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Ottawa
With the passage of new regulations in Prince Edward Island, legislation now exists across Canada allowing nurse practitioners (NPs) to work.
All the provinces and 2 territories have passed new legislation. In the Yukon, where nurses have worked as NPs for many years, the Registered Nurses Act is broad enough to cover the extended practices of the NP.
An NP is a registered nurse with additional education in health assessment, diagnosis, treatment and management of illnesses and injuries (Box 1). Qualifications vary across Canada, but typically baccalaureate-trained RNs take additional university courses and have at least 2 years of on-the-job training. More than 20% of NPs have a master's degree.
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"An NP is not a substitute or replacement for the family doctor," says Madge Applin, manager of legislation and regulation at the Canadian Nurse Practitioners Initiative. "The ideal way of using the collected knowledge and skills of an NP and doctors is having them work together in a team-based environment where competency and skills are matched to the patient's needs."
The initiative, a Canadian Nurses Association (CNA) project with $8.9 million in funding from Health Canada's Primary Health Care Transition Fund, is developing a national framework to integrate NPs into primary health care. Its final report this spring will include recommendations on the standardization of the licensing, testing and role of the NP, plus regulations and legislation on their practice, core skill set and education.
NP initiatives began appearing in the 1970s but mostly disappeared by the early 1980s. In the past decade there has been renewed interest from provincial and territorial governments in using NPs to improve access to primary health care, especially in remote communities and areas with physician shortages.
"An NP could care for non-emergency patients who are [in emergency departments] simply because they don't have access to primary care," says Applin.
In 2004, there were 878 licensed NPs in Canada, up by more than 20% from 2003, according to a September 2005 report from the CNA and the Canadian Institute for Health Information.
According to the report, 71% of these nurses say they work as NPs, 9% as staff or community-health nurse, 4% as instructor, professor or educator, and 3% as manager. Nearly a quarter (23%) of NPs worked in hospitals, and 45% worked in the community-health sector.
But as one PEI community clinic found recently, it's not always easy to mix the practice of doctors and NPs. Last summer, the PEI Health Department ended a pilot project to integrate NPs into a community clinic in O'Leary.
"The practitioners didn't understand where they stood with each other," explains Dr. Kathryn Bigsby, past-president of the Medical Society of PEI.
The Association of Registered Nurses of PEI agrees that the difficulty with that pilot was the lack of rules and regulations governing practice. "It did move us forward though," says Executive Director Becky Gosbee.
Bigsby agrees that the regulations were well considered, but PEI physicians still have mixed feelings about the need for NPs. Some are excited at the possibility of doing business differently, but others see the introduction of NPs as cause for concern about the government's commitment to increasing the number of family physicians.
PEI has a shortfall of 18 doctors; 200 physicians now practise on the island. Meanwhile, 6 NPs are "ready to go" in PEI says Gosbee.
In 2003, the Ontario government hired 117 NPs to help improve access to health care in rural and remote areas.
Linda Jones, an Ottawa NP for 21 years, says misunderstandings can be averted if roles are made clear. "Once there's an understanding that we're not doctor replacements, we complement each other's roles, then there's a lot of goodwill in a relationship," says Jones.
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When NP Sandra Hooper approached Dr. Mary Gordon about setting up a 6-month pilot program at the Sexual Health Clinic run by the City of Ottawa, she met no resistance. "She was actually quite receptive to the idea. She had worked in the past with NPs and enjoyed their roles."
Staff were concerned about "role ambiguity" midway through the pilot so Hooper worked with staff to clarify the scope of practice for NPs. Hooper now works at the clinic and its satellite clinics in high schools full-time.
Her advice to others considering setting up a collaborative practice is to clarify roles and scope of practice. "We're not trying to be mini-doctors," she says. "We do have expectations of regular consultations. Anything outside our scope of practice, we have to consult."
NPs are covered under liability insurance from either the CNA or their own regulatory body. The Canadian Medical Protective Association and Canadian Nurses Protective Society have signed a joint statement about liability.
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(e) 0820-3946 (p)
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