A SURVEY OF NURSE PRACTITIONER PRACTICE PATTERNS IN BRITISH COLUMBIA

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University of Victoria School of Nursing, PO Box 1700 Victoria, British Columbia V8W 2Y2

A SURVEY OF

NURSE

PRACTITIONER

PRACTICE

PATTERNS IN

BRITISH COLUMBIA

January 2014

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Co-Principle Investigators

Esther Sangster-Gormley, RN, PhD (Corresponding Author) Assistant Professor, School of Nursing

University of Victoria PO Box 1700 STN CSC

Victoria, British Columbia V8W 2Y2 egorm@uvic.ca

Brenda Canitz, BA, BScN, MSc Executive Director

Partnerships for Health University of Victoria

Co-Investigators

Rita Schreiber, RN, PhD Professor University of Victoria Elizabeth Borycki, RN, PhD Assistant Professor University of Victoria

Linda Sawchenko, RN, MSHA, EXTRA Fellow Interior Health Authority

Trail, British Columbia Noreen Frisch, RN, PhD

Professor and Director, School of Nursing University of Victoria

Karla Biagioni, BSc, MA Ministry of Health

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Victoria, British Columbia Research Coordinator April Feddema, BA Research Assistant

Janessa Griffith, BA, MSc Research Assistant Joanne Thompson, BSc

Acknowledgment

This project was funded by the Michael Smith Foundation for Health Research. We would also like to thank the nurse practitioners who participated in this study.

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LIST OF TABLES

Table 1. Employment Status ... 5

Table 2. Practice Settings ... 7

Table 3. Members of HealthCare Team Co-located with NP ... 8

Table 4. Patient Populations Served ... 9

Table 5. NP Satisfaction with Resources and Supports ... 11

Table 6. Direct Patient Care Activities ... 13

Table 7. Activities Other than Direct Patient Care ... 14

Table 8. Frequency of Presenting Symptoms or Conditions ... 16

Table 9. Patterns of Diagnostic Testing Ordered ... 17

Table 10. Frequency of NP Diagnosis of Chronic Conditions ... 18

Table 11. Frequency of NP Prescribing Pharmaceuticals ... 19

Table 12. Health Care Professionals with whom NPs Consult ... 22

Table 13. Frequency and Reason for Collaboration and Consultation... 23

Table 14. NPs’ Perceived Contributions of Their Role ... 25

Table 15. Facilitators and Hindrances to NP Role Implementation ... 26

LIST OF FIGURES

Figure 1. Geographic Distribution of NPs ... 6

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EXECUTIVE SUMMARY

In British Columbia (BC), the first nurse practitioners (NPs) graduated and were hired into regional health authorities beginning in 2005. Early expectations for the role included increasing accessibility, expanding health care options and filling gaps in the BC healthcare system. NPs were expected to provide safe, competent, and acceptable care to British

Columbians. As of January 2014 there are 287 NPs registered in BC.

The Practice Pattern Survey was part of a larger study funded by the Michael Smith

Foundation to evaluate the integration of NPs in BC. The purpose of the survey is to provide evidence of how NPs in BC are practicing. Data were collected from June 2013 through November 2013. The survey was first conducted in 2011 and a report of the findings was given to the Ministry of Health in 2012.

A total of 96 NPs returned the survey, 90 were practicing in BC and 6 were not currently practicing as NPs in BC. All participants held a Masters of Nursing degree, the majority were female, and their average age was 46. Participants had practiced as a registered nurse an average of 20 years before becoming an NP, the mean length of time as an NP was five years. The majority of NPs were employed full-time by one of the regional health authorities, and were practicing in diverse geographic locations.

The majority of participants practice in community based settings where they were the only NP in the practice. NPs were caring for a variety of populations such as First Nations, homeless, frail seniors, and new immigrants. Participants indicated that they spend the majority of their time engaged in direct patient care activities. They care for frail seniors in their homes or residential care facilities, and practice in youth clinics and homeless shelters. In all settings they assess, diagnose and manage a variety of acute and chronic conditions, order diagnostic tests and prescribe medications. Most indicated they experience problems carrying out their practice responsibilities as a result of restrictive legislation that does not recognize NPs as authorized providers of care or their scope of practice.

When not providing direct patient care, non-clinical activities included educating other learners, such as NP and medical students, professional development and community outreach. Outreach activities included advocating for marginalized or underserviced populations, building relationships with community resource groups, and developing specialized programs/clinics for patients.

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Participants submit ICD9 diagnostic codes and NP encounter codes to the MOH and/or their health authority employer. They commented that there was inconsistency in code submission due to inadequate training, no technical support or standardized system for submission within their organizations.

The majority of NP participants were and many work more than 40 hours a week and are not remunerated for over-time. Participants were accountable to at least one supervisor. NPs consult and collaborate with a variety of other health care professionals.

