The Value of Registered Nurses in Collaborative Family Practice: Enhancing Primary Healthcare in Canada

Transcription

1 32 LEADERSHIP PERSPECTIVE The Value of Registered Nurses in Collaborative Family Practice: Enhancing Primary Healthcare in Canada Vicki Kennedy, RN, BN, MN, CRE COPD Nurse Clinician Royal University Hospital Saskatoon, Saskatchewan Abstract With the current focus on improving efficiencies and quality of care within the Canadian healthcare system, primary healthcare (PHC) is receiving renewed attention. The time is right for highlighting the value that registered nurses (RNs) can bring to collaborative practice in primary care settings. This paper discusses the untapped utilization of RNs in primary care in Canada, arguing for a strong leadership role for nurses and citing examples of RN services that could enhance care and improve population health and cost-effectiveness. Internationally, other countries with strong PHC strategies in place offer potential lessons regarding features that could be adapted in Canada. Introduction: No Time Like the Present The time has come for registered nurses (RNs) to assert the value they bring to primary healthcare (PHC) in Canada, practising in collaboration with family physicians. In reformed PHC, individuals and families are partners in care, working with a team who partner with other providers and services, addressing social determinants of health, integrating and coordinating the majority of healthcare. Over the last decade, Canada has made some progress towards PHC reform; however, performance with respect to quality indicators, in comparison with other

2 The Value of Registered Nurses in Collaborative Family Practice: Enhancing Primary Healthcare in Canada 33 countries the Netherlands, Germany, the United Kingdom, Australia and New Zealand is suboptimal (Dahrouge et al. 2012; Davis et al. 2010). Countries that have sound PHC strategies in place have better health outcomes, better equity, lower mortality and reduced healthcare costs (Aggarwal and Hutchison 2012). The largest group of healthcare providers in Canada are nurses, and they are present throughout the system; thus they are well positioned to effect change at the national level. The next step in strengthening PHC in Canada is for key stakeholders to commit and dedicate resources to concur on a feasible vision and strategy (Aggarwal and Hutchison 2012). The purpose of this paper is to highlight the value that nurses 1 bring to optimizing PHC through collaborative team environments, and to discuss how PHC models in other countries have integrated RNs into family practice. Registered Nurses in the Context of Primary Healthcare In embarking on interdisciplinary collaboration, it is helpful to situate the value of nursing knowledge to ensure optimal merging of disciplinary mindsets (Smith 2008). As the concepts of caring and health are fundamental to the discipline of nursing and its focus on knowledge development, RNs have a significant role to play in all areas of healthcare, validated by how nursing is defined, and especially related to the definition of PHC. But first, a distinction must be made between primary healthcare and primary care. The World Health Organization s Declaration of Alma-Ata defines primary healthcare as essential health care based on practical, scientifically sound and socially acceptable methods and technology, made universally accessible to individuals and families in the community (WHO 1978). PHC is the first point of contact with the health system, and establishes a continuing healthcare process with full community participation. It seeks to maintain human developmental stages affordably in the interest of patients self-reliance and self-determination. In contrast, primary care is the healthcare given by family physicians and other providers (Muldoon et al. 2006). Such providers typically act as the principal point of consultation for patients within the system and coordinate other specialists that the patient may need. The International Council of Nurses (ICN), which supports the Declaration of Alma-Ata (WHO 1978), endorses the notion of RNs practising in primary healthcare. Its position paper states that access to and equity in PHC, notably nursing services, are integral to improving the health and well-being of all (ICN 2007).

