Nurses and Nurse Practitioners of BC
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Reflecting on the B.C. Budget 2014, by Julie Fraser, RN, MN, ARNBC President

Earlier today, February 18, 2014, the B.C. Government revealed its 2014 Budget along with Service Plans for each Ministry.  ARNBC has had some time to reflect on the budget, and hope that registered nurses and nurse practitioners will take an interest in reading the documentation and considering how this budget will impact their practice and Nursing in B.C.

Government has identified a 2.3% increase ($385 million) in the health budget for 2014.  While this might seem substantial at first glance, ARNBC is concerned that this modest increase in funding will not adequately cover the needs of our growing healthcare system.  Health authorities are already struggling to provide patient-centred care within limited budgets.  Nurses are growing alarmed as services and programs that support patients, families, and communities are reduced or eliminated across the province.  We are committed to working with nurses and government to raise and address these challenges.  We also recognize that changes in the budgets of other Ministries and program areas, which are unrelated to health, may have significant impact on the social determinants of health.  ARNBC believes that adequate health care funding is absolutely essential to the future of our publicly funded healthcare system and the welfare of all British Columbians.

The Ministry of Health Service Plan 2014/15 – 2015/16 was released today in conjunction with the budget. We were discouraged to see that the expertise, skills and knowledge of nurses appears to have been overlooked in this important strategic document.   Nurses and nurse practitioners are the backbone of the healthcare system and ARNBC will work with government to ensure the Nursing voice is heard and reflected in the future plans of the Ministry.

We encourage all registered nurses and nurse practitioners to review the Budget documents and share your thoughts and ideas on the impact they will have on your practice and patients.

Link to Budget 2014: http://bcbudget.gov.bc.ca/2014/default.htm

Link to the Ministry of Health Service Plan 2014/15 – 2015/16: http://bcbudget.gov.bc.ca/2014/sp/pdf/ministry/hlth.pdf

ABOUT JULIE FRASER, RN, MN, ARNBC PRESIDENT

JulieJulie Fraser is a Clinical Nurse Specialist in the area of Home Care. She has been a registered nurse for more than 15 years and has practiced in a number of different settings from residential care to acute medical and surgical care units, before focusing on community nursing, working in both clinical and educator roles.

28 thoughts on “Reflecting on the B.C. Budget 2014, by Julie Fraser, RN, MN, ARNBC President”

  1. I was discussing today how disappointing it is that the voice of Nursing has been so absent from Ministry tables the last few years - so I'm really glad to hear that we are back to working toward having nurses having a more cohesive voice in large-scale decisions such as these!

    I'm hoping that the increased funding for income assistance will help some of our most vulnerable citizens to maintain or increase their health behaviours - but there being no mention for subsidized or equitably-priced housing leads me to not be optimistic about this.

  2. We continue to be confronted with an incredibly disappointing situation in this province in which policy decisions are being made in the back rooms by self-interested parties. It has been apparent to all who have been watching that that “Doctors of BC” (formerly known as the BC Medical Association) has a direct pipeline to dictating government policy in their interests, while other professional groups have been systematically frozen out of the policy conversation. Doctors of BC has been signaling on its website and Twitter feed (@DoctorsOfBC) for several weeks now that it supports nurse practitioner practice only when it is under the delegated authority of medicine. It uses the “collaboration” euphemism to imply that anything other than delegated authority is a failure to collaborate. Instead, it has been singing the praises of the physician assistant as a new professional entity in BC. Of course physicians prefer these physician assistants! They don’t work autonomously, under their own regulated authority, just under the delegated authority of physicians. And make no mistake – that is not simply a technical detail. The people of BC need to understand that a key difference between nurse practitioners and physician assistants is that PAs create a mechanism for physicians to increase their billing potential, while in contrast they have not yet found a way to increase their income via nurse practitioners.

    The public must be helped to understand this so that it can express its outrage. All nurses know that what is needed in BC is efficiency, equity and rational spending in health care - not solutions designed to drive up physician salaries! It is high time we came together to insist – loud and clear - that the Ministry of Health must reinstitute a formal nursing presence so that it has the capacity to listen to professional voices beyond the confines of the Doctors of BC. That group, by whatever name it chooses to call itself, has proven time and time again that it is motivated by self interest – not real solutions!

  3. Natasha Prodan-Bhalla

    It saddens me that once again Nurses and Nurse Practitioners have been left out of the discussion entirely in terms of how to improve access to primary health care in BC. This budget is just another indication that the newly named Doctors of BC and the Ministry of Health are working together to ensure Doctors remain the only practitioner who is capable of delivering primary health care when we all know there are alternatives. Our patients deserve better than this- they want options and the Ministry of Health should be supporting this instead of turning a blind eye.

  4. I read this blog, the MOH service plan and the press release from the BCNPA with sadness, frustration and anger! I am wondering how the CRNBC will also react to the statement that the NP scope of practice will be determined by the College of Physicians & Surgeons! How dare they! We would never presume to tell what was their scope!! And all our hard work, successes with patient outcomes and our significant contributions to the healthcare of British Columbians despite our small numbers is completely invisible... Is this Ontario all over again and how to stop the insanity!?

  5. I was pleased to see the many references with these documents to the issues of access as well as collaboration - too bad the overall tone seems focused on one professional group. We have had some amazing initiatives in this province focused on inter professional collaborative patient centred practice (IECPCP projects) however our provincial inBC network did not survive once Health Canada $ ended. Key Messages from these projects, as well as research conducted on NP integration in BC I think can be summarized as simply as our A,B,Cs! A - it is all about access - to the right provider, at the right time and in the right location. B - it is better! Better for patients, for providers and for the system. C - collaboration requires communication - respectful and open communication involving all key participants, including patients and all professionals. I hope in BC we can build on what we have already learned, and pay attention to the evidence before making any major policy changes. Remember we all have a voice and right now we need to be heard.

  6. We have come a long way since the first days of entering practice as Nurse Practitioners with concern to both professional autonomy as well as expansion of our scope. Yet, we remain under the constant threat of having our practice and future rooted in uncertainty and dominated by the strong influence of paternalistic, self-focused groups. The public has learnt a great deal over the years about our new role and in the practices where British Columbians had access to seeing NPs the health outcomes demonstrate the high level of care provided. However, despite our collective effort there is still a great deal of nebulosity concerning public knowledge about access to NP care and about the extend of our scope of practice. Furthermore, limitations on the NP model of care delivery and practice settings place us in a vulnerable position of not being always able to work at our full potential. Bringing us upfront in the public eye through vigorous Mass Media initiatives would give the public a fighting chance to express what they want about care access and options.

