NURSE PRACTITIONERS – AN UNDERUTILIZED RESOURCE
Danny Guo, Kevin Zuo. UBCMJ 2012 4(1):24-26.
The nurse practitioner (NP) is a relatively new care provider in the Canadian healthcare system. NPs are registered nurses (RNs) with extensive clinical experience and higher education to conduct advanced health assessments, make diagnoses, order and interpret lab tests, prescribe drugs, perform advanced interventions, monitor outcomes, and make referrals to other healthcare providers. Although the positive impact of NPs in improving patient access to timely and quality care has been widely demonstrated, NPs continue to be grossly underutilized in Canada. We provide our thoughts on how to expand the role of the NP in healthcare delivery.
KEYWORDS: nurse, registered practitioner, underutilized, interdisciplinary
Although the Canadian healthcare system provides universal coverage and demonstrates excellence in patient outcomes, long wait-times continue to be a major problem. One strategy to address this issue was to train more nurse practitioners (NPs) with the introduction of the $8.9 million Canadian Nurse Practitioner Initiative in 2004.1 NPs are registered nurses (RNs) with clinical experience and higher education who conduct advanced health assessments, order and interpret lab tests, make diagnoses, prescribe drugs, perform advanced interventions, monitor client outcomes, and make referrals to physicians and other healthcare providers.2 As highly trained healthcare professionals, NPs have demonstrated improved access to timely and quality care, especially in remote communities and areas with physician shortages.1, 3-6 In spite of this, NPs represented only 0.9% of Canadian nurses in 2010.7 By reviewing current literature on the NP profession, this article will explore how NP collaboration with physicians can improve healthcare quality and accessibility, examine current barriers to expansion of NPs, and propose recommendations to improve NP integration in the healthcare system.
COLLABORATION BETWEEN NPS AND PHYSICIANS
While it is true that both NPs and physicians are qualified to diagnose illnesses and prescribe medications, it is a misconception to assume that these are antagonizing roles. When NPs and physicians are viewed as collaborators instead of competitors, the benefits of this cooperation become clear. With their extensive training and experience as nurses, NPs have exceptional patient communication skills and are able to participate in both the care and cure of the patient.8 By bringing a diverse range of experiences, including comprehensive patient education and chronic care management, NPs promote greater flexibility and adaptability in team management.9 Indeed, in comparison to physicians, NPs have demonstrated improved patient outcomes in diabetes management and primary care consultations,3,4,5,7 as well as providing emergency patients with shorter wait times compared to physicians.10 By assisting in investigating, diagnosing, and treating common or familiar illnesses, NPs can effectively reduce the workload of physicians and increase overall team performance. In cases where NPs are uncomfortable with diagnosis or treatment, they will always have the option to consult medical specialists for advice. Finally, although NPs and general practitioners (GPs) are no different in their costs to healthcare funding,11 historically, NPs have been more willing to practice in rural areas than newly trained GPs so the expansion of NPs may improve the access to care in underserved rural populations.12
LIMITATIONS TO NPS IN CANADA
Job opportunities and compensation
Despite the many years of clinical practice, advanced training, and tuition/licensing fees required for NP licensure, NP salaries in Canada vary radically between provinces and individual healthcare settings. In 2009, the average hourly wage of NPs across Canada ranged from $29.00 to $56.45.13 This phenomenon may be due to a lack of unionization for NPs, making compensation negotiations less standardized and thus generating large discrepancies in NP salaries across different provinces. Indeed, in BC, where NP compensation is comparatively generous, there is actually a job shortage of NPs.14 In 2011, the British Columbia Nurse Practicioner Association (BCNPA) reported that out of the 240 certified NPs (213 trained and 27 new graduates), 55 (22.9%) were actively seeking employment.14 While this trend may not be present across Canada, it is crucial to recognize that the NP profession cannot expand unless job availability is ensured.
