Ontario gives nurse practicioners power to admit, discharge patients.

[ploughboy]

http://www.healthzone.ca/health/newsfeatures/article/971626--ontario-gives-nurse-practitioners-power-to-admit-discharge-patients?bn=1

 

For me, the most interesting line in the article was: “So with that I have a new list, so this needs to continue, and the next (goal) will be RN prescribing.” - Doris Grinspun, Executive Director ONA [emphasis added]

 

 

It's quite remarkable how focused the ONA is on advancing nursing scope of practice.

[Satsuma]

Yes...and then there are those radio ads that keep playing, about how nurses provide the highest value in healthcare - or something along those lines. I've heard it so many times, you'd think I'd know it by heart.

 

I just wonder, why aren't physicians doing any of these public relations campaigns etc. I keep hearing all these ads for nursing, allied health, optometrists...where are physicians in all of this?

[MarathonRunner]

Well, honestly, for some prescriptions, I think it is kinda ridiculous that I need to see a doctor to have them renewed. If I need my birth control pills renewed, or my thyroid medication renewed, and my blood levels are all normal, my blood pressure is normal, and I'm having no issues, than why do I need to see a physician?

 

When I lived in Europe it was great - if I needed a renewal and I was having no problems or issues than the nurse in the front office was able to issue the renewal. If I was having problems or if it was time for my blood work, then I saw the doctor. As a patient, I have to say that system worked great!

 

It's often hard enough to get an appointment to see a family physician. Why not make it easier for patients to get their regular prescriptions renewed?

[obi]

Why not make it easier for patients to get their regular prescriptions renewed?

 

Because it won't stop there. The problem isn't "giving the doctors space to do their real job" its "holy sh!t we don't have enough doctors, whats the quickest way to fix the problem in the short run"

[lostintime]

Well it challenges the whole idea of our training. If nurses can do EXACTLY what doctors can do, then why the hell are we training for 4 years med + 2 years as GP's and 5+ years as specialists?

 

I'm all for shorter training IF the evidence shows that we all don't need that much training to be competent at what we do and to ensure patient safety. Sure, who wouldn't want less training?

 

What I don't get is this two tier b.s. where you get some people with less training doing the same thing as people with more training. What does that say about our training? That it's useless because other people with less training can do the same thing?

 

Sure, some meds perhaps nurses can give. Heck, med students can probably renew. But all it takes is one person to f- up and s.hit hits the fan, and the patient suffers. There are minute details that aren't routinely picked up unless you have the experience/training. And guess what, it's gonna suck when you're that patient who gets screwed over.

 

So the government should make up their mind. Either reduce training for EVERYONE or stop w/ this nonsense.

 

And how exactly does it save money to hire nurses who are paid BY THE HOUR? I highly doubt that's cost effective when they get paid like close to $100k on an hourly wage where they work like what 37.5 hours per work and get 1.5x pay for overtime. Sure, that's going to save SO much $$$.

 

Or who knows, maybe this just means NP's are going to be doing R1/clinical clerk scut work.

[MarathonRunner]

Because it won't stop there. The problem isn't "giving the doctors space to do their real job" its "holy sh!t we don't have enough doctors, whats the quickest way to fix the problem in the short run"

 

But that hasn't happened in other countries.

 

Like I said, in Europe, the nurse was able to renew my prescriptions. I still saw the doctor once a year, for an annual check-up and to have my blood work done. Plus, if I had any issues, I could see him as well. But for normal, regular renewals, it would have been a waste of both his time and my time for me to go in and see him, just to say, "hi, I need my thyroid meds and my birth control pills renewed." If I had any issues or questions, he was more than happy to see me (and he would discuss my thyroid levels via email, which I greatly appreciated, so I didn't have to take time to go in and see him! If my blood work had changed, and I needed a stronger prescription, he mailed it to me, or left it at the front desk with the nurse - again, saving both of us time).

 

Having lived in Europe for a few years I can see that we certainly do some things incredibly inefficiently here in Canada. Letting nurses, NPs or PAs do some of the work that doctors currently do isn't going to destroy Canadian health care. It hasn't in other countries - why would it here?

