The provision of health care in the Northwest Territories (NWT): a joint statement on health care reform in the NWT, September 1998

Northwest Territories Medical Association* and Northwest Territories Registered Nurses Association†

CJRM 2000;5(1):12.

[ résumé ]

• Abstract
• Résumé
• Introduction
• A vision of health care reform
• Principles
• Recommendations
• Definitions
• References and bibliography

In this document, the Northwest Territories Registered Nurses Association and the Northwest Territories Medical Association outline their vision of health care reform in the province as a consistent, collaborative model of primary health care reform, collaborative practice and accountability. Next, the roles of the primary health care nurse practitioner and the physician in a collaborative practice model are defined. Finally, recommendations to help facilitate the development of a collaborative practice model under the broad headings of education, collaboration and governance are enunciated.

L'Association des infirmières diplômées des Territoires du Nord-Ouest et l'Association médicale des Territoires du Nord-Ouest énoncent dans ce document leur vision d'une réforme du système de santé du territoire qui passerait par la réforme uniformisée des soins primaires, la pratique en collaboration et l'imputabilité. Le document définit aussi les rôles respectifs des infirmières de première ligne et des médecins dans un modèle de collaboration puis, pour favoriser l'élaboration d'un tel modèle, propose des recommandations en matière d'éducation, de collaboration et de gouvernance.

[Contents]

The purpose of this paper is to describe a collaborative model for health care delivery in the NWT. Although this document is focussed specifically on collaborative primary health care delivery by physicians and nurses, we do recognize that there are health care providers in other disciplines (e.g., physiotherapy, occupational therapy, social work, pharmacy) whose involvement in a model of collaborative primary health care will be essential to that model's success.

The need for this document arose from recent changes in the administration of primary health care delivery in the NWT. With regionalization and the loss of a central organizing structure to ensure uniformity of primary health care delivery and management in the NWT, it has become apparent that different regions have differing levels of experience in administering and managing primary health care to the members of their communities. If the Regional Health and Social Services Boards (RHSSBs) lack an experienced, consistent approach to the delivery of primary health care, then there is a risk that the care given to patients in the different regions will vary widely, and in some cases fall below nationally accepted standards. The division in April of 1999 of the NWT into NWT and Nunavut further supports the need for a proposal for a consistent approach to the problem of primary health care delivery.

Health care reform is upon us and the continued challenges to providing quality health care in the NWT make it apparent that the role of the nurse in all health centres needs to be clarified and that new models for health care delivery need to be proposed. As key providers of health services in the NWT, nurses and physicians have an active interest in ensuring that any changes maintain the appropriate quality of care and ensure that care is provided by competent practitioners. This document is a joint project by the NWT Medical Association (NWTMA) and the NWT Registered Nurses Association (NWTRNA). Its intent is to positively influence the direction of health care reform. The recommendations of this document are directed toward all of the groups that are intimately involved in health care reform in the North. These groups include the NWTRNA, the NWTMA, the Department of Health and Social Services (DoHSS) and the RHSSBs.

In this document, the NWTRNA and the NWTMA outline their vision of health care reform in the NWT as a consistent, collaborative model of primary health care reform, collaborative practice and accountability. The roles of the primary health care nurse practitioner (PHCNP) and the physician in a collaborative practice model are defined. A series of recommendations to help facilitate the development of a collaborative practice model under the broad headings of education, collaboration and governance is also defined.

[Contents]

The NWTRNA and the NWTMA believe that community-based primary health care is the most appropriate and economical model for delivering health services. Health care should be delivered by the most appropriate provider based on the level of competency of the individual practitioner. This supports the vision of the government of the NWT for health care delivery.

In smaller communities, nurses work in an ex-panded role, using advanced skills and knowledge to provide primary health care. In larger communities, physicians working in private clinics or hospital- based clinics provide access to the system. The NWTRNA and the NWTMA believe quality care could be enhanced by implementing a collaborative model of primary health care in all communities.

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The World Health Organization, in its Alma-Ata declaration of 1978, defines primary health care as follows:

Essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.... It is the first level of contact of the individual, the family and the community with the national health system, bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.¹

Health Care delivery in the NWT is guided by primary health care principles that ensure safe, competent, effective and ethical client/patient care by the most appropriate health care provider. The goal is to ensure quality care by the most appropriate caregiver, in the most appropriate setting, at the appropriate time and in the most cost-effective and economical manner.