NP participants perceived their major contributions to patients and families as: a) increasing access to care, b) spending time with patients, c) promoting health education, and d) managing chronic diseases. They contributed to their organizations by supporting others and providing leadership, and to the healthcare system by providing access to care and cost savings.

NP participants identified as hindrances to role implementation the inadequate knowledge or understanding of the NP role by managers, physicians, and other staff, lack of managerial and physician support, legislative barriers, and funding issues. In spite of these, facilitators of role implementation include support from collaborating physicians, employers and communities, and the personal attributes, passion, and hard work of other NPs.

The results of the 2013 practice pattern survey provide an ongoing insight into NP practice patterns in BC. As indicated by these findings NPs are practicing within their legislated scope of practice in diverse communities with people of all ages. Barriers to role integration continue to exist almost 10 years into implementation of the role and will need to be considered by government and employers of NPs.

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BACKGROUND

The nurse practitioner (NP) role has existed in North America since 1965 (Mason, Vaccaro, & Fessler, 2000), yet in British Columbia (BC) the role is relatively new, having first been

introduced in 2005, almost 10 years ago. The Ministry of Health’s (MOH) interest in the NP role can be traced back to the 1970s (Haines, 1993). This early interest was not sustained; however, renewed efforts to implement the NP role began again in 1997 with joint efforts of the MOH and the Registered Nurses of British Columbia (RNABC1_{) to define the role for the}

BC context (RNABC, 1997). In 2005 the first NPs graduated and were soon registered by the College of Registered Nurses of British Columbia (CRNBC) and hired into regional health authorities. The defined NP scope of practice was intended to allow for an autonomous professional practice model with minimal restrictions (CRNBC, 2006a; CRNBC, 2006b). Because of this, NPs were expected to increase accessibility to acute, long-term and primary health care (PHC) services; expand health care options; and fill gaps in the BC healthcare system (RNABC, 2004).

The NP role has been evaluated more than any other role in healthcare, and researchers have demonstrated that: a) NPs provide safe, effective care; b) patients are satisfied with care provided by NPs; c) patient health outcomes are improved; d) NPs facilitate functioning of multidisciplinary care teams (DiCenso et al., 2010; Horrocks, Anderson, & Salisbury, 2002; Newhouse, 2011); and e) patient health status, functional status, number of visits to emergency departments and hospitalizations are similar for NPs and physicians (Stanik-Hutt et al., 2013). This evidence supports the BC MOH’s expectation that NPs will provide safe, competent, and acceptable care to British Columbians.

This report is based on the findings of a survey of NP practice patterns conducted from June 2013 through November 2013. The survey was part of a larger study evaluating the integration of NPs in the Province. The specific purpose of this survey was to provide evidence of how NPs in BC are practicing. We were interested in learning about the populations for whom NPs provide care, the health conditions they most frequently diagnose and treat, and their

collaborative relationships, as well as their job satisfaction and other general aspects of their practice activities.

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METHODS

Originally we obtained permission to use a survey previously developed to assess NP practice patterns in Nova Scotia (Martin-Misener et al., 2010). With permission from the developers we modified the survey to reflect the BC context. We then pilot tested the survey with two

experienced NPs in the Province to determine clarity, appropriateness, and ease of use. This was our second use of the survey, with the prior administration in 2011. Ethics approval was obtained from the University of Victoria.

To ensure consistency, we adhered to the same three recruitment strategies used in 2011. Once again, we did not have direct access to the names and addresses of registered NPs, therefore we contacted CRBNC, who agreed to mail a researcher-prepared letter of invitation to the 135 registered NPs who had previously consented in their registration renewal application to be contacted for research purposes. The written invitations contained an electronic link

participants could use to access the questionnaire. We sent a follow-up letter, which included the link, after three weeks and a third letter with a paper copy of the survey and a stamped return envelope one month from the second. For our second strategy, we obtained permission from the BC Nurse Practitioners Association (BCNPA) to post a link to the survey on their website. Finally, we emailed an invitational letter to 72 University of Victoria NP alumni who had voluntarily given us their email addresses.

A total of 96 NPs returned the questionnaire. During the time we were collecting data (June-Nov. 2013) approximately 250 NPs were registered in BC, our sample represents 38% of NPs in BC. This is an increase from 2011 when 31 NPs responded, providing a three-fold increase in the number of participants. Ten surveys were incomplete, however we were able to use some of the data from these questionnaires, and six NPs were not practicing in BC and completed only demographic information and questions related to why they were not practicing in BC. We cannot calculate an exact return rate because we are unaware of the number of NPs

viewing the BCNPA website who responded to our link to the survey. Not all NPs responded to all of the questions on the survey, and this is reflected by different numbers given for total respondents to various survey items. Therefore, for clarity we provide the number responding to the question along with percentage when appropriate.

