Eighteen interviews were conducted. Table presents participant demographic characteristics. The chronic conditions listed in patients' files are numerous and varied, including hypertension, hyperlipidemia, diabetes, osteoporosis, osteoarthritis, cardiovascular heart disease, heart failure, peripheral vascular disease, chronic obstructive pulmonary disease, asthma, migraine, depression and other conditions frequently seen in primary care, in various combinations. As planned, we were able to verify from the interviews that patients had various levels of experience with nurses working with doctors and from those with experience (n = 15), levels varied from low to high. An example of low level of experience (coded L with the participant number in quotes below) was a few encounters with a nurse and a doctor during a limited time for initial training on diabetes control over a several-week period. An example of high experience (coded H with the participant number in quotes) was a regular follow-up by a nurse and a doctor within the context of an FMG with repeated visits to both professionals specifically. Some experiences were outside the context of primary care (e.g. follow-up by a nurse (home visits) and family doctor (office visits) following surgery with a specialist). Nevertheless, we were able to classify all participants regarding their openness to the involvement of nurses in primary care practices (through the exploration of ideal scenarios when participants did not relate any experience) and found the majority to be receptive (13/18).
Characteristics of the sample
Three major themes emerged from the analysis and are summarized in Table . Themes are reviewed in detail below and illustrated with quotes from the interviews.
Expectations of improved primary care practices
Main expectations expressed were about accessibility and continuity of care. Many felt that the participation of nurses in primary care practices could improve accessibility to care for themselves as well as for others. Being able to reach the family doctor or the nurse in a timely manner when required meant that their care needs would be effectively responded to within an acceptable timeframe. Because the nurse was perceived as being able to facilitate contact with the doctor, patients generally expected that their doctor would be more readily accessible for themselves or for other patients. In addition, patients expected greater continuity of care and a higher quality of medical follow-up, simply through contact with both the nurse and the doctor instead of a single professional.
Participant 10-H: "I really know that if I need to, for an emergency, I can see a nurse, who would see that my case was serious! [...]You always feel more secure when you know that you can call, when you know that a nurse is there to talk to, or that she'll come and see you right away, if it's an emergency, [...] it could allow you to see the doctor more quickly."
Participant 11-H: "[...] if it's the nurse that's doing it, the doctor can stay longer and see other patients that are waiting [...] This lets the doctor see other people that haven't been able to find a family doctor, maybe simply because the doctor doesn't have enough time [...]."
Participant 13-L: "Well, I'm going to be treated faster, because if there's anything that the nurse can do, it's going to be done right away; the nurse is going to handle it, and he (the doctor) can see another patient."
Patients expressed one main concern that contradicts the above statements: the fear of not being able to see their family doctor. The possibility of having a follow-up visit with the nurse instead of the doctor raised feelings of hesitation and insecurity.
Participant 4-L: "Meeting with my own doctor! I feel that ... it seems to me (hesitation), of course I would feel more secure with my doctor than with the nurse! Anyway (hesitation), you can meet with the nurse, but ... replacing the appointment with, ah, with a nurse... I don't know!"
Dual view of the nurse's role and competency
The issue of shared roles between doctors and nurses is an important source of anxiety for the patients we met. Many of them tended to see the nurse's role as a traditional one of assisting the doctor with various duties. Asked to describe the nurse's role, they mentioned the following activities: facilitating the doctor's tasks, making a preliminary assessment of the health problem and reporting it to the doctor, prioritizing cases to determine the order of patient consultations, taking blood samples, and performing lab tests requested by the doctor.
Participant 18-L: "So, to help the doctors do their jobs. Like, ah ... let's say when you come to the family clinic, [...] a nurse takes your blood pressure, weighs you, and so forth."
Participant 12-H: "As far as I'm concerned, the nurse is there to help the doctor. [...] Sort of between the patient and the doctor."
Participant 9-L: "Then if you have blood tests, well, she (the nurse) can do it right away."
However, other activities reflecting a broader view of the nurse's role were reported, such as providing information on health problems or prescriptions, adjusting the medication, providing follow-up for chronic disease, informing, reassuring, and treating minor conditions.
