Abstract
Nurse practitioners are becoming familiar figures on the Canadian health care scene. Now licensed in all provinces and territories, the workforce doubled from 800 in 2004 to 1,626 in 2008. 1 Despite the growth and evolution of the profession, there is some lingering confusion about when and where they are qualified to work and the quality of care they can provide. A perception exists that seeing a nurse practitioner instead of a doctor is second-class care, best suited for times and places where a doctor is unavailable.
Research suggests otherwise. There is a large and growing body of evidence that shows nurse practitioners deliver care as well as their physician counterparts – sometimes more effectively. And while the autonomy of and substantial overlap in scope of practice between the two professions is recognized as occasional sources of tension,2,3 there are examples of effective collaboration.4,5
Nurse practitioners in Canada
Nurse practitioners first appeared in Canada in the 1960s in response to shortages of primary care physicians in rural and remote areas. They were the subject of renewed interest in the 1990s, as part of efforts to improve access to primary health care in a context of deepening shortages of doctors as well as growing demand for services arising from older Canadians, chronic illnesses and mental health problems.
Nurse practitioners work in settings such as community health centres, home-care agencies, northern health centres, public health units and family practice units or physician offices and, more recently, in long-term care settings and emergency departments. They are trained and educated to conduct health assessments, perform a variety of medical procedures, prescribe drugs, and diagnose and manage common illnesses and injuries through ordering and interpreting diagnostic tests. 6 They also have expertise in health promotion and preventive care. Because they have comprehensive skill sets and may cost the health system less than primary care physicians,7,8 nurse practitioners are often a component of primary health care reform strategies. 9 For example, in order to increase patient access to primary health care, clinics are being developed with physicians functioning primarily in a consulting role to the nurse practitioner. 10 In British Columbia, nurse practitioners have been integrated into traditional fee-for-service practices. In Ontario, 26 clinics led by nurse practitioners are being introduced in communities with physician shortages.
Tried and true
Since a pioneering study of nurse practitioners in Burlington, Ontario, in 1974, 11 at least 28 randomized controlled trials have been conducted, predominantly in the USA, the UK and Canada. These studies have consistently shown that nurse practitioners are effective, safe practitioners and can positively influence patient, provider and health-system outcomes. A 2002 review of scientific studies compared nurse practitioners and physicians providing first-contact care to patients in primary health care settings and found that patient health outcomes were equivalent. 12 Nurse practitioners tended to spend more time with patients and order more tests, but no differences were found in the number of prescriptions, return visits or referrals to specialists.
The evidence that nurse practitioners are making a difference in the Canadian health care system is accumulating. One study found their inclusion in primary health care teams in four different primary health care models in Ontario was associated with high-quality chronic disease management. 13 In addition to improved patient outcomes, one Canadian study found when nurse practitioners were added to an emergency department, patients were more than twice as likely to be seen within wait-time benchmarks, their length of stay was cut in half and the proportion of patients leaving without being seen was down by one-third. 14
The proof is in the patient
The patient's perspective is critical when it comes to health care. The previously mentioned 2002 review of studies found that patients who saw a nurse practitioner reported higher levels of satisfaction and better quality of care in comparison to the care provided by physicians. 12 Studies also indicate that patients appreciate their communication style and the extra time spent.15,16 Patients tend to be more satisfied with the type of advice provided, too. 17 For example, nurse practitioners tend to ask more questions and offer more information and options than physicians.
A growing body of evidence suggests Canadians are highly satisfied with care provided by nurse practitioners. A 2009 Harris/Decima poll of 1,000 Canadians 18 found that:
one in five has been treated by a nurse practitioner; a majority would like to see the role expanded; greater than three in four would be comfortable seeing one in lieu of their family doctor and; four in five feel that expanding their roles would be an effective way of managing health care costs (although it should be noted that there is a paucity of evidence on their cost-effectiveness relative to physicians in Canada).
Given public calls for increased access to care, reduced wait times, and more services related to the ageing population, chronic illnesses and mental health problems, nurse practitioners have the potential to contribute significantly to the improved delivery of health care in Canada.
Disclaimer
Mythbusters articles are published only after review by experts on the topic. CHSRF is an independent, not-for-profit corporation funded through an agreement with the government of Canada. Interests and views expressed by those who distribute this document may not reflect those of CHSRF.
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