..by Terrance Hunsley
This article has been excerpted from a paper prepared in my PhD studies at the U.ST Paul/U. of Ottawa School of Social Innovation. (At the age of 75, I decided I was mature enough to settle down and complete my studies.)
Holding a key to a vital public need, restrained by political and bureaucratic inertia and elite hegemony, caring for people who love them and desperately need them, are nurse practitioners (NP’s). With a little extra training in geriatrics, and a major expansionary program of “training up” registered nurses to become NP’s, they could take over primary health care for seniors, providing an elegant solution to an emerging crisis, and also reduce some pressure on provincial health budgets. They have the track record to prove it, and they can be trained up in a very short time (about two years). And there is a large supply of RN’s available for training.
Nurse practitioners (NPs) are advanced practice nurses who integrate clinical skills associated with nursing and medicine in order to assess, diagnose and manage patients in primary health care settings and acute care populations, as well as ongoing care for populations with chronic illness. (CNA, 2022)
Just what older people need. NP’s have been recognized and formally trained in Canada since the 1970’s. They were hired by governments to provide services in remote or depressed areas where doctors did not want to go, or occasionally by doctor clinics who extend their roster of patients by incorporating NP’s into their practice.
The work of NP’s has generally been recognized as exemplary. Within their scope of practice, which covers the majority of primary care needs, they provide service on a plane with general practitioners. They can do this because primary care only rarely demands the complexity of knowledge that physicians may acquire from extended years of training. NP’s work for just over half the cost of doctors, and can be trained at less cost. But they are only practicing to the full scope of their capacity for the most part, in remote areas or specialized clinics.
In 2016, Freakonomics did a podcast on nurse practitioners in the USA, reporting that many studies have shown that both client satisfaction and health outcomes have been equal or higher with NP’s than with MD’s, while NP’s cost about fifty percent less. A comment from the podcast, about the confidence that the public has in nurses in general:
For 15 years straight, nurses have topped the Gallup Poll list of professions that Americans say are most honest and ethical. Last year, nurses got an 84 percent approval rating. The next closest: pharmacists, with 67 percent, and then doctors, with 65. (Freakonomics, 2016)
So why are nurse practitioners still fringe actors in a health care system which needs them?
Enter the state. In the global capitalist system, the liberal-democratic nation state treads a tender line among competing interests to deliver social services which respond to broad public needs while not disturbing existing power balances. Tending to the health of the population is one of those areas which serves all, but wherein there is constant tension among the providers, between the providers and public, and among all stakeholders, including capitalists. When the needs of the public expand “out of proportion,” privatisation and individualization of risk is possible, but so, hope the nurses and NP’s, is transformative change.
Emerging from an Oppressed Profession
Although there are male nurses, it has historically been a primarily female role. The word “nurse” related originally to nurturing a baby, a pretty basic form of production of human capital, we might say. Raising children, nursing them through illness or injury acquired in their play and competitions, caring for the sick and elderly, dressing the wounds of the warriors.
In Plato’s Meno, Meno attempts to define “virtue” for Socrates:
Let us take first the virtue of a man-he should know how to administer the state, and in the administration of it to benefit his friends and harm his enemies; and he must also be careful not to suffer harm himself. A woman’s virtue, if you wish to know about that, may also be easily described: her duty is to order her house, and keep what is indoors, and obey her husband. (Plato, 380BCE)
In contrast to nursing origins, the medical profession grew from philosophy and theology as a scientific practice. It dates as far back as Greece, 300-400 BCE, when Hippocrates established a medical school. The Romans adopted Greek medicine when they became dominant in the region and spread it throughout the empire. (Britannica, n.d.) They began to build hospitals, and the practice was taken up by Christian churches. From its earliest days, Christianity encouraged its devotees to tend the sick, and this was a major factor in its expansion. Priests were often also physicians.
… The Protestant reformers, led by Martin Luther..closed convents, but local officials recognized the public value of hospitals, and some were continued in the control of local governments. (Toman, 2007)
Of course, local government, like church leadership, was still a work of men. Nurses were trained on the job in the hospitals and were often not paid until they proved their competency. It was a very practical arrangement, and served as a model for nurses’ training into modern days.
