Nurse practitioners in Canada: Beginnings, benefits, and barriers

I N T E R N AT I O N A L Nurse practitioners in Canada: Beginnings, benefits, and barriers Odette N. Gould, PhD (Associate Professor of Psychology)1, Dusty Johnstone, BA (Graduate Student)2, & Louise Wasylkiw, PhD (Assistant Professor of Psychology)1 1 Mount Allison University, Department of Psychology, Sackville, New Brunswick, Canada 2 University of Windsor, Department of Psychology, Windsor, Ontario, Canada Keywords Interprofessional relations; health services accessibility; physician-nurse relations; attitudes of health personnel; rural health care. Correspondence Odette N. Gould, PhD, 49A York Street, Sackville, NB, Canada E4L 1C7. Tel: 506-364-2456; Fax: 506-364-2467; E-mail: [email protected] Received January 2006; accepted June 2006 doi:10.1111/j.1745-7599.2007.00210.x Abstract Purpose: The goal of this qualitative study was to investigate the experiences of nurse practitioners (NPs) 1 year after they were first introduced to a mostly rural Canadian province. Data sources: Qualitative analyses of individual 45-min interviews with seven of the nine NPs in the province were carried out. Conclusions: Three main themes of importance were identified. First, a nursing philosophy with a holistic approach was described as being clearly different from medical care. Second, difficulties and barriers encountered in the establishment of the profession in the province were described. Third, despite these barriers, a pioneering outlook characterized by a sense of excitement and pride in the work was expressed. Implications for practice: For NPs to work effectively to reduce healthcare costs and increase access to health care, they need to be accepted by both the public and the other healthcare professionals. Moreover, it may be difficult for NPs to maintain their philosophy of care in the face of the expectations placed upon them. Healthcare systems throughout the western world are facing many changes and are often perceived as being ill-equipped to deal with these changes (Temmink, Francke, Hutten, van der Zee, & Abu-Saad, 2000). In Canada, for example, a shortage of physicians, as well as the aging of the population and the concomitant increase in healthcare demands, have led to accessibility problems, decreases in satisfaction with care, and fears that the present system is untenable. One of the major changes to healthcare systems across the world is the increasing number of nurse practitioners (NPs) in primary health care. In Canada, particularly since the 1990s, NPs have been proposed as a key strategy to reducing healthcare costs (Laurant et al., 2004; Ryan, 1998; Way, Jones, Baskerville, & Busing, 2001) and increasing healthcare access (Nurse Practitioners Association of Ontario, 2004; Way et al., 2001). Many of the studies investigating the acceptability of NPs as primary healthcare providers have focused on patients’ views (Enggist & Hatcher, 1983; Hooke, Bennett, & Dwyer, 2001), although some researchers have also carried out focus groups (Wilson, Pearson, & Hassey, 2002) or interviews (Marsden & Street, 2004) with physicians and other healthcare team members. However, it is proposed here that the presence of NPs in the healthcare system will only be beneficial in the long term if the individuals who take on this new role are not only given the means to be effective but also feel themselves to be effective as healthcare providers. In July 2002, the province of New Brunswick, a mostly rural province in eastern Canada, first passed legislation to permit NPs to practice in the province. In the present study, the experiences of NPs as they begin to be integrated into an existing healthcare system are described to better understand the benefits and challenges of the profession. This article describes the experiences of the NPs who first practiced the profession in New Brunswick approximately 1 year after they began their work. The focus of this study Journal of the American Academy of Nurse Practitioners 19 (2007) 165–171 ª 2007 The Author(s) Journal compilation ª 2007 American Academy of Nurse Practitioners 165 NP practice in Canada was to explore the NPs’ perceptions of being accepted as primary healthcare providers by their patients and the NPs’ levels of professional satisfaction. Semistructured interviews were carried out with seven of the approximately nine NPs working in the province when the data were collected. Qualitative analyses of transcribed interviews were carried out in order to best capture the experiences of these NPs. Method Participants Seven NPs working in New Brunswick were interviewed. All were female, and the mean age of the sample was 46.8, SD = 8.45 (range = 36–60 years). The number of years spent practicing as an NP ranged from 10 months to 25 years (M = 7.1 years, SD = 9.02). The majority of NPs were licensed within the past 2 years. However, two of the participants had been working as NPs in the United States (for 25 and 7 years, respectively) before coming to New Brunswick. On average, the interviewees had worked as RNs for an average of 21.1 years (SD = 11.9, range = 3–40 years) before becoming NPs. All of the NPs interviewed were primary healthcare practitioners, with six of them currently working in community health centers and one in private practice. Procedure A semistructured interview format was used. A core set of questions was developed by three researchers (one of whom has a nursing background) with expertise in healthcare research, questionnaire design, and interview techniques. These questions were developed after a review of the literature on the work of NPs in primary health care. The core questions focused on NPs’ own experiences and views concerning