  7. BIG disappointment! No suggestion of anything people care about, and a definite turn away from promoting health on any front. Nothing about nurses, public health, or nurse practitioners, all of which demonstrably improve health and access to health services. But this government is unconcerned with the evidence and would rather take their instructions from Doctors of BC.
    Premier Christy Clark’s priorities have nothing to do with the health and well-being of the people. Her budget sounds glorious. Too bad she’s banking on near-fantasy gains from liquefied natural gas exports and kicking the court-ordered settlement with the teachers back to the courts, hoping that by the time someone has to face reality, it’ll be another party in office.Do unto others and then leave.

  8. This government has so far paid only "lip" service to the call for primary health care renewal.

    Health care is turning into a "money pit" with no significant changes in the way we do business in the past 20 years. Despite a plethora of evidence showing the benefit of interprofessional collaboration to patient outcomes. Including, the benefit of Nurse Practitioners in that mix, the government continues to rely on the "voice and direction" of organized medicine and its own self serving interests.

    Its high time we ceased doing the same old thing and expecting differant results. Which politicians will have the courage to stand up for expanded choice and options in healthcare for the citizens of BC, and stop listening to the same old tired rhetoric from physicians.

  9. I echo the sentiments of many of the comments that have already been posted. NPs have been actively practicing in this province since 2005 and here we are in 2014 and we continue to struggle with maintaining our professional role, value and identity in this province. Interesting in this day and age that physicians continue to be such strong 'drivers' of how health care is being delivered and how health care dollars are allocated. Nurses must find/use their voice and become active in changing this imbalance and I agree as someone else already mentioned there needs to be a formal nursing presence at the Ministry of Health level.

  10. Happy that the ARNBC will be working with nurses and government to bring nurses voices and safe patient care to the forefront. Underfunding our public health care system feels like a slippery slope, leading us ever closer to privatization

  11. As reported in today's Globe and Mail -- "the auditor is "questioning value for doctors' pay in BC" and calling for system level accountability for the billions of dollars allocated to physicians' salaries in the province.

    The auditor affirms the concerns that nurses have been expressing for the past decade over the stalemate and lack of progressive direction in health policy in this province - and calls into question the government's ability to make informed decisions about physician services.

    Nurses and their patients experience those gaps each and every day as physicians maintain their monopoly as gatekeepers to essential health care, and it would appear that policy initiatives are in place to ensure this continues. It is indeed sad to see that British Columbians continue to lack access to basic health care services at the point of entry to the system, and that this BC government continues to fail to engage nurses and nurse practitioners as active participants in policy and care delivery. We could do so much more and bring badly needed insights and solutions.

    It is timely for ARNBC to publicly renew its call for a nursing policy advisory committee reporting directly to the minister, along with the re-establishment of a nursing policy directorate in government. Nurses must continue to ask some tough questions regarding outcomes and challenge government to address why BC continues to lag behind other provinces in primary care reform.

  12. Again organized medicine is dictating the direction of health care in BC. Its clear that the Doctors of BC (BCMA) has been working hard at the ministry level to ensure they get their needs addressed. Unfortunately this has not translated into improved outcomes for patients or efficiencies in the health care system. Instead it has created more care silos and rather having health care professions working together it is dividing us.

    Patients and taxpayers should be alarmed by the amount of money being spent to create more and more incentives to just do the work of providing care.

    We are long overdue for strong nursing representation within the ministry. Perhaps if the nursing directorate still existed and had some actual power and influence we would not find ourselves so divided today.

  13. Debra McPherson will be on Global TV at 7pm tonight to address this issue.

    "She will explain how the government has violated the collective agreement by not hiring more nurses and how that’s affecting safe patient care. Gail Conlin, a Steward from Surrey Memorial Hospital will join McPherson to talk about how staff shortages are causing big problems for front line nurses and patients."

  14. I really appreciate all the wisdom reflected in this blog and in the responses that have been posted. I fully agree that nurses in this province should engage with the Ministry to show that we have the expertise to provide solutions to BOTH improve health care delivery/health status as well as reduce costs.

    As nurses we can help to help to improve the quality and sustainability of the health care system overall--vs the patch work and ultimately expensive and inequitable cost cutting that we have too often witnessed provincially and nationally over the past 10 years. Solutions that nurses have the expertise to promote can be found by re-visiting the 2002 Romanow Report* (which I know has been mothballed by the federal government, but is still highly salient). Such solutions include, for example:

    • More widely accessible home care services so that patients can move out of hospital with better support for themselves and their families;
    • Increased long term care beds to remedy the cuts to long term care implemented over a decade ago and subsequently improve the quality of care as well as de-congest expensive acute care beds;
    • Improved primary health care through better utilization of NPs and RNs in interdisciplinary community care centres to support people with chronic illnesses;
    • Evidence informed RN staffing ratios to improve patient safety and prevent complications that are expensive in fiscal as well as human terms; and
    • Better control of escalating pharmaceutical costs.

    As part of our strategic action I believe that the ARNBC ought to work with the Doctors BC (the former BCMA) as well as the BCNU and CRNBC. I think nursing’s (largely) adversarial relationship with medicine at provincial policy tables is hurting everyone…

    Paddy Rodney, RN
    *Commission on the Future of Health Care in Canada. (2002). Building on values: The future of health care in Canada. Ottawa, ON: Authors. [Also known as the ‘Romanow Report’]

    1. Again some excellent points about systems issues and what nurses can contribute. I recently read an article in the CMAJ. It was a commentary about some of the problems in the system. It had a very medical focus, which is no surprise. But I did appreciate the following:

      "An effective feedback loop is one that responds to community input and that of front-line providers, while resisting the "diseases" that can so easily provide nefarious feedback, such as the following:
      - the drive to profit; ( this is really killing the system, FFS make collaboration challenging, but not impossible)
      - the impulse to accommodate providers over patients;(still not a patient centred system)
      - the temptation to make use of technology just because it is there; and (technology needs to make sense to the user and contribute to the patient journey in a positive way)
      - the pressure to build system that respond to impressions and provider interest rather than evidence.