In 1874 the first formal nursing training program in Canada, inspired by Florence Nightingale, was started in Ontario. Programs spread with hospitals across the country. Then came military duty and a boost for nursing as a profession:
… When Canadian nurses volunteered to serve during World War I, they were made commissioned officers … so that enlisted patients and orderlies would have to comply with their direction. They were often close to the front lines, and the military doctors – all men – delegated significant responsibility to the nurses because of the high level of casualties, the shortages of physicians, and extreme working conditions… (Toman, 2007)
History shows they earned their stripes. Physician and nurse professions thus have different roots, one in science and competition; one in care and nurture. And for the most part, the early patterns have persisted:
As with other female‐dominated service occupations, nursing work is socially constructed as relational, altruistic and maternal, whereas men are more likely to work in roles that are professionally competitive, self‐interested and oppositional… The feminist standpoint challenges those power relations and resulting domination… (Gullick, Accessed 2022)
NP’s as a modern social innovation
In the 1970’s the nurses associations in the country convinced universities to introduce training for nurse practitioners. It was good timing for the innovation. The welfare state in Canada and elsewhere had undergone three decades of incremental growth. The middle class was flourishing. Labour organizations held political power. Feminist and other equality-seeking groups were gaining ground. Women were pouring into the labour market and the professions. Medicare had been introduced in the late ’60’s, and demand for primary care had ballooned. Nonetheless, the Registered Nurses Association of Ontario report that NP training was discontinued.
Early research into the role demonstrates that patient satisfaction with NPs is high and that they provide primary care as safely and effectively as physicians. In spite of this, NP educational programs were largely discontinued in the 1980s due to: a lack of support from the medical community; the perceived threat of the role to the livelihood of physicians; and the absence of the appropriate regulation and legislation to guide NP practice. (RNAO, 2022)
In the 1980’s and ’90’s the development of community health centres to serve disadvantaged population groups, encouraged a restart. The federal government had also established nursing stations in the north. Nurses in these stations were often practicing without doctors, and working beyond their normal scope of practice. And in the USA, NP’s were gaining ground:
…in 1981, the Office of Technology Assessment… (reported that)…NPs provided equivalent or improved medical care at a lower total cost than physicians. NPs … decreased the cost of patient visits by as much as one-third, particularly when seeing patients in an independent, rather than complementary, manner… In 2009, the total tuition cost for NP preparation was less than one year’s tuition for medical (MD or DO) preparation. (AANP, 2013)
In 2007, the Government of Ontario decided to establish 25 Nurse Practitioner-Led Clinics (NPLC’s) with the first in Sudbury in 2009. The number has changed only marginally since, although the evaluations have shown positive health outcomes, patient satisfaction and cost savings. NP’s are also finding jobs in specialized settings such as mental health outpatient centres, sexual health and opioid clinics.
The emerging crisis and potential for social transformation
Canada is viewing an approaching demographic tsunami with mounting numbers of seniors and consequent pressures on health care systems. The result of vast improvements in our population health and longevity, we have seen it coming for decades. The National Institute on Aging (NIA, 2020) tells us that the current 17-18% of the population that are seniors will grow to about 25% by 2035. Seniors use a lot of health care, and the older they get, the more they use. According to the Conference Board of Canada, average annual spending on health care is about $12,000 per person 65+; about four times that for younger people. (Outlook, 2018) The cost goes up with age, and seniors 85+ are the fastest growing population group. The cost of their care will triple over the next three decades, and that is only if we can provide them access to high quality primary care and home care. Otherwise it will go higher through emergency services and institutional costs. Older people see their doctors much more often, so not having a doctor is serious, because it results in higher cost treatment for maladies that could have been prevented or ameliorated.
The pandemic triggered a tragedy among seniors in residential care. The crowded conditions and substandard care, of which providers and governments were well aware, resulted in 16000 deaths. But showing they can act quickly when motivated, an early Ontario government response was to put into place legislation (Bill 218) which would protect government and providers from being sued for negligence, unless gross negligence could be proven, and that the provider had not made a “good faith effort”. (Downey, 2020)
All while the workers, many of them new immigrants and women, were being exploited, underpaid and deliberately kept in precarious work arrangements for the sake of high profits. (Hunsley, 2021) The public is now demanding improvements in health care quality and availability, and in the employment conditions of health care workers. Improving their wages and getting rid of substandard care wards will be expensive and will add to the existing projections of cost increases.
But the pandemic has also transformed another known problem into an emerging crisis. People who need care will not be able to find it. Doctors, nurses, and other health care workers are burning out from the stress and bad working conditions and are retiring, or moving to other jobs, just when their numbers should be expanding rapidly. Health human resources systems are not supplying enough replacements, let alone expanding the capacity of the system.