the role and responsibilities of NPs, appropriate types of training for NP work, and experiences of working with patients and other healthcare professionals. Examples of questions used include What do you consider your role as a nurse practitioner to be?, How do you feel your profession is perceived by your clients?, and How do you feel your profession is perceived by others in the medical community? Participants also completed a short demographics questionnaire that asked participants about age, educational background, and years of professional experience. The NPs were interviewed individually for approximately 45 min each using a semistructured format. Each interview was tape-recorded and subsequently transcribed. The content of each transcript was analyzed qualitatively by two individuals using the methodology described by Attride-Stirling (2001). Specifically, all ideas 166 O.N. Gould et al. expressed by the interviewee were first highlighted. In a second phase, repeating topics were recognized and quoted exemplars of each topic identified. Finally, salient overarching themes and their inter-relationships were identified after extensive discussions between the two scorers. Results Three main themes emerged during the content analyses: care philosophy, barriers, and pioneering outlook. These themes were created by inter-relating the six topics identified by the scorers: (a) approach to care, (b) client issues, (c) NP as profession, (d) acceptance, (e) relationship with other professions, and (f) system issues. As can be seen in Figure 1, the themes of care philosophy and barriers were somewhat more dominant than the theme of pioneering outlook. Interestingly, many of the topics that made up these two themes had dual aspects, in that they expressed both these primary themes, and at the same time highlighted the pioneering nature of NP work in the province. In the text below, italics are direct quotations, and the seven participants are labeled by the letters A to G in brackets following the quotation. Exemplar quotes are used to support and elaborate the main topics discussed. Patient care philosophy The major theme that emerged in the analyses was the particular approach to patient care that NPs adopted. The use of a traditional nursing orientation was emphasized throughout, with a focus on developing a relationship with the patient and an awareness of the whole person being offered health care. Three main topics were identified: (a) approach to care, (b) client issues, and (c) NP as a profession. Approach to care One of the key features of NP’s approach to care was the time they allocated to each patient, ‘‘Usually, I spend 40 Care Philosophy Client Issues Barriers Approach to care System NP as a profession Other professionals Acceptance Pioneering Outlook Figure 1 Model of themes developed from interviews. NP practice in Canada O.N. Gould et al. minutes with new clients and 20 with return visits. It sometimes takes longer than that’’ (F). Thus, NPs focused on listening to their clients and giving their clients the time needed to express their concerns in full, ‘‘I don’t like to cut people off, I just can’t do that, and so when they are talking about something I think is important, or they say things that they need to say, then I run over’’ (C). Clearly, NPs were not only willing to spend extra time with their patients but they were also confident that this extra time led to better care, ‘‘You can’t help anybody health-wise if you don’t hear what they are saying to you’’ (E). Thus, spending more time with patients was an important part of their approach to care, and this approach was perceived as being possible only because a fee-forservice model was not used by NPs, ‘‘I’m able to take the time with them, which I expect fee-for-service physicians in particular would find difficult’’ (B). Central to NPs’ approach to care was patient involvement. Thus, educating patients was an important part of their role, ‘‘I always try to give them a new bit of information. I hope that they would eventually build and they would learn more about their disease’’ (A). This included not only educating patients as part of illness prevention goals but also in order to ensure adherence to prescribed regimens, ‘‘I find a lot of people do follow instructions fairly well, because I try to spend a lot of time making sure I have their buy-in before I make recommendations’’ (B). In conclusion, the approach to care that NPs adopted involved an awareness of the importance of time and education in providing optimal care to patients. Client issues NPs emphasized the importance of history taking with their patients, and considered the multitude of potential issues that could have an impact on health, ‘‘It’s not just the medical aspect of treating the problem, it’s looking at the big picture’’ (C). NPs tried to consider the interaction of all factors and did not examine the health problem in isolation, ‘‘You can’t just see one problem at a time because they are all related’’ (E). This included working as part of a team to deal with patients’ housing issues, mental health problems, and financial problems relating to medication purchases. There was a strong awareness that the holistic approach to health care practiced by nurses and NPs differed from the medical approach. For example, when asked to describe the duties of an NP, one NP’s response included the following statement, ‘‘Docs historically have been educated to look after illness, where nurse practitioners are educated to look after health [.] we provide holistic care and it’s not medical care, it’s health care’’ (E). Interestingly, this more holistic approach came through in the language used by the NPs in terms of discussing