Primary health care

Primary health care is the first level of contact with the health care system and should form the basis of any comprehensive health care system. It

• ensures accessibility to health and health services to all populations
• maximizes individual and community involvement in the planning and operation of health care services
• emphasizes services that are preventive and promotive rather than curative only
• encourages health, social and economic development.

Health care reform

• Health care reform must be driven by the desire to meet patient and client needs in the safest, most effective way possible and must contribute to quality care.
• Clients/patients have a right to be informed of, and to participate in, decisions that will affect their care.
• Health care reform must recognize the unique and shared competencies of PHCNPs and physicians and promote optimal use of these competencies in the interest of client/patient care.
• Physicians and PHCNPs are guided by ethical practice and professional standards. The decision-making process in health care reform must support the practitioner's accountability as a member of a self-governing profession.
• Physicians and PHCNPs are accountable for acquiring and maintaining the level of competence required in the provision of safe and effective care.
• Health care professionals, in this instance physicians and nurses, should collaborate at all levels of decision-making.

Collaborative practice

A joint Canadian Nurses Association and Canadian Medical Association working group developed the following set of principles for collaborative practice. They are general in nature and are intended to guide and support the ongoing development of collaborative practice models in a variety of settings. Collaborative practice involves the following:

• patient centred care with a minimum of 2 caregivers from different disciplines working together with the care recipient to meet assessed health care needs
• development of a shared or common vision, values and philosophy focussed on meeting care needs
• clear definition and understanding of team member roles and responsibilities by all stakeholders
• a climate of respect, trust, mutual support and shared decision-making
• effective communication among all team members
• empowerment of all team members
• respect for autonomous professional judgement
• respect for autonomous choices and decisions of the care recipient.

Accountability

Accountability for the decisions of health care reform is shared by agencies, physicians and PHCNPs. Safeguards must be in place to protect clients/patients from incompetent and unethical practice.

• There must be mutual agreement among employing agencies, physicians and PHCNPs for the delegation of medical functions.
• Agencies are accountable for establishing a formal mechanism for decision-making and an approval process for delegated medical functions, and for setting standards of care that are consistent with professional competencies and legislated scopes of practice.
• Agencies are accountable for monitoring and implementing quality improvement measures that address the competent performance of delegated medical functions.
• Physicians are accountable for the decision to delegate, whereas PHCNPs accepting delegation are accountable for accepting and performing the delegated functions. The parameters and clinical guidelines for such delegation must be established and well understood by PHCNPs and physicians.

Within the limits of the system, patients should have a choice of, and qualified access to, their preferred primary health care provider.

PHCNPs' role

The PHCNP is a health service provider who works autonomously as well as collaboratively within an interdisciplinary team. The role of the PHCNP includes 2 major functions: those within the scope of nursing practice (community health services), and those that have been traditionally restricted to the scope of practice of physicians (primary medical care).

Community health services

Coordinating and implementing programs to provide the following:

• community development
• health promotion
• health protection
• disease and injury prevention
• support services
• treatment
• rehabilitation
• population-based research.

Primary medical care

Primary medical care comprises the provision of acute, chronic and emergency care services including the following:

• assessment/diagnosis
• autonomous intervention/treatment/management, including the limited prescription of pharmacologic and non-pharmacologic agents within the context of collaborative practice
• follow-up/referral.

Physicians' role

In a collaborative care model, family physicians have an expanded role from the one that they traditionally have occupied as primary medical care providers. Primary medical care consists of first-contact assessment of a patient and the provision of continuing care for a wide range of health concerns. The scope of primary medical care includes the diagnosis, treatment and management of health problems; disease prevention and health promotion; and ongoing support, with family and community intervention where needed.

Given the unique challenges of providing primary health care in the NWT, a collaborative model of patient care requires physicians to increase the portion of their role, which includes the following:

• determining appropriate delegated medical functions and shared competencies
• aiding in education of primary health care practitioners and other allied health workers
• coordination and supervision of collaborative primary medical care
• development of clinical guidelines and protocols
• program development and implementation with mental health, substance abuse and social services workers
• public education
• quality assurance audits
• population-based research.

