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Focus10-a3.inddCentre for Rural and Northern Health Research
Ontario’s Primary Health Care NPs
Primary Health Care Nurse Practitioners (PHC NPs) A Profi le of PHC NPs
are registered nurses (RNs) with advanced knowledge and decision-making skills and the legislated authority Who are they?
to perform an extended role. They offer comprehensive primary health care to individuals across the lifespan and practise in a variety of settings. The care they offer includes communicating a diagnosis, prescribing certain Their average age was 46 years, with the majority drugs, and ordering certain diagnostic and laboratory between 46 and 55 years of age (41%) and between 36 tests. Since 1998, PHC NPs have registered with the College of Nurses of Ontario as members of the Extended • About 70% had an NP certifi cate from one of the ten universities in the Council of Ontario University The number of PHC NPs has been increasing steadily in Programs in Nursing (COUPN) or equivalent, and Ontario. This publication reports fi ndings from a survey 22% had a master’s degree in nursing.
of PHC NPs conducted in 2008. The survey is part of an • On average, respondents had worked as an RN for 17 annual (2006–2010) tracking study of NPs employed in years, as an RN[EC] for 6 years, and in their current the province. The results are based on 378 respondents, a sample representing 53% of all PHC NPs in Ontario in 2008.
Where are they?
Besides the core tracking questions about employment and practice characteristics, the 2008 survey asked • Survey respondents practised across all 14 Local about PHC NPs’ relationships with their collaborative Health Integration Networks (LHINs) in Ontario, with physicians and other health care professionals, barriers the largest number in the North East (54) and the to their diagnostic and prescriptive authority, and their smallest number in the Central West (fewer than 5).
is based on Primary Health Care Nurse Practitioner Tracking Study: The 2008 Survey Report by Oxana Mian, Irene Koren, and Raymond W. Pong of the Centre for Rural and Northern Health Research, Laurentian University.
The authors are grateful to the Nursing Secretariat of the Ontario Ministry of Health and Long-Term Care for funding the research, the College of Nurses of Ontario for assisting in identifying the study population, and the Primary Health Care Nurse Practitioners who participated in the study. The interpretations and conclusions expressed here are those of the authors and no endorsement by the Ministry or the College is intended or should be inferred. • Almost 40% of PHC NPs’ practices were located outside large urban areas, whereas only 20% of Ontario’s general PHC NPs’ Main Practice Settings
population live there. 35% of respondents practised in by Percentage (n=378)
communities with a population less than 25,000.
• About one third of respondents worked in multiple Physician’s offi ce / Family practice unit locations (on average, three locations per week), with most of these reporting an average travel time of 20 minutes or less between work locations.
Employment status and remuneration
• 80% were employed full time, 15% worked part time, and about 3% were self-employed or had casual employment. Approximately 20% of the respondents’ • More than 80% earned an income of over $80,000. Most of the 7% earning less than $60,000 worked • 72% of the PHC NPs earned a salary, while 26% were paid an hourly wage. More than 70% reported a salary increase in the last two years.
Percentages do not add up to 100 due to rounding.
• More than half (55%) reported that the Ontario • The most often mentioned client group was the Ministry of Health and Long-Term Care (MOHLTC) “typical” family practice clientele (74%), followed by funded their main NP position through their low income earners (62%), the unemployed (50%), employer. A further 29% reported that MOHLTC • The average clientele consisted of adults (43%), • About 70% of survey respondents planned to stay in seniors (25%), infants and children (16%), and their current position for the next fi ve years. They adolescents (14%). Three-quarters of the respondents cited several positive aspects of their work, including had clients from all four age groups.
excellent team work, work satisfaction, commitment to their clientele, and ability to work to the full scope • Over a typical month, PHC NPs spent on average 77% of their work time on direct patient care. The rest of their time was spent on teaching (6%), non-nursing • Three-quarters of the 27% who planned to leave their tasks (6%), nursing administration (5%), research current position in the next fi ve years said they would be seeking another PHC NP position. They hoped to move on to a more challenging job, a more supportive Time Spent on Direct Care Activities During an
work environment, or a higher salary.
• Among the most valued employment incentives, PHC NPs listed higher salaries, fi nancial support for continuing education and professional development, and better non-fi nancial benefi ts, such as extended health plan.