      What I see more and more are patients who are rather disengaged recipients of care rather than participants. They are lost in the complexity of a system most of us are challenged to understand. Add to this the pace of change and lack of clear direction for the future of health care delivery and you have the 'perfect storm'.

      A perfect place to start might be with the primary health care charter. This time let's take better Aim and include ALL stakeholders. Let's move away for a physician centric model.

  15. As an RN and a future NP, I am happy that the budget has stimulated conversations about the way that we deliver health care. I truly hope that this will be a catalyst to some much needed discussion and change in our health care system.

    It has been well documented internationally that Primary Health Care is not only cost effective, but improves patient outcomes. As an emergency nurse I have experienced first hand the pressure that hospital based, tertiary care puts on patients, health care providers and the entire system. The services we provide are essential but our patients want and deserve more.

    As nurses, we work with our patients every day to help them overcome the barriers of a broken system. This gives us a unique vantage point that it is our responsibility and privilege to share. We now need to take this knowledge a step further. We are all incredibly creative and able to find ways to navigate the system for our patients. It is this creativity that gives nurses a unique voice when it comes to health care reform. We need to recognize these strengths and bring them to the table when we are advocating for our patients.

    Money won't fix a broken system. However, if we partner with other health care providers to create solutions to the multitude of problems that exist in our heath care system, and advocate for those solutions, we might be able to make changes that go well beyond the budget!

  16. For a strategic service plan that asserts an engaging and collaborative approach to British Columbia’s health priorities, development of the plan lacked collaboration from many key players. Considering the valued role and sheer numbers of nurses and nurse practitioners in BC, which together account for more than 31,000 registrants (Canadian Nurses Association [CNA], 2012a; CNA, 2012b), it is surprising that neither of these health providers nor their regulatory body were given the opportunity to be involved in the strategic planning. Perhaps it should not come as a surprise, given the Doctors of BC recent stance on the NP role, supporting the role only when under the delegated authority of a physician (Burton, 2014). This statement in itself reflects the direction and level of support the BC physicians have for the continued expansion of the role and ultimately the care NPs should be “allowed” to provide in the province. This highlights the physicians’ agenda for maintaining their role as gatekeepers for primary health care in BC.

    In light of rising health care demands, the need for collaboration between health care professionals to provide optimal primary health care is essential. Many of BC’s current challenges are country wide concerns, such as the increasing aging population, increasing rates of chronic disease, and disparities in access to a primary health care provider (Ministry of Health, 2014). As a result other provinces are finding innovative, collaborative solutions to increase accessibility, while providing quality care, positive outcomes and cost saving measures. I find it surprising that other avenues and methods of delivering care, such as health teams and NP led clinics which have been successfully implemented in other provinces, are not being analyzed and considered for implementation here in BC. Instead, a physician led model continues to be supported rather than a transition to team based primary care and expansion of the primary health care provider pool (Hutchison, Levesque, Strumpf, & Coyle, 2011). The exclusion of other health care providers in the strategic planning, along with the physician centric wording of the service plan presents the appearance that physicians continue to monopolize the system and stifle change.

    Unfortunately the Ministry of Health does not openly acknowledge other key players in the system, such as NPs. This devalues some of the significant progress NPs have made in both role development and in working towards increasing healthcare access for high priority populations. This lack of acknowledgement is not only disheartening, but may also encourage NPs educated in BC to consider using their skills and education in other provinces or territories where the NP role is better supported, autonomous, and enables NPs to practice to their full scope to meet the healthcare needs of Canadians.

    References

    Burton, A. (2014, February). News release: Budget puts B.C nurse practitioners in jeopardy. BC Nurse Practitioner Association. Retrieved from http://bcnpa.org/wp-content/uploads/2014/02/NewsBudgetFINALupdated1.pdf

    Canadian Nurses Association. (2012a). 2010 workforce profile of registered nurses in Canada. Retrieved from http://www.cna-aiic.ca/~/media/cna/page%20content/pdf%20e/2013/07/26/11/07_rn_snapshot_e.pdf

    Canadian Nurses Association. (2012b). 2010 workforce profile of registered nurses in Canada. Retrieved from http://www.cna-aiic.ca/~/media/cna/page%20content/pdf%20en/2013/07/26/11/2010_np_profiles_e.pdf

    Hutchison, B., Levesque, J.F., Strumpf, E., & Coyle, N. (2011). Primary health care in Canada: Systems in Motion. The Milbank Quarterly, 89(2), 256-288. Retrieved from http://www.uregina.ca/gspp/marchildon/WRTCfiles/Hutchison%20Reading.pdf.pdf
    Ministry of Health. (2014, February). 2014/15-2016/17 service plan. Retrieved from http://bcbudget.gov.bc.ca/2014/sp/pdf/ministry/hlth.pdf

  17. The Ministry of Health Service Plan 2014/15 – 2016/17 contains discouraging recommendations impacting primary care services in British Columbia (BC). The concerns reflected in this document are two-fold. First, nurse practitioners (NPs) are poorly represented as primary care providers. Second, therein lies a significant concern regarding the notion that an NP’s scope of practice is to be determined by the College of Physicians and Surgeons of BC (CPSBC).

    NPs are registered nurses with advanced education and experience. NPs provide primary care services by diagnosing and treating many illnesses, ordering diagnostic tests, and prescribing medications (British Columbia Nurse Practitioner Association, 2014). NPs do not aim to replace primary care physicians, but strive to work collaboratively with physicians to improve the accessibility of primary health care services. Since the initiation of NPs in BC in 2005, NPs have proven to be competent, effective and safe primary care providers (Kaasalainen et al., 2010; Pohl & Kao, 2014). Sadly, NPs are underrepresented in the Ministry of Health Service Plan 2014/15 – 2016/17. The notion put forth by the Ministry of Health stating that the scope of practice is to be determined by the CPSBC is nonsensical. The BC Health Professions Act (1996) recognizes NPs as autonomous care providers, not as delegated care providers under the authority of physicians. By reducing the autonomy of NPs to work under the delegated authority of physicians, it is a significant step backwards for the profession and its capacity to meet the primary health care needs of our citizens. If physicians wish to have input on the NP scope of practice, it should be in collaboration with nursing regulatory bodies; they cannot simply take over this task in its entirety. The government has allowed the Doctors of BC (formerly known as the BC Medical Association) to monopolize primary health care – failing to recognize that our health care system requires adaptation to reflect the aging population and increasingly complex and chronic health issues of our citizens. I challenge the Ministry of Health to place precedence on patient-centered care by recognizing the value of NPs in meeting the primary health care needs of BC residents.

