Her goal is simple, yet ambitious: to change the face of Canadian health care. As a nurse practitioner (or what the media has dubbed "super-nurse") and past-president of the Nurse Practitioners' Association of Ontario, Paula Carere could do just that.
A day in the life of a nurse practitioner
It's an overcast Wednesday morning and Carere is sipping coffee as she looks over the schedule of patient appointments. In 20 minutes, people will begin filing through the doors of Lang's Farm Community Health Centre in Cambridge, Ont. Carere is ready for whatever comes her way, thanks to the 33 years she has spent in health care. Carere graduated from the University of Ottawa with a bachelor of science in nursing.
After working as an intensive care unit nurse and director of patient services, she felt she wanted to take a different tack with patient care and enrolled in the nurse practitioner program at Laurentian University. "I didn't want to focus just on illness," she explains. "I thought I could serve patients best by concentrating on prevention through support and maintenance of healthy behaviours. When I became a nurse practitioner in October 1998, it allowed me to take an independent leadership role to help in this way."
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First into her examining room this morning is a mom, with her 18-month-old toddler, 10-year-old twins and tween daughter in tow. It's shot time – another round of immunizations for the youngest and flu shots for everyone else. While the needles are prepped, Carere asks Mom how the kids are doing. The eldest is being treated for attention deficit hyperactivity disorder (ADHD) and the younger ones are complaining about ear troubles. Carere has followed the kids' health since before they were born and she knows the family's medical history without having to consult their charts.
When Carere is out of the room weighing and measuring the kids, Mom, without being prompted, says, "Paula is great. We love it here. We've been to other clinics, but we like this one best." Before she leaves today, she'll schedule flu-shot appointments for Dad and her other three kids, too.
Page 1 of 4 – Is visiting a nurse practitioner appropriate for you? Discover some of the health care duties a nurse practitioner can perform on page 2.
There's an easygoing friendliness between Carere, 55, and the family. When the youngest is getting bored, she whips out a sheet of animal stickers that she knows will amuse him for the time being. And though the kids are antsy about getting needles, they don't flinch when she lifts up their shirts and puts a stethoscope on their backs to listen to their breathing. When she's finished, she scrawls prescription renewals for the ADHD meds and the troop leaves with a chorus of cheery goodbyes.
The nurse practitioner will see you now
"Our approach is a person-centred one; it's not about me as the provider and how I define health. It's about combining what you as the patient see as your health needs with my knowledge and expertise, to reach the best outcome for you," she explains. "As nurse practitioners, we are trained to look at the person and their lifestyle and create a strategy that not only addresses illness, but also focuses on health maintenance and disease prevention, too." Carere, who lives in Guelph, Ont., has worked as a nurse practitioner at this clinic for 12 years; here, every patient is part of a collaborative family health team and usually gets an appointment within 24 hours.
Nurse practitioners serve as the point person, or unofficial coach, within the team. They guide patients to whatever resources are needed – whether it's to diabetes education or to a specialist or to a social worker. They handle 80 to 85 per cent of the patients on their own, without them having to see the clinic's physician.
For Canada's health-care system, which faces long wait times and a shortage of doctors and money, this is a good thing. The hope is that spending health-care dollars on more nurse practitioners will help bridge the gaps in the system. It makes good economic sense, since the services of a nurse practitioner cost less than those provided by physicians. Nurse practitioners are salaried employees, whereas doctors bill per service.
What nurse practitioners can do
Nurse practitioners are regulated provincially (but regulation in the Yukon is not yet final). Their scope of responsibilities may vary from province to province, but in general, here's how they serve patients.
• Make a diagnosis identifying a disease, disorder or condition;
• communicate the diagnosis to the client and other health-care professionals as appropriate;
• initiate, order or prescribe consultations and referrals;
• order and interpret screening and diagnostic tests (with some limitations); and
• recommend, prescribe or reorder drugs (with some exceptions).
Page 2 of 4 – Learn more about a the evolving role of nurse practitioners within the health care community on page 3.
Why finding a nurse practitioner should get easier
In most provinces, nurse practitioners are considered essential. They practise in every province and territory and their numbers have almost doubled between 2003 and 2007. Now, there are approximately 1,600 nurse practitioners in Canada. In 2003, Ontario made a commitment to have 25 new nurse practitioner-led clinics by 2012. The first opened in Sudbury, Ont., in 2007; there are now 11 such clinics in the province.