Participant 10-H: "The nurse can help in a lot of ways! Ah ... sometimes you've got a really bad cold or, ah ... an allergy, or ah [...], she could give you some advice, the names of the drugs, the ... or send you in to the doctor right away."
Participant 14-L: "She's there to make us feel more secure."
Participant 1-L: "It calms me down just to talk with the nurse instead of waiting until later to ... because when you're not sure, you rack your brains for nothing, a lot of the time."
Participant 9-L: "She can do Pap-tests; they can do Pap-tests, too, the nurses."
The issue of competence was raised by the majority of patients. Broadly speaking, participants said they were confident about the nurses' competence in most situations. However, for their own particular situation, or for certain specific tasks, they did not necessarily feel that nurses should provide treatment that was traditionally provided by their doctor, even if the nurse worked in collaboration with their doctor.
Participant 18-L: "Of course the nurses, and others, have received ... have done their studies. So, I have confidence in their qualifications."
Participant 3-L: (Talking about a drug prescription) "Oh yes, yes, yes! Yes, yes, yes! On this subject I would be very leery. Me, I would prefer that the doctor handled it."
Participant 1-L: "But, say they passed an exam ... I don't know, eh? I don't know enough about the nurse's skills, what she could have in the way of skills, and the doctor, now, ... I mean ... I know that the doctor, he can give me all the care that I need ..."
Conditions for the successful involvement of nurses in primary care practices
Patients suggested that certain conditions must be met for the optimal involvement of nurses in primary care practices. The first condition is to establish a good information sharing and communication system between doctor and nurse. Patients expect seamless information-sharing such that information provided to a professional is available to other professionals involved in the relationship, while respecting confidentiality. However, this information sharing may be somewhat asymmetric, and in this sense, depends on the trust that must be developed, particularly with respect to the care that the nurse provides. It frequently emerged that patients expect the doctor to validate the nurse's decisions to some extent and that the communication system should serve this purpose.
Participant 1-L: "Let's say I go to see the nurse for ... I'm using the example of drugs again [...] me, if she tells me that I should stop taking this pill or start this other thing, well, I'd really like my doctor to know what's going on before the nurse does it."
Participant 3-L: "That when I go to see the doctor ... my doctor ... that he knows I've been to see the nurse ..."
Participant 1-L: (Speaking about sharing the medical chart) "Everything is confidential between the two of them"
Here again, the perceived competence of the nurse and the resulting trust appear as essential conditions including the knowledge update component.
Participant 8-L: (Talking about competence) "Someone who has kept up, who has kept abreast with the latest information, [...] Especially for ... often these types of diseases, the same things keep turning up: heart problems, diabetic complications [...], somebody who keeps informed on all that, and who has the capability to understand how it works ... oh yes! Me, I would trust that person, yeah!"
Patient 5-L: (Talking about the nurse) "But I have to trust the person!"
The roles of primary care professionals (family doctors and nurses) are perceived as having to be clearly defined so that the patient knows which services to expect from each one. This was often expressed by patients in the form of a hesitation while speaking about the role of the nurse as illustrated in the following quote.
Participant 1-L: (Talking about collaboration between a nurse and his own doctor). "Well in an office, it's... I don't know... I would see a nurse... what I mean is... for my medication, those things... it would be OK, not bad but uh... I would still like to see my family doctor to reassure me, to say, uh... really uh... in reality, my family doctor is the one who is aware of everything ... but if it's for uh... to review a prescription of something like that, I don't know... will the nurse be able to do medical acts that the, the doctor uh... can do...I don't know! If I arrive and have a pain somewhere and uh... for sure that she will not be able to give me an examination for uh..."
Among other conditions for the participation of nurses in family practices that emerge from the analyses, we should mention the nurse's proper use of health care protocols and the employment stability of health care professionals. Patients expect to keep the same nurse and to develop a long-term relationship with him/her, similar to the relationship they have with their doctor.
Participant 2-L: "But if she follows the same protocol, then... then if she has doubts, and she says "I will make, I will not make the decision, I will ask the doctor", well that's OK, trust is established."
Participant 8-L: (Talking about the long term follow-up by the same nurse). "So I don't have to start my story all over again and then uh... because my story some parts uh... are long eh!"