EVALUATIONOFFAMI LY PRACTICE NURSE DEPLOnlENT IN URBAN MEDICALPRACTICE IN NEWFDUNDLAND
by
Larry Willi am Chambers.B.A. (Hons.), M.Sc.
0
A thesis submitted inpart ia l fulfillment of therequirement s for the degree of
Docto r of Philosophy
Div i s ion ofCorrmunityMedic ine Memoria lUni ve r s i t yofNewfo undla nd
Janua ry 1978
St.John's Newfoundla nd
The FamilyPracticeNurseEducationProgra m of Memorial Univers ity ofNewfoundla nd wasestabl i shedto pre pareexper ienced.
dipl oma- anddegre e-hol din g nursestoas suee an expanded nur singrole in primary he alth care setting s. Thetopic of this thesis is the eval ua tionof theillllact of sixgr aduate s of thi sprogramon private medt cal practices in 51. John'san.dCorner Brook. Newfoundland. .The evaluati oncomponent of thefamilypractice nurse projectbegan in 1973 with thede vel opnent ofinstrurrent s to mea sure the family practice nurse 's impact on the effectivenessofpettentcare.pat ie nt and health professional satisfaction.qual ityofcare. practice service output and organizati on. and financia1aspect s of the practi ces .
Effectivenes sofPat ie nt Care: In.order-to asse ss the effective- ne ss and.safetyof thepri mar y care provided by a family pr act i ce nurse, a randomized ci i r.ical trial was conducted inone of the St.
John' spractices be t weenJune 1975 and "".ay 1976. Before and after the trial,standardi zedmeasurementsof physic a l, social . andemotional functionwere administeredbylayinterviewersto 572 patients who received conventiona lcare by the familyphysician and to 296 patients whoreceivedcare mainly fromthe family practicenur se . At the start of the study. statistic al analyses revealed the comparability of the two groups of pat ientswith respect to all three health out come measurements . At the er:d of the study, the hea1th outcomesof the twogroupsof patients were found cosoe rebfe, Thes e results corrob- orat etheevidenceder iv edfrom ot her controll edtrials thatfamily practi cenurses /nursepract iti oner s pro vi deef fe c t i ve care.
ii
Satisfaction: Satisfaction and acceptance of family practice nurses was found high for patients,physicians and allied health professionals.
Quality of Patient Care: Quality of patient care standards were maintained after the introduct ionof femt ly practice nurses. Before and after evaluations were achieved by using the indicator condition method. Minimalexplicitprocess criteria for the management of pa ti ents wi th12 i ndica tor conditions andthe use of 14 dr ugs were approvedbyanad hoc peergro upof comuntty physicians. These cr iteria we re applied to the practicesusi nga single blinddesign and abstracting unalteredmedica l records. A standardizedscore for each practice was used to cceeare management of indicatorcondition scores and clinical use of drug scores before and after attachment of the fami ly practice nurses. For each of the indicatorconditions and the drugs assessed similar levels of adequacy were observed between study periods. These explicit (objective) audit resultsagreed withthe iltlllicit (subjective) assessmentsof the familyprac t ice nurse s by their physicia ncolleagues.
PracticeService Output andOrganizat ion: The additionof a family pract ice nurse to anurban medica lpr act ice increasedser vi ceoutp ut in fourout ofsix cases. Physicia n/ fami lypractice nur s e teams we re studied usi ngdaily logs offamilypracticenurseactivity, physician claims to the provincial~dicalCare Plan,time study sheets, and function delegation questionnaires. Practices using family practice nurses had a mean increase of 141 in the number of patient services during the first year offamily practice nurse attachment;the neen
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increase for atl physicians in the provincewas 9. The number of patients in the six study practices changed only slightlywhile servicesper patient increased by151. Family practice nurses prov ided totalcare in4~of office services, and participated with physicians in"a further26t;.
No consistent changes were noted in the age and sex of patients seen or in the amountof time the phys tc ten spent in the office.
Financial Aspects: Estimatedlos ses were experienced byfour of six fee-for-s e r vi ce family physicia nsin a study ofre venues generated andexpenses incurred by the six family practice nurses who had held salariedpositions for one year in private medical practices.
Daily service diaries were used to make annual estimates of family practice nurse generated revenues. Data from these diaries were linked by computer to yearlyphysician service data maintained by the provincial Medi cal Care Plan.