And, as part of the $137 million overhaul of British Columbia's health-care system announced in June 2010, nurse practitioners will become an integral part of doctors' practices. That will help ensure that the 250,000 B.C. residents who don't have a family doctor will get primary health care, according to Kevin Falcon, the province's health minister.
Meanwhile, in July 2010, Quebec announced it will spend $117 million to boost the number of nurse practitioners in that province from 56 to 556 before 2018. Alberta is also on board when it comes to recognizing the value of nurse practitioners, but has yet to back it up with the necessary funding. Last fall, Alberta's health minister, Gene Zwozdesky, said the government would examine the obstacles confronting nurse practitioners.
How nurse practitioners can enhance family health care
Despite the boom in nurse practitioners, the picture has not been entirely rosy. Nurse practitioners face a lack of public awareness about what they do and what their role is. Some patients think that nurse practitioners are doctors; they're not. Some believe that nurses and nurse practitioners are one and the same. In fact, nurse practitioners start off as registered nurses, then train for another two years, after which they can perform a range of services, such as writing prescriptions (with some exceptions), administering physicals, ordering tests and providing referrals to specialists.
Nurse practitioners have also faced a turf war with some physicians, who fear that the wider range of nurse practitioners' responsibilities could encroach on theirs. In 2009, the Family and General Practice section of the Ontario Medical Association (OMA) lobbied against the government's plan to allow nurse practitioners to lead local health clinics.
OMA section chair Dr. David Bridgeo was quoted as saying, "Having these roles filled by nonmedical personnel is like having a member of a flight crew fly an airplane." Resistance from some doctors has meant that nurse practitioners have had to convince doctors of their value and their ability to perform duties that were once the sole domain of physicians. Carere forgives the politicization of the role of nurse practitioners. "Once our health-care colleagues have developed trust in nurse practitioners' skills and knowledge, the working relationship becomes comfortable and natural."
Page 3 of 4 – Think you might like to see a nurse practitioner? Discover where to find an nurse practitioner close to home on page 4.
New rules and roles for nurse practitioners in Ontario
Carere and her colleagues in Ontario may face another round of trust building once the realities of Bill 179 hit clinics and hospitals, possibly as early as April. Passed in December 2009, the bill expands the nurse practitioner role even further, allowing them to prescribe an expanded range of drugs and to order any type of X-ray and CT scan. The changes will come into effect as soon as Ontario's College of Physicians and Surgeons amends its bylaws and updates its practice manuals.
At the last appointment of Carere's 10-hour day, she sees a 43-year-old woman with chronic depression. She slumps in the chair across from Carere, exhausted by the effort it took to come in. She has started taking an antidepressant, but still has trouble getting out of bed and feels unable to work. Carere is determined to find the cause of the woman's pain. Her story slowly comes out. It includes a series of physically abusive relationships, a custody battle over her son, and an out-of-control teenager. She's frustrated, and very sad.
Going the extra mile
Carere formulates a plan. "You can't just sleep all day. You need a routine. And I think we need to deal with your son's behavioural issues and we'll get some support and counselling for you, too." After names and phone numbers pass hands, the woman thanks Carere and walks out of the examining room with more spring in her step. The lines on her face are softer and there's the slightest hint of a smile.
Carere looks pleased, too. She could have just renewed the woman's prescription for venlafaxine, but she knew it was important to go further. As a nurse practitioner, she had the tools and training to do that. And she seems to recognize that this is how the face of Canadian health care can change – one patient and one nurse practitioner at a time.
How to find a nurse practitioner
British Columbia Nurse Practitioner Association: bcnpa.org/search
Health Link Alberta: 866-408-5465
Yukon Telehealth Network: 867-667-8033
Yellowknife Health and Social Services Authority: 867-873-7276
Health and Social Services: 800-663-5738
Contact Marta Crawford, Primary Health Care Branch, Manitoba Health: 204-786-7342
Saskatchewan Association of Nurse Practitioners: sasknursepractitioner.org/find-an-np
Health Care Connect: 800-445-1822; ontario.ca/healthcareconnect
Tele-Care: Call 811
HealthLink: Call 811
Prince Edward Island
Island Information Service: 800-236-5196
Newfoundland and Labrador
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