    References

    British Columbia Nurse Practitioner Association. (2014, February). News release: Budget puts BC Nurse Practitioners in jeopardy. BC Nurse Practitioner Association. Retrieved from http://bcnpa .org/wpcontent/uploads/2014 /02/NewsBudgetFINALupdated1.pdf

    Health Professions Act, RSBC 1996, c 183.

    Kaasalainen, S., Martin-Misener, R., Kilpatrick, K., Harbman, P., Bryant-Lukosius, D., Donald, F., … DiCenso, A. (2010). A historical overview of the development of advanced practice nursing roles in Canada. Nursing Leadership, 23(Special Issue), 35-60.

    Ministry of Health. (2014). 2014/15 – 2016/17 service plan. Retrieved from http:// bcbudget.gov.bc.ca/2014/sp/pdf/ministry/hlth.pdf

    Pohl, J. M., & Kao, T. S. (2014). The primary care nurse practitioner. In A. Hamric, C. Hanson, M. Tracy, & E. O’Grady (Eds.), Advanced practice nursing: An integrative approach (5th ed., p. 396-428). St. Louis, MO: Elsevier Saunders.

  18. The lack of involvement from nurses and nurse practitioners (NPs) in the 2014 health care budget is incongruent with the goals of the budget. The 2014 BC budget has a focus on health care and health care planning (BC Government and Service Employees’ Union Research, Campaigns and Communication, 2014). In order to successfully provide care for BC residents, collaboration with all health care providers should be sought by the government, including nurses and NPs. Although increases in health care dollars are minimal, the 2014 health care budget places cost effectiveness and value for money at the center (Canadian Broadcasting Corporation, 2014). Auditor General Russ Jones (2014) mentions the lack of evidence of value for money in our current fee-for service (FFS) billing system.
    The health care budget highlights the need for a collaborative strategic plan, despite leaving out the crucial role of NPs in this plan. The Auditor General discusses the barrier to collaborative health care and the implementation of NPs imposed by the current FFS billing system (Canadian Broadcasting Corporation,2014). The Primary Health Care Charter includes NPs as part of the solution to help address shortages of primary care providers in BC (BC Ministry of Health, 2007). This leads to the observation that NPs are still an integral part of health care and cannot be left out of the equation. Open dialogue with our MLAs on the importance of NPs in health care planning and value for money (Pogue, 2007) is essential in moving forward to provide cost effective and outcome oriented care in BC.

    References:

    BC Government and Service Employees’ Union Research, Campaigns and
    Communication(2014).BC budget 2014: Boring, balanced and bad news. Retrieved
    from http://www.bcgeu.ca/sites/default/files/2014_BC_Budget_Summary.pdf

    BC Ministry of Health (2007). Primary health care charter: A collaborative approach.
    Retrieved from
    http://www.health.gov.bc.ca/library/publications/year/2007/phc_charter.pdf

    Canadian broadcast corporation (2014). BC Auditor General Report: Jones, R. (Feb 21,
    2014). Retrieved from
    podcast.cbc.ca/mp3/podcasts/bcearlyedition_20140221_12089.mp3

    Pogue, P. (2007). The nurse practitioner role: into the future. Nursing leadership (20) 2.

    Retrieved from: file:///C:Users/Owner/Downloads/NL_vol20_no2_pogue%20(1)pdf

    Canadian Broadcast Corporation (2014). Minister of Health Terry Lake. Retrieved

    from podcast.cbc.ca/mp3/podcasts/bcearlyedition_20140225_32166.mp3

  19. Terry Lake (2014), the Minister of Health presented the Ministry of Health (MOH) 2014/15 – 2016/17 Service Plan, which highlights the provincial government’s commitment in providing quality health care in terms of “effective, appropriate, safe, accessible and acceptable” services (as cited in MOH, 2014, p. 3). Lake (2014) also emphasizes a commitment to “cross-sector” and “patient-centered care” (as cited in MOH, 2014, p. 3).

    Upon reviewing the Service Plan, I agree with the British Columbia Nurse Practitioner Association’s news release stating the Service Plan has a favorable focus on physicians rather than including and collaborating with other health professions (Burton, 2014). The Doctors of BC have their own agenda for many reasons. British Columbia’s Auditor General, Russ Jones, discusses the fee-for-service model which many physicians work within, stressing this model focuses on activity versus patient outcome (Canadian Broadcasting Corporation, 2014). Considerable overhead expenses further encourages physicians to see many patients in a short amount of time, but this method does not coincide with the MOH’s stated commitments. How is this system fostering effective, appropriate, accessible and acceptable care? The fee-for-service model does not encourage physicians to utilize and collaborate with a multidisciplinary team including Nurse Practitioners (NP) as they are unable to bill for that service (Donald et al., 2010).

    Objective 3.2 of the Service Plan indicates utilizing resources to their best potential in order to improve patient health outcomes (MOH, 2014). One key action is to increase the scope of NPs by working with the College of Physicians and Surgeons of BC (CPSBC) (MOH, 2014). Why is the CPSBC given this authority? Where is the College of Registered Nurses of British Columbia's voice for policy changes? BC nurse leader Dr. Sally Thorne (2014) indicates Doctors of BC are reluctant to support NPs as primary health providers unless they work under physicians' authority (as cited in Burton, 2014). How is this fostering collaboration? How will NPs deliver their expertise within a system that is continuously undercut by physicians?

    The MOH has put forth commitments and objectives in a contradictory manner. Is this their way of remaining within the new budget?