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FINDINGS

Demographics

All participants held a Masters of Nursing degree, 92 % (n=88) were female, and the average age was 46 years (range 27-61 years). Participants practiced an average of 20 years as a registered nurse (RN) before becoming an NP indicating that NPs had returned as highly experienced RNs to pursue a graduate degree in nursing. The mean length of time

participants had practiced as an NP was 5 years, up from 3 years in 2011. Eighty eight percent (n=79) were registered as family NPs, and 12% as adult or pediatric NPs (n=11). The majority of NPs (n=90) were currently practicing as an NP in BC; six were not practicing as NPs. Eight participants indicated they were registered outside of BC; two in the Northwest Territories, two in Alberta, one in Saskatchewan, two in Ontario, and one in the USA.

Employment Status

More participants (80%; n=72) held permanent full-time positions compared to 68% in 2011, and 12% (n=11) were in part-time positions compared to 26% in 2011. Twelve percent (n=11) of 65 participants practiced in dual roles, for example, RN/NP, part-time as an NP and casual as an RN, or casual RN and full-time NP. One participant was employed primarily as a Director of Care and worked part-time on weekends as an NP. The majority of participants were employed by one of the six regional health authorities; 64% were employed by Interior, Vancouver Coastal and Fraser Health Authorities. In Table 1 we summarize participants’ employment status.

Table 1. Employment Status

0 n=4 n=4 n=5 n=11 n=72 0 10 20 30 40 50 60 70 80 Temp PT (0%) Other (4%) Temp FT (4%) Locum (6%) Perm PT (12%) Perm FT (80%) N=90

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Work Settings

Geographic Distribution

Participants were geographically dispersed in the Province, practicing in rural settings, small towns, and large metropolitan areas. Figure 1 is a display of their location based on population density.

Figure 1. Geographic Distribution of NPs

We compared the geographic distribution of NPs to the population distribution of British Columbians, because we expected that NPs would be uniformly distributed and represented in the same percentages as the rest of the population. However, according to the 2011 BC Stats population estimates, 72% of British Columbians live in metropolitan areas with populations more than 100,000; 15% live in towns between 10,000 and 100,000; and 13% live in towns of less than 10,000. Therefore, it appears that the percentage of NPs working outside of major metropolitan areas is 17% larger than expected. The percentage of NPs practicing in rural and remote areas increased since 2011, when 35% of NPs worked outside of large metropolitan centers. The number of NPs practicing in large urban areas (more than 100,000) decreased from 65% in 2011 to 55% in 2013.

Practice Settings

Participants practiced primarily in community based settings (86% n=69), including

community health centres, physician offices, Aboriginal health centres, home care and public health. This is comparable to our findings in 2011 when 84% of NPs listed community based

n=89 23% 22% 55% Metropolitan area population >100,000 Towns 10K-100K Towns < 10K

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settings as their primary practice location. Thirty two percent (n= 26) of NP participants were employed in ambulatory clinics, emergency departments or hospital in-patient settings, compared to 39% in 2011. In 2013 a smaller percentage (9%) practiced in long-term care facilities compared to 16% (n=5) in 2011. Table 2 is a summary of practice settings in which NPs were employed in 2013.

Table 2. Practice Settings

Practice Settings* n %

Community/Primary Health Care Centre 50 56 Ambulatory Clinic/Outpatient Department 13 14

Physician Office 10 11

Aboriginal Health Centre 10 11

Hospital in-patient 10 11

Long-term Care Facility/Residential Care 7 8

Emergency Department 5 6

Public Health 5 6

Home Care 3 3

Outpost Nursing Health Centre 3 3

Other 19 21

*Multiple responses allowed

“Other” settings included outreach clinics, travel medicine, mental health and addictions rehabilitation centres, refugee clinics and hospital out-patient clinics. In most settings (74%, n=61), there was only one NP. The mean number of full-time NPs in each setting was 1.29, the maximum number of co-located NPs was four, other than in acute care settings where there were up to 11 NPs working in different units. Twenty five NPs indicated there were one or two part-time NPs co-located in their settings.

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Interdisciplinary Team Members

NPs indicated they practiced in settings with interdisciplinary team members, most often medical office assistants (88%), physicians (73%), and registered nurses (57%). Table 3 includes team members co-located with NPs. In addition to those listed in Table 3, 43% of NPs listed mental health workers, exercise therapists, rehabilitation assistants and care aides as others not included on our list.

Table 3. Members of HealthCare Team Co-located with NP

Team Member* n %

Medical Office Assistant(s)/Receptionist(s) 80 88

Physician(s) 68 73 Registered Nurse(s) 52 57 Social Worker(s) 34 39 Dietician(s) 31 39 Pharmacist(s) 23 25 Physiotherapist(s) 21 24

Licensed Practice Nurse(s) 21 22

Occupational Therapist(s) 18 18

Paramedic(s) 6 9

Midwife(s) 3 1

Other 34 43

Patient Populations Served

We asked NPs to identify the patient populations that were the primary focus of their practice. Table 4 is a summary of the populations for whom NPs provided care. NPs were able to

indicate more than one population.