[Contents]

Education

1. All nurses providing primary health care in the NWT should have completed a formal, standardized, nurse practitioner training program.
2. An accredited PHCNP program should be established in the NWT.
3. The Advanced Nursing Skills Education Program (ANSEP) currently exists² and should be developed into an accredited nurse practitioner training program.
4. An accredited nurse practitioner training program in the NWT must incorporate the trans-cultural aspects of health care.
5. The above program needs to include prior learning assessment mechanisms to determine equivalencies for course credits. Prior learning assessments provide recognition for knowledge and skills acquired through experience.
6. Until recommendations (1) through (3) can be implemented, all new PHCNPs should be provided with ANSEP training at the time of employment.
7. A program for continuing education based on context of practice should be developed. This could include certifications and/or module learning for advanced nursing practice.
8. Designated teaching health centres should be established to provide a practicum component of PHCNP training as well as a training venue for community physicians.
9. Physicians in the North, particularly those just starting practice in the NWT, should receive orientation with respect to their expanded role in a collaborative system.
10. A coordinated and standardized continuing education program with appropriate resources should be developed to enhance the education component of community visits by physicians.
11. Standardized guidelines for preceptorship of PHCNPs need to be developed.
12. Physicians and PHCNPs should have the opportunity to acquire managerial skills both to support collaborative care and to offer meaningful input into future health system change.
13. A PHCNP registry should be developed.

Collaboration

1. Communities should have a designated physician who provides comprehensive and continuous medical care for the residents of that community in collaboration with the PHCNPs in that community.
2. Physicians should increase their time and expand their role within communities to encompass increasing teaching needs, case planning and community advocacy in a collaborative care model.
3. Between community visits, the designated physician should review all clinical patient data that originates from the community (e.g., laboratory and x-ray results). The physician should also be involved in the in-hospital care of patients from their designated community.
4. Advanced telemedicine technology should be used to facilitate collaboration among physicians and nurses.
5. Given the expanding roles of physicians and PHNCPs in collaborative care, the NWTMA, the NWTRNA and RHSSBs should review physician and nurse resource requirements on an on-going basis.
6. Retention issues must be addressed. General supports for PHCNPs that have been present in the past, such as housing subsidies and travel allowances, and new initiatives, such as funded, regular, remote nursing conferences in a centre like Yellowknife, should be implemented to increase job satisfaction and improve retention of PHCNPs.
7. A pilot project(s) to assess and evaluate the patient outcomes of a collaborative primary care model should be developed. The pilot project(s) should include at least one PHCNP and at least one physician. Evaluation should be ongoing and a final evaluation should be carried out within a defined time frame to provide feedback for future initiatives of a similar nature.

Governance

1. The DoHSS should establish a Joint Primary Health Care Steering Committee. Minimum representation should include the NWTRNA, the NWTMA, the RHSSBs, DoHSS and public representation. This committee could provide guidance and recommendations regarding the following issues:
   • curriculum requirements for a PHCNP training program
   • evaluation tools for PHCNPs within this program
   • standardization of guidelines for joint primary health care
   • recruitment and retention issues for all primary health care professionals
   • guidelines for clinical supervision and patient referral for PHCNPs
   • development of appropriate audit mechanisms
   • evaluation of administrative and legislative barriers to collaborative practice
   • ways to promote the role of the PHCNP.

   Other stakeholders should be brought in as issues relevant to them are addressed.

2. A medical director should be appointed to each RHSSB.
3. Physicians and nurses should attend RHSSB meetings to assist in education of the Board regarding collaborative practice, to monitor and evaluate the RHSSB and to have meaningful input with regard to RHSSB decision-making.
4. The RHSSBs and the NWTMA should explore alternative funding mechanisms to support collaborative primary health care activities by physicians.
5. A standardized exit interview should be given to all physicians and nurses leaving primary health care practice in the NWT.
6. The DoHSS should provide regular review and assessment of RHSSB functions in providing collaborative primary health care.
7. The expectations that the community has of its health centres and community nurses should be explored.
8. The infrastructure of the health centres across the NWT needs to be standardized.
9. An appropriate standard of accreditation should be developed and should be applied to all health centres in the NWT.
10. Individuals providing primary health care in health centres should be credentialled, based on training and experience, by the RHSSB before employment.

We recognize that all of the above recommendations will, to differing degrees, require the provision of funding on the part of the RHSSBs and the DoHSS. The feasibility of each recommendation, and their financial implications will have to be determined.

