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


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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.
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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;
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
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
Hindawi Publishing Corporation
Nursing Research and Practice
Volume 2014, Article ID 170514, 9 pages
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
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-
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
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-
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
() 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
consultative Mixed Consultative Mixed or
consultative Consultative Exclusively
Type of clientele
Large territory refers
to a geographical area
covering more than 
cities and hundreds of
Varied client e l e ,
cally poor
Small, dense
Clientele with
chronic illnesses
Large territory
High birth rate
Large territory
Clientele with
chronic illnesses
Large territory
Clientele with
illnesses, socioe-
Small, dense
Home care
clientele (with
the exception of
palliative care)
Small, dense
Type and number of
professionals working
closely with the
MDs,  RNs, 
assistant,  social
worker, 
psychologist, 
nutritionist, 
MDs,  RNs, 
assistant, 
assistants, 
social workers, 
MDs,  RN, 
nursing assistant
assistant, 
MDs,  RNs, 
social workers, 
therapists, 
Patients seen by the
PHCNP on a daily
basis in the walk-in
Around –
patients/day - patients/day  patients/day Around 
Around 
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
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
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
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
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
competency and present our results in relation to the seven
descriptors of this competency in order to better understand
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
needs. In the high-performing settings, this needs analysis
preceded the arrival of the PHCNP and helped clarify the
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
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
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:
develop, to some extent, its own modus operandi
with the nurse practitioner regarding what they
(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),
partners was greatly reduced. is initial screening made it
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:’s having a vision for nursing practice, saying,
only about the PHCNP, and where we should put
her, but to ask what role she should play in relation
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-
Having clearly dened roles in primary care teams also
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 clinics
overall performance:
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
(1) Describing Own Role and at of Others.Roleclarication
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
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
prescribe it? OK. (Physician partner)
Nevertheless, once the PHCNPs had settled fully into
their role, some respondents were very satised with their
...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
need to respect the fact that the PHCNP won’t be
doing things exactly the same way we do them.
(Physician partner)
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
(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
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 persons 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 persons
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
about cases. (PHCNP)
is type of consultation did occur not only between
physicians and PHCNPs, but also between nurses and other
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
physician, the sharing of clienteles raises issues about the
physicians’ medical role:
We’re only going to have the complicated cases,
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
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
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
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
Conflict of Interests
e authors declare that there is no conict of interests
regarding the publication of this paper.
Nursing Research and Practice
Institutes of Health Research (CIHR) and by the Quebec
Ministry of Health and Social Services. e authors thank
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... For functional co-management, GPs and APNs alike identified effective communication, mutual respect and trust as key factors for success [12]. And in Switzerland, recent findings have linked increased exchanges with stronger GP-APN collaborations [40]. The current study's qualitative insights confirm that, for APNs, regular, need-adjusted interactions with their collaborating GPs are essential. ...
... Among care teams, those that implement institutional processes to support clear role division tend to yield the best outcomes [40]. Alongside team functionality, clear role definition is the most common issue, as it influences interprofessional collaboration [41]. ...
... To ensure role clarity in daily operations, MediZentrum has two proven formats: patient conferences and quality circles. The literature shows that formats which foster a clear understanding of the different roles are essential [40]. One further approach to role anchoring -which is also expandable -is to assign part of each incoming GP's in-service training to an APN. ...
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Background The rising global population of older persons with chronic conditions demands new primary care models. Advanced practice nurses (APNs) can help meet that need. In Switzerland, APNs have only recently been introduced in primary care and little is known about their daily practice. This study aims to describe APNs’ activities and general roles at four sites with multi-professional primary care practices in the Swiss cantons of Bern and Solothurn. Methods To study the practices of APNs at the study sites, we adopted a social constructivist perspective, lending methods from ethnographic field research. We interviewed, observed and accompanied participants over five months, generating rich data on their daily practices. The analysis followed Braun and Clarke’s six-step thematic analysis process. Results The APNs’ daily practices cover three main themes. Their core activities are working with expanded clinical skills and being on-site specialists for patients and their relatives. These practices are surrounded by net activities, i.e., taking care of patients in tandem with the physicians and regular visits in residential long-term care facilities. The outer activity layer consists of cohesive activities, with which APNs anchor and facilitate their role and catalyze further development of the care model. APNs tailor their expanded medical knowledge and nursing practice to maximize the value they provide in patient care. Conclusions This study extends our knowledge of APNs’ daily practice within a Swiss multi-professional primary care practice. Our results indicate competencies that need to be integrated in APN education and point out the high potential of APN integration in such primary care practices.
