Part nurse, part doctor, no job
By Richard Watts, Times Colonist March 11, 2010
Nick Fitterer is a UVic student in the masters program to become a nurse
practitioner, but government policies have made it difficult to find work.
Most recently graduated nurse practitioners are working as registered
nurses, a job they are over-qualified for.
Photograph by: Debra Brash, Times Colonist
University of Victoria master's degree student Nick Fitterer is just months away
from graduating as a nurse practitioner, and is anxious to get out in the
community treating patients in his role as part-nurse, part-doctor.
But Fitterer, a 32-year-old father of two, is caught in what even health officials
admit is a conundrum. He's studying for a job that is supposed to be the next new
trend in health care, yet he'll have a hard time finding work because the system
hasn't kept pace, and doesn't have any spaces for him.
"Everything about [becoming a nurse practitioner] made sense. It was logical. I
thought there would be a need for it. But politically speaking, we've hit a bit of
wall," he said.
Nurse practitioners were first recognized in B.C. in May 2005 through changes to
the provincial Health Professions Act. They are registered nurses who have a
bachelor's degree in nursing and have worked for at least two years, then
returned to university for two more years to earn a master's degree.
The extra qualifications put them a step above RNs, but not on par with a
general-practice physician. They can prescribe most medications, but not
narcotics and botox, can deal with most common ailments, and can order most
tests and x-rays.
The position was touted as an effective way to deliver primary health by taking
over some of the duties now mostly delivered through GPs, who are in short
supply.
According to 2008 data from Statistics Canada, 132,000 British Columbians don't
have a general practitioner, or about four per cent of the population age 12 and
over. A 2009 study by Victoria-based Hollander Analytical Services Ltd. found
that patients with chronic diseases who don't have family doctors cost the health
system nearly three times more than those who don't. For example, diabetes
patients without a general practitioner cost the health system on average
$17,000 a year, compared to $5,900 for those who see their doctor regularly,
says the study.
But the concept of nurse practitioners has failed to catch on enough to absorb
the numbers who are graduating, leaving many out of work, or forced to work as
registered nurses -- jobs for which they are overqualified.
"There is a big need there and we could make a dent in that need, if we could
just go to work," said Lynn Guengerich, president of the B.C. Nurse Practitioners'
Association.
According to Guengerich, 179 nurse practitioners held active licences in B.C. as
of September. But about 50 are looking for a job or are working below their
qualifications. She said those figures show six nurse practitioners were working
in private practices with doctors, one was employed by government, and 117
were attached to various health authorities.
Meanwhile, the combined universities of Victoria, B.C. and Northern B.C. are
graduating about 45 nurse practitioners every year.
The province supports the idea of nurse practitioners -- it set aside $62.7 million
for health authorities to fund the positions between 2005 and 2010 -- and says
they can offer substantial savings in primary health care. On average, a nurse
practitioner in B.C. makes $119,000 a year, compared to $98,411 for a registered
nurse, and $247,517 for general practitioner (from which office rent and staff are
paid.)
Yet the Ministry of Health agrees the health-care system isn't quite sure how to
make best use of nurse practitioners' skills. In a prepared statement, the ministry
said that "because the nurse practitioner role is very new in our province, the
ministry and health authorities are building innovative models to support
placement of nurse practitioners."
One hurdle for nurse practitioners is that while the legislation allows them to treat
patients without direct supervision by a physician, they are not allowed to bill the
Medical Services Plan on a fee-for-service basis, like doctors.
That means nurse practitioners can't hang up their shingles and start seeing
patients in their own private practices -- they either have to work in a practice
alongside a doctor, or in a clinic funded by a health authority.
But without the fees paid for their services, few practices can support nurse
practitioners.
So that takes the nurse practitioners back to the health authorities, which
concentrate the biggest portion of their resources on hospitals, leaving little for
clinics offering primary care. According to the Vancouver Island Health
Authority's 2009-2012 service plan, more than $900 million of its $1.7-billion
budget goes to acute care, compared to just $58 million to population health and
wellness -- the money that would be used for nurse practitioners.
"It's a bit of a conundrum," said Victoria Power, director of primary health care
and chronic-disease management for VIHA.
Indeed, of VIHA's more than 17,000 employees, there are only 17 nurse
practitioners -- they work in urban clinics like the Access Health Centre at 713
Johnson St., and in clinics in smaller communities like Cortes Island and at
Mount Washington.
It's a different story in Ontario, where government policy has pushed harder with
a variety of funding models to get nurse practitioners into the system since they
were first recognized in the 1970s.
Paula Carere, president of the Nurse Practitioners' Association of Ontario, said
about 1,600 are now registered in Ontario. They work in a variety of clinics,
providing primary care, and their salaries -- $87,000 to $89,000 -- are paid
directly by the Ontario Ministry of Health. They can work on family health teams
with doctors, in nurse practitioner-led clinics and in community health centres, set
up to tend those who traditionally find themselves without a family doctor, like
immigrant populations or the mentally ill.
Carere said the Ontario government is so committed to nurse practitioners, it
plans to increase the numbers of nurse practitioner-led clinics from 11 to 25
within the year. "It's very interesting to watch the momentum," said Carere. "It's
kind of exciting here."
The Ontario experience is encouraging for people like Dr. Rita Schreiber,
program co-ordinator for UVic's nurse practitioner program, who believes it's only
a matter of time before B.C. follows suit.
"We are only five years into this project," said Schreiber. "It can be expected that
we would have bumps in the road.
"We just push forward and say what needs to happen and it will eventually
change. And it will because logic does win out occasionally."
rwatts@tc.canwest.com
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