[lostintime]

But that hasn't happened in other countries.

 

Like I said, in Europe, the nurse was able to renew my prescriptions. I still saw the doctor once a year, for an annual check-up and to have my blood work done. Plus, if I had any issues, I could see him as well. But for normal, regular renewals, it would have been a waste of both his time and my time for me to go in and see him, just to say, "hi, I need my thyroid meds and my birth control pills renewed." If I had any issues or questions, he was more than happy to see me (and he would discuss my thyroid levels via email, which I greatly appreciated, so I didn't have to take time to go in and see him! If my blood work had changed, and I needed a stronger prescription, he mailed it to me, or left it at the front desk with the nurse - again, saving both of us time).

 

Having lived in Europe for a few years I can see that we certainly do some things incredibly inefficiently here in Canada. Letting nurses, NPs or PAs do some of the work that doctors currently do isn't going to destroy Canadian health care. It hasn't in other countries - why would it here?

 

Are those mid-levels also good at detecting subclinical hypothyroidism or asking about side effects and doing a focused physical to test for those things? Sure, I know most GP's don't do those routinely but not every patient is the same and some are on a LOT of meds with a lot of co-morbidities and could benefit from greater evaluation.

 

One of the GP's I worked with said it best, "We know which corners to cut. You guys have to do everything." Yes, because when you don't have experience, when you cut the wrong corners, the patient suffers. Sure, you might do excessive work, but at least that's not harmful. Things may look easy, but cutting wrong corners = bad outcomes if you don't know what you're doing.

[MarathonRunner]

Are those mid-levels also good at detecting subclinical hypothyroidism or asking about side effects and doing a focused physical to test for those things? Sure, I know most GP's don't do those routinely but not every patient is the same and some are on a LOT of meds with a lot of co-morbidities and could benefit from greater evaluation.

 

One of the GP's I worked with said it best, "We know which corners to cut. You guys have to do everything." Yes, because when you don't have experience, when you cut the wrong corners, the patient suffers. Sure, you might do excessive work, but at least that's not harmful. Things may look easy, but cutting wrong corners = bad outcomes if you don't know what you're doing.

 

I didn't say that the mid-levels should do everything. I said that they should be able to do some things, like renew some simple, standard prescriptions when there are no problems. Like I said, in Europe, I still saw my family physician once a year, to make sure that I was on the right dosage of thyroid medicine, etc. But three months later, when I needed the prescription renewed, if I was feeling fine and had no symptoms, the nurse renewed the prescription for me.

 

We need physicians because they are the ones who diagnose and prescribe the right amounts of medications. When a medication change is needed, they are the only ones with the knowledge and expertise to do it.

 

But when I've been on the same dosage of thyroid medication for years, I'm having absolutely no symptoms, and have my blood levels, blood pressure, etc. checked once a year, by the physician, why would I need to see him or her every three months (like I do here in Canada) just to have the same prescription that I've been taking for years renewed?

 

You bet that the moment I'm feeling fatigued, or my skin starts getting dry, or I start losing ridiculous amounts of hair, I want the doctor, not the nurse. And I do want to be checked out by the physician once a year to make sure everything is in order. But having experienced health care in another country, and having experienced care by incredibly talented PAs in the Canadian Forces, I do think we have doctors doing some things that mid-levels, especially NPs and PAs can do.

 

We need doctors. Heck, I'm entering med school to become a doctor. But I don't think we need to have them doing everything that they currently do. And I don't feel threatened by giving mid-levels the scope of practice to do more things that are within their ability to do - especially when those with similar training have been doing so in other contexts (the military, other countries) without problems.

[LeX-]

Pharmacists can just fax physicians for refill requests on behalf of the patient. The physician signs a sheet listing the specific medications that are requested to be refilled, and then this sheet acts as a hardcopy prescription.

 

Not sure why we need nurses to be authorizing prescription refills, unless the pure reason is to bill for a "visit".

