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Serving communities well?

Debate rages over the role of nurse practitioners

Mike W. Bryant
Northern News Services

Yellowknife (Dec 10/01) - For decades now, nurses have been the primary caregivers in the North.

Necessity demands it. The isolation, lack of physicians and resources, have all contributed to a working environment where nurses are often all that stands between providing care and having no care at all on the front lines of community medicine.

NNSL Photo

Nurse practitioner students Kathleen Matthews (left) and Jane Brebner demonstrate an ear examination procedure -- just one of many tasks performed by nurses on the frontlines of community health care. - Mike W. Bryant/NNSL photo

Yet, now that a nurse practitioner program has begun at Aurora College, there is a fear -- as one Newfoundland doctor put it -- that a "grey area" may be settling in on the field of community health care.

Newfoundland is important because it is the province on which the NWT has based its nurse practitioner program.

Dr. John Hagg, a surgeon practicing in Gander, says it is a question of scope. Since the first batch of Newfoundland nurse practitioner graduates took to the field in 1998, doctors there have wondered whether it is appropriate for nurse practitioners to be used as physician replacements.

"They are very much a mixed blessing," said Hagg. "What they really are like what they had in China 20 years ago, when you had the 'bare foot doctor,' going around doing a few simple things, but not fully-trained as physicians."

Hagg said some Newfoundland doctors feel a year-long course, mostly taught by other nurses, does not provide enough training to nurse practitioners, who perform a myriad of tasks traditionally associated with physicians. They prescribe antibiotics, order X-rays, perform diagnoses, among other duties.

Even though they are covered for liability under the Newfoundland Health Act, Hagg said there is some anxiety among physicians that nurse practitioners may be tempted to work outside the guidelines set out for them.

"We've had a lot of trouble in central and Northern Labrador where a nurse practitioner's signature appears under the family doctor's name," said Hagg. "Our legislation requires that a nurse practitioner has a collaborative relationship with a physician, but that doesn't always happen."

Madge Applin, executive director of the Centre for Nursing Studies in Newfoundland, said the outcry of some physicians in the province against nurse practitioners is based more on hubris than legitimate concerns.

"That's a bit of a scare tactic, which is not valid," said Applin. "We have regulations in place."

She pointed out that the nurse practitioners training program was approved and reviewed by medical experts from outside of the province, and has received largely positive reviews by both the government and the public.

However, the questions raised by some Newfoundland physicians have not gone unheard in the NWT.

NWT Medical Association president Dr. Ken Seethram wonders why GNWT's department of Health and Social Services would approve a nurse practitioner program without having legislation in place.

"We still haven't seen any written case law or any case opinion from the Department of Health and Social Services, or even at a national level, that with this type of model says we're (physicians) actually well protected," said Seethram.

"There's not many physicians willing to lose house and home over someone else's mistake."

What makes the whole situation problematic, said Seethram, is that physicians are currently legally responsible for the treatment primary care givers provide in remote communities, even when the doctor is not present.

The worry is that if a patient decides to sue for malpractice, the family physician responsible for that region could be sued for any mistakes a nurse practitioner might make if he or she were to act beyond their scope of practice.

Like Hagg, Seethram questioned the lack of physicians teaching the nurse practitioner program at Aurora College. A doctor currently sits with the college's advisory committee, but there are no full-time physicians teaching the course.

"They haven't come through with a number of criteria to meet our approval," said Seethram.

"They need to have proper accreditation. They still haven't told us what board, if any certified board, will be accrediting the program."

And even if physicians were requested to teach the program, with only 50 physicians in the NWT and who are facing an ever-increasing workload, they do not have time or manpower to teach the course, said Seethram.

Aurora College in Yellowknife initiated a nurse practitioner program last September. There are currently three registered nurses taking the 16-month course at $1,500 a semester.

As for Seethram's concerns over training at Aurora College, health programs instructor Pertice Moffitt said it is not necessary for there to be full-time physicians on the faculty.

It is still essentially a nursing program and any area where a physician or pharmacologist's expertise is needed, one is hired to teach that relevant part of the course.

"What we're doing is educating nurses in the area of health promotion, health prevention, and health treatment," said Moffitt. "The goal is to protect the public. You want educated nurses out there."

Moffitt reiterated the fact that nurses have been working in an extended capacity in the North every since they began to arrive 50 years ago or more. The sole purpose of having a nurse practitioner training program is to legitimize what they have been doing all along.

It is anticipated that a bill outlining the scope under which nurse practitioners can work will be introduced in the legislative assembly in February.

Dr. Andre Corriveau, NWT chief medical officer and assistant deputy minister for the department of health and social services, said the real problem is that even with legislation in place, it is still unclear what would happen if a patient treated by a nurse practitioner were to sue for malpractice.

There is simply not enough of a precedent that can be referred to. As of yet, there have been no malpractice cases filed involving nurse practitioners anywhere in the country.

"I'm not trying to say they (physicians) don't have a legitimate concern," said Corriveau. "It is a bit of an unknown."

Corriveau added that there is not only a great deal of overlapping of duties between nurses and physicians, but between general practitioners and specialists, hospital administrators and surgeons, and so on.

The scope of a nurse practitioners role can be defined by legislation, but there are no guarantee that any one party can be assessed the blame in entirety if anything were to go wrong.

Regardless, the three NWT nurse practitioner students at Aurora College are set to complete the course in December 2002. All of them have extensive experience working in Northern communities.

Kathleen Matthews has been a registered nurse since 1985. In the last seven years, she has worked in several Northern communities, including some on Baffin Island, Rae Lakes, and Rae-Edzo.

All she wants to do, she said, is serve the communities well.

"I felt the need for more education, because that type of nursing requires a very expanded role," said Matthews.

"I want to provide the best patient care I can."