During the year'of family practice nurse attachment, the six physicians experienced a mean increase in gross Medical Care Plan
~of $11,350 with an additional extimated mean increase of $2.690 when solo family practice nurse services were included. Physicians' subject ive appra i sa 1sand actua1 fi nanci a1s ta tements from thepracti ces were used to estimate annualexpenses rele ted to the employment of the family practice nurses. The first procedure indicated average costs of employment were $14,700 and the other 519.770.
The estimated physician losses in net income, though real. were not substantial given(l) this was the first year of the family pract ice nurse attac hment. (2) thepurposesof thefamily practicenurs e at t achment were exploratoryto determine the femt l y practice nurse's
tv
role in the practice and not primarily to demonstrate the profit- ability of employing family practice nurses. (3) the fee-for- service method of payment on the whole discourages delegation of tasks and allocation of time for teaching, factors not present with physicianson salary.
ACKf<OWLEDGH1ENTS
This project was possible largely due to the efforts of Dr.Boyd Suttte , formerly Associate Dean of the Division of Corrmunity Medicine. Nemorfe l Universityof Newfoundland {now Assistant Deputy Ministerof Corrrnunity Health Services of the Government of Ontario} and his encouragement and support of the concept of family practice nurses in Newfoundland.
As study subjects. the physicians (Drs.G. Russell,D. King, C. Hc, H. Wight. I. Simpson and P. Mowbray) and the family practice nurses(E. O'Driscoll.P. Power, G. Hunt. \i. Williams.M. Haynes, and D. Doyle) were extremely cooperative and helpful throughout the duration of the project.
The Division of Comnunity hedtc tne staff who have worked on the project since 1973 in submitting proposals and renewals to Health and Welfare Canada,data collection and sunrnarization have shown that evaluation projects of this nature must be a team effort.
These persons include Valerie Surrmers,flargaret Burke, Regina Power, Michael Kavanagh, Barbara Angel,and Rosemary Cantwell whose untimely death in 1976 was a shock to us all.
Thelat e r stages of the project were pulledtogetheronly because of the persistent hard work of Ann West in the Division.
Tony Sheppard in the Newfoundland and Labrador Computer Services provided the expertise to extract the relevant information from the Medical Care Plan data file.
The helpful cctment.s and suggestions from Drs.G. Fodor, K.Hodgkin,and J. Ross are much appreciated.
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Special thanks is offered to Dr. R.M.~iowbraywho suggested that the project be the topic of this Ph.D. Thesis.
The indicator conditionstudy would not have been possible without the continued support of Drs. Vince McMahon.Hunter Earle. and John Bessell. Dr. Earle'sdeath in 1976 was greatly felt in this project as in the many other activities in Newfoundland in which he was involved.
I am grateful to Miss Heather Riggs and Mrs. Elle nDunphy for their secretarial help.
This project became feasibleonly after receiving the financial support of the NationalHealth Research and Development Program.
Research Programs Directorate. Health Programs Branch of the Department of National Healthand Welfare.
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TABLE OF COIlTENTS
Page
Title Page _ _ .
Abstract... ... .. .. . . . ... .... .... ... ii Acknowledgements... ... . . .. ... .. ... ... vi
Table ofContents vii i
List ofTables xii
List of Figur es xiii
CHAPTERI BACKGROUND OFTHE FAMILYPRACTICE NURSE CONCEPT•. •• . . ••
(i) Introducti on .
(ii)Definitions (Roles) .
(iii )American Experience. .. 12
(tv) ProgramsOutsideNor t hAtrer i ca . . . .. . 14 (v) Nurse Practitioner Progra msin Ca nada . 15 (vi) The Memoria1 Universi tyof Newfound1 and
Family Practice Nurse Educati onProgram... .. . .. 18
(vi i ) The Students 21
(viii) le gal Aspects 22
(ix) Study Oesign andSample 26
(x) Orga niza t io nof this Thesis 27
CHAPTERII HOW EFFECTIVEAND SAFE IS THE FAMILY PRACTICE NURSE? HEALTH OUTCOfIES OF PATIENTS INTHE ST.