... This informed the selection of an interdisciplinary team whose actions are tightly linked and would influence the quality of newborn care. Successful clinical audit teams include those with well-defined roles for each member to prevent free riding whereby some members fail to contribute their fair share in team effort [53,54]. Other characteristics of successful teams have been identified as those that have a committed chair who supports QI initiatives, are diverse and constitute the key decisionmakers from departments involved in newborn care, have hospital managers as part of the team, promotes equality, open dialogue and confidentiality during the audit meetings [40,43,45]. ...
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Clinical audits are an important intervention that enables health workers to reflect on their practice and identify and act on modifiable gaps in the care provided. To effectively audit the quality of care provided to the small and sick newborns, the clinical audit process must use a structured tool that comprehensively covers the continuum of newborn care from immediately after birth to the period of newborn unit care. The objective of the study was to co-design a newborn clinical audit tool that considered the key principles of a Human Centred Design approach. A three-step Human Centred Design approach was used that began by (1) understanding the context, the users and the available audit tools through literature, focus group discussions and a consensus meeting that was used to develop a prototype audit tool and its implementation guide, (2) the prototype audit tool was taken through several cycles of reviewing with users on real cases in a high volume newborn unit and refining it based on their feedback, and (3) the final prototype tool and the implementation guide were then tested in two high volume newborn units to determine their usability. Several cycles of evaluation and redesigning of the prototype audit tool revealed that the users preferred a comprehensive tool that catered to human factors such as reduced free text for ease of filling, length of the tool, and aesthetics. Identified facilitators and barriers influencing the newborn clinical audit in Kenyan public hospitals informed the design of an implementation guide that builds on the strengths and overcomes the barriers. We adopted a Human Centred Design approach to developing a newborn clinical audit tool and an implementation guide that we believe are comprehensive and consider the characteristics of the context of use and the user requirements.
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Introduction A well-functioning health system delivers quality services to all people when and where they need them. To help navigate the complex realm of patient care, it is essential that health care professions have a thorough understanding of their scope of practice. However, a lack of uniformity regarding scope of practice across the regulated health professions in Australia currently exists. This has led to ambiguity about what comprises scope of practice in some health care professions in the region. Objective The objective of this review was to explore the literature on the factors that influence scope of practice of the five largest health care professions in Australia. Methods This study employed scoping review methodology to document the current state of the literature on factors that influence scope of practice of the five largest health care professions in Australia. The search was conducted using the following databases: AMED (Allied and Complementary Medicine Database), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane Library, EMBASE ( Excerpta Medica Database), MANTIS (Manual, Alternative and Natural Therapy Index System), MEDLINE, PubMed, and SCOPUS. Additional data sources were searched from Google and ProQuest. Results A total of 12 771 publications were identified from the literature search. Twenty-three documents fulfilled the inclusion criteria and were included in the final analysis. Eight factors were identified across three professions (nursing & midwifery, pharmacy and physiotherapy) that influenced scope of practice: education, competency, professional identity, role confusion, legislation and regulatory policies, organisational structures, financial factors, and professional and personal factors. Conclusion The results of this study will inform a range of stakeholders including the private and public arms of the healthcare system, educators, employers, funding bodies, policymakers and practitioners about the factors that influence scope of practice of health professions in Australia.
... 26 Additionally, role clarification is a competency that professionals must develop to ensure that their own role is well understood by the rest of the health care team. 27 These findings necessitate further discussion between faculty members representing both professions to define the roles and responsibilities expected of each in IPE. ...
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Background: Interprofessional education (IPE) is argued as an educational strategy for promoting communication and collaboration amongst prospective healthcare professionals. The benefits of IPE have culminated in improved patient care leading to enhanced satisfaction for patients and healthcare practitioners. Therefore, further exploration is needed to assess the readiness for IPE through healthcare students’ perspectives, specifically medical and nursing students.This study aimed to assess medical and nursing students’ readiness for IPE and the effect of gender on their readiness.Methods: A quantitative study design using the Readiness for Interprofessional Learning Scale (RIPLS) was employed on 150 medical students and 150 nursing students. Data was analyzed using descriptive and Mann-Whitney statistical analyses.Results: The readiness of IPE score was statistically significantly different between medical and nursing students (p-value <0.0001), with nursing students (Median 4.34) found to have higher readiness or indicate more positive attitudes toward IPE compared to medical students (Median 3.73). Students are found to have a positive attitude or readiness towards IPE. This study also revealed that there was no significant difference in IPE readiness based on genders (p-value 0.087).Conclusion: It is essential to engage students in preparing the implementation of IPE for health sciences courses. Further workshops for IPE can be a strategic step to enhance readiness of the students.