[Contents]

Expanded role

An expanded role is one where the registered nurse is required, as part of his or her job description, to provide services or perform functions beyond those that are routinely done as part of nursing practice by the general nursing population. Often these services or functions require advanced knowledge or skills.³

Primary health care

Essential health care, based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.... It forms an integral part of both the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.¹

PHCNP

A working title for the purposes of this document for registered nurses whose role and functions in providing primary health care services require advanced nursing knowledge and skills. The focus of the PHCNP is community health nursing with particular emphasis on community development and health promotion as well as knowledge and skills in assessment, diagnosis, intervention, treatment management, drug therapy and referral functions, which are shared with physicians, pharmacists and other service providers.⁴

Scope of practice

A profession's scope of practice encompasses the activities for which the professional is educated and authorized to perform and is influenced by the setting in which they practice, the requirement of the employer and the needs of the patients or clients.⁵

Contexts of practice

The conditions in which nursing and medicine are practised encompassing: type of agency (institution, community, home); client/patient population (age, health needs, health status); availability of resources; independence and autonomy of practice.⁶

This article has been peer reviewed.

[Contents]

1. World Health Organisation: Declaration of Alma-Ata. Geneva: The Association; 1978. www.hadar.m.se/svensk/text/sh7131.htm. Accessed Dec. 10, 1999.
2. Advanced nursing skills inservice program (ANSIP): course outline. Yellowknife: Government of the Northwest Territories; revised February 1996.
3. An expanded role of the RN in the NWT [discussion paper]. Yellowknife: NWT Registered Nurses Association; 1997.
4. Guidelines for registered nurses in advanced nursing practice providing primary health care services in under-serviced communities in Alberta. Edmonton: Alberta Health; August 1994.
5. Determining the scope of practice. Guidelines for NWT nurses. Yellowknife: NWT Registered Nurses Association; 1994.
6. Guidelines for shared competencies & delegated medical functions. Halifax: College of Physicians and Surgeons of Nova Scotia / Registered Nurses Association of Nova Scotia; January 1997.

Bibliography

The "Provision of Primary Health Care in the Northwest Territories" Collaborative Care Project Committee utilized the following documents, not used as references in the article, as the background for its discussions and recommendations.

1. Guidelines for nursing practice decisions. Yellowknife: NWT Registered Nurses Association; 1992.
2. Bapsford R. Nurse practitioners in Ontario. Canadian Nursing Management February1995.
3. Zacharias R (project director). Northwest Territories Health and Social Services draft strategic plan. A review and recommendations for an integrated health and social services system in the Northwest Territories, Canada. Mississauga (ON): Med-Emerg International. May 1997.
4. Discussion document on primary health care reform in Canada [green paper]. Toronto: College of Family Physicians of Canada
5. Corriveau A. Human resources issues in health reform [discussion paper]. Yellowknife: Northwest Territories Department of Health and Social Services; November1996.
6. The nurse practitioner [discussion paper]. Toronto: Canadian Nurses Association; February 1993.
7. Human resources issues in health reform [comments]. Yellowknife: NWT Registered Nurses Association; February1997.
8. Corkal J, Butcher D, Shillington J, Carruthers A. Haste makes waste. Yellowknife: Northwest Territories Medical Association; November 1996.
9. Position paper on nurse practitioner curriculum. American Academy of Nurse Practitioners; 1998. www.aanp.org/position.htm. Accessed Dec. 10, 1999.
10. Scope of practice for nurse practitioners. American Academy of Nurse Practitioners; 1992. www.aanp.org/scopeof.htm. Assessed Dec. 10, 1999.
11. Nurse practitioners in Ontario: Back to the future? Toronto: Canadian Nursing Management; February 1995. p. 5-7.
12. The Minister's Working Group on Nurse Clinicians. Final Report to the Government of Nova Scotia. Halifax. September 1996.
13. Pat McLean, Managing Director: Canadian Nurses Protective Society: Personal communication regarding legal liability for nurse practitioners. July 1997.
14. Competencies for registered nurses providing extended health services in the Province of Alberta. AARN Newsletter 1996;52(6):12-3.
15. Walters DJ, Toombs M, Rabuka LA. Strengthening the foundation: the physician's role in primary health care in Canada. CMAJ 1994:150(6):839-47.
16. Working together. A joint CNA/CMA collaborative practice project. HIV/AIDS example [background paper]. Ottawa: Canadian Medical Association; Mar. 25, 1996.