JOHN'S RANDOMIZEDCONTROLLEDTRIALOFTHE
FAMI LY PRACTI CE NURSE... . ... . .... ... 3D (i) Participating Personnel and Background... 31 (i i) Methods... ... . . . ... 32
(a) TheSt udy Population. 32
vi ii
Page (b) Randomizat ion •..•. •.••.. • . ••• • •.. •.• • .. • . • 33 (c) Selection of Persons for Surveys
Before and at theEnd of the
Experimenta lPeriod ..•• ... ....•.. . .... .••.34 (d) HealthOutcome~asuremen ts.... •.. •.• •. ••• 36 (e) Statistical Analyses..•• .•. . • . •• •• •••... • . 38 (i i i) Results....•••..."•.. .. . .• . . . ... . . •. , ... 39 (a ) Patient Satisfaction.... .••..••.•. ••• . . ..• 39 (b) Corq>arabilityof theControl and
Experi mental Interview Cohor t s at the Start of theTrial.•...•. ... . . .41 (c ) Physical Function at the End of
theExperimental Period... • : ••. . • .•• . .• 45 (d) Emot ional Functionat theEnd of
the Exper-tnent al Period... • ..•. .•...•45 (e)Social Function at the End of'the
Exper-t nentel Period... ...•... . .•. .... • 45 (iv) Discus s ion.••.•...•.. ..••....•...•..•. . .•.•47
(a) The Health Status'11ea sur ement s'
Sensiti vityto Change.. . ... . . . ... ..• ..• . . .47 (b) tonoar-tson With Other
Controlled Trials ...• . .• . ••. . ..•..• • 49 (c ) PatientSa t i s f ac t i on ...• . •...•.••.... .. 53 (v) Conclusion .... ... ... .•. . . • .•. ... .•. . . .. . 55 CHAPTERIII WHATHAPPENSTO THEQUALITYOF CARE ? QUANTITATIVE
ASSESSflENT OF THE QUALITYOFCARE PROVIDEDIN PRACTICESWITHFAMILYPRACTICENURSES•• • ••"•••• •• ••••• 56
(i ) Introduction.. . . ... ... .. .... . •...• 57 (ii)Methods...• •.•..• . .... • •....• • . •.. . •.. . .."59
(a) The Deve lopment of Criteri afor
Clinical Judqe nent ..••.•...• .••..•• •.. .;.. 60 fx
Page (b) Eligibilityof Episodes of Care
ForInclusionin the Study 60
(c) Peer Advisory Group 61
(d) The Study Setting 62
{t i il Genera l Planof theStudy 63
(a) Probes 63
(b) Abstractors 64
(c) Pretesting of Measuring Inst runents and Validationof Cli nical Criteri a 65
(d) Statistica lAnalyses 66
(iv) Results 67
(v) Discussion. 71
CHAPTER IV WHATIS THE ROLE OF THEFAM I LY PRACTICE NURSE ANO HOW DOES THE ROLE AFFECTTHE SERVICE OUTPUT OF GENERAL PRACTICE?... . .. ... .... ... .. ... .. 75
(il Int roduct io n 76
(ii) Methods... .... . .. 77
(a) St udySample 77
(b) Data Sources.. ......... . ............ 73
(iii) Results 81
(a) VolumeofServices 81
(b) Type ofPatients 84
(c) Types of Services 90
(d) Clinical andNon-cl tni ce l
Appor tionmentof Tine·.·.· 91
(e) Profess iona lSatisfaction.... . 94
(tv) Discussio n 95
(a) ServiceOutput. .. 99
Page
(b) PracticeOrganization 101
(v) Concl usion.·.·· ' 102
CHAPTER V WHATISTHE FINANCIA LIMPACT OF FAMILY PRACTICE NURSESIN MEDICALEDUCATION? •• .•• .••• • • • ••• • ••• • ••.•103
(i) Introd uction 4••••••• • •••• ••••••104 (ii)Methods.•..• • ••.• •• • • •• ••• • •••••••• • • •• • • • • • •106 {a) St udySample••• • • • • • • •••• • ••. •• • • • •• •. .•·106
(b) Data sources 106
(c )Ana1ysis l08
(d) Determination of Family Practice Nurs e Prect.tceOverhead Expenses 110 (iii)Results•••••••.•••••• •••••••• •••••• ••••••.•.•1l1
(a) Annual Incre as ein Income 111 (b ) AnnualExpenses As cr ibed to Family
Practi ce Nurses 113
(c) AnnualProfi tab il ityofFamily
Pract i ce Nurses 115
(iv)Disc ussion 117
CHAPTER VI SUMJo!I\RY AND CONCLUSIONS••• • •• • • •.••.•••• ••• • •••••• •.•122
List of References 132
Appendix A Le gal Guidel ine sfor Fami ly PracticeNur-ses••.• •.••• •149 Appendix B Annotat edBibliographyof Selected Articles on
Mid-LevelHealth Professionals 155
Appendix C Collectionand Linkageof Family Practice Nurse Day bookData with Medical CarePlan Data 247 AppendixD InstrumentsDev el opedto Gather Data in the