the ‘‘pieces’’ involved in caring for a patient, ‘‘What we’re really well known for is providing all the pieces that have traditionally been missing from a medical practice: the prevention, the promotion, the family cohesion, all of those bits and pieces’’ (E). Many respondents also discussed the differences between different locations where NPs were practicing. Particularly relevant to patient care were the contrasts between the roles practiced by NPs in rural and urban settings, ‘‘My role here, because it is a small facility, tends to be quite broad, and it encompasses a lot of different roles that would perhaps be done by different people if it was an urban area’’ (B). One related issue that was discussed by many respondents was the lack of medical access experienced by many patients, ‘‘The people are surprising me in that they aren’t coming from the local area, but they are travelling from far away [.] they don’t have access so they are willing to come here’’ (D). Many of our respondents, particularly those working in rural areas, perceived that they provided the only health care available to many patients, ‘‘A great number of these folks, actually, that are coming to see me, haven’t had a healthcare provider for maybe 5 years’’ (D). In addition to a consideration of clients’ issues, a third key topic essential for understanding patient care philosophy entails the profession of NPs. NP as profession Many NPs in our study explained that they chose to become an NP to work beyond the scope of practice of registered nurses, ‘‘With the higher level of education and the experience, I’m able to go beyond the normal scope of nursing’’ (D) and to better serve their patients, ‘‘I was working in a rural community, where there was poor access to health services. I also found that there were people who would come in who were more comfortable dealing with myself, as a nurse, and they wanted [me] to do things I was unable to do within the current healthcare system. I was really interested in being able to carry on’’ (B). Several respondents had read or heard about NPs and were interested in the role even before it was available in the province. They expressed an appreciation for the independent role they can adopt as an NP, and enjoyed having ‘‘their’’ own patients. While they saw themselves as part of the nursing profession, ‘‘We are gradually taking back what was nursing in the first place’’ (E), there was nonetheless an awareness that as an NP they were moving closer to the traditional role of physicians, ‘‘Being a nurse practitioner in many ways is a blurring of roles between nursing and medicine’’ (D). In conclusion, the NPs expressed a distinct philosophy of care that differed, in their view, from that of medical care. Their words expressed a strong belief in the need to spend time listening to patients as a key part of the nursing approach to care. At the same time, the ability to go beyond the traditional scope of practice in order to become the main healthcare provider for patients was also highly valued. 167 NP practice in Canada Barriers One of the major themes that emerged in the analyses was that of the barriers (existing and expected) experienced by the NPs as they attempted to accomplish their work in the province. Three main topics linked together to create this theme: (a) acceptance, (b) relationships with other professionals, and (c) system issues. Acceptance The NPs discussed at length that the public, as well as physicians, were mostly unfamiliar with NPs. Meetings with new clients were described as often including a presentation of what the role of NP consisted of, and what they could or could not do. The establishment of a new practice also involved extensive advertising and media work. Overall, however, the NPs perceived high levels of acceptance from their clients, ‘‘I explain to them who I am and what I do and what my basic skills would be, and how I relate to the physicians here and how we work together. I think they’re just trying to get a handle on that, and they’ll say that they feel really good about seeing a nurse practitioner’’ (A). Despite the educational outreach, a few NPs noted that clients seemed to confuse them with physicians, ‘‘They see me as their healthcare provider and many of them call me doctor. I try to change them from that, but again, that is a cultural piece’’ (D). Although these NPs clearly expected that older patients would be less accepting, it was not clear that these age differences were in fact occurring, ‘‘You would think that younger people would be more accepting of nurse practitioners than older people, but that has not necessarily been the case’’ (B). Moreover, at least one NP noted that even though individual clients were accepting of NPs, the public as a whole may have been less so, ‘‘Communities will pay for the education of physicians, so they will come back and work . and we [NPs] don’t see those initiatives. I’m not sure the public values nurse practitioners in the same way’’ (B). Barriers perceived by NPs were not only limited to clients’ acceptance of them but also included the relationships NPs have with other professions. O.N. Gould et al. interviews indicated, however, that some of these NPs identified at least some physicians as being strongly supportive, ‘‘Here in this facility I just have an excellent relationship with all of the physicians. It really works out well’’ (B). Although NPs were aware that they were required to work in conjunction with physicians, ‘‘It is the law that nurse practitioners can’t work without a doctor [.] a physician has to be available for collaboration’’ (B), there seemed to be a range of attitudes toward the form that this relationship should take. For some, a strong