Work profi le
• The surveyed PHC NPs estimated they had on average 13 face-to-face appointments and four telephone consultations daily. Fewer than 5% provided online consultations. About 13% had on-call responsibilities Ontario’s Primary Health Care NPs: 2008 Update Percentage of PHC NPs Who Rated Their Relationships with Various Health Care Providers
as Positive, Needing Work, or Not Applicable (n=378)
No t spe ci fi ed
No t app li cab l e
Needs w o r k
Po si ti ve
Ot he r
A lli ed
So c i al
Men t al
Ph y s i c i an s
he al t h
w o r k er s
he al t h
ou t s i d e
w o r k er s
p r ac t i c e
Relationships with Other Health
Asked to choose among strategies to improve Care Professionals
interprofessional relationships, 31% of the PHC NPs selected “enable RN[EC]s to work autonomously/to full scope of practice” and 29% chose “increase mutual Almost a quarter (23%) of the PHC NPs’ clients came respect, trust and communication between members of directly to the NP without a referral. Others were referred different professions.” Respondents added suggestions, by family physicians (29%), RNs (12%) and other health including: reduce legislative barriers, promote the NP role within the health community and increase public When clients’ health care needs required care beyond awareness, increase multi-disciplinary education and PHC NPs’ scope of practice, NPs collaborated with interaction, encourage interdisciplinary team building, family physicians or referred clients to other health care and pay specialists the same fees for referrals from NPs providers. On average, the surveyed PHC NPs provided care for 80% of their clients with little or no physician consultation. The other 20% consulted with an average of about four physicians each. Most (87%) spent less Prescribing and Diagnosing
than two hours per week consulting with their main collaborating physician. They typically felt that they had PHC NPs are legislated to prescribe only those drugs, diagnostic tests or laboratory tests that are on one of three provincially regulated lists. Respondents estimated More than 75% reported high or total satisfaction with the that on average they could not order about a third of relationship with their main collaborating physician. Most drugs (e.g. warfarin, antidepressants, ventolin) and agreed that the physician with whom they worked most about a quarter of diagnostic and lab tests (e.g. some often understood the NP role (87%), that the physician X-rays, bone mineral density tests, ultrasounds, PSAs) supported them to work to their full scope of practice that they judged their patients needed. In these cases, (93%), and that collaborative relationships had improved they had to seek the signature of their collaborating with time (92%). PHC NPs estimated that they made on average 9 referrals during a typical week (numbers ranged from 0 to 50).
Many respondents described how the current legislation caused challenges and frustrations in their day-to-day Fewer than 5% of respondents reported refusal of their practice. The drug list was described as “very limiting” referrals of clients to family physicians, social and mental and “inconsistent.” One third of those who commented health workers, and allied health workers. However, more said that the current drug list prevented them from than half (56%) said their referrals to specialists were not practising to their full scope. Others said that waiting accepted by the specialists; they were sometimes accepted for a physician’s signature was time-consuming and only if co-signed by the collaborating physician. About ineffi cient, or that it took too long for new drugs to be half said that their relationships with specialists “need added to the list, thus preventing NPs from meeting work.” As well, 20% thought that relationships with RNs current best practice standards. Some expressed required improvement. Many felt that the PHC NP role frustration caused by limits on initiating, renewing, or and scope of practice were generally poorly understood by adjusting dosages of medications commonly used to Ontario’s Primary Health Care NPs: 2008 Update 3 Similar comments were made about the restrictions on Retirement Plans
diagnostic and laboratory tests, and how they limited PHC NPs’ scope of practice and autonomy and created Only six PHC NPs among those who responded to the survey planned to retire within a year at the time of the survey. On average, PHC NPs wanted to retire at age Although collaboration with physicians and medical 60 but expected to retire at 62. Younger PHC NPs were directives were helpful in dealing with challenges around more likely to want and expect to retire at a younger age prescriptive and diagnostic authority, many thought those were only partial solutions. More profound legislative changes were deemed necessary.
About half of the surveyed PHC NPs would delay retirement for fi ve or six years if such incentives as increased salary or fl exibility in work arrangements or part-time work were available. About 40% said their [My job is] “wonderful, fulfi lling, challenging.” spouse’s retirement plans would affect their own: some would retire at the same time as their spouse, others [I hope our role] “continues to progress and would stay on for fi nancial reasons.
“Tremendous energy is being spent on fi ghting the Concluding Notes
“Family Health Teams are a great concept for • Many of Ontario’s PHC NPs work in towns and small primary care delivery, but a big barrier is the cities. They work in a variety of settings, some of incentives bonus the MDs receive for the work which are new (e.g. NP-led clinics).
the PHC NPs do. This payment model is not constructive for team building.” • Among the challenges for PHC NPs are barriers to practice to a full scope and a lack of familiarity with “What I do is appreciated and extremely needed NP practice among other health care providers.
or my patients would be without health care, but the present restriction of prescribing and ordering • There is a need to examine the variety of models of diagnostics tests is beyond frustrating.” of NP practice, of their implications for practice organization, and ultimately their impact on health “Amongst fi ve full-time NPs we manage the care of 8,000 patients who are orphaned. If recognition of the real scope of practice we experience [in the North] could be realized, it would be much better for client care.” Research in FOCUS
Centre for Rural and Northern Health Research
for Rural and Northern Health Research (CRaNHR), Laurentian University. Each issue is a summary of a study conducted by CRaNHR researchers. As a form of knowledge dissemination and transfer, it is intended to make research accessible to a wider Ontario’s Primary Health Care NPs: 2008 Update
De LA BOURBOULE à LA LECHERE Le Congrès du SNETAA s’ouvre, ce 21 mai 2007, à LA LECHERE, en Savoie, station thermale, située en basse montagne, accueillant les personnes d’un certain âge souffrant de troubles circulatoires ou de rhumatismes. Il est vrai que ses eaux sont également efficientes pour qui souffre de troubles gynécologiques. Or, il et bien connu que la gente féminine e