expertise, and for
us to take our own place. at was a really, really
positive thing. (PHCNP)
e PHCNP’s arrival was a catalyst for redening the roles
of every member of the primary care team. According to this
nursing director,
ey asked me to review roles and to optimize the
roles of registered nurses. So we reviewed the roles
of the licensed practical nurses, who were doing
more than they were supposed to be doing. We
reviewed the roles of the registered nurses, who
weren’t doing enough. (Director of Nursing)
In several settings, the PHCNP’s role was developed by
building on the complementarity of roles already existing in
the team.
(7) Integrating Competencies/Roles Seamlessly into Models
of Service Delivery. In several settings, integrating PHCNP
competencies into new models of care delivery resulted in
the creation of specic clinics for PHCNPs, such as teams
for the prevention and treatment of sexually transmitted and
blood-borne infections (STBBI). is type of clinic provided
an opportunity for PHCNPs to promote their role within
the establishment and not just in the primary care team and
to showcase the distinctive characteristics of the PHCNP’s
role in comparison with the role of physicians. ese special
projects extended outside the boundaries of the primary care
clinic; they were projects that involved the entire organization
andallowedservicedeliverytobemodulatedbasedonthe
PHCNP’s competencies.
In another setting, the PHCNP was a core resource for
training nursing sta, in order to achieve optimal integration
of collective prescriptions among nurses (e.g., adjusting
antihypertensive medication):
e new director’s vision consisted of fostering the
autonomy of each professional role. To achieve
this, implementing and developing collective pre-
scriptions was essential. (PHCNP)
e arrival of the PHCNP was thus an opportunity to
optimize services to the population. e less well performing

Nursing Research and Practice
settings were those that did not incorporate any special
projects into the PHCNP’s work.
5. Discussion
From the analysis of our empirical data, two major conclu-
sions emerged regarding role clarication in primary care
teams: role clarication is both an organizational process
and a professional competency. Overall, half of the settings
studied(/)weredenedas“high-performing,”inthatthey
had successfully integrated the PHCNP into the primary care
team, there was clarity and consensus among team members
about their roles, and interprofessional collaboration was well
established within these teams.
5.1. Role Clarication: An Organizational Process. In the
settings studied, the best performing teams were those that
introduced organizational processes to support role clarica-
tion. e organizational processes could take several forms:
developing a matrix to clarify professional roles, allocating
formal time for discussing roles, or implementing special
projects for PHCNPs, such as STBBI clinics. According to
D’Amour and colleagues [], these elements correspond to
the dimension of formalization of interprofessional collab-
oration through the use of tools and information exchange.
Our data suggest that, for optimal results, role clarication
needs to be planned. At the level of nursing administration,
in settings where a “champion” was designated to oversee
optimal implementation of the PHCNP role and make it
known to others before the PHCNP’s arrival, the integration
was facilitated and colleagues had a better understanding of
the role. Several researchers have emphasized the key role
of nursing leaders in implementing new nursing roles. eir
understanding of these roles aects the implementation of all
aspects of the role [,,,].
5.2. Role Clarication: A Professional Competency. e sec-
ond conclusion emerging from this study is that role clar-
ication is a competency professionals need to mobilize to
ensure their own role is well understood by all team mem-
bers. As such, professionals have the responsibility for fully
understanding their own role and the various dimensions
associated with their practice, so they can explain it to the
team, make the case for it, and negotiate accordingly. e
professionals need to identify all the ways in which the mobi-
lization of this role clarication competency is manifested.
e best performing settings were those in which individuals
were able to talk about their own roles and understand those
of other professionals. is paper provides a rst empirical
application of the Canadian National Interprofessional Com-
petency Framework and contributes to a better understand-
ing of the development of the interprofessional collaboration
competency and more specically of the role clarication
competency. To facilitate the appropriation of the dierent
descriptors associated with role clarication and reduce
overlap, these descriptors could be reduced to four. Several
interview comments could have been encoded in more than
one competency descriptor (e.g., Competency : describing
own role and that of others and Competency : considering
the roles of others in determining own professional and
interprofessional role). Research is needed to further clarify
the distinction between these competencies. Our research has
shown that applying the Canadian National Interprofessional
Competency Framework empirically is sometimes dicult.
Some data fell within more than one descriptor at a time.
Nevertheless, using the CIHC framework was helpful in
developing a better understanding of the role clarication
competency and thereby fostering its full deployment.
6. Practical Implications
is study has provided a deeper understanding of the pro-
cesses of role clarication when the PHCNP role is integrated
into primary care teams. A limitation in case studies concerns
the ability to generalize the results to larger contexts, since
the cases studied are situated in particular contexts. It is
nevertheless possible to draw some practical implications, as
presented here.
Eective role clarication processes are those that include
both an organizational dimension, in which processes are set
up to facilitate role clarication, and an individual dimension,
in which professionals are able to communicate clearly
all aspects of their roles. All the settings agreed that role
clarication processes must take into consideration patients’
needs. Role clarity is a key determinant of interprofessional
collaboration. Our data showed that no team had planned
for a systematic role clarication process in a given time
and space. Nevertheless, according to Carmel and Baker-
McClearn [], professional roles are dynamic and become
transformed by the practice context and by interactions
with other professionals. ese authors consider that roles
are constructed and negotiated by means of the everyday
processes experienced by members of the team. e roles
are dened not only by these interactions, but also by
legislation and by professional regulatory agencies []. For
thesereasons,rolesarenotstatic;theyevolvewithpatients’
needs, providers’ experience with the role, technological
developments, training received, and legislation, and as such,
they need to be redened over time. erefore, it would be
important, as the years go by, to set aside time and space to
discuss how roles are changing in primary care teams.
In conclusion, our aim in this paper has been to gain
a better understanding of role clarication processes in
primary care teams in Quebec. Role clarication is a key
determinant of interprofessional collaboration, with both an
organizational and a professional component. As such, it is
the responsibility of both the organization and the primary
care team members. Interprofessional collaboration is a
complex competency for clinical teams to acquire, and role
clarication is one of the essential competencies they need to
master.
Conflict of Interests
e authors declare that there is no conict of interests
regarding the publication of this paper.

Nursing Research and Practice 
Acknowledgments
isstudywassupportedbyagrantfromtheCanadian
Institutes of Health Research (CIHR) and by the Quebec
Ministry of Health and Social Services. e authors thank
JohanneCharlandforhercommentsonanearlierversionof
this paper.
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