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Research and job description can benefit all provinces & territories

By Kathleen Bykowski, Tammy O’Rourke,  & Donna M. Wilson
March 21, 2022

Primary care is typically described as the first point of contact individuals make with the health-care system when they require health services (Starfield, Shi, & Macinko, 2005). Access to readily available primary care providers is associated with positive health outcomes, higher rates of preventive care, and lower health-care system costs (Canadian Institute for Health Information, 2016). However, not all Canadians have equal access to this important service.

In Alberta’s Rural Health Services Review, Albertans living in rural communities described accessibility to primary care as one of their most concerning issues. Alberta is not the only Canadian jurisdiction facing this concern. Adequate access to primary care is an issue for rural residents in all provinces and territories.

Significant evidence suggests that primary care access could be improved through the expanded use of nurse practitioners (NPs) in rural communities. Some provinces, such as Ontario and BC, have started using NPs more widely to support improvements in the delivery of primary care in both rural and urban settings. However, poor understanding of the NP role remains a persistent barrier to having NPs practising independently in rural primary care settings.

Poor understanding of the NP role remains a persistent barrier to having NPs practising independently in rural primary care settings.

Helping understand the NP role

To address this lack of understanding and provide clarity about the role of NPs, we created a knowledge synthesis of published literature (peer-reviewed documents) and grey literature (legislative acts, regulations, and remuneration documents) and drafted a comprehensive role description.

The knowledge synthesis and role description that follow can be used to advance the hiring and integration of NPs in rural primary care settings. The synthesis and description provide health-care organizations, governments, and communities with clear direction on the hiring and use of NPs in primary care settings, consequently improving access to primary care services for individuals living in rural Alberta. This valuable contribution can be used by other provinces and territories, as all parts of Canada have rural communities at risk for inaccessible or inadequate primary care services (Statistics Canada, 2021).

Knowledge synthesis: 5 themes

1. Benefits of NPs in rural primary care settings
   1. Individuals who have a consistent primary care provider are more likely to receive comprehensive health care.
   2. Primary care practices are embracing diverse care providers.
   3. NPs make autonomous decisions for a wide range of health conditions.
   4. NPs utilize expert medical knowledge, in conjunction with a holistic nursing approach, to support the provision of comprehensive, patient-focused care.
2. Benefits of a clearly defined role
   1. Enables patients to be informed about the specific roles of their health-care providers.
   2. Improves cohesiveness of the multidisciplinary team.
   3. Eliminates role confusion that leads to incomplete role implementation.
   4. Ensures a better understanding of the holistic model to help prevent the biomedical model from taking precedence.
   5. Reduces the potential for variability in NP practice.
3. Practice characteristics of NPs in rural primary care
   1. Independently perform comprehensive health assessments, diagnose common problems, develop treatment plans, and prescribe medications.
   2. Perform a variety of clinical skills, including abscess incision and drainage, skin suturing, nail reduction, lab and imaging interpretation, casting, and pelvic examinations.
   3. Support health promotion activities such as education and screening patients for disease risk factors.
   4. Order necessary investigations to confirm or reject their differential diagnoses, such as electrocardiograms, urinalysis, cholesterol, and hemoglobin.
   5. Coordinate and provide referrals to other health-care professionals as required.
4. Government and NP regulations in Alberta
   1. Under the Health Professions Act, NPs are advanced registered nurses who provide restricted activities as authorized by the College and Association of Registered Nurses of Alberta (CARNA).
   2. NPs in Alberta are experienced registered nurses with a minimum of a master’s level education.
   3. NP scope of practice in Alberta includes advanced health assessment; diagnosis; ordering and interpreting diagnostic tests; prescribing pharmacotherapy, treatment, and advanced interventions; monitoring client outcomes; follow-up care; and consultation and referrals.
5. Compensation and remuneration of NPs in Canada
   1. Recommended salaries for a full-time NP ranged from $103,000 to $135,000 in Ontario, British Columbia, and Saskatchewan. Benefit packages cost an additional approximately $28,000.
   2. Primary care networks in Alberta are supported by the provincial government, which allocates funding of $125,000 annually for an NP.
   3. The cost of an NP (salary plus benefits) is less than the basic fee-for-service schedule under the Alberta Health Care Insurance Plan.