and close collaborative relationship existed; for others, a simple referral process was described; and for others, the relationship seemed somewhat distant. For example, ‘‘I’m very clear in saying to patients that if there is something going on with you and I don’t know what is going on, then there are physicians in the office whom I consult with and we will together come up with what is wrong with you’’ (G); ‘‘Most nurse practitioners have developed their own practice and follow their distinct patients, and it is a more consultative relationship with the physicians they work with’’ (A); ‘‘I’m lucky if I have someone [a physician] in the building one day a week, and so I take advantage of that when I do’’ (C); ‘‘It’s very independent: we can refer, but we don’t need to [.] we refer very few people to the doctor’’ (E). Many NPs saw themselves as being part of the healthcare team, ‘‘It’s an interdisciplinary partnership’’ (E), and being the manager that linked patients to other caregivers, ‘‘You can make sure that the patient is being seen by the right people and is in the right place at the right time’’ (F). However, they saw the existing healthcare system as being hierarchical, ‘‘It is a hierarchy and we know that physicians are sitting at the top’’ (A). Finally, although a team approach was preferred, NPs indicated that for the most part, they consulted with pharmacists only in special cases, such as when the NP was inexperienced, or the patient’s medication needs were particularly complex. Overall, collaboration was a cornerstone of the NP profession even though relationships with other professions could be challenging. Finally, a third issue related to perceived barriers concerned the structure of the current healthcare system. System issues Relationship with other professions Acceptance among other healthcare professionals, particularly physicians, has not been as high as that experienced with patients, ‘‘There are some physicians that have been very supportive of the role, but in general, I would say that most have not been supportive and that is one of the barriers that we’ve had. I think we’ve gotten through a lot of the governmental barriers like legislation and things like that, and I really feel that it is a territorial issue, which is too bad’’ (C). Many NPs commented that physicians saw them as a threat, either to their income or to their role, ‘‘We’re seen as taking over a physician’s role [that] is a barrier’’ (E). Analysis of the 168 The most salient barrier from the perspective of these respondents was systemic to the healthcare system. Most NPs commented that the fee-for-service model used by physicians was a strong deterrent to having NPs work in the province, ‘‘Wherever nurse practitioners are and there is a fee for services system, that is a problem’’ (C). They recognized that under a fee-for-service system, the presence of NPs was a threat to physicians’ income, as well as a possible encroachment on their traditional role. The respondents felt that they could accomplish their work as NPs much better in a salaried position, ‘‘Because of our medicare fee-forservice, docs don’t have the time to do all this [the services O.N. Gould et al. provided by nurse practitioners] and that’s one reason why, as nurse practitioners, we opted to go the salaried route. Because it gives us the opportunity to do extra things’’ (E). Another important barrier mentioned by multiple respondents were the difficulties surrounding referrals to specialists. Although NPs could make referrals, many specialists refused these, ‘‘They will still get paid if they receive a referral from a nurse practitioner, but they don’t get the same amount as if they were referred by a physician’’(A); ‘‘For the good of the patient the physician has to put their name on it, but at the same time, by doing that it is going to perpetuate that the physician is doing the work, when actually it is the nurse practitioner doing the work’’ (G). Finally, some NPs also commented that the inability to prescribe narcotics was problematic because of the inability to offer pain control for patients. This was a particular problem for NPs working in rural settings where access to physicians was limited and where many patients had done physically demanding and damaging work from a young age. Interestingly, a few respondents also commented that the lack of access to narcotics had a positive component because it meant that they need not deal with drug-seeking clients. In conclusion, many barriers were mentioned by the NPs. For some issues, such as the payment system used by physicians, the frustration was seemingly widespread, and these NPs seemed to have little optimism for improvements. Other issues, such as limits on prescribing narcotics and acceptance from colleagues, were discussed as barriers by only some of the NPs interviewed. For still other issues, optimism was more widespread, as emerged in the final theme discussed below. Pioneering outlook Finally, a third major theme that was identified was a strong sense of excitement and pride that underlay many of the topics discussed above. Despite the barriers encountered, and partly as a result of the philosophy of care adopted, these respondents clearly felt their profession would—and should—develop and expand in the future. The NP’s words suggested a belief that they were at the vanguard of a new dimension of health care in the province. The term pioneering outlook was used here to reflect optimism, anticipation, and the sense of preparing new paths for others to follow. Below, the same topics that illustrated the philosophy of NPs and the perceived barriers are discussed in relevance to the theme of pioneering outlook. Acceptance As discussed