The results of the 2013 survey indicate that a higher percentage of NPs are working with First Nations or Inuit (40% compared to 16%), homeless (32% compared to 19%), seniors (23% compared to 13%), and new immigrants (20% compared to 10%) than in 2011. This is

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congruent with groups identified by the MOH as high needs populations. These are also populations with complex health conditions and multiple social issues that affect their health.

Table 4. Patient Populations Served

Population* n %

All ages across the lifespan 36 41

First Nations or Inuit 35 40

Homeless/street involved patients 28 32

Mainly adults 23 26

Patients with one specific condition 22 25

Mainly seniors 20 23

Newcomers (immigrants) to Canada 18 20

Mainly Women 10 11

Mainly children or youth 8 9

Other 16 18

Compensation

Salary. Most NPs (79%/n=70) indicated that their position was funded by a health authority. Based on 20 NPs employed full-time who reported their salary, we calculated their average annual salary to be $101,612 up from $97,698 in 2011. Half of NP participants who were employed full-time indicated they were satisfied or very satisfied with their salary, and 34% were either dissatisfied or very dissatisfied with it. Nine NPs employed part-time reported their salary and level of satisfaction; four indicated that they were satisfied with their salary and 3 were dissatisfied or very dissatisfied.

Overtime. Roughly half the participants (53%, n = 47) indicated that they worked more than 40 hours each week and the majority (89%) were not financially compensated for working extra hours. NP participants indicated that they were able to have time off with pay in lieu of remuneration.

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Continuing education. The majority of NP participants (87%, n=77) received paid time off to attend continuing education opportunities, however, there were limitations. These included only provincial educational programs were eligible, payment was available for conference fees but not travel or accommodation, and travel had to pre-approved by their manager. NPs indicated that the amount received annually to cover education programs ranged from $700 to $1,000. They also indicated that the amount of time and compensation has recently decreased.

Resources and Supports

NPs were asked to rate their satisfaction with resources and supports provided by their employer on a scale of 1 to 6, where 1 represents very dissatisfied, 2 dissatisfied, 3 minimally dissatisfied, 4 minimally satisfied, 5 satisfied and 6 very satisfied. NPs were most satisfied with support from other health care providers and least satisfied with data management support and MOH requirements, e.g. forms, legislation and encounter codes.

Satisfaction with these resources and supports increased slightly across all aspects in 2013 compared to 2011 while staying in the same order of satisfaction. Table 5 lists resources and supports and NPs’ level of satisfaction beginning with those supports and resources with greatest levels of satisfaction.

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Table 5. NP Satisfaction with Resources and Supports

Resources and Supports Mean

(n=89)

Support from other health care providers in your setting (RNs, etc.) 5.2

Clinical examination space 4.8

Information support (Internet, digital library, online guidelines, decision support systems)

4.8

Office space 4.8

Support from your physician colleagues 4.7

Support from your direct supervisor 4.7

Policies of CRNBC, e.g. QA, Continuing Competence, etc. 4.6

Clerical support 4.6

Technology (fax, telephone, computer, pager, mobile phone etc) 4.6

Orientation to the expectations of your employer 4.4

Technology support 4.4

Orientation to your practice setting 4.3

Employer policies that support full implementation of the NP role 4.3

Telemedicine/Telehealth support, e.g. video equipment 4.2

Orientation to the electronic medical/electronic health record 4.2 Data management support e.g. access to databases, analysts, statisticians 3.8 BC Ministry of Health requirements, e.g. forms, encounter codes, legislation, etc. 3.5

NP legislation. Eighty percent (n=70) of NP participants, compared to 97% in 2011, indicated they experienced problems providing patient care as a result of restrictive legislation that does not recognize NPs as authorized providers or allow them to complete and sign numerous governmental forms. These forms include driver’s license physicals, Worksafe BC, ICBC, various Revenue Canada forms, DNR forms, disability forms and insurance claims. NP participants indicated that their inability to prescribe controlled substances for patients experiencing pain and some mental health conditions was a barrier to practice. In spite of the enactment of Bill 10, the Nurse Practitioners Statutes Amendment Act in August 2012,

legislative changes that would allow NPs to complete various forms and practice to their full legislated scope of practice remain pending.

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At the time of this report, federal legislation enabling NPs to prescribe controlled drugs and substances has been approved. Provincial regulation allowing NPs in BC to prescribe

controlled drugs and substances is the responsibility of CRNBC. The College is developing competencies and standards for NP prescribing controlled drugs and substances.

Accountability. The majority of participants indicated that they are directly accountable to at least one supervisor (n=79, 90%). Thirty-five participants were accountable to an RN manager while 33 were supervised by a non-nursing manager and 9 had a physician manager. Eighty percent (n=69) had some form of an annual performance review that was either conducted by their supervisor, the CRNBC quality assurance audit and self-assessment, and/or a peer review.