Suggested role description: rural primary care nurse practitioner

Purpose

• Provide comprehensive primary care to rural communities, including health promotion, disease prevention, and management of acute and chronic disease.
• Advocate for individuals and empower patients to achieve their optimal health and well-being by using the principles of primary health care as a foundation of practice.
• Increase access to consistent primary care services by independently carrying a caseload of approximately 800 patients.

Salary, work hours, and benefits

• Approximately $125,000 salary plus $28,000 benefits cost.
• Full-time position (1,926.4 hours per year).

Education and licensing requirements

• Registered nurse with a minimum of a master’s degree in nursing.
• Active registration with CARNA as a nurse practitioner or graduate nurse practitioner (NP or GNP).
• Practice with accordance to Schedule 24 – Profession of Registered Nurses under the Health Professions Act.
• Perform restricted activities as per the Government Organization Act, in conjunction with the College and Association of Registered Nurses of Alberta Restricted Activities Standards.

Clinical responsibilities

• Perform physical examinations and comprehensive health assessments.
• Perform health histories, as indicated, that include personal and family history, sexual history, health habits, stressors, genetics, and risk factors.
• Screen patients for disease risk factors and early signs of illness.
• Make differential diagnoses based on history and assessment.
• Order or perform investigations to rule out or support differential diagnoses.
• Provide low-risk prenatal obstetric care and healthy newborn care.
• Provide pharmacological and non-pharmacological therapies, as well as education on the rationale, cost, adverse effects, and contraindications of therapies.
• Assess and provide treatment for acute episodic illness, such as earache, sore throat, musculoskeletal injury, fractures, or lacerations.
• Based on patient response, prescribe, titrate, or discontinue medications as appropriate for treatment of chronic illness, such as hypertension, diabetes, or asthma.
• Provide treatment — including but not limited to education and counselling, psychotherapy, medication prescription, and referrals to other care providers and facilities as appropriate — for common mental health concerns,.
• Perform invasive and non-invasive procedures including, but not limited to, abscess incision and drainage, arterial blood gas collection, suturing of lacerations, wart removal, skin biopsy, foreign body removal, nail reductions, and orthopedic casting.
• Provide family planning and contraceptive services, including Papanicolaou smears, diaphragm measurements, and intrauterine device insertion and removal.
• Order and interpret diagnostic imaging, including plain radiographs, computed axial tomography, magnetic resonance imaging, ultrasound, and mammography.
• Order and interpret laboratory investigations such as electrocardiograms, urinalysis, cholesterol, and hemoglobin.
• Complete driver medical examinations and necessary forms as required by the Alberta government.
• Collaborate with other health-care professionals to ensure comprehensive care and follow-up care, as required.
• Provide referrals to multidisciplinary health-care providers including, but not limited to, family physicians, specialty physicians, occupational and physical therapists, speech-language pathologists, pharmacists, dietitians, psychologists, counsellors, recreation therapists, and social workers.
• Provide education on medications, nutrition, growth and development, sexual health, stress management, injury/illness prevention, exercise, tobacco cessation, and screening self-examinations.
• Recognize signs and symptoms that require emergent intervention and consultation.

References

Canadian Institute for Health Information. (2016). Primary health care in Canada: A chartbook of selected indicator results. https://secure.cihi.ca/free_products/Primary%20Health%20Care%20in%20Canada%20-%20Selected%20Pan-Canadian%20Indicators_2016_EN.pdf

Starfield, B., Shi, L., & Macinko, J. (2005). Contribution of primary care to health systems and health. The Milbank Quarterly, 83(3), 457–502. https://doi.org/10.1111/j.1468-0009.2005.00409.x

Statistics Canada. (2021). Rural Canada statistics. https://www.statcan.gc.ca/en/subjects-start/society_and_community/rural_canada

Kathleen Bykowski, RN, BA, BScN, is a master’s of nursing student at the University of Alberta.

Tammy O’Rourke, BS/MS, NP, PhD, is a nurse practitioner and an assistant adjunct professor, Department of Family Medicine, University of Alberta.

Donna M. Wilson, RN, PhD, is a professor in the Faculty of Nursing, University of Alberta.