The Nature of the Relationship Between Comprehensive Primary Care Nurse Practitioners and Physicians: A Case Study in Ontario.

Abstract

The purpose of this thesis was threefold – First to investigate the emergence from the existing health system of nurse practitioners as a new occupation. Second to make sense of how nurse practitioners developed as primary care providers in the province of Ontario. Third to understand the nature and development of the intra-professional relationship between primary care nurse practitioners and physicians in local practice settings. I used a case study approach, with both historical (document review) and empirical (ethnography and interview) components. The empirical data was analyzed from an interpretive perspective using thematic analysis. A number of theoretical perspectives were drawn on, including Kingdon’s Agendas, Alternatives and Public Policy model, Abbott’s Occupational Jurisdiction model, Van de Ven et al’s Innovation Journey model, and Closure Theory. The study makes 3 contributions to new knowledge. First it documents the unfolding of events and actions over time, and thus serves as a historical summary. Second it adds an analysis of the case of nurse practitioners as an emergent occupation to the existing body of sociological analyses of professions. Third, it provides insight into how nurse practitioner - physician relationships are impacted at the local level because nurse practitioners are obligated to develop a relationship with a physician in order to be able to deliver comprehensive primary care services. The empirical component of the thesis analyzes and describes the nature of this relationship at a practice level. It also describes the use of ‘workarounds’ to bypass legislated restrictions in nurse practitioners’ scope of practice. It analyzes how structural differences in the manner of regulation, payment, and employment status between nurse practitioners and family physicians contribute to different styles of practice and perpetuate the hierarchical relationships between nurses and physicians. This knowledge has potential generalization to other emerging occupations, such as physician assistants and paramedics