[bones]

I just have a quick question re: nurse practitioners who can discharge patients from hospital: if there is a bad outcome as a result of a discharge from hospital, who ends up taking legal responsibility? Is it the nurse practitioner or the 'most responsible physician' who admitted the patient?

 

Does this new legislation allow nurse practitioners to discharge patients independently, without approval (and/or instructions) from the responsible physician?

 

In addition to all of the other points made above re: differences between nurse practitioners and MDs in scope of practice, knowledge base, etc. there is also the issue of ultimate legal responsibility for patients... which, if I understand correctly, currently always falls on the physician's shoulders.

 

This is one of many reasons why physicians spend long years in school, pay high insurance premiums, earn a comfortable salary, etc etc.

 

<apologies if this didn't make sense, I've got exams and LMCC looming and my mind is fried>

[lostintime]

Yea I agree. If they're so into "practicing" independently, they should take the legal responsibilities independently as well. Can't have the cake and eat it too.

 

And I'm not sure about community hospitals, but in academic centres, I've yet to see a NP work on weekends, yet I see residents and physicians discharging/admitting patients left, right, and centre. If they're really that keen, sure, go take all the responsibility and let the med students, residents, and attending all take the weekend off while they admit/discharge everyone. But that would probably crash the healthcare system if they're being paid overtime for all the "call" hours they do that everyone else just does for free or pennies (with the exception of the attending).

[Mandibular]

its because of stupidities like this that current medical students shy away from family practice. what a shame...

There's an article in the most recent "santeinc" where the author compares a GP and a NP based on productivity and cost to the health care system. Comparing apples to apples, NPs cost WAY more than GPs for the same amount of work done!!!

 

http://www.santeinc.com/indexfr.htm

 

Just click on the third article in the most recent issue. It's in french, but there's a summarizing board with all the numbers i

[Satsuma]

It's often hard enough to get an appointment to see a family physician. Why not make it easier for patients to get their regular prescriptions renewed?

 

Pharmacists can already do this. I've had pharmacists renew stuff several times. fyi, in case you ever need something and your fam doc is not available.

[taiga gal]

The reality is the NPs are useful in some really rural areas where GPs/doctors are scarce .

 

the reality is that RN's not NP's or MD's are the front line health care providers in rural and remote Canada. In fact NP scope of practice originated with these RN's who have to deal with a myriad of issues, both emergent and chronic.

 

re salary, besides Nunavut, I make the highest wage as an RN in Canada, it ain't anywhere near 100 K even if i chose not to have a life and worked OT. but maybe for an NP?

 

there are some good points here to reflect on.

[NLengr]

I like the NP concept. They can be a good value to the system, if used correctly. For example, at my centre, several depts don't have any residents. As a result, the attending were having to do all the floor scut during the day, which cut into clinic/OR time. Now there is an NP who basically works like a junior resident and handles the routine floor work. The attendings are only needed if something weird is going on PE, strange infection etc.

 

It's a good system. I will say however, the NP works hard and isn't One of those nurses who's main priority is to make sure break is well planned out and happens at exactly the right minute.

 

As for regular RNs prescribing, it makes me uncomfortable for anything stronger than Tylenol. Yes there are some great nurses I have worked with who I would trust with the privilege, but the majority I have worked with don't have the skills or knowledge related to diagnostics and treatment to be able to do the job.

 

Honestly if we are gonna give a mid level prescribing ability make it the pharmacists.

 

Oh yeah and family practice? Your watching it either die, or undergo a radical transformation.

[coastalslacker]

Mid-levels are inevitably coming and I think it's a good thing. I've seen PAs and NPs used with tremendous efficiency in the US - there's no reason we can't do that here. My experience with nurse practitioners in my own hospital has been varied. Some are excellent - some are absolutely terrible (as in they contribute absolutely nothing - residents complain, Social Work complains, nurses complain, and they sit back and rake in 100k).

 

As a surgeon, I'd love to have a mid-level as my surgical assist in the future as opposed to a family physician. This is a potential area of huge savings. We have family docs paid tonnes of money to assist on surgeries when all you really need is somebody with reasonable hands who can follow instructions. Doesn't have to be an NP or PA either, even they have a superfluous amount of learning for what is required of them.