Practice Activities

Direct care activities. NPs were involved in a variety of clinical and non-clinical practice activities. Participants were asked to estimate the number of hours per week they spend providing various patient care activities. Table 6 is a compilation of selected patient care activities and the approximate number of hours per week NPs engaged in the activity in 2013 and 2011. The number of participants indicates the number responding to the question in 2013. Because of the multidimensional practice of NPs, the data may reflect work hours counted in two or more categories simultaneously.

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Table 6. Direct Patient Care Activities

Patient Care Activity 2013 Mean Hours/week

2011 Mean Hours/week

Number of Participants

Management and monitoring of chronic illness, e.g. stable angina, diabetes, hypertension, asthma

15.1 13 75

Health counseling/education 13.2 10.5 76

Wellness care/health prevention, e.g. breast & cervical screening, immunization, lifestyle & behaviour changes

10.9 7.9 75

Management and monitoring of mental health concerns, e.g. depression, anxiety, stress

10.7 7.46 75

Episodic care for minor acute illness/injury, e.g. colds, flu, sore throat, ankle sprain

9.1 5.8 73

Episodic care for major acute illness or surgery, e.g. unstable angina, acute abdominal pain, post-op care

7.6 4.9 66

Health promotion, e.g. community development, policies affecting social determinants of health

5.4 2.76 65

Community outreach 5.0 .53 44

Palliative care 1.5 1.08 60

When compared to 2011, NP participants were spending more time in all direct care activities, most notably in managing chronic illnesses and mental health issues, health prevention, and providing episodic care for minor and major acute illnesses. Community outreach included making home visits, providing youth and outreach clinics, and providing care in local shelters.

Non-direct care activities. Table 7 compares the average number of hours spent by NPs performing non-direct care activities in 2013 to 2011. The number of participants are those responding to the 2013 survey.

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Table 7. Activities Other than Direct Patient Care

Activity 2013 Mean Hours/week 2011 Mean Hours/week Number of Participants

Providing education/training to other learners 5.6* 2.7 59

Personal professional development 2.6 2.16 71

Community development/outreach 2.4 1.43 57

Management/leadership (including development of policies, programs, etc)

2.2 3.03 66

Team meetings related to patient care 2.2 2.83 75

Research 1.7 .62 53

*includes hours when NPs have students

Between 2011 and 2013, NP participants spent more time providing education/training of other learners, community development and research. They spent less time developing policies and programs, and attending team meetings.

From Tables 6 and 7 it is clear that NP participants spend the majority of their time in direct care activities. The majority of their non-direct activities involved working with others, for example educating and training learners, such as NP and medical students, finding

appropriate patient resources, and professional development. Given the ongoing new developments in medications, clinical practice guidelines, and treatment recommendations NPs need professional development to remain knowledgeable and competent.

Community development/outreach. The CRNBC competencies include an expectation that NPs engage in community outreach activities. In 2013, 41% (n=33 of 80) of participants reported that they performed community development/outreach as part of their practice, up somewhat from 35% in 2011. A few examples of community development/outreach included creating patient advocacy for marginalized or underserviced populations, building relationships with community resource groups, developing specialized programs/clinics for patients (e.g., weight loss, diabetic foot health, pre/post-natal teaching), and managing chronic health conditions.

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NP Practice Characteristics

Patient roster. The survey asked “How many patients are on your roster of patients?” The mean number of patients rostered to full-time NPs was 356, up from 334 in 2011. Some participants commented that it was difficult to answer this question because they were in settings that used a shared-care model of care and patients were not assigned to an individual care provider. Other NP participants indicated they worked in drop-in clinics or with transient populations that were difficult to track; that they provided care to homebound frail elderly; or practiced in an acute care setting.

Home visits. Sixty-one percent (n=48) of participants made home visits compared to 48% in 2011. Commonly cited reasons for home visits were to provide care to elderly patients or those with mobility problems, and to provide palliative care. NP participants (44%; n=34) referred patients to residential care and 22% (n=18) provided primary care to those living in residential care.

Acute care. The majority of participants were not assessing or treating patients in the

emergency department, conducting group visits, or admitting and discharging patients from acute care. Nonetheless, 87% (n=68) were following patients after they were discharged from hospital.

Patient assignment. Patients were assigned to the care of NPs in a variety of ways; patients book their appointments directly with the NP (35%), were assigned based on need or triage (33%), or were assigned by the medical office assistant (24%). Sixty-eight percent had no locum replacement when they were away from their practice. The majority of NPs (85% n=68) were not on-call.

Diagnosing, Test Ordering, and Prescribing Patterns

All participating NPs reported that they diagnose patients with a variety of health conditions or symptoms, prescribe pharmacotherapeutics, and order diagnostic tests on a routine basis. Table 8 is a summary of the presenting symptoms or conditions NP diagnose daily or weekly.