Role definition and acceptance from stakeholders
Besides variable compensation, another major barrier to enhancing NP integration is role definition. Explored in more detail by Sangster-Gormley et al., the general lack of role definition and role standardization confuses co-workers as to the NP’s capacity and responsibility; in turn, this leads to a general lack of support and acceptance of NPs in the hospital environment.15,16
In some extreme cases, GPs have voiced their concern that the introduction of NPs will disrupt continuity of care and therapeutic relationships between the family doctor and his or her patients, as well as ultimately replace GPs with NPs as the latter are less costly to employ.17 Other physicians argue that NPs have insufficient training and experience, and thus should have limited autonomy.15
NPs have also experienced difficulties in patient acceptance. Despite steady growth, the NP is still a relatively new profession in Canada and patients may not associate a nurse with someone who diagnoses, prescribes, and follows up.18, 19 In fact, Sawchenko et al. conducted a survey about NPs in 2008 in BC and found that only 48% of the respondents had heard of NPs.20 Once they were informed about the role of NPs, 73% of the respondents were willing to be assessed by NPs instead of physicians, while 23% were unwilling.20 Clearly, patient awareness and acceptance are areas that must be improved in order to increase NP utilisation.
RECOMMENDATIONS FOR IMPROVEMENT
Reduce income variability and improve job availability
The transition of an RN into an NP results in increased responsibility and scope of practice; unfortunately, this promotion is accompanied by uncertain employment prospects and potentially less compensation. The creation of a common negotiating body and standardization of provincial policies for NP compensation can help address the issue of variable income, while close collaborations between educational institutions offering an NP program and policy makers who allocate funding for hiring NPs can help address the issue of unmatched supply and demand for NPs in each province.
Promote public awareness and understanding
As most nurses focus on supporting physicians and following their management orders, it is unsurprising that a large proportion of the general population is unfamiliar with the concept of a nurse who can practice like a doctor. In order for more NPs to successfully integrate into our healthcare system, patient acceptance and appreciation of NPs as leaders in primary care needs to be established. Hence, increasing public knowledge, understanding, and recognition are important first steps in expanding the role of NPs. Possible strategies include creating media broadcasts, providing information pamphlets in care centres, and increasing exposure of educational websites.
Promote professional acceptance by better defining role boundaries
The role of NPs must be better defined in individual healthcare settings. Although an NP’s legal scope of practice and professional capacity may not be significantly different from GPs (Table 1), their worksite specific roles vary greatly depending on location and situation. This role variability can become an advantage if it is well defined and understood by both the NP and the specific healthcare team prior to the onset of employment. This mutually accepted role definition allows for a framework for inter-professional cooperation that would provide a foundation for effective patient management in primary care settings with both physicians and NPs. By clearly outlining which types of patient situations are better suited for physician or NP management, healthcare centres will be able to promote more efficient cooperation and health care. Furthermore, NPs should be encouraged to consult medical specialists for advice in cases where they are uncomfortable with diagnosis or treatment. As an example, Sangster-Gormley et al. made three recommendations for improving NP integration, which can be summarized as:
1. Involving stakeholders, such as managers and physicians, in defining the roles of NPs in their workplace. As healthcare professionals generally work in teams, this will promote an understanding of the NP’s scope of practice and how they can function in the team to promote patient care.
2. Accepting NPs as team members and placing value in their prior experiences by other members of the healthcare team.
3. Declaring the intention of integrating an NP into the healthcare team. By doing so, expectations and professional roles can be defined early to promote team logistics and collaboration.
As members of a patient-centred healthcare system, all healthcare professionals should work collectively to implement reforms that improve patient care. While NPs are not trained to provide care equivalent to physicians, they have demonstrated their ability to provide timely, quality care in rural and urban settings, and hence can work together with physicians to improve the efficiency of health delivery. Despite initiative by the Canadian government, poorly defined professional roles and scopes of practice, variable income, and lack of job opportunities impede the growth of the NP profession. With the current shortage of primary care physicians, especially in rural areas, as well as the retirement of babyboomers, now is the time when effective integration of NPs can help improve our healthcare system.21 By addressing the major barriers to NP expansion, healthcare systems can maximize the potential of NPs as experienced and flexible healthcare providers.