[bloh]

And this is why we have a shortage of family physicians. Why go into family med when the government highlights the fact that you'll be on the same level as a nurse?

[SolitaireAddikt]

Oh yeah and family practice? Your watching it either die, or undergo a radical transformation

 

Will Family Medicine really die out if nurse practitionners are given more power? I'd imagine that their role would be similar to what MarathonRunner described seeing in Europe- nurses refill prescriptions allowing GPs more time to deal with more serious issues. I really see myself going into Family Med, so I would be curious as to why you think it may be a dying field.

[apache]

i agree, i think it's a good idea for the basics. similar to the legislation that pharmacists here can prescribe/renew prescriptions, but with restrictions

 

Well, honestly, for some prescriptions, I think it is kinda ridiculous that I need to see a doctor to have them renewed. If I need my birth control pills renewed, or my thyroid medication renewed, and my blood levels are all normal, my blood pressure is normal, and I'm having no issues, than why do I need to see a physician?

 

When I lived in Europe it was great - if I needed a renewal and I was having no problems or issues than the nurse in the front office was able to issue the renewal. If I was having problems or if it was time for my blood work, then I saw the doctor. As a patient, I have to say that system worked great!

 

It's often hard enough to get an appointment to see a family physician. Why not make it easier for patients to get their regular prescriptions renewed?

[NLengr]

I also said it could be a radical transformation. The healthcare team concept similar to Europe or the trial clinics in Ontario is where we are going I feel. Nurse or NP handles BP checks, OCP renewals etc. Physician handles acutely ill people, or people who need more in depth reassessment (for example a nurse notices poor BP control over the past few visits, poor asthma control etc.). You might have a dietician or a PT in the office too.

 

If we are just going to make nurses like cheap family docs with inferior training, then family med will die. Physicians won't go into Family med and the govt will actively try to undercut it for the assumed cost savings.

[SolitaireAddikt]

I also said it could be a radical transformation. The healthcare team concept similar to Europe or the trial clinics in Ontario is where we are going I feel. Nurse or NP handles BP checks, OCP renewals etc. Physician handles acutely ill people, or people who need more in depth reassessment (for example a nurse notices poor BP control over the past few visits, poor asthma control etc.). You might have a dietician or a PT in the office too.

 

If we are just going to make nurses like cheap family docs with inferior training, then family med will die. Physicians won't go into Family med and the govt will actively try to undercut it for the assumed cost savings.

 

Thanks for the clarification.

[NLengr]

The only problem is that med student won't see it that way as GPs in such an environment would get paid less. Regardless, I would never go to an NP for anything unless I identified the problem first. I've volunteered in an emerg dept. ad I've seen nurses (with lots of experience) brush a lot of things off only to have the physician not agree.

 

 

Why would they get paid less? They'd still see a full patient list, it's just they would be less routine f/u type stuff. They could easily remain salaried (ehich is becoming an ever increasing portion of family docs, or they could be FFS especially if the fee schedule was set up correctly.

 

The throughput on the entire clinic would be higher too since you have multiple people working.

 

As for NP's they are qualified and safe to work inside thier scope of

practice. Multiple studies show that. Plus an NP is not the same as a regular nurse.

[leviathan]

This is one of the reasons why family med is not high on my list although it used to be. Even naturopathic doctors can prescribe medications and order investigations (that they have no idea the indications for or how to interpret) in BC.

[gb35]

I really hope FM doesn't die out. It's kind of my dream career. But I can definitely see a system where FM works together with NP, PT, and dietitians to greatly increase the quality of primary care, and decrease the burden on ERs and specialists.

[lostintime]

Meh unions decrease efficiency in this country. But that's another story/topic lol. I mean, you can really still have SAFETY but not necessarily all this "I'm on my 15 min break now so too bad if the patient has to wait". And it's not even level playing ground since only CERTAIN people in the population are part of unions like teachers, nurses, TTC workers lol.