3 34 Nursing Leadership Volume 27 Number The Canadian Nurses Association has also advocated for PHC as the most effective way of providing healthcare to the population (CNA 2002). More recently, the CNA has expressed its vision for nursing and health over the next decade: to work collaboratively with a variety of partners, ensuring a sustainable and high-quality healthcare system (CNA 2009a). Keeping people well by linking health to the social determinants of health a cornerstone of the PHC approach is a focus of that vision (CNA 2009a). Yet, underutilization of health human resources has been identified by numerous studies (Besner et al. 2005). The ICN s position statement on promoting the value and cost-effectiveness of nursing states that nurses are often an underused and undervalued healthcare resource (ICN 2001). Underutilization is wasteful and unjustifiable, and of particular concern given the predicted shortage of healthcare professionals in the future (Besner et al. 2011). Canada s current reactive, illness-focused healthcare model is unbalanced, with the majority of our RNs working in hospitals. Would it not make sense to work upstream and have more nurses in primary care to promote health and prevent illness? Effectively, the PHC approach lends itself to RN practice, specifically in the context of family physician clinics and other collaborative PHC settings. Articulating the Role of RNs in Primary Healthcare The nurse practitioner (NP) role has gained much attention in the literature and has increased in prevalence in healthcare settings, particularly in terms of PHC, over the past decade (CNA 2006). NPs have worked hard to demonstrate leadership in establishing their role, providing high-quality care to individuals and families, particularly in rural settings where there is a significant shortage of physicians. Meanwhile, although attention to PHC has increased, the role of the RN within PHC has been neglected. In 2008, the Canadian Family Practice Nurses Association (CFPNA) was established by a small group of family practice/primary care nurses who had a vision of minimizing their sense of professional isolation. CFPNA has undertaken initiatives to ensure that physician leaders, and their counterparts in nursing, are aware of the contributions that RNs make to primary care and PHC (CFPNA 2013). RNs would do well to emulate NPs in demonstrating the importance of general RN practice: the value of the discipline of nursing to PHC, and the unique skill set of RNs, are at risk of getting lost if this knowledge is not asserted. The increasing prevalence of NPs in the United States prompted Gooden and Jackson (2004) to explore RNs attitudes towards nurse practitioners. These authors concluded that the success of the NP role relies heavily on the support of

4 The Value of Registered Nurses in Collaborative Family Practice: Enhancing Primary Healthcare in Canada 35 RNs, and that patient care will be optimized when NPs and RNs have more exposure to each other because a mutual understanding of their roles will have a positive impact on care delivery. This finding highlights the need for increasing RNs practice, not only in collaboration with family physicians, but with NPs as well. Why is there not widespread penetration of RNs in all practice settings in Canada? Nurse-led care is common in family practice settings in the United Kingdom, Australia and New Zealand (Hoare et al. 2011), all of which have established competency standards to ensure high-quality nursing care (Annells 2007). In these countries, family physicians have at least one RN working collaboratively with them in primary care, with a diverse scope of practice. The College of Family Physicians of Canada (CFPC 2007) has issued a vision statement on inter-professional care that states all patients in Canada will have access to a family physician and registered nurse working together in a primary care setting. The college believes the whole system benefits when family physicians and RNs collaborate, with the potential to reduce wait times and increase access. Yet, there is a lack of consensus regarding the role that nurses should play in primary care (Besner et al. 2011), and the absence of a clear vision for PHC reform makes determining their optimal utilization difficult. Besner and colleagues (2011) concluded that a population needs driven approach towards integrating RNs into primary care may result in a lack of role clarity and consequent resistance, or at least lack of interest, from nurses. Oelke and colleagues (2012) reported similar themes derived from an environmental scan of primary care settings across Canada, together with Alberta stakeholder interviews, to understand the roles of providers, and delivery models of nursing services, within leading practices. Oelke s study was undertaken to facilitate nurses capacity to practise to their full scope in primary care. Themes that emerged included a vision for nursing in primary care settings, organizational design, roles and responsibilities, nursing role ambiguity/scope of practice and inter-professional collaborative practice (Oelke et al. 2012). There would appear to be discrepancies among professional organizations, frontline RNs, leaders and health policy decision-makers related to theory and reality in primary care, with the identity of RNs needing to be enhanced. The Registered Nurses Association of Ontario states that because the role of the RN in primary care has received little attention by employers, professional associations and governments, this role is underutilized a disadvantage to the public and to the healthcare system (RNAO 2012). Much of the literature suggests that RNs should be prevalent in primary care, but this is not the current reality (see Appendix online at