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Table 8. Frequency of Presenting Symptoms or Conditions

As indicated in Table 8, NPs are caring for patients presenting with symptoms associated with musculoskeletal (MSK) pain or injury, depression/anxiety, infections, fatigue, and skin

disorders on a daily basis. These are the same top five symptoms or conditions indicated in 2011. On a weekly basis they are most often caring for patients with low back pain, fatigue, skin disorders, and headaches. All conditions included in Table 8 are those that would be expected in primary care settings. Additionally, NPs commented that they saw patients with addiction issues and mental health issues other than depression.

Table 9 is a summary of the frequency with which NPs order laboratory tests and diagnostic imaging studies. n=43 n=38 n=35 n=26 n=24 n=18 n=17 n=16 n=16 n=12 n=11 n=11 n=10 n=10 n=10 n=10 n=6 n=6 n=5 n=4 n=4 n=26 n=28 n=27 n=32 n=35 n=35 n=38 n=31 n=24 n=27 n=31 n=33 n=22 n=17 n=15 n=10 n=29 n=23 n=31 n=17 n=13 0 10 20 30 40 50 60 70 80 MSK pain or injury Depression/anxiety Infections Fatigue Skin disorders Acute Cough Low Back Pain Chronic Cough Localized edema Fever Chronic Dyspnea Headache Acute Dyspnea Generalized edema Post op/post procedural follow-up Prenatal care/GYN Vertigo or dizziness Recurrent chest pain Chronic Abdominal Pain Acute Abdominal Pain Acute chest pain

Daily Weekly

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Table 9. Patterns of Diagnostic Testing Ordered

The range of NPs’ ordering of diagnostic testing is consistent with primary care practice and is within the NP scope of practice. The diagnostic tests ordered relate to the most common

symptoms and conditions for which NPs are providing care. These results are consistent with the results in the 2011 survey.

Chronic conditions. On average, 70% of patients cared for by NPs have more than one chronic condition. Table 10 demonstrates the frequency of common chronic conditions diagnosed by NPs. This also demonstrates that NPs diagnose conditions associated with high use of the health care system. While many NPs diagnosed Type 2 diabetes (DM) and hypertension (HTN) daily or weekly, fewer regularly diagnosed congestive heart failure (CHF) or renal disease. Indeed many NPs hardly ever diagnosed DM, CHF or renal disease, however all NPs regularly diagnosed depression and most diagnosed HTN.

n=3 n=19 n=20 n=21 n=26 n=28 n=37 n=59 n=60 n=63 n=68 n=18 n=27 n=23 n=23 n=31 n=17 n=22 n=13 n=4 n=8 n=4 0 20 40 60 80 Bone density CT scans Immunology Virology Pelvic/abdominal ultrasounds Cytology/pathology Electrocardiograms X-rays Hematology/blood bank Microbiology Biochemistry Weekly Montly

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Table 10. Frequency of NP Diagnosis of Chronic Conditions

NP prescribing. NPs’ scope of practice includes prescribing a wide range of

pharmacotherapeutics. Table 11 displays the classes of medications NPs prescribe, along with the frequencies of prescribing daily or weekly.

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Table 11. Frequency of NP Prescribing Pharmaceuticals

Of the classes of drugs listed in the survey, NP participants most often prescribe drugs to treat infections, diabetes, and cardiovascular conditions. NP participants commented that they also prescribed anti-depressants, anticoagulants, and pain medications, which were not listed in the survey.

Encounter Reporting

In BC there are two ways in which data on NP practice are recorded: ICD9 and encounter codes. Fifty six of 79 (56%) NP participants reported that they submit ICD9 diagnostic codes. This is down from the 66% submission rate in 2011. Twenty of 77 (26%) NPs submit ICD9 codes to the BC MOH, while 27 of 77 (35%) submit them to their local health authority. Fourteen of 77 NPs (18%) who submitted ICD9 codes were unsure where the codes were

n=25 n=32 n=21 n=22 n=18 n=21 n=4 n=16 n=17 n=9 n=6 n=9 n=7 n=6 n=4 n=11 n=4 n=36 n=20 n=29 n=26 n=37 n=25 n=32 n=23 n=23 n=22 n=17 n=17 n=16 n=11 n=13 n=7 n=13 0 10 20 30 40 50 60 70 Antiinfectives Cardiovascular agents Vitamins Gastrointestinal agents Antihyperglycemics

Skin & mucus membrane agents

Antihistamines

Contraceptives

Hormones and synthetic substitutes

Vaccines/immunizations

Autonomic drugs

EENT preparations

Central nervous agents

Antitussives, expectorants, and mucolytics

Smooth muscle relaxants

Electrolyte, caloric, & water balace agents

Blood formers and coagulators

Chart Title

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submitted because someone else completed the submission process. Twenty-one percent of NPs did not submit ICD9 codes.