    References

    Burton, A. (2014). News release: Budget puts BC nurse practitioners in jeopardy. Retrieved from http://bcnpa.org/wp-content/uploads/2014/02/NewsBudgetFINALupdated1.pdf

    Canadian Broadcasting Corporation. (2014). BC Auditor General report. Retrieved from http://podcast.cbc.ca/mp3/podcasts/bcearlyedition_20140221_12089.mp3

    Donald, F., Martin-Misener, R., Bryant-Lukosius, D., Kilpatrick, K., Kaasalainen, S., Carter, N., … DiCenso, A. (2010). The primary healthcare nurse practitioner role in
    Canada. Nursing Leadership, 23(Special Edition), 88-113. Retrieved from http://www.longwoods.com/content/22271

    Ministry of Health (2014). 2014/15 – 2016/17 service plan. Retrieved from
    http://bcbudget.gov.bc.ca/2014/sp/pdf/ministry.hlth.pdf

  20. The 2014/15 – 2015/16 British Columbia Ministry of Health Service Plan unveiled several key changes that will inevitably influence the way health care is delivered in BC for the foreseeable future. One of the changes included in the service plan will be that the Ministry of Health will be working with the Royal College of Physicians and Surgeons - the regulatory body for physicians in BC - to oversee the role of NPs, instead of the College of Registered Nurses of BC (CRNBC) (Ministry of Health, 2014). This raises questions as to why the CRNBC was bypassed and why nursing organizations were not consulted about the policy change (British Columbia Nurse Practitioner Association, 2014). Furthermore, there is speculation the policy change is related to the Doctors of BC recently indicating that it will only support NP practice when “it is under the delegated authority of medicine” (British Columbia Nurse Practitioner Association, 2014, p. 1). This statement in conjunction with the aforementioned policy change, suggests the Ministry of Health is being persuaded by physicians to marginalize the role of NPs in the future and create a physician-centric health care model.

    BC has the largest growing population of senior citizens in Canada, and it is expected that this population group will double over the next 25 years (Ministry of Health, 2014). As the number of senior citizens rises, there will be a corresponding increase in chronic disease conditions and the need for health care services (Ministry of Health, 2014). This is of concern to British Columbians given that chronic disease management is a significant economic burden. NPs have proven to add-value in chronic disease management because of their ability to address “the multidimensional nature of chronic problems” such as lifestyle changes, and psychosocial issues (Boville, Saran, Salem, Clough, & Jones, 2007, p. 360). If NPs are marginalized in the future as a result of the policy change previously indicated, this may lead to a lack of primary care providers, especially in rural settings, resulting in patients shifting to acute care settings for chronic disease management. This shift may further compound the existing economic burden of chronic disease and lead to poor health outcomes. As such, it is critical that NPs voice their concerns to their local MLAs, as well as to the local media,in order to prevent further barriers to NP role integration into the BC health care system. Furthermore, I speculate that if the government is not held accountable by NPs in BC, other provincial governments may take a similar approach to the role NPs play in their respective provinces.

    References

    Boville, D., Saran, M., Salem, J. K., Clough, L., & Jones, R. R. (2007). An Innovative Role for Nurse Practitioners in Managing Chronic Disease. Nursing Economics, 25(6), 359-364. Retrieved from http://www.medscape.com/viewarticle/568422_2

    British Columbia Nurse Practitioner Association. (2014, February). News release: Budget puts BC Nurse Practitioners in jeopardy. BC Nurse Practitioner Association. Retrieved from http://bcnpa .org/wpcontent/uploads/2014 /02/NewsBudgetFINALupdated1.pdf

    Ministry of Health. (2014, February). 2014/15-2016/17 Service Plan Victoria, BC: Ministry of Health. Retrieved from http://bcbudget.gov.bc.ca/2014/sp/pdf/ministry/hlth.pdf

  21. The 2014/15 – 2016/17 Service Plan recently released by the Ministry of Health (2014) identifies a priority goal of delivering health care services that are responsive, effective, and that ensure value for money in the B.C. health care system. Furthermore, the Service Plan emphasized the need to strengthen the foundation of the health care system "around interprofessional teams and functions" (Ministry of Health, 2014, p. 12).

    What could be identified as contradicting and ambiguous is that the Service Plan does not mention the involvement of nurse practitioners in primary health care delivery, rather only physicians. With over 37,000 professional nurses in B.C. the Ministry of Health cannot accurately state that the current Service Plan reflects engagement and collaboration with key stakeholders as there was no consultation with the nursing groups of British Columbia in planning future development of health care for the province (British Columbia Nurse Practitioner Association, 2014). Multiple studies have also shown that utilizing NPs reduces overall health care spending, increases cost effectiveness in health care, improves access to primary health care, and increases patient satisfaction with quality of care (Bauer, 2010, p. 231). For health care provision to be truly effective, responsive, collaborative, engaging and "value for money" NPs need to be actively included by the Ministry of Health as a key stakeholder in health care planning, development and reform.

    Another major point of concern in the Service plan is the Key Action statement "to increase the scope of practice for Nurse Practitioners in B.C. by working with the College of Physicians and Surgeons of B.C. and other credentialing organizations" (Ministry of Health, 2014, p. 17). NPs are professionally trained, highly-educated, autonomous, and self-regulating healthcare providers whose scope of practice is currently regulated by CRNBC, not Doctors of B.C., as per the Health Professionals Act (Health Professions Act, 1996). It would be equally inappropriate if the Ministry of Health were to state that further development of physicians' scope of practice would be done under supervision of CRNBC, since physicians too are a self-regulating and autonomous profession. By suggesting that Doctors of B.C. have authority over NP scope of practice the Ministry of Health is impeding the right of NPs to practice autonomously and self-regulate their own profession, as well as contravening the Health Professions Act (1996).

    References

    Bauer, J. C. (2010). Nurse practitioners as an underutilized resource for health reform: Evidence-based demonstrations of cost-effectiveness. Journal of the American Association of Nurse Practitioners, 22(4), 228-231. DOI: 10.1111/j.1745-7599.2010.00498.x

    British Columbia Ministry of Health. (2014, February). 2014/15- 2016/17 Service Plan. Victoria, BC: Ministry of Health. Retrieved from http://bcbudget.gov.bc.ca/2014/sp/pdf/ministry/hlth.pdf

    British Columbia Nurse Practitioner Association. (2014, February). News release: Budget puts BC Nurse Practitioners in jeopardy. BC Nurse Practitioner Association. Retrieved from http://bcnpa .org/wpcontent/uploads/2014 /02/NewsBudgetFINALupdated1.pdf

    College of Registered Nurses of British Columbia. (2014). https://www.crnbc.ca

    Health Professions Act, RSBC 1996, c 183.