Famil y Practice Nurse Project .271
Appendix E Detailed Tables ···· 319
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Table 1 .Tabl e 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table8 Table 9
Table 10 Table 11
Table 12
Table 13 Table 14 Table 15 Table 16 Table 17 Table 18 Table 19
LIST OF TABLES
Page Diffe rencesinPhysi ci anTrainin g andPrac t ice•. '," . Diffe re nces in Nurses'Trainin g andPractice .... ••.•.... Comp lerrenta ryAspects of PrimaryandHospital
Ca re... . . ... . . . . .. . ... .. .. .. ... ... ... 10 Potent ia lAreas ofConflictBetween the Physi ci an andthe Family PracticeNurse... ... . . . ... ... 11 Prof ile s of Ten Family Practice Nurses... ... .. .. . . 28 Measurements of Sat i sfaction of Contro1and
Exper i men t al Patients. ...•.•... ... ... . . . .• •.. .•... 40 Comp ari son of the Cont ro landExper i ment al Inter vi ew Cohor t s at the Startofthe Tria l.. ... ... .... .... 42 Physical Funct i on (ForPatients Both Befo reand
at theEndofthe Expe r i rrent a1 Period).... .... . . .. . ... 43 Health StatusChangesAmong Patients Assessed
Both Before and at the EndoftheExpe r i mental
Period..•. . . ... .. . ... . . .. .. . ... ... ... ... . . .. . .. 48 Sunmary ofResults from SixCont rolle dTria lsof Nurse Practitioners... ..•...• . .... .. ... . . .. ... ..• .. . 51 Rangein Number ofEpisodesof IndicatorConditions Asses sed perPrac t ice andAverage Scored Adequate (X)Before andAfte rAttachmentofFamily Pract ice Nurses to Five FamilyPractices.. .. ... ... 68 Range in Numberof EpisodesofDrug Use Assessed perPr acti ce and Average Scored Adequate(X) Bef or e andAfter Attachment of Family Prac t i ce
Nurse s to Five Practices 69
Age andSex Distribu tionofOff ice Visit Pat i ent s
in the Six Practi ces1974, 1975, and 1976 88
Pre sentin g Complaints of Patients for Whomthe
FamilyPract i ce Nursetook Major Responsi bi 1ity.. . . . ... . 89 Types of Medicatio n"Prescribed "by Fami ly
PracticeNurses .. .... . . .... . . ... ... .. .. . .... . . ... .. 92 Profes si onal Satisfactionof Family PracticeNurses... 96 Pe r forma nce of Practices... .... ... .. ..•.. . . . .. •. ... . ..112 Es ti mat es of Annual Expenses Ascr ibed to Family
Pract i ce Nurses.. • .... . ... • . ... .• .• • . . . .• . . .. ... . ..114 Es ti mat es of Annual Profitabi lityof Family Prac t ice Nurses... .•... ...• .. .. ... . .• ... .... .•... . ••. .•. . •. ....•. 116
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LIST OF FIGURES
Page
Figure Fami1y Pratt;ce Nurses; n Newfoundl and1975- 76. ... . .. . 24 Fi gur eII Schedule of Tine and Events during
Implementationof the Trial . 35
Figure III
Figure IV
Figure V
Figure VI
Emotional Function and Social Function at the Beginningand at the End of the
Experf eent 46
Nunner-of Services per Year: 1974, 1975.and 1976 {Study PracticesA toFandProv inc ial MeanforAll NewfoundlandPhysicians (ver tica l bar±1and2 Standa r dDeviatio n) 82 Div ision of Responsibilitybetween Physician
andFamilyPract ice Nurse (TotalServices Over
All Six Practices) 85
Clinical and Non-clinicalApportionrrent of Time
by Health Profess tonel. 93
xiii
CHAPTERI
BACKGROUND OF THEFAMI LY PRACTICE NURSE CONCEPT
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(1) Introduction
long and extensive collaborationamong interested provincial and national organizations preceded the acceptanceof the deve l opnent of the Newfoundland Family PracticeNursePilotProject. The purpose of the pilot pro jectwas to provide nurseswith formal educationto enable them to funct ioninan expanded role inthe provision of primary care in Newfoundland.