... Establishing relationships with other team members is essential for fostering a sense of trust and understanding among the group members. 2 To bridge the gap and achieve beneficial interdisciplinary collaboration, it is necessary to have a thorough understanding of the role. 3 Furthermore, my mentor, who has 25 years of experience as an NP, has dealt with insurance regulations, restrictions, approvals, and denials and has a better understanding of the intricacies of the system. Moreover, according to my NP mentor, although New York state recently granted full authority practice, 4 an NP in the US must adhere to stringent practice standards and regulations, particularly in medication situations. ...
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This is a reflection on a 2-month international practicum at the Bassett Medical Center as part of my elective course during my final semester of graduate school at the Zurich University of Applied Sciences. The transition from being a registered nurse (RN) to being a competent nurse practitioner (NP) presents challenges such as adapting to the new role as an experienced RN to an aspiring NP, learning about the role of autonomy, and new responsibility for patients, and fully executing the NP role. This means that becoming familiar with the role of an NP with a focus in cardiology is, in my case, of particular importance. To overcome this uncertainty, I chose an international clinical placement in a country with experienced NPs to build up knowledge for transitioning from RN to NP, professional development, and self-assurance.
Role understanding of expert nurses in primary and acute care in Germany: A descriptive cross-sectional study Abstract. Background: Innovative care concepts are necessary to cope with the increase in complex care situations due to a rising number of older people with chronic diseases and a simultaneous shortage of nursing and medical staff. In the context of the implementation and development of new, innovative nursing roles, an unclear role understanding is considered a barrier. Aim: Description of expert nurses' (EN) role understanding in primary and acute care in Germany. Method: Using questionnaires, EN are asked cross-sectionally about role clarity, competencies and performance as well as perceived autonomy and interprofessional collaboration. Results are analysed descriptively. Results: A total of eight (primary care) and 14 (acute care) EN completed the questionnaires. The majority of EN often/very often perform both the clinical (77.5% and 85.7%, respectively) and the expert role (75% and 78.6%, respectively) and indicate that they can explain their role to patients (75% and 92.9%, respectively) and physicians (87.5% and 90.9%, respectively). Having a high degree of autonomy is more likely to be perceived by EN working in acute care. Conclusion: Although there are similarities in terms of role understanding, EN working in acute care can apparently benefit from already established structures, which is reflected, among other things, in their perceived autonomy.
Introduction : Advanced practice nursing has recently been introduced into the French health care system, eliciting a wide range of reactions from health care professionals. Many studies have focused on the benefits of advanced practice nursing (APN) and the steps to be taken to promote its implementation. Very few, however, have explored the feelings of general practitioners (GPs). The objective of this study was to explore the representations, feelings and expectations of GPs in a territorial professional health community (CPTS) with regard to the APN in ambulatory care.Method : A qualitative study with an approach inspired by grounded theory was conducted, based on individual or focus group semi-directive interviews with GPs of a CPTS.Results : 12 GPs were interviewed. The axial analysis allowed the construction and characterisation of two categories : “Being two” and “Defining the job”.Discussion : The properties located at the intersection of these two categories related in particular to the question of “medical power”.
This integrative review identified challenges for interprofessional home care and provided recommendations for improving geriatric home care. A search of six databases identified 982 articles; 11 of them met the review’s eligibility criteria and were included in the review. Quality appraisal of the included studies was performed using two tools (Critical Appraisal Skills Program for Qualitative Research and Mixed Methods Appraisal Tool), and their overall methodological quality was found to be satisfactory. After applying D’Amour et al.’s framework, four “challenge” themes emerged: (1) lack of sharing, (2) lack of partnership, (3) limited resources and interdependency, and (4) power issues. Recommendations included providing practical multidisciplinary training guided by a standardized model, establishing streamlined communication protocols and a communication platform reflecting the actual needs of users by involving them in its design, and asking interprofessional team members to commit to home care planning and to cultivate a collaborative culture and organizational support.
