Primary Health Care Nurse Practitioners in Canada
DiCenso, Alba, Auffrey, Lucille, Bryant-Lukosius, Denise, Donald, Faith, Martin-Misener, Ruth, Matthews, Sue, Opsteen, Joanne, Contemporary Nurse : a Journal for the Australian Nursing Profession
Key elements of primary health care reform in Canada include enhanced access to care, increased emphasis on health promotion and disease prevention, and use of multidisciplinary teams including nurse practitioners (NPs). While NPs were introduced in Canada 40 years ago, it is only recently (March 2006) that all 10 provinces and two of three territories in the country have passed legislation that permits NPs to implement their expanded nursing role (Hass 2006). In this paper, we will briefly review the historical development of the NP role in Canada and situate it in the international context; describe the NP role, supply of NPs in the country, and the settings in which they work; propose an NP practice model framework; summarize facilitators and barriers to NP role implementation in primary health care delivery; and outline strategies to address the barriers.
HISTORICAL DEVELOPMENT OF NP ROLE IN CANADA
NPs in Canada date back to 1967 when the first education program was developed at Dalhousie University in Nova Scotia to prepare NPs to work in nursing stations in remote areas of northern Canada (May 1967). The 1970s saw the release of the Boudreau Report (1972) and the joint statement by the Canadian Nurses Association (CNA) and Canadian Medical Association (CMA) Joint Committee (1973) that supported the development and introduction of the NP role, as well as the development of university programs to prepare NPs for roles in rural and urban settings. Between 1970 and 1983, a number of university programs to prepare NPs were developed and graduated about 250 NPs. All, but two programs that prepared NPs to work in northern nursing stations, were closed by 1983 because of a perceived oversupply of physicians in urban areas; lack of remuneration mechanisms; the absence of provincial/territorial legislation; little public awareness of the role; and weak support from policy makers and other health professionals (Mitchell, Pinelli, Patterson and Southwell 1993; DiCenso, Paech and IBM Corporation 2003). The 250 NPs continued to practice through the 1980s, working mainly in northern nursing stations and community health centres (non-profit organizations, governed by community-elected boards of directors, that provide primary health and health promotion programs for individuals, families and communities) and northern nursing stations.
In the 1990s, provincial governments reduced the number of residency positions in anticipation of a continued oversupply of physicians. At the same time, governments embarked on health reform agendas designed to ensure more efficient use of resources and to shift the emphasis from treatment to health promotion, disease prevention and community-based care. The need for alternatives to residents for the delivery of patient care and the increased focus on wellness care rekindled interest in the role of the NP. Provincial and territorial governments funded university-based educational programs to prepare NPs and passed legislation to allow them to function in an expanded role, the most recent being Prince Edward Island that passed NP regulations in 2 006. The Yukon Territory is currently without legislation governing NPs (Canadian Nurses Association and Canadian Institute for Health Information 2006).
The NP role was first developed in the United States in 1965 and continues to flourish there with most NP educational programs at the graduate level. An international survey of countries (n=40) conducted by the International Council of Nurses (ICN) International Nurse Practitioner/Advanced Practice Nursing Network (INP/APNN) found that 30 countries had formal education programs for advanced nursing roles and 13 had regulatory mechanisms for the NP role (International Council of Nurses, 2001). World-wide there is significant interest in NPs to address the health needs of individuals, families and communities in a variety of settings; however, role ambiguity, titling inconsistencies and confusing variations in scope of practice, educational preparation and credentialing are challenges that must be addressed for continued evolution of the role (Schober 2004). …