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CMAJ - July 14, 1998JAMC - le 14 juillet

Rural medicine: What role should nurse practitioners play?

Beth Ryan

CMAJ 1998;158:68-9

[ en bref ]

Beth Ryan is a freelance writer living in St. John's. Jane Stewart is a freelance writer living in Winnipeg.

© 1998 Beth Ryan, Jane Stewart

In brief

Rural physicians and other professionals attending a recent conference in St. John's reached consensus on a number of issues surrounding the role of nurse practitioners. The issue is important for rural doctors, since some people think NPs can help solve the physician shortage in rural areas.

En bref

Les médecins ruraux et d'autres professionnels qui participaient récemment à une conférence à St. John's se sont entendus sur un certain nombre de questions entourant le rôle des infirmières de première ligne. L'enjeu est important pour les médecins ruraux, car certains pensent que l'on pourrait avoir recours aux infirmières pour résoudre les pénuries de médecins en région rurale.

A group of doctors and nurse practitioners (NPs) have reached a consensus on how they can work together to provide quality health care in rural and remote parts of Canada. On May 5, about 130 health care professionals gathered in St. John's for a policy conference during the annual meeting of the Society of Rural Physicians of Canada.

The group considered the expanded roles that NPs, regional and outpost nurses, and nurse midwives are already playing in many remote communities, and then discussed future roles and educational requirements for NPs. By day's end, agreement had been reached on several principles:

  • the establishment of national guidelines concerning the scope of practice of NPs;
  • a recognition that NPs need enhanced skills and education;
  • the development of pay schemes that allow physicians and NPs to work cooperatively instead of competitively; and
  • an understanding that NPs' duties will change according to their location.
The status of nurse practitioners varies from province to province. Ontario has legislation governing their practice but British Columbia does not, while Newfoundland recently passed legislation that spells out their roles and responsibilities.

Defining the scope of practice for NPs was a key issue at the policy conference, with both doctors and nurses expressing concerns about the nature of the NP's role in rural areas. "I don't believe nurse practitioners can or should solve the problem of rural shortages [of physicians]," said Dr. Lydia Hatcher of Whitbourne, Nfld.

She has been involved in the development of guidelines for the scope of practice of NPs on behalf of the Newfoundland and Labrador Medical Association. "Nurse practitioners can assist doctors in rural and remote areas but they cannot be the primary health care providers," she said. "Doctors must remain the coordinators of health care."

Joan Marie Aylward, Newfoundland's minister of health and community services, said the demand for NPs has been driven by the public, particularly people in rural communities that have trouble recruiting and keeping doctors. "Nurse practitioners are not a panacea for the problems in rural health care," said Aylward, a nurse and a former president of the province's nurses' union. "But working in a multidisciplinary practice, they can address some of the problems."

Aylward said her government has no intention of replacing doctors with NPs or of requiring nurses to work without support from doctors.

The nurse practitioners at the session called for collaborative working relationships that allow health professionals to do what they do best. Linda Jones, an Ontario NP with 10 years' experience, said her province's legislation helps clarify her responsibilities and her relationship with doctors.

"My clinical partner doesn't need to delegate responsibilities and approve what I do," said Jones. "I'm there as an equal member, not as a physician assistant. Nurse practitioners are there in our right to offer our own style of health care."

Some of the doctors shared her opinion of what multidisciplinary practices should entail. Dr. Dale Dewar of Wynyard, Sask., has worked successfully with NPs in northern communities. "They did a lot of the interacting with patients, referred patients, handled the day-to-day work," said Dewar. "I would like to see them across the board — in cities and in rural areas. They provide the social context that physicians don't always offer."

Other rural doctors explained how nurse practitioners helped to reduce the time they spend on call by dealing with some of the cases themselves and calling the doctor only when necessary. This intermediary role is considered particularly important when someone is the lone physician in a community or region.

Sidebar: Society for rural MDs hits recruiting trail in Manitoba

Jane Stewart

The Society of Rural Physicians of Canada received a warm welcome in Winnipeg this spring when it held its first central region — Alberta, Saskatchewan, Manitoba and Ontario — meeting. The Winnipeg visit, held during the annual assembly of the Manitoba chapter of the College of Family Physicians of Canada, was designed as both an information event and a chance to recruit members for the society's central region.

The concept that led to the creation of the society was well received by physicians attending the meeting. "I'm glad to see an organization such as this," commented Dr. David Cram of Souris, Man. "It's time rural physicians were recognized for the expertise we provide."

"Suddenly there's a feeling of belonging in a profession in which we've always felt like outsiders," added Dr. David O'Neil of Trochu, Alta., who has been serving as president of the central region pending elections.

If anything was uniting physicians attending this meeting, it was frustration over working conditions and a sense of exclusion from mainstream medicine. Cram cited long hours, a tedious call schedule and professional and geographic isolation as some of the most persistent difficulties faced by rural physicians. There were also complaints that their medical associations fail to represent them fairly when global budgets are being divided. "But [rural practice] still attracts some physicians because of the relationship with patients and the lifestyle," Cram added.

Among its ongoing activities, the society is attempting to develop a position paper regarding on-call and working conditions for rural doctors. Its unique rural perspective also has been incorporated into a joint position paper on rural maternity care, which was developed in collaboration with the College of Family Physicians of Canada and the Society of Obstetricians and Gynaecologists of Canada.

The society hopes these kinds of activities will strengthen the voice of rural physicians and help them achieve their goals of sustainable working conditions for rural physicians and equitable treatment of rural communities and their residents.

The Society of Rural Physicians, which currently has 600 members, is a CMA affiliate that was incorporated in 1992. Its publication, the Canadian Journal of Rural Medicine, is published quarterly by CMA Publications. The society is establishing a library of rural medicine and has an electronic mailing list and a Web Site (www.gretmar.com/srp/home.html). The society's goal and task in the years ahead will be to make its members' voices heard far beyond the wilderness.

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