  22. As the reaction to the recently released British Columbia (BC) Ministry of Health service plan heats up, it is important to remember that there are encouraging voices speaking amidst the cacophony of discord. Julie Fraser (2014) rightly asserts that the voice of nursing is an essential voice in the health care policy landscape, while Hannah Varto (2014) reminds us all of the importance of bringing an educated public into the discussion as well. Additionally, Varto clearly details valid criticisms of the fee for service model of physician payment. These criticisms are elucidated in the Auditor General’s report (Office of the Auditor General of BC, 2014) that asks pressing questions about value for health care dollars in relation to physicians’ services. In addition to physician remuneration, we must also consider how physician performance directly influences how a great deal of health care money is spent (Ballinger, as cited in Canadian Institute for Health Information, 2013). The Auditor General’s report points out that there are currently no mechanisms in place to ensure that money paid to physicians is cost effective. Despite these challenges, Minister of Health Terry Lake insists that innovative measures for providing and funding health care are indeed developing across BC (Tobin, 2014).

    All of these voices are vital in any discussion surrounding the spending of health care dollars. Physicians have historically driven many health care policy discussions due to their advanced education and fundamental role in health care. However in this age of instant information, an increasingly informed public and a wealth of highly trained and skilled health care professionals, physicians and their professional bodies must remember that they are but one seat at the table. Health care professionals from a variety of disciplines, along with patients, taxpayers and politicians all have a stake in the wise spending of precious health care resources. Consequently we must all work together respectfully to meet our collective goals.

    References

    Canadian Institute for Health Information. (2013). Number of doctors in Canada rising, as are payments for their services. Retrieved from http://www.cihi.ca/CIHI-ext-portal/internet/EN/document/spending+and+health+workforce/workforce/physicians/release_26sep13
    Fraser, J. (2014, February 18). Reflecting on the B.C. Budget 2014, by Julie Fraser, RN, MN, ARNBC President [Web log post]. Retrieved from https://www.nnpbc.com/blog/reflecting-on-the-b-c-budget-2014-by-julie-fraser-rn-mn-arnbc-president/
    Office of the Auditor General of British Columbia. (2014). Oversight of physician services. Retrieved from https://www.bcauditor.com/pubs/2014/report11
    /oversight-physician-services
    Tobin, S. (Producer). (2014, February 25). B.C. Minister of Health Terry Lake [Audio podcast]. Retrieved from http://www.cbc.ca/earlyedition/
    Varto, H. (2014, February 22). Doctors should not be a business, by Hannah Varto, MN, NP(F) [Web log post]. Retrieved from https://www.nnpbc.com/blog/doctors-should-not-be-a-business-by-hannah-varto-mn-npf/

  23. Amidst the recent media attention surrounding the 2014/2015-2016/2017 BC Budget and subsequent recommendations by the provincial Ministry of Health (MOH), the need for evaluation of the current amount of collaboration between the MOH, influential pluralist groups and nurse practitioners (NP) has become evident. As an NP student, optimism for ongoing development, role expansion and increased autonomy for NPs has given way to trepidation for the future of NP practice in BC.

    Our Minister of Health, Terry Lake (2014), emphasizes that the BC MOH is taking a collaborative approach amongst “health authorities, physicians and health care providers, the Doctors of BC, unions and other stakeholders” (p. 3) in order improve patients’ health care experiences, reduce health care costs and improve the health care of the population. However, one of the key actions set out in Objective 3.2 in the MOH (2014) 2014/15 – 2016/17 Service Plan invalidates this collaborative effort by suggesting that the scope of practice for NPs be increased through collaboration with the College of Physicians and Surgeons of B.C. and other credentialing organizations rather than involving the College of Registered Nurses of British Columbia (CRNBC).

    As Health Canada (2007) states, NPs receive rigorous educational preparation, must maintain equally rigorous registration requirements, and meet practice standards in order to work within diverse practice settings. Despite this, Doctors of BC have implied that NP practice will only be supported under “the delegated authority of medicine” (British Columbia Nurse Practitioner Association [BCNPA], 2014, para. 4). Thorne (2014) asserts that according to Doctors of BC, collaboration is considered unsuccessful unless physicians are overseeing the practice of other health care providers (as cited in BCNPA, 2014).

    Historically, collaboration between physicians and NPs has been challenged as a result of issues such as liability, scopes of practice, funding and competition (Keith & Askin, 2008, as cited in Burgess & Purkis, 2010). As a result, in 2008 a health services dissertation study was initiated, investigating how collaboration drives NP role integration into primary health care. This study found that inter-professional collaboration leads to increased autonomy, flexibility and role development allowing NPs to be more responsive to the needs of their patients (Burgess & Purkis, 2010). Moreover, adequate collaboration fosters positive working relationships between physicians and NPs. The question is, six years after this study supported that collaboration has supported NP role expansion and recognition, why is the CRNBC being left out of the discussion around increasing scope of practice by the MOH? What collective steps can we take to change this process?

    In order to ensure British Columbians receive efficient, accessible health care NPs must increase their visibility and continue to work on building collaborative relationships with other health care providers (Keith & Atkin, 2008). Furthermore, NPs need to take collective action at regional and provincial levels in order to secure policy discussions and further role development (Burgess & Purkis, 2010; BCNPA, 2014). For the benefit of patients and the future of our profession, it is time that the voice of the NP is truly heard in BC.

    References:

    Burgess, J., & Purkis, M. E. (2010). The power and politics of collaboration in nurse practitioner role development. Nursing Inquiry, 17(4), 297–308. Retrieved from http://fhs.mcmaster.ca/APNNursingChair/documents/Burgess_Purkis_2010.pdf

    British Columbia Nurse Practitioner Association. (2014, February). News release: Budget puts BC nurse practitioners in jeopardy. British Columbia Nurse Practitioner Association. Retrieved from http://bcnpa.org/wp-content/uploads/2014/02/NewsBudgetFINALupdated1.pdf

    Health Canada. (2007). Nursing issues: Primary health care nurse practitioners. Retrieved from http://www.hc-sc.gc.ca/hcs-sss/pubs/nurs-infirm/onp-bpsi-fs-if/2006-np-ip-eng.php#fnb14-ref

    Keith, K., & Askin, D. (2008). Effective collaboration: The key to better health care. Journal of Nursing Leadership, 21(2), 51-61.

