Expanding health care options

Nurse practitioners help fill MD shortage void

Barry Gerding/Black Press Vernon Jubilee Hospital nurse practitioner Kathy Lepp.

Nurses are trained to care for their patients, but not to encroach within a doctor’s realm of making a diagnosis or deciding treatment options.

But with the introductory regulation of Nurse Practitioners in B.C. back in 2005, the scope of nursing has evolved.

Like all registered nurses, Dana Jones was ingrained with the traditional role of a nurse in her university training, and carried that forward working at a Downtown Eastside clinic in Vancouver and then enhancing her primary and acute care skills working at Vancouver General Hospital’s emergency department.

“I just found that kind of nursing wasn’t my thing. During my emergency hospital training, I always wanted to follow up with patients admitted to the hospital. I like that care aspect of relationship building,” Jones recalled.

She took on an opportunity to work in clinics at Inuvik in the Northwest Territories and remote aboriginal communities in northern B.C., where a nurse’s traditional scope of care was expanded.

“You would follow set algorithms of what medications someone with certain symptoms can be prescribed, but you made the decision whether it was needed or not,” Jones said.

“It opened up a whole new world of learning for me. When training as a nurse, it is drilled into you that you don’t make a diagnostic assessment, that is the role of a physician and outside of your scope.

“So after that experience, coming back home to work in primary care and not being able to give out Tylenol without a doctor’s approval became challenging for me.”

Today, Jones is part of a fraternity of 66 nurse practitioners (NPs) working within Interior Health operating a health care practice in Kelowna—the Rutland Aurora Health Centre—as a family MP with her clinic partner Pamela Klassen.

Since moving to Kelowna in 2013, she has built up a patient roster of 600, largely based on health care service referrals, but is now taking on self-referred patients who qualify for NP care.

Currently, it is estimated some 30,000 people in Kelowna don’t have a family doctor.

To book an appointment with Jones, a patient can’t already have a family doctor, must live in the Central Okanagan area (Peachland to Lake Country), and face chronic or long-term care issues such as high blood pressure, diabetes, drug addiction, mental health concerns or infectious diseases such as hepatitis.

Kathy Lepp began as an NP in several resident care facilities in the North Okanagan, before taking on a new role as a hospitalist NP at Vernon Jubilee Hospital last year.

Unlike Jones, Lepp works within the confines of the hospital. Her involvement with patients begins and ends at the VJH.

Her role is partly a reflection of an increasing number of family physicians withdrawing from their hospital privileges to focus their attention on their medical practice.

“When patients leave, I sometimes get asked if I can see them on an ongoing basis but that’s not my role here,” Lepp said.

All NPs are trained to provide clinical care that includes diagnosis and management of disease/illness, prescribe medications, order/interpret laboratory/diagnostic tests and initiate referrals to specialists.

Within that context, the ministry of health describes NPs as embracing a holistic view of health care, addressing the physical, emotional and social aspects of a patient’s health care needs.

“You see health care from both the perspective of a nurse and a doctor in this role which offers a challenge to enlarge my knowledge to a fuller capacity,” Lepp said.

And working in a hospital environment, she adds, offers access to a wide range of health care experts, further enhancing a collaborative process of delivering health care.

“The ultimate goal for me is to provide good quality patient care, to optimize their rate of recovery and either see them released and back home or transition into residential care,” Lepp said.

Jones says the traditional paradigm of training doctors to identify and treat diseases is changing as new physicians today are being taught to build a rapport with patients and understand how economic, social and lifestyle background issues can contribute to a person’s health outlook.

“It takes time to build a trusting relationship and educate someone on how to control their diet or address lifestyle issues that are contributing to their health issues, and NPs are in a position to do that.

“My goal for someone with diabetes is not to manage your diabetes but for you to manage your diabetes. I can provide the information you need to know and guide you through the health care system, but I can’t make decisions for you.

“If you need to quit smoking or change your diet, it’s ultimately up to you to accept and make those changes in your life, and that often takes time and numerous visits to get that win.”

Story of interest: Role of nurse practitioners continues to expand

Donna Mendel, director, advanced nursing practice for IH, says with NPs now being in B.C.’s health care system for more than a decade, the benefits are starting to become more evident both by overworked GPs and patients.

“We are pleased to see that happening,” Mendel said. “The demands of the health care system ask us to look at all service providers and find new ways to optimize the scope of what they can do, whether they be physicians, NPs, social workers, therapists or registered nurses.

“We are seeing that right now in terms of improving primary care outcomes.”

Dr. Alan Ruddiman, president of the Doctors of BC association, said doctors value the role and contribution of NPs, but don’t believe they are the answer to the doctor shortage in B.C.

“We train about 288 doctors a year in B.C. but research tells us we need that to be about 450 physicians a year to replace doctors who retire or move elsewhere,” Ruddiman said.

He said his association believes the highest quality of care for patients is derived from various health care service providers working in a collaborative team effort with medical doctors.

Story of interest: IH board chair applauds expanded role of nurses

Jones also acknowledges that NPs are not the solution to the current shortfall of access to family physicians in this province, saying the current health care system is broken and needs to transition into new ways of delivering services and educating the public to better look after themselves.

“If you promote a healthier lifestyle—stop smoking, alcohol consumption and get more exercise—you get better health outcomes. But to do that requires time and intense rapport-building and coaching with patients, and our health care system doesn’t do that.

“If people quit smoking and exercised regularly, it would reduce acute care admissions by half to most hospitals.”

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