An encounter code is part of the encounter record and is used to represent the service performed by an NP. Encounter codes are used to capture NP practice activities and while similar to physician fee item codes they are not used for billing purposes. Encounter codes were originally developed by the BC MOH specifically to collect data on NPs’ practice

activities. The information included in an NP’s encounter record serves the same purpose as a medical claim submitted by a physician or other health care practitioner. NPs are expected to submit encounter records that include encounter codes. Seventy-one percent (n=55 of 78) of NPs reported they submitted encounter codes, compared to only 58% in 2011. Twenty-three percent (n=17 of 73) submit them to the BC MOH, 40% (n=29 of 73) submit them to their local health authority, and 14% (n=10 of 73) were unsure of where the codes were submitted. Twenty-three of NPs (n=17 of 73) reported they did not submit encounter codes.

In their comments about the use of encounter codes and the process for submitting encounter records, NPs expressed inadequate understanding about the reason for submitting codes, particularly around the lack of feedback after submitting them; the time consuming,

cumbersome submission process, and the inadequacy of the codes in reflecting their practice. Other comments included that there was inadequate training on the appropriate use of the codes, no technical support, and no standardized system for submission within their organization.

In 2013 a MOH NP Encounter Code Working Group comprised of practicing NPs, health authority representatives, members of the BCNPA, University of Victoria researchers, and MOH employees was formed to revise the encounter codes for the first time since 2008. A revised list of encounter codes has been submitted and approved by the MOH. Information on the MOH’s website related to encounter record submission is currently under revision.

Educational tutorials are also under development. It is expected that these initiatives will increase the number of NPs submitting encounter records to the MOH.

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Collaboration, Consultation, and Referral Activities

Collaboration with Family Physicians

Seventy-six percent (n=60) of participants worked in a direct relationship with one or more physicians; 70% of NPs (n=54) were satisfied or totally satisfied with their relationship with the physicians with whom they most often collaborated. These percentages are consistent with the results in the 2011 survey. Comments from NPs indicated that, in some situations, physicians had limited time for collaboration and in other situations physicians’

understanding of the NP role was insufficient, which could lead to dissatisfaction with the relationship.

Consultation with Specialist Physicians and Other Health Care Professionals

The majority of NPs referred patients to specialist physicians and to a variety of other health care professionals. NPs indicated that specialist physicians sometimes would not accept their referrals, most commonly because of specialists’ inadequate understanding of the NP role and belief they would not receive payment for taking these referrals. Several NPs commented that, although the referrals were accepted, sometimes the results were returned to the GP in the office instead of the NP, creating some confusion. NPs also referred patients to an array of health programs including diabetes programs, home care, mental health and addiction

services, and community based self-help programs. Table 12 is a display of the types of health care professionals to whom NPs referred patients.

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Table 12. Health Care Professionals with whom NPs Consult

In addition to those listed in Table 12, NP participants commented that they refer patients to clergy, podiatrists, optometrists, counselors, registered massage therapists, respiratory therapists, diabetic nurse educators and naturopathic doctors. In all, NPs consult and collaborate with a wide range of health professionals.

Receiving consultations. NP participants indicated that they received referrals from other health team members; 70% of participants received referrals from family physicians, specialist physicians, other NPs, public health nurses, and home care and mental health care staff. This is up significantly from the 40% in 2011 who indicated they received such referrals.

Reasons for collaboration/consultation. On a weekly basis, 41% (n=33) of participants initiated informal face-to-face discussions of patient care concerns with physicians and 36% (n=28) met with other health care providers to discuss patient concerns. Table 13 is an

n=8 n=30 n=36 n=44 n=54 n=60 n=70 n=71 n=71 n=75 n=78 n=88 n=90 n=99 n=92 n=70 n=64 n=56 n=46 n=40 n=30 n=29 n=29 n=25 n=22 n=12 n=10 1 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Family Practice Nurses Chiropractors Midwives Family Physicians Other NPs Public Health Nurses Mental Health Workers Pharmacists Social Workers Occupational Therapists Home Care Nurses Dieticians Physiotherapists Specialist Physicians

Refer Do not refer

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illustration of the frequency with which NPs collaborated with other health team members along with the reasons for collaborating on a daily or weekly basis.

Table 13. Frequency and Reason for Collaboration and Consultation

Achievement of Expected Outcomes in NP Practice

Forty four percent of NP participants (n=35 of 79) indicated there were specific health

outcomes they were expected to achieve, and they spoke of these in their narrative comments. Examples of expected outcomes included: a) reduction in the number of patient visits to the emergency department, b) reduced hospital admission of residents in long-term care, c) reduced readmissions after hospitalization, d) follow-up care of frail elderly, e) improved chronic disease management, f) increased immunization rates, screening mammograms and Paps, and g) increased access to a primary health care. However, 56% (n=44 of 79) indicated there were no specific outcomes they were expected to meet.