5 36 Nursing Leadership Volume 27 Number Following consultation, the CNA (2012) reported four themes that nurses, the public and other professionals identify as priorities with respect to the role of nursing in supporting better health, better care and better value: that the nursing profession should (a) lead system transformation, (b) focus on the determinants of health, (c) promote healthy lifestyles and (d) strengthen the voice of advocacy for and by nurses. What the public wants is a trusted, distinct voice, the voice of nurses advocating on behalf of Canadians as champions for excellent care, particularly in primary and preventive care. Knowledge and research speak to the role and importance of RNs presence in PHC. However, this ideal has not yet been translated into practice. One of the challenges to standardizing RN practice in PHC is the absence of knowledge among the medical and nursing professions about what RNs do and can contribute (Allard et al. 2010). It is important that RNs as leaders assert themselves and proactively work towards fundamental change, providing a complementary role in primary care delivery. When RNs have a more prevalent presence and assert leadership in PHC in Canada, as is the case in the United Kingdom, Australia and New Zealand, an appreciation by other healthcare professionals of the valuable role of RNs will ensue. Partnering with stakeholders who have creative and international expertise is worth considering. This approach would help define and facilitate role definition, and the transition and widespread integration of RNs into primary care and PHC. Nurse leaders, rather than physicians and health policy decision-makers, must plan and define the future of nursing in primary care (Price 2007). In this regard, further research to explain integration of nursing service delivery, and action research to identify key indicators of successful transition processes and outcomes, may be beneficial (Banner et al. 2010). The undeniable benefits of having RNs working in collaborative family practice include improved health, quality of care and cost-effectiveness. The Value of Improved Health and Quality of Care There is a clear need to document the value of RN participation in collaborative practice so that the public, other healthcare professionals, policy decision-makers and nurses themselves understand the important role that nurses have to play in primary care and PHC. Literature highlights the fact that both the Canadian public and nurses underestimate the value of nurses contribution owing to a lack of understanding of RNs full scope of practice beyond the hospital setting (Besner et al. 2011; Fortin et al. 2010). Examples of services provided by RNs in New Zealand include childhood immunizations from the ages of six weeks to five years, and taking cervical smears, both of which procedures require certification.

6 The Value of Registered Nurses in Collaborative Family Practice: Enhancing Primary Healthcare in Canada 37 The diversity of clinical services that RNs can bring to enhance primary care and PHC is vast and includes wound care; conducting diagnostic tests; assisting with minor surgical procedures; giving injections and immunizations; triaging; counselling; performing general health, vision and mental health screening; administering nebulizers; phlebotomy; suture/staple removal; and patient education and health promotion. The presence of RNs in primary care increases accessibility for patients, and the logic of one-stop shopping results in better quality of care and improved health unarguably, the most important outcomes. In addition to clinical services, RNs provide a uniquely holistic approach to patient care. Holistic nursing care in the primary care setting enables patients to develop strategies to improve their own health and well-being, in the spirit of selfdetermination (Besner 2005). RNs collaborating with family physicians can dedicate time to health promotion strategies to improve health outcomes for patients in a primary care clinic. This may include managing continuous quality improvement and recall registries. From the standpoint of PHC, RNs working collaboratively with family physicians are in a good position to get to know patients throughout the lifespan, and are typically more accessible than family physicians. Building trusting relationships leads to better understanding of how the social determinants of health affect individuals and families. One recent study reported that family physicians believed it is beneficial for nurses to manage continuity and relationship-building issues (Ehrlich et al. 2012). Another study concluded that nurses knowledge of primary care patient subpopulations was significant in helping to prevent and close gaps in care (Attwell et al. 2012). Understanding patient subpopulations from a holistic health orientation enables improved quality of care and better health. Practising at the grassroots level, RNs in primary care gain a good knowledge and understanding of the resources available in the community and, therefore, are more inclined than physicians to advocate for patients by referring to and liaising with community partners and services. This knowledge is valued by family physicians, who know it improves care (Ehrlich et al. 2012). In New Zealand, nurses provide case management, education and care coordination services for individuals with type 2 diabetes a PHC initiative that has provided professional rewards with positive patient outcomes, enhanced by seamless collaboration and communication with family physicians. Client education and care coordination in clinics are varied and not limited to diabetes (Hoare et al. 2011; Wright et al. 2005). Studies in the United States and Europe have demonstrated the value of having RNs plan and coordinate high-quality chronic disease care in the form of assessment, follow-up and support for behavioural change and self-management (Wagner et al. 2001). Inadequate coordination of care between