1. Hass J. Nurse practitioners now able to work across Canada. CMAJ. 2006 Mar 26;174(7):911.
2. Scope of Practice for Nurse Practitioners. College and Association of Registered Nurses of Alberta. 2011 [updated 2011 September, cited 2012 Feb 25]. Available at: http://www.nurses.ab.ca/Carna-Admin/Uploads/2011_NP_Scope_of_Practice.pdf
3. Lenz ER, Mundinger MO, Hopkins SC, Lin SX, Smolowitz JL. Diabetes care processes and outcomes in patients treated by nurse practitioners or physicians. Diabetes Educ. 2002 Jul-Aug;28(4):5908.
4. Lenz ER, Mundinger MO, Kane RL, Hopkins SC, Lin SX. Primary care outcomes in patients treated by nurse practitioners or physicians: two-year follow-up. Med Care Res Rev. 2004 Sep;61(3):332-351.
5. Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ. 2002 Apr 6;324(7341):819-823.
6. Kinnersley P, Anderson E, Parry K, Clement J, Archard L, Turton P, et al. Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting “same day” consultations in primary care. BMJ. 2000 Apr 16;320(7241):1043-1048. 7
. Regulated Nurses: Canadian Trends, 2006 to 2010. Canadian Institute for Health Information;2011 [2012 Feb 26]. Available from: https://secure.cihi.ca/estore/ productFamily.htm?pf=PFC1691&locale=en&lang=EN&mediatype=0
8. Grumbach K and Bodenheimer T. Can Health Care Teams Improve Primary Care Practice? Innovations In Primary Care. 2004 Mar 10;291(10)1246-1251.
9. Wagner EH. The role of patient care teams in chronic disease management. BMJ. 2000 Feb 26;320:569-572. 10. Considine J, Kropman M, Stergiou HE. Effect of clinician designation on emergency department fast track performance. Emerg Med J. 2010 Jun 26;27:838-842.
11. Venning P, Durie A, Roland M, Roberts C, Leese B. Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care. BMJ. 2000 Apr 15;320(7241):1048-1053.
12. Grumbach K, Hart G, Mertz E, Coffman J, Palazzo L. Who is Caring for the Underserved? A Comparison of Primary Care Physicians and Nonphysician Clinicians in California and Washington. Ann Fam Med. 2003 Jul;1(2):97-104.
13. Lamarche K, Tullai-McGuinness S. Canadian nurse practitioner job satisfaction. Nurs Leadersh (Tor Ont). 2009;22(2):41-57.
14. Watts R. Part nurse, part doctor, no job. Victoria Times. 2010 March 11.
15. Wilson A, Pearson D, Hassey A. Barriers to developing the nurse practitioner role in primary care — the GP perspective. Family Practice. 2002 Dec;19:641-646.
16. Sangster–Gormley E, Martin–Misener R, Downe–Wamboldt B, Dicenso A. Factors affecting nurse practitioner role implementation in Canadian practice settings: an integrative review. Journal of Advanced Nursing. 2011 Jun;67(6):1178-1190.
17. Lague G. Do nurse practitioners pose a threat to family physicians? Can Fam Physician. 2008 Dec;54(12):1668-1670.
18. Laurant MG, Hermens RP, Braspenning JC, Akkermans RP, Sibbald B, Grol RP. An overview of patients’ preference for, and satisfaction with, care provided by general practitioners and nurse practitioners. J Clin Nurs. 2008 Oct;17(20):2690-2698.
19. Dicenso A and Bryant-Lukosius D. Clinical nurse specialists and nurse practitioners in Canada. Canadian Health Services Research Foundation. Published June 2010. Retrieved June 27, 2012 from http://www.chsrf.ca/Libraries/Commissioned_ Research_Reports/Dicenso_EN_Final.sflb.ashx
20. Sawchenko L, Fulton T, Gamroth L, Budgen C. Awareness and acceptance of the nurse practitioner role in one BC health authority. Nurs Leadersh (Tor Ont). 2011 Jan;24(4):101-111.
21. Bailey T. Waiting for a family doctor. Can Fam Physician. 2007 Mar;53(3):579-580.