above, our respondents perceived a generally positive level of acceptance for the profession of NP in the province. Moreover, many of the statements expressed NP practice in Canada a confidence that acceptance would continue to increase in the future, ‘‘Nationally it is becoming more recognized and talked about’’ (C), and that the key to this increased acceptance was educating the public about what NPs can do, ‘‘The more we put out to work, the more the clients will understand what the role is, and the more they will advocate it’’ (E). At the same time, there was a recognition that certain barriers existed that would make this a challenging goal, ‘‘The government has already committed to new positions in the province, in the last budget, and we’re expanding. But I think we have to do a lot of working in making it very clear in terms of what nurse practitioners do and what their role is’’ (A). The sense of acceptance and pioneering was also discussed with an emphasis on New Brunswick differing from (or lagging behind) other places in terms of the integration of NPs into the healthcare system, ‘‘I have worked in Northern Ontario where nurse practitioners have worked for some time, and they are well accepted and respected and I think it’s just a matter of time before it is accepted here’’ (A); ‘‘It’s been going on there [US] longer and they are more integrated into the healthcare system and in New Brunswick and Canada we are still stumbling’’ (G). Relationship with other professions The sense of pioneering was also expressed through hopes and expectations of how the relationships between NPs and other professionals on the healthcare team would change over time. While one individual focused on the importance of familiarity in effecting this change, ‘‘The doctors [in the US] were very used to working with nurse practitioners and there was none of this argument about what they could or couldn’t do, they just knew what they did. I think over time that is what we’ll see here, but it will take time to get to that point’’ (E), another mentioned the age group of their colleagues as also being important, ‘‘I find a lot of the younger physicians are more in tune with that, in terms of having different diverse roles for health professionals, especially nurse practitioner work’’ (A). It was also noted that NPs are expected to also have an indirect effect on the relationships between healthcare professionals. The nursing profession’s focus on using a team approach was emphasized by many respondents with the associated hope that this team approach would become more widespread, ‘‘I think part of our education as nurses and nurse practitioners is about the importance of teamwork and I think that as we come into the system we will encourage more and more teamwork, so I think we will be a good model to dissipate the hierarchy’’ (B). Also linked to these changes in the profession was the hope that care from NPs will become more widespread, ‘‘I hope that it continues to develop and that it develops as an equal team member across the board [.] we are trying to change the trend of people seeing just physicians’’ (F). 169 NP practice in Canada O.N. Gould et al. NP as profession 2001). High levels of patient satisfaction with NPs also bode well for the extended use of a variety of healthcare providers for dealing with increasing healthcare costs (Government of New Brunswick Health Services Committee, 1999). Acceptance from physicians, however, was more problematic. Thus, our interviews highlighted similar situations to those observed elsewhere in Canada, where referrals from family physicians to NPs rarely occurred (Way et al., 2001), and in England, where attitudes held by general practitioners were very ambivalent (Marsden & Street, 2004). A more long-term perspective raises interesting issues. As more patients begin receiving care from NPs, will NPs be able to continue the approach to practice that yields high levels of patient satisfaction? Many of the NPs interviewed as part of the present project were still in the process of developing their practices. Indeed, many of them had given themselves, or had been given, very specific goals in terms of the number of patients they should have in their practice. Patient loads at present varied from 150 to 500 patients, and two NPs specified that their patient load was less than half of what they expected it to be in the future. These NPs saw between 8 and 15 patients in a 10-h shift, with the majority spending approximately 30 min with a returning patient and up to an hour with new patients. One question of interest is therefore whether NPs’ care goals can be met without limits being applied to the amount of time spent with each patient. Once NPs have a full patient load, will they regularly be able to spend 40– 60 min with a patient? Will they be able to provide each patient with a holistic form of care that involves attention to many aspects of patients’ lives not traditionally addressed in medical care situations (e.g., finances, lodging, family, education, employment)? Optimally, a team approach to health care where NPs work closely with other professionals such as social workers and psychologists will develop. Although settings where such team approaches are emerging, they remain few, particularly in rural areas where access to health care is most problematic. The levels of work satisfaction experienced by NPs can be seen to be linked to how the role of NPs develops. Interestingly, an analysis of the present and future role of NPs in the province highlights a series of subtle contradictions. In New Brunswick, as elsewhere (e.g., MacDonald & Katz, 2002; Marsden & Street, 2004) territoriality issues continue to be important. For example, on