7 38 Nursing Leadership Volume 27 Number physicians and nurses potentiates a significant problem in managing chronic conditions, a point worth consideration from the perspective of primary care (Greß et al. 2009). In the United Kingdom, where RNs practise in collaboration with family physicians, success in improving care for people with diabetes was found to be significantly associated with the degree of teamwork (Stevenson et al. 2001). Research has also focused on determining whether the relationship between quality of clinical care and nurse staffing in primary care is attenuated or enhanced. In an observational study, Griffiths and colleagues (2011) confirmed increased quality of care with increased nurse staffing in relation to several conditions, including chronic obstructive pulmonary disease, coronary heart disease, hypothyroidism and diabetes. These authors concluded that primary care settings with RNs performed better than those without RNs. In Canada, the Enhancing Practice to Improve Care (EPIC) project, which studied management strategies to improve primary care in British Columbia, found that collaboration and leadership of nurses was a critical factor, particularly with regard to role clarity and implementing teamwork (Attwell et al. 2012). In a Quebec study, Fortin and colleagues (2010) found that when nurses collaborated with family physicians in the care of patients with multimorbidity, patients expected sharing of information between the providers to optimize care. Family practice/primary care RNs in Nova Scotia reported a high degree of collaboration with family physicians and other healthcare professionals, and acknowledged that collaboration improves holistic care, continuity of care and patient and provider satisfaction (Todd et al. 2007). Data collected by Besner and colleagues (2011) from patients who had received RN services in the primary care setting suggested a high satisfaction rate and increased ability to cope as a result of the nurse patient relationship. Patient satisfaction is a common measure of quality of care. In a cross-canada study, Browne and colleagues (2012) noted a limitation of systematic reviews and analyses of nursing and healthcare system outcomes: research tended to focus too narrowly on the question does it work? rather than on specific provider characteristics, benefits of nursing interventions and cost quantification. Exploring these factors may provide evidence on the outcomes of RN services in primary care settings, documenting the links between the presence of RNs and improved patient health and quality of care. When RNs and family physicians work collaboratively and are readily accessible to each other in a primary care setting, communication regarding patient care

8 The Value of Registered Nurses in Collaborative Family Practice: Enhancing Primary Healthcare in Canada 39 improves. The nurse physician relationship is stronger with effective collaboration and face-to-face communication, together with respect for each other s roles and skill sets. This synergy results in better understanding of the patient s needs, more time for the patient, and consequently improved health and quality of care. RNs and physicians collaborating rather than consulting in primary care makes for greater efficiency in logistics. Providers and patients are under the same roof, improving workload efficiencies for RNs and physicians in a team environment and meeting patients needs in a timely, safe and appropriate manner. The Value of Cost-Effectiveness In a publicly funded healthcare system such as Canada s, everybody benefits from cost-effectiveness. Changing demographics, specifically our aging society, have increased the burden on the healthcare system as baby boomers retire. With people living longer, the prevalence of chronic conditions has increased. In Europe, costs for chronic care have risen such that the ability of the current system to meet future societal demands has been questioned (Greß et al. 2009). PHC s focus on health promotion and illness prevention can alleviate some of the strain on secondary and tertiary care, but such intervention requires time, dedication, skill and resources. RNs, with their diverse skill set and knowledge, may provide cost-effective, high-quality primary care by optimizing patients self-management, thus obviating some of the expense of secondary and tertiary healthcare. The increased use of more nursing-intensive care in prevention and health promotion may not save costs initially, but if improved outcomes are assigned a monetary value, these approaches are likely to be significantly costeffective, with the health gain most evident for high-risk, high-needs patients (Jacobson 2012: v). An Australian government decision was made to invest millions of dollars to employ full-time RNs in primary care in order to ease some of the fiscal burden on hospitals; 58% of potentially preventable hospitalizations were related to chronic disease (Australian Government Department of Health and Ageing 2009). In the United Kingdom, a literature review suggested that collaboration between physicians and RNs might be the most cost-effective investment in family practice development (Rashid 2010). An Alberta study found that the RN skill set in primary care produced the greatest benefit to patients, resulting in a healthier population and reduced healthcare costs (Robinson 2011). The Registered Nurses Association of Ontario has identified the potential cost-effectiveness of apportioning physicians skills such that nurses can appropriately partner with them (RNAO 2012).