1 n=4 n=6 n=6 n=11 n=16 n=13 n=26 n=23 n=6 n=8 n=10 n=16 n=19 n=18 n=21 n=28 n=33 0 20 40 60

We conduct research together We participate in the same continuing education opportunities

We jointly plan strategies to address issues affecting the health of the community

We jointly plan for changes in the organization of the practice

We jointly plan how to address or optimize systems in our practice to care out specific activities

I communicate about emerging health issues in the community with other health care providers I initiate informal telephone discussions re patient care concerns with MDs

I meet face-to-face on a regular basis to discuss patient care concerns with other health providers

I initiate informal face-to-face discussions of patient care concerns with MDs

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We asked NPs to indicate if they collected data to evaluate their role, and 50% (39 of 78) indicated they did so to aid with the evaluation of their role. Fifty percent did not collect such data. Of those who collected data, 30 participants provided narrative comments describing the types of data collected for evaluation. Their descriptors were general; examples of types of responses included patient satisfaction surveys, self-audits, a review of specific goals, encounter codes and ICD9 codes. Although NPs may be expected to meet specific health outcomes, limited outcome data is currently collected. Thus there is merit in an evaluation framework NPs and employers could use to assess outcomes.

Contributions of the NP Role to Individuals, Organizations and

Healthcare System

We asked NPs to give us their perception of the three most important contributions they made to patients and families, to the organization in which they worked, and to the healthcare

system. NPs perceived their major contributions to patients and families as: a) increasing access to care, b) spending time with patients, c) promoting health education, and d) providing chronic disease management strategies. They saw the contributions to their organizations as supporting others and providing leadership. Perceived contributions to the healthcare system were providing access to care and cost savings (Table 14).

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Table 14. NPs’ Perceived Contributions of Their Role Contributions to Patients and Families

Access to care Continuity of care

Spending time with patients Health promotion and education Chronic disease management

Contributions to Employing Organization

Mentoring nursing and support staff Leadership skills

Reduced wait times

Reduced emergency visits, hospital admissions and length of stay Improved access for hard to reach populations

Chronic disease management Collaborative approach to care

Contributions to Healthcare System

Increased access to care for underserved/marginalized/vulnerable populations Cost savings through reduced hospitalizations/length of stay

Patient satisfaction

Decreased use of acute care services

Facilitators and Hindrances to NP Practice

Facilitators. NP participants identified several facilitators and hindrances to role implementation (Table 15). Support from others was the most frequently mentioned

facilitator. Specifically, NP participants identified that support from collaborating physicians was very important. Support from their employer and the local community were also viewed as facilitative. Several NP participants mentioned the success and hard work of other NPs in their practice environments and across the province as being directly instrumental to their success. Finally, participants identified that personal attributes, passion, and hard work by the NP him/herself facilitated the implementation of their roles.

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Table 15. Facilitators and Hindrances to NP Role Implementation Facilitators of NP Role Implementation

 Physician support

 Leadership vision and commitment

 Supportive team

 Community support

 Personal initiative

 Understanding of role

 Having an NP mentor

Hindrance to NP Role Implementation

 Inadequate support from administrators and physicians

 Lack of understanding of the NP role by others

 Restrictive legislation

 Lack of funding for positions

Hindrances to role implementation. NP participants identified as a hindrance the inadequate knowledge or understanding of the NP role by managers, physicians, and other staff. They also identified lack of managerial and physician support, legislative barriers, and funding issues as hindrances to role implementation.

Unfortunately NPs identified similar hindrances in our 2011 survey, indicating that issues relating to support, funding and legislation continue to encumber NPs and their ability to care for patients. Although these can be barriers to practice, in the right environment, support, adequate funding, and non-restrictive legislation become facilitate NP practice.

The MOH began initiatives to implement the NP role in 1997 and NPs have been practicing in the province since 2005. It is unfortunate that some administrators and physicians are

unsupportive, legislation continues to restrict their practice and a model of sustained funding has not been secured.

NPs Not Practicing in BC

A few participants (9 of 96) were currently underemployed or not employed as NPs in BC. Six participants were not employed as an NP and three worked part-time as an NP and part-time as an RN. Four participants worked full-time as an NP but also worked casual RN shifts.

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Of those who were not practicing as an NP in BC, we asked them to explain. Most

commented that they had been only able to find work that was too far from home. They also indicated that they had found employment at times, but only on a temporary basis, for example, a maternity leave.

CONCLUSION

The results of this survey builds on data obtain from the 2011survey of NP practice patterns in BC. Results indicate that NP participants are practicing to their currently regulated scope of practice, however legislative limitations and inadequate availability of full-time employment present ongoing challenges for NP role implementation. Although facilitators exist, there are hindrances to role implementation that will need to be addressed in order to create new NP positions and continue to integrate the role into the BC healthcare system.

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