There was already a shortage of primary care physicians, and they are not trained in geriatrics, unbelievable as that may seem. The National Institute on Ageing (NIA) tells us that there are just over 300 geriatric doctors in Canada, for a population of over 6 million seniors, compared to about 2800 pediatricians for 8 million children. What is even more difficult to believe,
… No Ontario medical school, for example, currently offers core training in geriatrics, but every school offers core training in pediatrics despite that the majority of patients in the health system are likely to be older people. (National Institute on Ageing, 2020)
The new doctors also don’t take the large caseloads that the older ones did. A physician recruiter for medical clinics told me that new primary care doctors will generally take about 1000 patients where the older ones (some of which were paid partially based on the number of patients on their roster) might take 2000 and more. “And”, this person said of the new doctors, “they don’t want to serve seniors. They require too much time.” As the Ontario Medical Association puts it:
Even before the pandemic, there were long wait times to see specialists and access critical diagnostic tests, treatment and surgeries in the province. At least one million Ontarians don’t have a family doctor and can’t get the treatment or preventive care they need. …Plus, the pandemic caused 20 million health services, including doctor visits, surgeries, diagnostic tests, etc to be missed, and 40% of Ontario doctors to consider earlier retirement. (OMA, 2022)
At the time of writing, the shortage in health care personnel has made few headlines, but it soon will become evident. So far however, governments have not significantly expanded nurse-practitioner deployment for primary health care, despite the potential to save money and improve service by doing so. Old people who need geriatric primary care – care which is team-based, preventive, which monitors their multiple chronic and episodic illnesses – who would love to get care from them; can’t. They are told instead to get into their automobiles and drive to a clinic where on each visit they may discuss with a doctor, one symptom. One symptom. Which ache shall we discuss this month? Forget diet, exercise, loneliness, depression, confusion about medication, perhaps even confusion to get in the car and drive to the doctor. Forget that funny lump on the skin. Get something prescribed for the most painful problem.
And to add to a critical situation… even with the heavy demand on health care professionals, people who remain in their homes instead of institutions, in other words, the vast majority of elders – receive far more care informally, by friends and family, than from the formal system. MacDonald, Wolfson and Hirdes indicate that informal care amounts to about triple the combination of public and privately funded care:
Overall, home care hours provided by all three sources are projected to more than double by 2050 – from approximately 300,000,000 unpaid, 70,000,000 publicly-funded and 30,000,000 privately-paid hours in 2019, to approximately 645,000,000 unpaid, 150,000,000 publicly-funded and 75,000,000 privately-paid hours in 2050. (MacDonald, 2019)
Informal caregivers, most often women, despite – and because of – wanting to provide the best care possible to a loved one, often pay an enormous personal price in time, effort, emotional and physical stress and financial loss. Health Quality Ontario had already documented that 44% of home care clients with informal caregivers (meaning almost all) report their caregiver experiencing distress, anger or depression. (HQO, 2019) And the tsunami is just forming. The older group, who need care, are increasing faster than the younger group who provide the informal support. And governments wanting to avoid providing institutional care will push even more responsibility onto the informal caregivers who will be providing care to people with even more complex and demanding care needs. This multi-dimensional crisis will take a serious toll on Canadian society.
Another crack in the present system has been exposed by the pandemic. Hospitals and institutions with patients can’t operate without nurses. But for many years hospital and health system administrators have hired the minimum number of nurses required by regulation, and have regularly pressured nurses to work overtime and long work shifts to avoid having obligations to more than the minimum number.
In a 2009 Report the Canadian Nurses Association predicted that Canada could see a shortage of 60,000 full-time nurses by 2022. Tim Guest, president of the association, said that estimate is based on a number of factors, including retirement projections, and doesn’t account for the impacts of the pandemic. (Current, 2022)
In the USA, when the pandemic burned out nurses and ICU’s were overcrowded, a substantial number of nurses decided to become “travelling nurses,” essentially, temporary contract workers. (New York Times, 2022) Suddenly, many hospitals were forced to pay three or four times the normal salary to get a nurse to sign on. Soon, recruitment agencies started offering nurses inflated salaries or per diems to move to another location. Nurses are finding that they can call the shots, and can decide what hours and what days they wish to work. Nurses with intensive care specialties were in the lead, but the option seems to be opening up for others. So nurses acting en masse, or as individuals in a market that was so fragilely constructed and now is fractured, can exercise substantial market power. Nurse practitioners may very well find themselves in a similar situation, as the pandemic has literally knocked many physicians out of the market.
What might NP’s do to improve their situation?
NP’s should and probably have asked nurses’ associations to support a drive to achieve a billing code to permit them independent operation. They could also be negotiating directly with medical associations to develop an approach acceptable and advantageous to both. A classic class compromise, where NP’s gradually take over geriatric primary care while physicians become more specialized and are available for consultation, might be workable. NP’s are making some progress on this in the USA.