Interprofessional collaborative practice has been shown to be an appropriate model of care for chronic disease management in primary care. However, how patients play a role in this model is relatively unknown. The aim of this constructivist grounded theory focus group study was to explore the perceptions of patient advocates regarding the role of patients in interprofessional collaborative practice for chronic conditions in primary care. Primary data were collected from patient advocates, from public and private Australian organisations and who represent patients with chronic disease in primary care, through focus groups in July–August 2020. Videoconference focus groups were recorded, transcribed verbatim and inductively, thematically analysed using the five‐step approach by Charmaz: (1) initial line‐by‐line coding, (2) focused coding, (3) memo writing, (4) categorisation and (5) theme and sub‐theme development. Three focus groups comprising 17 patient advocates with diverse cultural and professional backgrounds participated. Two themes and five sub‐themes relating to interprofessional collaborative practice teams were constructed from the data. In theme 1, patients ‘shifted across the spectrum of roles’ from ‘relinquishing control to the team’, ‘joining the team’ to ‘disengaging from the team’. The second theme was the need for ‘juggling roles’ by ‘integrating patient role with life roles’, and ‘learning about the patient role’. The diversity and variability of patient roles as described by patient advocates highlight the challenges of working with people with chronic conditions. The diverse patient roles described by advocates are an important finding that may better inform communication between patients and health professionals when managing chronic conditions. From the health professional perspective, identification of the role of a patient may be challenging. Therefore, future research should explore the development of a tool to assist both patients and health professionals to identify patient roles as they move across the spectrum, with the support of policy makers. This tool should aim to identify and promote patient engagement in interprofessional collaborative practice in primary care settings.
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Introduction: Since the onset of the COVID-19 pandemic, virtual care has gained increased attention, particularly in primary care for the ongoing delivery of routine services. Nurses have had an increased presence in virtual care and have contributed meaningfully to the delivery of team-based care in primary care; however, their exact contributions in virtual models of primary care remain unclear. The Nursing Role Effectiveness Model, applied in a virtual care and primary care context, outlines the association between structural variables, nursing roles and patient outcomes. The aim of this scoping review is to identify and synthesise the international literature surrounding nurse contributions to virtual models of primary care. Methods and analysis: The Joanna Briggs Institute scoping review methodology will guide this review. We performed preliminary searches in April 2022 and will use CINAHL, MEDLINE, Embase and APA PsycInfo for the collection of sources for this review. We will also consider grey literature, such as dissertations/theses and organisational reports, for inclusion. Studies will include nurses across all designations (ie, nurse practitioners, registered nurses, practical nurses). To ensure studies capture roles, nurses should be actively involved in healthcare delivery. Sources require a virtual care and primary care context; studies involving the use of digital technology without patient-provider interaction will be excluded. Following a pilot test, trained reviewers will independently screen titles/abstracts for inclusion and extract relevant data. Data will be organised using the Nursing Role Effectiveness Model, outlining the virtual care and primary care context (structure component) and the nursing role concept (process component). Ethics and dissemination: This review will involve the collection and analysis of secondary sources that have been published and/or are publicly available. Therefore, ethics approval is not required. Scoping review findings will be published in a peer-reviewed journal and presented at relevant conferences, targeting international primary care stakeholders.
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This integrative review synthesises research studies that have investigated the perceptions of nurse practitioners and medical practitioners working in primary health care. The aggregation of evidence on barriers and facilitators to working collaboratively and experiences about the processes of collaboration is of value to understand success factors and factors that impede collaborative working relationships. An integrative review, which used systematic review processes, was undertaken to summarise qualitative and quantitative studies published between 1990 and 2012. Databases searched were the Cochrane Library, the Joanna Briggs Institute Library, PubMed, Medline, CINAHL, Informit and ProQuest. Studies that met the inclusion criteria were assessed for quality. Study findings were extracted relating to a) barriers and facilitators to collaborative working and b) views and experiences about the process of collaboration. The findings were narratively synthesised, supported by tabulation. 27 studies conducted in seven different countries met the inclusion criteria. Content analysis identified a number of barriers and facilitators of collaboration between nurse practitioners and medical practitioners. By means of data comparison five themes were developed in relation to perceptions and understanding of collaboration. Nurse practitioners and medical practitioners have differing views on the essentials of collaboration and on supervision and autonomous nurse practitioner practice. Medical practitioners who have a working experience with NPs express more positive attitudes towards collaboration. Both professional groups report concerns and negative experiences with collaborative practice but also value certain advantages of collaboration. The review shows that working in collaboration is a slow progression. Exposure to working together helps to overcome professional hurdles, dispel concerns and provide clarity around roles and the meaning of collaboration of NPs and MPs. Guidelines on liability and better funding strategies are necessary to facilitate collaborative practice whether barriers lie in individual behaviours or in broader policies.
