Let’s Maximize The Contribution of Health Care Professionals

A change to the Nursing Act, consolidating regulation and oversight of Registered Nurses and Licensed Practical Nurses, received widespread support—with one exception.

Doctors Nova Scotia, which is the profession’s advocacy group and bargaining agent, took exception to the removal of a requirement that nurse practitioners have a formal relationship with a physician before being allowed to practice.

They argue that when a nurse practitioner’s patient has needs that go beyond their scope of practice, the nurse practitioner should be able to access a physician. There is no issue if the patient has a family physician.

But if not, the doctors wanted the legislation to compel the nurse practitioner to have a formal relationship with a physician. Having one makes sense.

In fact, it is compelled by the nursing Code of Ethics which says, “Nurses collaborate with other health care providers… to maximize health benefit to persons receiving care… recognizing and respecting the knowledge, skills and perspectives of all.”

And, “Nurses practice within their own level of competence and seek (appropriate) direction and guidance… when aspects of the care required are beyond their individual competence.”

Why, then, is there a need to include it in legislation? If a doctor is puzzled by a patient’s symptoms, she is expected to refer the patient to an appropriate specialist. This is mandated by her profession’s regulator, not by legislation.

Nor is the family physician expected to pre-establish formal relationships with specialists that she might have to consult.

Speaking for the physicians, Dr. Mike Wadden protested that they “are not advocating for physician oversight on nurse practitioners or limitation on their scope of practice.”

This does not ring true. There was a time when the physicians were always at the top of a management pyramid, with other health professionals answerable to them.

Those days are, thankfully, in the past and removing the clause from the legislation is the right choice. If a nurse practitioner needs help from another health professional for a patient, he (like a doctor) will be responsible to his regulator to find that help.

The College of Physicians and Surgeons of Nova Scotia, the doctors’ regulator, endorsed the new legislation in its entirety, conspicuously not suggesting reinstatement of the clause that is being removed.

Health authorities are unlikely to fully respond to shortages in primary care by recruiting enough family physicians, particularly in an era when many of those want to have more work-life balance.

The evolution of nurse practitioners, now numbering 200, provides an important opportunity to improve access to primary care. Nurse practitioners can prescribe medications, order tests, and refer patients to specialists. We should keep the numbers growing and maximize their opportunities to provide care.

Most of the time, they will be co-located with physicians and other health professionals. Sometimes that will not be the case, as would occur if the physician normally used is on vacation or has left her practice.

Appropriate support systems should be available, for example through the regional hospitals. In Ontario, nurse practitioners can have their own practice and be paid by the government directly.

The possibilities for collaboration go well beyond nurse practitioners. Can physiotherapists contribute more to diagnosing muscle or bone injuries? Can pharmacists have a broader role in prescribing certain commonly employed medications?

Paramedics often spend long hours at emergency departments waiting to transfer responsibility for patients to hospital staff. Can their talents be usefully employed while they wait?

The wrong way to explore these possibilities is from the top, where decision-making is cumbersome and slow. For example, a plan to eliminate ambulance bottlenecks at emergency departments was supposed to be ready in mid-February. It is still not done.

Many of the health professions have codes of ethics and standards of practice, and processes for enforcing them. Within those constraints, let’s facilitate experiments that will maximize the benefits to patient care.

Let those be authorized, designed, and carefully managed at a local level. This will allow rapid decision making to abort ideas that aren’t working and tweak ones that show promise.

Then share the winners with other regions.


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