Physicians’ career interest in geriatric medicine continues to wane at a time when the health care needs of older adults are increasing… Nursing graduate school programs are preparing adult-gerontology primary care nurse practitioners . (Golden, Accessed 2022)
The nurses associations must also push for a major increase in training spaces and locations for residencies, both for nurses and for NP training. The need for both is obvious. They should also facilitate faster assessment of nurses with international qualifications, as there are many of them working for sub-professional pay in personal support worker positions. And they need to ask for a large improvement in their pay and working conditions, so that all health care workers can be appropriately paid. In other words, the nursing profession needs to get its act together.
To support the success of whatever plan they choose, the nurses should launch a large-scale promotion of their role and potential, drawing on their professional and commercial networks to support them.
The public is very supportive of them, and this support can be mobilized, especially in seniors’ organizations, which are becoming actively involved in health care. There is going to be a large increase in health care spending, and it is important that the pubic understand that health care is one of the best industries that society could be investing in. It has great economic and social benefits. It provides good jobs. It can even be an important part of a “green shift” to an ecologically-sustainable society. The USA already spends about fifty percent more on health care than we do. It makes up about 16% of their GDP, and the economy thrives from it. It is more than fifty percent private, where ours is about 30% private, but the important point to underscore is that the economy and society benefit from it, regardless of how the investment is made. The difference between public and private domination of health care is in the distribution of costs and benefits through the population.
Options for the Health Care System:
A NP that I spoke with told me that NP’s in Ontario have for the past two years, had scope of practice approval to do pretty much anything a physician can do in primary care, including diagnosis, ordering of special tests, and prescriptions. However, they are not permitted to order CT Scans and MRI’s because that technology is regulated by a different Act, and the government has not gotten around to amending it. Public service bureaucracies do not move quickly, and substandard services can be barely visible, as was proven when it took a pandemic to expose the mess of long term residential care.
With income-tested care, a two-tier health system could emerge. For example, in Alberta a large private firm (Telus) is hiring physicians on salary, matching them up with nurse practitioners, and offering the public a higher quality primary care with rapid access to specialists. There is a substantial extra cost, through a new private insurance offering. (Tyee, 2022) This appears to be a clear violation of the Canada Health Act, but the province may very well be willing to stare down the federal government on it, or may not even have to, as both governments may soon be in panic mode. The potential for adding a private tier to primary care is present, albeit the public might well rise up in defence of medicare.
Expanding the doctor supply (especially for geriatrics) is another option. Medical associations are becoming more supportive of this, especially as shortages become evident and the spectre of competition from NP’s emerges. But as we saw earlier in the NIA report, physicians like to be specialists, and family physicians don’t want to serve geriatric patients. And with a horizon of ten-fifteen years to achieve a major supply increase, the crisis will not be avoided. There have been efforts to import more doctors from abroad, and with some success, but not enough to substantially change the current situation.
The government could expand the NP supply and give them the same billing rights as doctors. This would permit a proliferation of new clinics and practitioners, although it might not respond directly to the shortage of geriatric care if NP’s had the same choices as doctors. It is also likely that this option would face a wall of physician opposition.
But giving billing codes to NP’s specific to delivery of geriatric care might work. The government could also decide to hire many more NP’s on salary and have them work out of community health centres and hospital clinics doing geriatric outreach and care. The same training efforts would be required. It might require a rethink of the role of community health centres, and there would be concerns about burgeoning bureaucracies, but it could be a way of coordinating primary care with home care and a community focus.
The expansion of NP supply could also incorporate collaboration agreements with MD’s. As the demand for MD’s to do geriatric primary care would decline, there would likely be take-up of collaboration agreements, including by some doctors entering retirement. As in the earlier option, a billing code for geriatric care could be issued, but with attractive consultation fees for physicians to be “on call” when NP’s might want a second opinion.
The above options could also be combined with maximizing telehealth/telemedicine virtual services, with a NP or nurse available for home calls, geriatric assessments, preventive care, etc. Doctors could be available for certain cases by a virtual linkage, perhaps with technology which might also transmit diagnostic information (such as “bluetooth stethoscopes”). An important advantage to this kind of service would be an ongoing linkage to home care and related support services, as well as to informal caregivers. This would also permit the province to embed the management of home care in primary care where it should be, instead of being administered by a separate bureaucracy.
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Thanks for drawing attention to this significant gap in our health system.
It is getting increasingly difficult for anyone to find a regular MP; it is long overdue to expand and elevate the roles of Nurse Practitioners. Is it not almost racist to say they are “good enough” for remote areas where doctirs are not available?