The expanding scope of nursing
By Allison Flynn
The integral role nurses play within the Canadian heathcare system is rapidly evolving. Their responsibilities are expanding and their roles are becoming more and more varied. As McGill’s School of Nursing gets ready to play host to a major conference to explore the obstacles and successes in implementing role change and expanding the scope of nursing, the Reporter sat down with Dr. Hélène Ezer who explained some the changes and how the School of Nursing is charting new directions.
There are some complex shifts reshaping health care today. Demographic changes, people living longer, changes in family composition…all of this putting pressure on an already strained system. How is the profession of nursing adapting?
Nursing has moved with the changes right from the very beginning and has been a major player in charting new directions – nurses have had to roll with the punches.
What are some of the main issues facing nurses today?
Their work has become much more complex with much pressure on the system to provide care. The number of patients nurses can handle on a daily basis has decreased because patients leave hospitals earlier and the ones who remain are the very ill. There is a limit to the caseload of seriously ill patients that nurses can safely carry. As a result, there aren’t enough nurses to handle those numbers.
The shortage of nurses has been a big factor in actually stopping things from being done sooner. Many of the delays in providing care in hospitals are related to the lack of nurses able to look after the patients.
Nurses need a comprehensive education to handle the complexity of patients who are gravely ill and to help them and their families find ways of managing with their disease. No matter what kind of training any health professional has, there will be a period in which you need concentrated, hands-on experience to develop the clinical judgement needed to provide safe care. This means that nurses cannot simply be “parachuted” from one unit to another, and staffing becomes a big issue.
What about these new, advanced nursing roles?
There is a broad range of nursing roles and responsibilities, both in hospitals and community- based institutions. Nursing roles have multiplied and the scope of nursing practice has increased. Many of these new roles have a particular focus – for example with parents and newborn babies, in mental health or home dialysis – and nurses become highly skilled in working with special populations.
In Quebec, one of the more recent and best known roles is that of the “infirmières pivot,” nurses who have an expanded scope of practice in helping cancer patients, not only at the time when they’re receiving treatments in hospital, but afterwards when they go home. This is a coordination and follow-up role that has been invaluable to these patients, to their anxious family members and to the other practitioners who are also working with them.
Tell me more about the Nurse Practitioner (NP) programs.
These programs are relatively new for Quebec. They were first created in specialty areas – neonatology, cardiology and nephrology – to alleviate the demands for specialized care. The newest of the NP program is in Primary Care. It is an attempt to meet the population needs for front-line health care as well as the management of chronic illness. The NP role has been a long time coming in Quebec. There is now a growing understanding of the potential of this role in improving care. The intention of the Minister of Health is to have 500 or more Primary Care NPs across the province in the next five years.
This is a frontline care role?
Yes. These NP’s do initial patient assessment; evaluate and treat minor issues and manage chronic problems. They have expanded responsibilities that allow them to order tests, to prescribe and adjust certain medications. At the same time they continue to do all the things nurses normally do – evaluating the health and physical status of a patient, listening, explaining, getting resources in place and helping patients and family members manage their everyday challenges.
NPs alleviate the demands on the system. They can deal with isolated everyday events like urinary tract infections or upper respiratory infections – problems that do not need specialized attention.
Another contribution is in helping people manage with chronic illnesses. This can be very time consuming for busy family physicians. In fact, nurses are often better at managing the day-to-day issues related to these cases than physicians are. The physicians are focused on making sure the treatment protocol is what it should be, and the “living with it” is a nursing responsibility.
How are patients responding to these nurses?
They love it. Somebody’s listening. Somebody’s asking questions. You get to tell your story, the whole story – not just where the pain is.
Is the NP program helping with the shortage? Is it attracting more nurses?
At the very beginning there was a lot of hesitation and scepticism but that is rapidly changing. In areas like neonatology, there is a small pool for recruitment because you don’t just pop into these high specialty practice areas without having had past experience. The Primary care program appeals to a much wider group of practising nurses. Since the government has actually said “we need these positions and we will fund them,” there’s been a much greater openness from the Family Medicine Groups to hiring nurse practitioners, and the number of applications to the program is up significantly.
Is it a master’s level program?
Yes. Part develops the program advanced practice component – dealing with complex family situations, negotiating in the system to get best care, etc. The other part focuses on the diagnostic, interpretive pieces related to physical symptoms and health status.
When did this program get going?
It started in 2007-08. We had some start up money from the Dean of Medicine and a three-year period of funding to start the program. It’s a very comprehensive, intensive program. Our students have done extremely well and they are proud of their program. It was a lot of work getting it together but it’s now ticking like clockwork.
How big is the cohort?
We started off with a small group that came mostly from the Abitibi region in Quebec. This year there are 10 students at McGill at different stages of study in Primary Care. The plan is to increase enrolment and to graduate12 students a year.
The SoN is hosting a conference on November 10 on the expanding roles of nurses. Why is this an important event?
Practising nurses and students just beginning their careers need to focus on the possibilities out there. But really, everyone in the system needs to understand the changing nature of nursing practice. Physicians, the primary professional partners of the nurse practitioners, are likely to benefit the most. This is a time of opportunity, and hopefully the conference will help show that.
It is also important to understand the challenges. The scope of what nurses are being asked to do when they graduate is enormous. If they are to succeed, they need to see things in a critical way, to bring knowledge from a wide range of areas and put it together. So it’s not about rote behaviour. It’s about critical analysis, systematic thinking and working with others to solve problems in a different way. This will be a challenge for those entering the profession. We need to prepare them with the knowledge and skills they need to master these challenges and move health care forward.
What’s the barrier?
We need educated nurses all the way up the system – at the Bachelors, Masters and PhD level. It’s a huge issue as there will be a wave of retirements in the next 5-10 years.
Are the changes in the profession attracting more applicants?
They have. The numbers continue to go up and we have been on a steady rise at McGill. That is very good news.
McGill’s SoN has been a leader in nursing education since it was founded nearly 100 years ago.
Looking ahead, what’s on the horizon for nursing?
Getting the resources together to handle a slow and steady increase of students. We will need physical space, staff to support the programs and teachers, which means funding.
We will be breaking new ground as we go and there will be challenges. There is an unpredictable element to the future, which is good. Things aren’t set in stone and there are opportunities to grow. It’s a great time to be in nursing, the rewards are amazing.
For all of us, nursing is a good deal.