9 40 Nursing Leadership Volume 27 Number Developing and providing services in new cost-effective models of healthcare is an initiative in which Canadian RNs should participate in a leadership role (CNA 2009b). In their cross-canada study, Browne and colleagues (2012) concluded that nurses with specialty training, or advanced practice nurses in a complementary role with physicians, created the most efficient nursing model and was more economical than usual care. The Canadian Nurses Association supports this approach and recommends changing the funding of care so that it is funded and structured where nurses lead (CNA 2012). Another cross-canada study found that improving performance in PHC can produce fiscal benefits: improved health results would have positive effects on employment, promoting growth and productivity; even increasing the influenza vaccination rate among the elderly population by 2.5% would result in a possible $16-million reduction in healthcare costs (Dahrouge et al. 2012: 6). Placing greater emphasis on interdisciplinary collaboration involving RNs in primary care is one strategy to improve performance and cost-effectiveness, bringing significant value to a new model of healthcare. Following the Leaders A complex problem requires multiple solutions. In the case of RN participation in family practice, one solution may be found in allied Commonwealth countries. While the healthcare systems of these countries are not perfect, they do offer a model of care that is worth examining, in which RNs play a significant role in leading the way. Looking to the United Kingdom, Australia and New Zealand is a good place to start in facilitating this process and advocating for change on various levels. These countries rate high with respect to PHC performance, and have many years of experience with RNs practising in collaboration with family physicians in primary care. Interestingly, in 2007 New Zealand rated higher than Canada in performance, and had lower health expenditure of $2,454 per capita compared to Canada s $3,895 (Davis et al. 2010). These figures demonstrate the cost-effectiveness of higher-quality care in a model in which RNs practise collaboratively with family physicians. Funding models and incentives have been implemented in the United Kingdom, Australia and New Zealand to support the employment of primary care nurses by family physicians. In 1970 the New Zealand government implemented a practice nurse subsidy scheme that subsidizes 70% of primary care nurse salaries (Hoare et al. 2011). This arrangement may facilitate pay parity between primary care and acute care nurses, excluding shift differentials. As in the United Kingdom, the enrolled population of a family physician practice in New Zealand determines partial funding through a capitation system introduced in 2003 (Joyce and Piterman 2011). This initiative is further to the introduction of primary health