    Lake, T. (2014). Message from the Minister and accountability statement. In Ministry of Health, 2014/15 – 2016/17 Service plan (p. 3-4). Retrieved from http://bcbudget.gov.bc.ca/2014/sp/pdf/ministry/hlth.pdf

    Ministry of Health. (2014, February). 2014/15 – 2016/17 Service plan. Retrieved from
    http://bcbudget.gov.bc.ca/2014/sp/pdf/ministry/hlth.pdf

  24. Point 3 under Objective 3.2 of the 2014/2015-2016/17 BC Ministry of Health Service Plan reads as follows: “Examine the use of … including the use of physician assistants, to supplement available medical services throughout the health system” (p. 17).
    Nurse practitioners (NP) are autonomous practitioners who are registered nurses with additional training and nursing experience; they can take patient histories, perform physical exams, diagnose and treat illnesses, order tests, and prescribe medications (British Columbia Nurse Practitioner Association (BCNPA), 2014). On the other hand, physician assistants (PAs) are “fully licensed medical practitioners who are trained to provide care under the direction and supervision of a doctor” (Doan, Sabhaney, Kissoon, Sheps, & Singer, 2011, p. 7).
    In the U.S, both disciplines evolved around the same time in the 1960’s to address physician shortages, though the background of PAs has been traditionally military while that of NPs has been nursing (Curren, 2007). PAs are trained in a medical model whereas NPs are grounded in the nursing model. In the U.S while all NPs are required to have a minimum of a master’s degree in nursing, PAs are currently able to practice with a “certificate, associate, baccalaureate or master’s degree” (Bednar, Atwater, & Keough, 2007, p. 158). Traditionally, PAs were trained in military settings to care for the troops at home, at sea and abroad. However, they are now slowly being introduced into the Canadian healthcare system (Doan, et al, 2012).
    Studies indicate that practice areas of both NP and PA overlap and are similar. A major difference is that NPs are autonomous practitioners whereas PAs require supervision by a physician (Reid & O’Neill, 2013; Wong & Farrally, 2013). Why then are we duplicating services? Should we not focus on NPs that are already practicing in BC and work on removing barriers that prevent their maximum utilization? I agree wholeheartedly with the statement released by BCNPA which stated that “it would be irresponsible to introduce yet another profession when they cannot stand up to organized medicine and demonstrate success with nurse practitioners” (BCNPA, 2014).
    It is evident that the Ministry of Health (MoH) has been looking into bringing PAs to healthcare practice in BC. The MoH has been investigating the role of PAs since the 1990’s. In 2005, the former British Columbia Medical Association (BCMA) issued a policy statement endorsing the use of PAs (Jones & Hooker, 2011). According to Jones and Hooker, in 2007 the BCMA requested fast tracking of a PA training program and subsequently in a 2009 a statement supporting PAs was released by the BCMA. Such statements endorse interests of both BCMA and government in using PAs in healthcare; Jones and Hooker (2011) confirmed this in their study when they added that “the development of PAs is due to the strong influence of both doctors and elected leaders” (p. e88). Furthermore, a study was conducted at BC Children’s hospital to help determine willingness of British Columbians (Canadians in general) to be seen by a PA and concluded that British Columbians are highly willing (Doan, et al., 2012).

    Wong and Farrally (2013) noted that NPs would likely face “numerous barriers to and in practice, including lack of government leadership, organized medicine, and physician attitudes, role confusion, and issues associated with payment models” (p. 8). These authors noted that PAs could encounter relatively fewer barriers to practice as “physicians prefer to work with PAs” (p. 8). This is exactly what is happening to the NPs now in BC. Wong and Farrally (2013) reported that the MoH had confirmed their commitment to BCMA that once NPs were fully implemented, they would explore the introduction of PAs. This statement is quite contradictory to what the MoH had outlined in the Service Plan. Wong and Farrally concluded that “the simultaneous implementation of NPs and PAs in BC would not be useful or advisable at the current time” (p. 76). I hope that the MoH will consider their advice and heed their suggestion.
    References
    Bedner, S., Atwater, A., & Keough, V. (2007). Educational preparation for Nurse Practitioners and Physician Assistants: An exploratory view. Advanced Emergency Nursing Journal, 29(2), 158-171.
    British Columbia Ministry of Health. (2014). 2014/15- 2016/17 Service Plan. Victoria, BC: Ministry of Health. Retrieved from http://bcbudget.gov.bc.ca/2014/sp/pdf/ministry/hlth.pdf
    British Columbia Nurse Practitioner Association. (2014, February). News release: Budget puts BC Nurse Practitioners in jeopardy. BC Nurse Practitioner Association. Retrieved from http://bcnpa .org/wpcontent/uploads/2014 /02/NewsBudgetFINALupdated1.pdf
    Curren, J. (2007). Nurse Practitioners and Physician Assistants: Do you know the difference? MEDSURG Nursing, 16(6), 404-407.
    Doan, Q., Hooker, R. S., Wong, H., Singer, J., Sheps, S., Kissoon, S., & Johnson, D. (2012). Canadians’ willingness to receive care from physician assistants. Canadian Family Physician, 58(8), e459-e464.
    Doan, Q., Sabhaney, V., Kissoon, N., Sheps, S., & Singer, J. (2011). A systematic review: The role and impact of the physician assistant in the emergency department. Emergency Medicine Australasia, 23(1), 7-15.
    Jones, I. W. & Hooker, R. (2011). Physician assistants in Canada: Update on health policy initiatives. Canadian Family Physician. 57(3), e83-e88.
    Reid, P. P., & O’Neill, K. (2013). Hiring into advanced practice positions: The Nurse Practitioner versus Physician Assistants debate. Journal of Nursing Administration, 43(6), 329-335.
    Wong, S.T., & Farrally, V. (2013). The utilization of nurse practitioners and physician assistants: a research synthesis. Michael Smith Foundation for Health Research, Nursing Research Advisory Council. Retrieved from http://www.msfhr.org/sites/default/files/Utilization_of_Nurse_Practitioners_and_Physician_Assistants.pdf

    1. Just remove Nurse from Nurse Practitioner and many identity problems will be gone. In eastern Europe Nurse practitioners have their own name without "Nurse". This addition makes life of nurse practitioners so complicated. The word "Nurse" left in the name of NPs to likely pacify almighty Medical community in North America. In Poland primary care providers similar to NPs are called Felczer or in Chinabarefoot doctors - pinyin .

  25. Brittany van Viegen

    The government of British Columbia (BC) recently released the 2014 budget, which coincides with the release of the Ministry of Health 2014/2015- 2016/17 Service Plan. The overall objective of the Ministry of Health is to improve the health of British Columbians while reducing health care costs (Ministry of Health, 2014). Terry Lake, Minister of Health recognizes that our population is aging, chronic illness is on the rise, and access to quality health care needs improvement across the province. While the importance of physician access is highlighted, the suggested utilization of other health care professionals, such as nurse practitioners (NPs) was dismal (Ministry of Health, 2014).