Anadvisory conmittee functioned fromthe earliest stages of planning of this pilot project. Membership of this advisory coenft tee included representatives from the College of Family Physicians (Newfoundland urench}. the Newfoundland Medical Association, the Faculty of~dici ne.
the Schoolof Nursingand the Provincia l Department of Health. The advisory conmtttee operatedat the policyle ve l and provided a rrechanism for early and continuinginvolverrent of the bodies concerned. Technical sub-comnt ttees and work.ingparties have had responsibility for specific tasks such as definition of the family practice nurse role. family practice nurse curriculum planning and consideration of evaluation techniques. In August 1973 financial support was first receivedfrom the Nationa l Health Research andDevelopment Program to proceed withthe development of this pil ot proj ect. Dip loma-anddegree-hol di ng nur s es were enrolled in this fede r all y supported family practice nur s e pilot project with the education program sponsored jointly by the Faculty of to'edicine and School of Nursing at the IJemorial University of Newfoundland.
(i1) Definitions (Roles)
For over fi fteen years there has been increasing discussion and
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controversy in Canada as to the optimum ne thod of fi11ing an alleged gap between the existing roles of the physician and the nurse (Depar-tmentof National Health and Welfare,1972a). Ithas been shown by Wolfe (1968) that physicians may spend an tnoo-tant proportion of their workdayin activitiesnot requiring their level of skil l. It has alsobeen demon- strated (CartwrightandScott. 1961; Crombie and Cross, 1957; Connelly
e tel, 1966;H u n t e ra n dC l a r k . 1 9 7 1 ;L e w i sa n dR e s n i k. 1 9 6 7 ;l e w i se tel,
1969;McKendry. 1968a; Rogers et e l , 1968) that. particularly in general practice. an attached nurse with no special preparation for an expanded role can accept delegationof many functions. presently restricted to physicians. It is at this point that the controversybegins. Inorder to encourage furtherdelegat ionof functionsand more efficient utilizationof expensive medical skills, the case for specific prepara t ion for a new role in health care has been advanced by proponents who fall in- to two groups;
(1)Those like McKendry (1968b) who support the concept of establ1shing a new health care worker -the physician associate;
(2) Those who advocate the development of an expanded role nur s e .
Thesela t t e r tendto predomi nate inCanada(CNA BoardTa ke s Stand on Physician'sAssistant, 1970 ; College of Family Physiciansof Canada. 1971 ; Department of National Health and Welfare, 1971, 1972a.1972b ; Newfoundland fo'edical Association, 1972; and Ontario Ministry of Health.
1969). They feel that the best course is the further development of an existing category of health care worker, rather than the constructionof a new one with its potential lygreater educational ,legal and
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organizational problems.to say nothing of those of patient and physician acceptability.
Discussionof this subject tn Canada is attendedbyconsiderable semantic confusion. Each writer advances his own concepts and his own terminology. Thus we have the Physician Associate. the Physician Assistant. the Nurse Practitioner. the Outpost Nurse. the Family Practice Nurse.among othernames appearing in Canada. Functionally.many of these roles overlap.
Acommonterminology, as partof a coordinated approach to this subject. is a basic requirementno t presently met. Spitzer and Kergin (1971)consideri ngonly expanded role nurses have suggested the term
"Nurse Practitioner" (for primary care settings) with "Nurse Clinic ian"
and "Clinical Nurse Specialist" in settingsother than primarycare.
In the primarycare context. any typology of assistants to physicians has to considerthe followi ngfour classes:
Attached Nurse
A degree or diploma nur se . often with public health training but with no preparation specific to an expanded rol e . Degree of delegation of functions variable and onan ad hoc basis when it occurs - working as a team member.
CLASS II Nurse Pract itioner- Family Practice Nurse
An expanded role nurse withpreparation specific to that role - involving the delegationof traditional medical functions - working as a team menber.
CLASS III Physlcian Assistant
A pe ra-rredfc-not strictlya nursing role.although nurses
- 5 - CLASS III Physician Assistant (Coot'd)
may be candidates for training program - a new category of health care worker with special training for a role. which involves a greaterdegree of delegation of technical medical procedures than Class II. e.g. bonemarrow biopsies .lurrba r puncture (Fende rson. 1974 ). Best known example.the Duke Physician's Assistant (Sadler et et , 1972) -working as a team meniler.
