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The number of NPs remains low because they are still largely constrained by legislation that does not allow them to practise to the full extent of their abilities. CHITOSE SUZUKI/ASSOCIATED PRESS
The number of NPs remains low because they are still largely constrained by legislation that does not allow them to practise to the full extent of their abilities. CHITOSE SUZUKI/ASSOCIATED PRESS

Andre Picard's Second Opinion

We're not short of MDs, we need NPs Add to ...

When Canadians say they don't have a doctor, what they mean, more precisely, is they do not have a primary care provider - a health professional to deal with their non-urgent woes, manage their chronic health conditions and offer preventive health care.

Much of this routine care - vaccination, blood tests, wound care, dietary counselling and so on - does not necessarily need to be provided by a doctor.

The work can and should be done by a nurse practitioner.

In the coming days, the Canadian Nurse Practitioner Initiative will release a new report, a follow-up to its important 2006 report entitled The Time is Now.

The report will say (though in more diplomatic language than this): When it comes to primary care reform, and the use of nurse practitioners in particular, Canada is a laggard.

Canada has about 60,000 physicians and more than 340,000 regulated nurses.

But according to the latest data from the Canadian Institute for Health Information, it has only 1,626 nurse practitioners.

In this country, we talk (and moan) incessantly about issues such as the perceived physician shortage.

Perceived because it is not at all clear if we need more physicians or if we need the existing work force to concentrate more fully on doctoring and less on peripheral matters than can be done more appropriately by other health professionals.

Why are we so reluctant to find and implement solutions like those laid out so clearly in the CNPI report?

Nurse practitioners are, generally speaking, registered nurses with additional, master's level training, qualifications that allow them to diagnose patients, provide some forms of treatment, refer patients to testing and prescribe some medication.

They are not mini-doctors. They are maxi-nurses.

And if we want to maximize the bang for our health-care buck, it is incumbent that we embrace NPs.

The concept has been around since the 1960s, when the role of nurses expanded dramatically, especially in rural and remote communities. But it wasn't until the 1970s that nursing schools implemented formal programs and started graduating NPs.

In the 1980s, most promising nurse practitioner initiatives disappeared, in large part because of the perceived oversupply of physicians and cuts to the nursing work force.

It was not until the 1990s when governments, for the first time since the introduction of medicare, began to cut health spending, that we dared talk about delivering care differently.

Growing access problems, particularly in primary care, renewed interest in nurse practitioners. But lack of legislation and regulation tied the hands of NPs and their potential employers.

In 1996, Alberta became the first province to recognize "registered nurses providing extensive services" and all others eventually followed suit. Last year, Yukon became the last jurisdiction to adopt legislation allowing nurse practitioners.

Yet the number of NPs remains low because they are still largely constrained by legislation that does not allow them to practice to the full extent of their abilities and by vested interests that don't want to surrender their power.

In some provinces, NPs operate under medical directives, meaning they are essentially subordinate to doctors.

In some jurisdictions, nurse practitioners can order tests, but only specific ones. Similarly, NPs can prescribe, but only from a specific list of medications. One of the biggest impediments to the broader use of nurse practitioners is their inability to prescribe narcotics (meaning pain medication).

If you smell a whiff of paternalism in the legislation, you're right. Surely, in 2010, we can recognize that nursing is a profession in its own right, not subordinate to medicine.

Outdated laws - particularly those pertaining to narcotic prescribing - need to be modernized to improve patient care.

There are vague rumblings that physicians oppose nurse practitioners because they threaten their income. That is only true, theoretically, in fee-for-service practices and, in reality, there is more than enough work to go around.

Where doctors and nurse practitioners work collaboratively - as they do increasingly on interdisciplinary teams with other health professionals like pharmacists, physiotherapists and dieticians - the relationship is a good one.

In Ontario, which has long been a leader in the use of nurse practitioners, there are even clinics at which groups of nurse practitioners have hired physicians. These NP-led clinics, which began in Sudbury, are expanding quickly.

Regardless of who runs the show, what matters is that access and care is improved. That it is cost-effective is a bonus.

One study showed that by adding a nurse practitioner to an existing practice, an additional 800 patients can be added to the roster. In a country where millions of people do not have adequate, timely access to a primary care provider, that number should grab the attention of policy makers.

A poll conducted last year found that 88 per cent of Canadians would be comfortable seeing a nurse practitioner at a clinic and 74 per cent would be happy to have a physical conducted by a NP.

The work of nurse practitioners, however, should not be limited to clinics. They have an important role to play in hospitals, from the ER through to dialysis clinics, in nursing homes, in home care and other settings.

Patients want to be seen by a competent, qualified health professional. The letters after their name, MD or NP, don't much matter.

Bring on the maxi-nurses, and promptly.

 

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