10 The Value of Registered Nurses in Collaborative Family Practice: Enhancing Primary Healthcare in Canada 41 organizations (PHOs), part of the Primary Health Care Strategy (PHCS) initiated in 2001 to support nurses, allocating funding to improve patient access through specific programs (NZ Ministry of Health 2014). RNs played a significant and innovative role in the implementation of the New Zealand PHCS, when the Ministry of Health selected 11 out of 149 PHC innovation proposals submitted by nurses to improve population health (Wright et al. 2005). Evaluation of the initiatives in 2005 highlighted nurses achievements and their confidence in engaging in future PHC practice. Clinical governance has been implemented in the United Kingdom to improve accountability for quality of care, a framework that has positive implications for developing and promoting the nursing profession (Charnock 2001). Australia introduced its Enhanced Primary Care program in 2007, which relates to care provided by nurses (Hoare et al. 2011). Annual incentive payments by the Australian government to family physicians promoting full-time employment of primary care nurses was introduced in 2010 (Joyce and Piterman 2011; New South Wales Nurses Association 2010). In Canada, obstacles remain. Family practice/primary care nurses in Nova Scotia identified challenges in their practice, including lack of remuneration (specifically, inadequate benefits and job security), inability to bill for nursing services through the provincial medical insurance plan and lower salaries in comparison to unionized nurses (Todd et al. 2007). This finding may be related to the highly prevalent fee-for-service primary care model in Canada, indicating that to attract and promote nurses to primary care, we must address the feasibility of remuneration on a par with that of unionized nurses, as well as alternative ways to reimburse family physicians employing nurses in primary care settings. Conclusion Nursing and PHC are indisputably connected by definition. RNs practising in primary care to their full scope of practice can make a significant contribution in collaboration with family physicians and nurse practitioners. Such collaboration between family physicians and RNs can result in improved health and quality of care, and be a cost-effective means of healthcare provision. Issues and challenges exist that may stall timely healthcare reform, but the fact is that the current model is not sustainable. This is no time for nursing, or any other healthcare discipline, to resist change. The nursing profession should assert itself, collaborating collectively with major partners in healthcare. If Canadian nurse leaders look to the knowledge, research and experiential learning in allied countries that have shown leadership and

11 42 Nursing Leadership Volume 27 Number success in PHC, they will be able to innovate and craft primary care nursing practice here in Canada and create a system that will be a source of pride. Correspondence may be directed to: Vicki Kennedy, Royal University Hospital, 103 Hospital Drive, Saskatoon, SK S7N 0W8; tel.: (306) ; vicki.kennedy@saskatoonhealthregion.ca Notes 1. In the discussion that follows, I have used the terms nurse and RN synonymously to indicate baccalaureate-prepared nurses. Acknowledgment I would like to thank Dr. Norma Stewart for her advice and support in the writing of this article. References Aggarwal, M. and B. Hutchison Toward a Primary Care Strategy for Canada. Ottawa: Canadian Foundation for Healthcare Improvement. Retrieved February 23, < Libraries/Reports/Primary-Care-Strategy-EN.sflb.ashx>. Allard, M., A. Frego, A. Katz and G. Halas Exploring the Role of RNs in Family Practice Residency Training Programs. Canadian Nurse 106(3): Annells, M Where Does Practice Nursing Fit in Primary Health Care? Contemporary Nurse 26: Attwell, D., L. Rogers-Warnock and J. Nemis-White Implementing Practice Management Strategies to Improve Patient Care: The EPIC Project. Healthcare Quarterly 15(2): Australian Government Department of Health and Ageing Primary Health Care Reform in Australia: Report to Support Australia s First National Primary Health Care Strategy. Retrieved February 23, < nphc-draftreportsupp-toc/$file/nphc-supp.pdf>. Banner, D., M.L.P. MacLeod and S. Johnston Role Transition in Rural and Remote Primary Health Care Nursing: A Scoping Literature Review. Canadian Journal of Nursing Research 42(4): Besner, J President s Update. The Power of Partnership Charting New Courses for RNs. Alberta RN 61(7). Besner, J., D. Doran, L. McGillis Hall, P. Giovannetti, F. Girard, W. Hill et al A Systematic Approach to Maximizing Scopes of Practice. Retrieved February 23, < Besner, J., J. Drummond, N. Oelke, R. McKim and R. Carter Optimizing the Practice of Registered Nurses in the Context of an Interprofessional Team in Primary Care: Final Report. Retrieved February 23, < Browne, G., S. Birch and L. Thabane Better Care: An Analysis of Nursing and Healthcare System Outcomes. Ottawa: Canadian Health Services Research Foundation. Canadian Family Practice Nurses Association (CFPNA) CFPNA Advocacy Work. Retrieved February 23, <

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