A thought on Nurse Practitioners.

In Editorial by Edmund Kwok1 Comment

Guest post by Linda B.

I have been a nurse for 12 years. All of them practiced in Canada, most of which have been in critical care. I started with a college education and a specialty certificate. Within the year I will be a master’s prepared Nurse Practitioner (NP), and almost everyone I know asks me what’s next…? I could stay right where I am – at the bedside in the Intensive Care Unit in a tertiary care hospital – but I would not be able to fully utilize the skills I will have acquired as an NP.

Truthfully, in my unit I would not be able to practice as an NP at all. Despite being certified for independent practice by my licensing body, I will not have the ability to independently order a medication or Xray, or communicate an unknown diagnosis to a family.

In fact, in most hospitals in my area I will not be able to independently practice. At best NPs are-in acute care in this city-treated much like a well trusted resident…who may or may not be able to sign their own orders. The staff doctor still signs off all charts, and therefore has to “see” the patients. The rationale is mostly due to billing reasons – OHIP does not direct pay NPs. Ever. Therefore, in order for an organization to recoup the cost of health care not delivered by a physician, there has to be independent funding, or one has to be able to bill for services rendered. No physician involved in the care: billing is not reflective of the care given or resources utilized. If this sounds crazy, distribution of health care dollars ($47 Trillion per year in Ontario alone) is another topic. The fact that I will not earn a higher wage than I do right now despite added responsibility and liability is another.

I do not believe I will ever replace a physician. In any context – primary care, in the community, in the hospital, anywhere. But I do believe that there are many ways in which the skills and abilities of a nurse practitioner can effectively care for the needs of individuals requiring health care. And, evidence also supports that an NP can provide effective, safe patient care. However there is much debate on what the role is for NPs in centers where they are not used.

Scope of practice for NPs changes, however, at the moment NPs can prescribe all unscheduled medications, order most XRays and Ultrasounds, perform the procedures that they have the knowledge, skill and judgment to carry out and that fall within the scope of their practice. It sounds broad, and a little vague, probably because it is. However, as an outsider it is very difficult to determine what the scope of practice is for a physician.

In concrete terms: in the ER an NP would be able to easily see, treat and disposition almost all CTAS 4 or 5 patients. They could do most of the initial assessments, manage and treat CTAS 2 or 3 patients handing off to physicians when needed. In many centers a lot of that is already done by registered nurses through a combination of medical directives and verbal orders. One of the busiest ERs in Toronto has effectively used NPs and reduced wait times.

The ER however, is considered an outpatient unit, and perhaps the leap to an inpatient unit is more difficult to make. Imagine however the effective use of an NP on an inpatient orthopedics ward. Daily, medically complex patients are admitted for an acute surgical orthopedic issue. An NP on service could assist in managing their chronic disease in hospital and do the appropriate discharge planning while the orthopedic surgeons can then manage the acute issue. NPs could independently order most lab and diagnostic tests best done in hospital to manage the ongoing chronic issues, as well as ensure holistic care of patients.

Nurse Practitioners are, above all, nurses. My view of a patient will remain, as it always has been, viewed through the lens of a nurse. It may be why NPs take more time with patients, feel the need to do more counseling and teaching. NPs uniquely understand that many people still do not understand chronicity of disease and its long term effects. And while physicians believe they do an adequate job of explaining their diagnosis and treatment plans to their patients – we have spent time with many patients after a physician leaves the room. We often know the questions that are still asked long after the diagnosis is delivered and the treatment plan has been set.

NPs still consult, test, treat, refer, assess, diagnose . . . and when we don’t know, or aren’t sure, we consult our peers, then partnered physicians, then specialists. However, as an independently licensed practitioner, NPs also know when they can assess, diagnose and treat a problem without any further need for consultation. Until the rest of the health care system understands and believes that, NPs will continue to be under-utilized – much like every other discipline in health care.

So what’s next? Probably primary care. If I’m lucky, an emergency department to keep up my acute care skills. Realistically? Maybe not Ontario. However, I have confidence that there is room for everyone’s skills in health care.

Author Bio: Linda B is an RN, certified in Critical Care and Emergency Nursing . . . who in the near future will be a Nurse Practitioner and will join the ranks of those health care professionals who are willing to not only be primary care providers but also believe in exceptional primary care for all Canadians.

Edmund Kwok

Edmund Kwok

Emergency Medicine. Quality Improvement. Patient Safety. Change Management. Healthcare Administration.

Frontdoor 2 Healthcare

Frontdoor2Healthcare, founded by Dr. Edmund Kwok in 2012, provides editorial and commentary on issues affecting Canadian healthcare from the emergency department’s “front door” perspective. Frontdoor posts allow for open sharing of the diverse opinions and perspectives of emergency physicians from across the country.

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