    In actual fact, the report can be perceived as contradictory. The Ministry of Health service plan states “a high performing health system is one that uses its resources in the best way possible to improve health outcomes for patients” (Ministry of Health, 2014, p. 17). However, this service plan also suggests that NPs will have their scope of practice increased only under direction of the College of Physicians and Surgeons of BC.

    NPs play an integral role as members of the interdisciplinary team providing a diverse array of services in primary, acute, and specialty care to their patients (Lausten, 2013). Furthermore, NPs have the knowledge and training to conduct psychomotor clinical skills and procedures and assess their patient’s need for further diagnostics, prescriptions, and treatment (Lausten, 2013).

    NPs are increasingly recognized as an underutilized resource for healthcare cost effectiveness and healthcare reform (Fund & Swanson-Hill, 2014). Over three decades ago a study was conducted highlighting that NPs reduced the cost of providing equivalent or improved healthcare by one-third in comparison to physician care (American Association of Nurse Practitioners [AANP], 2013). Many studies conducted subsequently also concluded that NPs provide adequate, more cost-effective care (AANP, 2013).

    Ultimately, the provincial government and Doctors of BC should be encouraging the implementation of NPs practicing autonomously and in their full scope of practice in the province of BC. This would provide increased accessibility to primary healthcare providers, improved patient satisfaction, and better overall patient outcomes through interdisciplinary collaboration between NPs and physicians, while reducing overall healthcare expenditure.

    References

    American Association of Nurse Practitioners. (2013). Nurse practitioner cost-effectiveness. Retrieved from http://www.aanp.org/images/documents/publications/costeffectiveness.pdf

    Fund, M., & Swanson-Hill, A. (2014). Cost-Effectiveness of Nurse Practitioner Care. Kansas Nurse, 89(1), 12-15.

    Ministry of Health. (2014). 2014/15 – 2016/17 service plan. Retrieved from http://bcbudget.gov.bc.ca/2014/sp/pdf/ministry/hlth.pdf

    Laustsen, G. (2013). What do nurse practitioners do? Analysis of a skills survey of nurse practitioners. Journal of the American Association of Nurse Practitioners, 25(1), 32-41. doi:10.1111/j.1745-7599.2012.00750.x

  26. As a registered nurse and student nurse practitioner in north-central B.C., I have heard very little about the NP role from either the local physicians or my RN peers. Our small community has had difficulties recruiting physicians for many, many years and we have been grateful to both English and South African physicians for making the trek north and helping us to fill with a gap that exists in much of rural Canada (Kapadia & McGrath, 2011).

    In light of the potential for creating collaborative teams of physicians and NPs to address these ever-present shortages, I have been shocked at the political environment, which appears to be hindering rather than facilitating this process, thereby putting the health of B.C. citizens in jeopardy. In particular I am surprised by the stance of the previous British Columbia Medical Association (BCMA) president Shelley Ross, who states “The trouble is, they don’t want to work under any direction from physicians” (Mickleburgh, 2013). The fact is NPs have been working autonomously for quite some time and have proven themselves to be both a safe and cost-effective choice in primary care (Bauer, 2010). In addition, it is surprising that the BC Ministry of Health, which in the past has clearly supported autonomous practice for NPs, could, in their recent 2014/15 – 2016/17 Service Plan, state that the scope of practice for NPs would be increased “by working with the College of Physicians and Surgeons of B.C.” (British Columbia Ministry of Health, 2014). This appears to be an intentional submission of control over NP practice to an organization whose purpose is to regulate physicians rather than NPs. Further, this could be seen as undermining the regulatory authority of the College of Registered Nurses. This rings of a return to the hierarchical system which existed in the past and I find that very distasteful.

    As a student NP I am concerned about the availability of jobs when the current NP student cohort reaches graduation. Although the NP4BC program, which began in 2012/2013, allows for funding of 45 NP positions per year over a period of three years, there is only sustainable funding for an additional 2.5 years (British Columbia Ministry of Health, 2013). Also, the current fee-for-service (FFS) payment structure only allows physicians to bill for their own services and thus serves as a disincentive to physicians’ participation in interdisciplinary teams and discourages them from hiring NPs directly. (Office of the Auditor General of British Columbia, 2014). Will there be ongoing employment for NPs in this environment?

    As a RN I am concerned that we are moving backwards in healthcare and losing what little bit of “team” we have all worked to achieve. I can only hope that the past president of the BCMA is simply another elected official who is speaking for a small minority and not for those who elected her, and that those who are most affected by this political wrangling will soon stand up and say “enough”. Let us hope that the recent name change of the BCMA to Doctors of BC will promote the change required to work together to find solutions that will enable all healthcare professions to deliver quality primary care to the citizens of B.C.

    References

    Bauer, J. C. (2010). Nurse practitioners as an underutilized resource for health reform: Evidence-based demonstrations of cost-effectiveness. Journal of the American Academy of Nurse Practitioners, 22(4), 228-231. DOI: 10.1111/j.1745-7599.2010.00498.x

    British Columbia Ministry of Health. (2014). 2014/15- 2016/17 Service Plan. Victoria, BC: Ministry of Health. Retrieved from http://bcbudget.gov.bc.ca/2014/sp/pdf/ministry/hlth.pdf

    British Columbia Ministry of Health. (2013 ). Nurse practitioners program. Victoria, BC: Ministry of Health. Retrieved from http://www.primaryhealthcarebc.ca/resource_np.html

    Kapadia, R.K., & McGrath, B.M. (2011). Medical school strategies to increase recruitment of rural-oriented physicians: the Canadian experience. Canadian Journal of Rural Medicine, 16(1), 13-19.

    Mickleburgh, R. (January 5, 2013). Are nurse practitioners the cure for B.C.'s family doctor shortage? Retrieved from http://www.theglobeandmail.com/news/british-columbia/are-nurse-practitioners-the-cure-for-bcs-family-doctor-shortage/article6970838/

    Office of the Auditor General of British Columbia. (2014). Oversight of physician services. Retrieved from https://www.bcauditor.com/pubs/2014/report11/oversight-physician-services.

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