Editorial
August 2009

Recently I spent 10 days in Vancouver, Canada specifically to look at the development of the nurse practitioner role there.  It was a fascinating week made even more delightful by the fact that it was of course very warm and sunny with daylight until about 9.30pm.  Given our current winter conditions it was real break!

The health system in British Columbia Canada is reasonably similar to that of New Zealand with regard to the funding and structure of primary health care (PHC) services but they have much more recently implemented a PHC strategy; about 2006 as opposed to 2001 in NZ.     Large sectors of the population in British Columbia are unable to access a General Practitioner and can only attend casual walk in clinics staffed by general practitioners providing cursory attention to the presenting problem.    Just as in NZ the demographic data shows that the level of the General Practitioner workforce is unlikely be sustained even at present low numbers.

The duration of implementation of the nurse practitioner role is comparable  (last 6-8 years) but British Columbia has proportionately more NPs in positions than we do in NZ.   I visited with faculty from the University of British Columbia, which has had a nurse practitioner program for several years.   The curriculum for nurse practitioner preparation is (as it is in NZ) a 2 year masters degree with relatively similar content.   Differences however are of interest and include:

• a much stronger focus on links to the clinical environment with active preceptoring in formal clinical placements of long duration.  In addition there is a stronger focus on procedural competence in course and clinical work.  They are far more focused on teaching and supervising skill as well as knowledge development.

• there are only three scopes of NP practice in BC;  family, adult and child.  The vast majority of candidates enroll in the family practice scope and all candidates are strongly prepared for a primary health care service delivery.  I did observe though that some candidates who had prepared in the family practice scope had effortlessly transferred to quite different roles; one in chronic pain care and one caring for a population of people recovering from severe trauma.
  
  
• the requirement that the students are enrolled full time for the 2 years thus supporting the arrangement of clinical placements to align with course work.  Students bear the cost of fees and unemployment for 2 years.    Most students are comparable to NZ students in that they are predominantly women who have been in the workforce for some years.  As in NZ they have significant uncertainty of employment once authorized so I found it quite amazing that so many students were prepared to make this level of sacrifice.

While I was there the OSCE  (Objective Structured Clinical Examination) testing
was being conducted.    In British Columbia the nurse practitioner candidate is authorized (following successful completion of the masters degree) through OSCE testing conducted in two batches a year.  The Nurse Regulatory Board oversees the examination and examiners are currently US licensed NPs although the intention would be to utilise Canadian NPs when there are sufficient with experience.    What is interesting about the OSCE is its highly objective nature and the fact that it focuses intensely on clinical skill and knowledge and does not privilege those who are able to write and speak with greater ease.  Having said that however NPs that I spoke to felt that while it was a safe and very effective model, there was further work to be done in translating what has essentially been a medical model of testing into a more nurse friendly process.  No-one wanted anything removed but they felt some additions could capture nurse specific characteristics of care.

During my visit I met with Barbara Mildon (Director of Nursing: Fraser Health) and talked with Linda Laechenko (Director of Nursing: The Interior).  Both have been responsible for NP position creation in BC and both have battled with funding structures, which directly challenge NP employment as they do in NZ   Both directors have however been allocated significant one off funding to construct the roles which do exist and which are directly responsible for the employment of 165 NPs in Vancouver and beyond in wider BC.  There are currently no suggestions to extend this process and no real attention to sorting the main stream funding processes which could facilitate greater use of NPs  ( sounds familiar!!).

I met with 10 NPs and visited 6 of them in their practice environments.  Without exception I was deeply impressed by their vision, expertise and the nature of the service they had crafted for specific populations.  Amongst the NPs I met an NP who is employed specifically to be the sole primary health care provider for about 600 Farsi speaking refugees who are largely young adults or children and have a very high incidence of post traumatic stress disorder.  Their only other option for service is the walk in clinics, which have 5 minute doctor appointments and that is the only option for the remaining 1000 of this population who she cannot enroll due to lack of staff and resource.  This NP had hired Farsi speaking interpreters and a social worker.  She had formed a relationship with a local pharmacy that was compounding products, which her population trusted for pregnancy, birthing and other problems.  In partnership with local community members she was conducting health education sessions.  With an NP student from UBC and a child health RN she was seeing these people with very complex needs for all presenting medical and health problems including antenatal care.  Of interest is the BC system that antenatal care is provided by GPs or NPs until 24-28 weeks when the woman is handed over to specific maternity providers.

I met an NP who is employed to provide full primary health care services to a large Punjabi Indian population with mental health and addiction problems and very high levels of diabetes and cardiovascular disease.  She too had instigated a huge range of community partnered health education endeavours and provided a weekly radio show and newspaper column which were accessed by the Punjabi population from all over Canada.  Again this was in addition to providing the full range of what we would call general practitioner services to this population.

In contrast I met an NP working in a private general practice taking enrolled patients from a diverse population.  Of particular interest was her energetic collection of outcome data and as an example she was able to demonstrate outstanding drops in HAB1c levels for people with diabetes.  Her GP colleagues made a special point of meeting with me to express their huge support for the model of care she provided and also expressed how much more satisfactory their own work experience was now that they could afford to spend more quality time on more complex medical problems.  This is of huge interest given the current drive by the RNZCGP (see recent NZ Doctor July 1st) to protect the need for GPs in NZ to have a primary contact and relationship with all presenting patients.

At the Maxine Wright centre for women living with violence and with addiction problems I met a wonderful NP providing full primary health care services and antenatal care to these young women and their babies and children.    Of note was the environment of the clinic, which included the daily serving of a free healthy lunch and a huge amount of parenting and child rearing education.  In addition cupboards of clothes and child resources were made freely available through relationships established with other community providers.

Meeting these NPs and observing their practice was extremely confirming of the model of NP practice as a transformative form of health service delivery.   The addition of previously designated medical skills to a nursing approach to primary health care resulted in services, which provided improved access, excellent outcomes and very community centered care.   In addition the simplicity of areas of practice was quite compelling given our current debates in NZ.

Of the 35 or so NP candidates sitting the OSCE while I was there only 1 had guaranteed employment despite the vast areas of unmet need in Vancouver alone.
It is an irony that just as in NZ, those supporting the development of NPs are having to battle medical resistance (although there were pockets of very strong support where doctors had actually worked with an NP) and the persistence of tedious bureaucratic, legislative and funding barriers to full utilisation of this valuable health workforce.   Imagine if one could actively measure for example the downstream consequences and costs of providing walk in clinic care to the 1000 refugees with complex health needs as opposed to providing NP led primary health care for them.     This trip has certainly refocused my energy in striving to have the NP role fully established in New Zealand.

Prof Jenny Carryer
Executive Director