the one hand, NPs are adamant that they are not threats to physician’s traditional roles, and that they prefer a team-based approach to care. At the same time, most NPs are talking about building ‘‘my’’ practice made up of ‘‘my’’ patients, many NPs would like to take on functions traditionally carried out by physicians (e.g., referrals, prescriptions of narcotics), and many NPs wished to work quite independently Finally, the words used by the respondents indicated that these individuals identified very strongly with their profession, ‘‘We have another group that will be graduating in 18 months/two years, and that is good because if the government didn’t think it was going to work, I don’t think they would have allowed the seats to continue’’ (C). Moreover, there seemed to be a sense of vocation associated to the profession, and a sense that the expansion of the profession was a positive outcome for society in general, ‘‘It is pioneering and hopefully there will be more nurse practitioners and there will be more positions and we’ll help the patients’’ (F). This outcome was seen as positive both because it provided patients with the care they wanted, ‘‘It is a holistic approach and that is what a lot of clients are seeking’’ (D), and because it provided a solution to healthcare access problems, ‘‘I think that if we continue to have the shortages [of physicians] that we are having, I see only more roles for nurse practitioners, in different places’’ (C). In conclusion, most NPs seemed to adopt an overall optimistic view of the future of their profession, as expressed succinctly by one particular respondent, ‘‘We’ve worked through quite a number [of barriers] in the province already . I always try to remain optimistic; to me they are just bumps in the road’’ (D). This optimism was clearly linked to the view that as patients and other healthcare providers become more familiar with NPs, acceptance will increase. These NPs clearly felt a sense of loyalty and belonging to their profession, despite the frustrations inherent in the role as it presently exists. Discussion The two main goals of this study were to investigate NPs’ perceptions of being accepted by patients, and NPs’ satisfaction with their work. Overall, our results indicated interesting contrasts between short- and long-term perspectives. In the short term, relatively positive outcomes were observed. In the long term, the effective integration of NPs into the province’s healthcare system can be seen as being somewhat less clear-cut. Generally, the New Brunswick NPs interviewed in this study perceived a high level of acceptance from their patients, due mostly to an approach to care that uses a holistic approach and that allows for lengthy interactions with patients. This perception is very much in-line with research on patient satisfaction, an increasingly important variable of interest in healthcare research (e.g., DiMatteo, 1998). Indeed, satisfaction depends on how well the patient feels the professional listens and understands the problem and is also highly correlated with how well the encounter fits with the patient’s expectations (Katik et al., 170 O.N. Gould et al. from physicians, pharmacists, and other providers. Although some respondents see the role of NP as being very different from that of physicians, others discuss the ‘‘blurring of the lines’’ between NPs and physicians. Moreover, the scope of practice of NPs in urban and rural areas are sometimes dramatically different. In parts of the province where physicians and other providers cannot be accessed by large parts of the populations, NPs are already putting a very expanded scope of practice into effect. The expectations that the individuals interviewed hold about their profession, and that others in the healthcare system have placed upon them are high. NPs are expected to provide holistic care and at the same time help reduce the costs of providing medical care to an aging population. One obvious question is whether NPs can fulfill these very high expectations. Irvine et al. (2000), in a study addressing acute care NPs, concluded that lack of clear job descriptions, conflicting demands and expectations, and lack of receptivity of the role by others were negatively correlated with the implementation of the role to its fullest. One possible outcome is that the type of care provided no longer reflects traditional nursing goals, and that NPs are forced to offer what becomes simply medical care with a limited scope of practice (Gottlieb, 1994). Such an outcome is likely to result not only in changes in the quality of care received but also in the professional satisfaction experienced by individuals who entered the profession with lofty goals. In conclusion, many of the issues highlighted by NP research in other regions, such as territoriality and illdefined roles, are reflected in New Brunswick as well. However, certain factors, such as the rural nature of the province and the advent of NPs at a time when the healthcare system is in relative flux, renders an analysis of the experiences of new NPs particularly relevant. The NPs interviewed here are pioneers, and as such will play an important role in determining the future of the profession in this province. Acknowledgments The authors would like to acknowledge the support of Social Science and Humanities Research Council of Canada in the form of a summer research scholarship to one of the authors. References Attride-Stirling, J. (2001). Thematic networks: An analytic tool for qualitative research. Qualitative Research, 1, 385–405. NP practice in Canada DiMatteo, M. R. (1998). The role of physician in the emerging health care environment. 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