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‘Chipping away at barriers’: Nurse practitioners filling primary-care gap

Slowly but surely, nurse practitioners are solidifying their place in primary care.

“There are 5 million Canadians without access to a regular primary-care provider – and most people think of that as family physicians,” says Lisa Little, RN, first vice president of the International Council of Nurses and former director of public policy at the Canadian Nurses Association. “But there’s huge potential in nurse practitioners in improving access to care, quality of care, health outcomes and system design that we are just not tapping into.”

Primary-care nurse practitioners (NPs) have a minimum of six years of academic training – an undergraduate RN degree and a master’s degree – plus clinical experience. They perform many of the same duties as family doctors, including assessing, diagnosing and managing patients, ordering tests, prescribing medications and referring patients to specialists.

The 25 NP-led clinics launched a decade ago in Ontario communities with high numbers of patients without a regular primary health-care provider have reduced the number of unattached patients and relieved pressure on emergency rooms. The clinics are led by nurse practitioners working with a team of health-care professionals and often have a consulting physician.

Parry Sound has one of these clinics, spanning six sites and 190 km along the eastern shores of Georgian Bay. Demand for patient care during the pandemic has increased, says Teresa Wetselaar, NP lead at the Parry Sound Whitestone NP clinic site. She sees her own patients at the clinic, plus sees physicians’ patients, including  cottagers who have complex medical conditions but are away from their regular physicians.

“A lot of the stuff we do (at) the six nursing sites is keep people out of the emergency department.” For example, she says, “(a man) cut his leg this morning and is coming in for stitches.”

The NP sites have same-day appointments for things like lacerations, ear aches or rashes, which helps manage the increase in patient volumes (about 300 per cent higher with the influx of cottagers) during the summer months.

For residents like Sheila Wesley, the Whitestone NP clinic provides her with excellent care and fast appointments. Wesley moved to the Parry Sound area six years ago and still has a family doctor in Thornhill, Ont., but she hasn’t seen him in-person since before the pandemic started.

“(The clinic) fills a community need and we’re lucky to have it,” Wesley says. An anonymous donor is matching community contributions up to $90,000 to help expand the clinic so it can add three more exam rooms and accommodate two full-time NPs and more health-care team members.

The NP-led clinic model is transformative, says Katie Hogue, NP and chief nursing officer, West Parry Sound Health Centre (WPSHC).

“We have a really integrated model between all of our community partners,” Hogue says. In addition to the NP-led clinic, which is under the umbrella of the WPSHC, Hogue oversees the rapid access addiction medicine clinic, leads the local primary-care table, is the medical consult for community social services and is medical director for the community paramedics program and the COVID assessment centre.

While Ontario was first out of the gate with NPs, and accepts about 225 nurses each year into primary-care NP programs, enrolment has not grown in more than a decade despite a 74 per cent increase in applicants from 2020 to 2021.

Canada has only 7,910 licensed NPs (compared to more than 325,000 in the U.S.) and only graduated 573 in 2020.

“The good news is that in 2019-20 we admitted 928 into nurse practitioner programs across the country, which is up 27 per cent from two years prior,” says Lisa Little. “So, clearly there is a recognition by provincial governments, in funding these seats, that there is a need for nurse practitioners.”

“There are so many models for how NPs could improve access in primary care.”

British Columbia is rapidly expanding NP enrolment and team-based positions for NPs in a variety of different service models, increasing program seats to a total of 80, with another 20 on the way.

B.C. has also filled 150 of 253 new NP jobs as part of the province’s team-based primary-care strategy that includes a range of different service models – family practices, urgent and primary-care centres, community health centres, First Nations primary-care centres and NP primary-care clinics – all linked in locally planned and delivered primary-care networks, says the B.C. Ministry of Health by email.

Three new NP primary-care clinics, in Nanaimo, Surrey and Victoria, are expected to have more than 20,000 patients attached by 2023.

“There are so many models that we should consider for how NPs can improve access in primary care,” says Little. This includes long-term care settings, where NPs have stepped up to lead during the pandemic and emergency departments, where patients can be triaged for treatment of common conditions like ear or urinary tract infections.

Stan Marchuk, president of the Nurse Practitioner Association of Canada, agrees.

“We have been chipping away at barriers to practice for decades now,” Marchuk says. “By and large, we have addressed a good proportion of them, but there is still old language that is buried in (provincial legislation) … It just takes the political will of government to modernize them and allow NPs to practice to their full scope.”

New Brunswick recently opened three NP-led clinics in Fredericton, Moncton and Saint John to try to shorten the province’s wait list for a primary-care provider, which stood at more than 40,000 last year. Each clinic will have six NPs and is expected to take 6,000 patients off the province’s wait list.

The new clinics are great, says Raelyn Lagace, NP and president of the nurse practitioners interest group of New Brunswick. But because of the pandemic’s impact on health-care professionals, Fredericton alone has seen 10 primary-care providers leave since the fall, she says, so the wait list continues to grow.

Lagace has worked as an NP for 11 years in New Brunswick as part of a primary-care team and has full autonomy over her patients.

“I’m a nurse practitioner because I care for people; I love having a little bit more time and providing a holistic model of care with my patients,” she says. “I’m a nurse at heart and I carry that forward within the way I practice as a nurse practitioner.”

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  • Donna LaPointe says:

    I am a Nurse Practitioner in a primary care setting. I believe I bring not only knowledge to my patients as well as the very important art of caring which many physicians do not understand or practice.

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Mary-Kay Whittaker

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Mary-Kay Whittaker is a fellow in the Fellowship in Global Journalism at the University of Toronto focusing on health professional education and health workforce planning.

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