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To discuss how case-study research was undertaken to explain the implementation of the nurse practitioner role in a Canadian province. In Canada, the nurse practitioner role was only recently introduced and one of the last provinces to implement it was British Columbia. At this time, no studies of the role's implementation in the province had been published and, although nurses refer to case studies more frequently in their research, the literature lacks concise explanations of the methodologies involved in creating them. A case study of the implementation of the nurse practitioner role, including participant interviews and document review. The development of an explanatory, single case study with embedded units of analysis in line with Yin's (2009) approach to case-study research. This article provides an overview of case-study research methodology and examples from a case study undertaken by the author. The use of case studies provides nurse researchers with opportunities to engage with phenomena of interest in their settings and so is suited to the complex nature of nursing practice. IMPLICATIONS FOR PRACTICE OR RESEARCH: Case-study research enables researchers to study areas of interest thoroughly and in the context in which they occur.
Résumé Université de Montréal.Le contexte actuel des systèmes de santé occidentaux réclame que des transformations soient opérées dans les modes d’organisation et de dispensation des soins de santé. Pour faire face à ces nouveaux défis, de nombreux établissements ont introduit de nouveaux rôles infirmiers ayant le potentiel de transformer l’offre de services. Cet article a comme but de mieux comprendre le déploiement de ces nouveaux rôles infirmiers en contexte québécois et d’identifier les facteurs qui favorisent ou entravent leur mise en oeuvre, en portant un intérêt particulier à la dimension du pouvoir médical. Notre analyse montre que l’introduction de nouveaux rôles nécessite que soient redéfinis les espaces d’autorité exercés par la profession médicale sur la prestation de l’ensemble des services de santé, incluant les services infirmiers. La question du pouvoir médical, aussi délicate soit-elle, est d’autant plus importante que la négociation des frontières entre la profession infirmière et la profession médicale se présente comme un incontournable pour maximiser le plein potentiel de ces rôles et atteindre les objectifs poursuivis en termes d’accessibilité, de globalité et de qualité des services.
This article presents a discussion of mixed methods (MM) sampling techniques. MM sampling involves combining well-established qualitative and quantitative techniques in creative ways to answer research questions posed by MM research designs. Several issues germane to MM sampling are presented including the differences between probability and purposive sampling and the probability-mixed-purposive sampling continuum. Four MM sampling prototypes are introduced: basic MM sampling strategies, sequential MM sampling, concurrent MM sampling, and multilevel MM sampling. Examples of each of these techniques are given as illustrations of how researchers actually generate MM samples. Finally, eight guidelines for MM sampling are presented.
In this article I describe and compare ct number of alternative generic strategies for the analysis of process data, looking at the consequences of these strategies for emerging theories. I evaluate the strengths and weaknesses of the strategies in terms of their capacity to generate theory that is accurate, parsimonious, general, and useful and suggest that method and theory are inextricably intertwined, that multiple strategies are often advisable, and that no analysis strategy will produce theory without an uncodifiable creative leap, however small. Finally, I argue that there is room in the organizational research literature for more openness within the academic community toward a variety of forms of coupling between theory and data.
This paper makes three suggestions to researchers for studying strategy process. First, define the meaning of process. Process is often used in three ways in the literature: (1) a logic used to explain a causal relationship in a variance theory, (2) a category of concepts that refer to actions of individuals or organizations, and (3) a sequence of events that describe how things change over time. The second suggestion is to clarify the theory of process. An interdisciplinary literature review identifies four types of theories of process that can be drawn upon: life cycle, teleology, dialectics, and evolution. The third suggestion is to design research to observe strategy process in such a way that is consistent with one's definition and theory of process.