If the recommendations of the recently released Primary Care Nurse Task Force are acted upon by the Ontario government, registered nurses will soon be identifying and treating ear and throat infections, initiating and overseeing contraception programs and managing patients with chronic illnesses.
They’ll be able to order and interpret diagnostic and laboratory tests, communicate diagnoses to patients, prescribe some medications and assume a lead role in care co-ordination. “It’s unconscionable in our view that many members of the public still do not have access to primary care when the nurses are there,” said Doris Grinspun, CEO of the Registered Nurses Association of Ontario (RNAO).
“If the role was fully utilized and maximized, the public would experience same-day access to primary care within six months to a year, so why haven’t we done it? What’s holding us back?”
The task force, with wide representation from the health-care sector, was established by the RNAO to explore the role of registered nurses and registered practical nurses in primary care and to make recommendations optimizing their contribution to the health-care system.
Thunder Bay clinic
Grinspun cited the Lakehead Nurse Practitioner-Led Clinic in Thunder Bay as an example of the efficiencies and positive outcomes possible when nurses in primary care are able to contribute to the full scope of their practice. “When I asked how it was possible that after a few months this clinic was able to meet the government target of 800 patients per nurse practitioner, they told me that the RN is seeing all the babies for measuring their development. It doesn’t need to be done by a nurse practitioner. The RN is doing all the pap smears and looking at children with ear and throat infections. These are all things that RNs have been trained to do. The nurse practitioners see the more complex cases and the physician who comes for two hours every two weeks is booked to see patients requiring a doctor’s care.”
The Thunder Bay Nurse Practitioner Clinic opened its doors in November 2010 with four NPs, an RN, an RPN, a social worker, a dietitian and a pharmacist. It quickly attained its full complement of 3,200 rostered patients and currently has a wait list of 400 people, said clinic administrator Kyle Jessiman. “That’s what I call a well-functioning site, but here’s the puzzling thing,” said Grinspun. “I came back from that meeting to (Health and Long-Term Care Minister Deb Matthews’) office and I brought with me a proposal that had been very recently sent. (The clinic) had two additional examination rooms and put in a proposal for two more NPs and an RN. That was in February and here we are six months later and the Ministry has still not responded. “So, we have a situation in Thunder Bay where we have the infrastructure ready to absorb more NPs and nurses, but instead the public is going to walk-in clinics and the emergency department. This is an example of system inefficiency.”
A second NP clinic, the Anishnawbe- Mushiki Nurse Practitioner-Led Clinic, opened its doors in Thunder Bay in March and is continuing to accept patients, according to Jessiman, but there are still upwards of 20,000 unattached patients in the area. “That was the number when we opened our clinic, but several physicians have retired since then, leaving practices of a few thousand patients to be picked up,” he noted.
Expanding the scope of practice and the number of nurses in primary care would be good for patients, doctors and the province’s bottom line, claims Grinspun. “The government will actually gain a return on the investment because there will be fewer walk-in clinics, fewer patients in ERs, fewer complications and better management of chronic illnesses.”
The cost of hiring more nurses for primary care should come out of global funding – not out of the pockets of doctors, said Grinspun. As for where the nurses will come from, Grinspun points out there are 3,000 RNs doing case management in the Community Care Access Centres. “Is that the best location for them, or would it be better for them to work in primary care?” she asks. “This is a system question.”
Expanding the scope of practice for primary care nurses will also help with retention, reduce the incidence of early retirement and attract more nurses to the profession once their knowledge and expertise are fully utilized, said Grinspun. The task force recommended a requirement for a 300-hour pharmacology course and continuing education for RNs in primary care, mirroring a similar requirement in the UK, where nurses have been able to prescribe medications for a number of years. Doctors, said Grinspun, are fully onside with the recommendation to maximize the current scope of practice for RNs and RPNs, but want more discussion about RN prescribing. Grinspun is optimistic about the ultimate acceptance of the task force recommendations.
“We had discussions with the premier, the minister and the opposition parties prior to the release of the report and everyone was extremely supportive. Grinspun hopes to see the maximization of the current scope of practice accomplished by 2013 and the passage of legislation expanding the role of nurses in primary care by 2015.