CLASS IV Physician Sur-rocate"
Usuallya nurse -in rural and northern areas. Frequently without (Hutchings,1965) but occasionallywith{Depar-tment ofNationa l Heal t handWelfare.1970; andRobertson, 1973 ) pre par at i on specificto providing primarycare unde r conditions of limited medica l supervision. That is.
frequently working in isolation NOT as a team mentler.
These classes of "mid-leve l health professionals" (Lippard and Purcell,1975)are envisaged as essentially representing differing degrees of specializat ioneach with special educational requirements with pro- visionfor vertical mobility. Thesubjectof this projectis ClassII - the Nurse Practitioner(Family Pract ice Nurse ) .
Pri or to thefirst formal educationprograms for expanded rolenurses in the 1960' s , a nuener ofdemonst rat ion projects in Canadaand the United Stateswere reported (Connelly et a l , 1966; Ford et e l , 1966~ lewis and Resnik,1967. Silver et e l , 1967; Yankauer et a l , 1969; and Yankaueret a1,1970). These fi rs t fonna 1 demonstrati onsinvol vednur ses ... Historicallywith the qrea test degree of mismatch between responsibilities
and prepara t ion .
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in extensions of the roles and functions of clinical-nurse specialists and public heal th nur s es . Inthe UnitedStates these activitiesoccurred in settings which provided care to pregnant women,infants and children. and to adults with chronic disease. lewis et at (l976) have argued that
"all were located in health departrrents or hospital clinics,and the conce r nof those responsible forthese efforts was to tnor ove the quality of care provide dto the recipientof services. Althoug htherewer e some occasional references to the relief of physicians from these types of activities. and thus some saving of physician. the primary objective was not repl acenent but tnorovenent". The intentions of the investigators reportingin Canada onsuch demonstra tionpro jec ts is less clea r(Day et el , 1969 ; andMcAuley, 1969 ). Early reports in Canada concentrated either on (a) the public health nurse working "on attachment" to the primary care physician's office to the physician's bringing public health nursing pr actice to the physician'sofficeandalsoprovid i nghimwith efficient corrmunity services liai s on (Day etal, 1969) , or (b)the registered nurseprovidinga broad range of nursingcare services to coeotenent medica 1 care servi ces and assuming more respons i bi 1ity in giving continuing health care while working within the physician'spractice setting(McAuley, 1969) .
Develo pmentof educat io nprograms to prepare individ ua ls to perform as exte nde rsof physicians orto serve as mid-level health professionals began soon after the demonstration activities. In the United States. the first trainingprograms were concernedwith the preparation of physicians ' assistants (incl udi ngMedex) (Andrealand Stead,1967; Estes,1968; Estes and Howard, 1970; ~ledex: Anothe ranswer to the physician shortage,1969;
Project plansto cut chores of physicians, 1969; andSt ead,1966).
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Organized nursing in the United States rejected the role of the "nurse practit ioner"as not with inthe scope of nursing until the late1960 ' s (Sadleret el, 1972;and Mussalem. 1969 ) . Since that time. there has beena ra pi d increase inthe nurrberof programs preparingvar ious nur sepract i t i oner s to functioninextended/expa ndedroles(Dobmeyer et el,1976; and Schroe de ret el, 1974).
Wis e (l972) and Bates (1975) have articulated Many of the potential role confl ictsbetween physician and family practice nurse which may affect thei rability to work together in private medical practiceinthe ccnmcntty. Wise (1972) lists the inadequacies of traditional physician andnurse tra i ni ng which he suggestshave caused problemsexper ie nce dby physic i ans and nur se s ert enn ttnq to workas a teamin pr ima rycare.
Tables 1and2lis t thediffe r en ce sintrainin g and pr ac tice of phy s ic i ans andnurses. Simi lar differences between primary care versussecondary tertiary hospita lcarehave been pointedout by Hodgkin (1978) (Table 3).
While Bullough (1975) encnes tzes therol e of sex as a potential role con- flict area between phys tciens and nurse,Bates (1975) pinpoi nts the fo 1- lowing pote ntialbar r iersto physician and family practice nurserole change. Accord i ngto Bates(19 75 ), each physician-n urse team must develop newways of workin gtogeth erandmustdo so agains taba c kgrou ndof long- standi ng prof es si onal territoriality. For example,conf licts bet wee n physici an andnurs e mayari sewhe n the shar i ngof analys isand de ci si on- making is viewedas anfnfr-f nqenent on the physician-patient re l a t i ons h i p or when there is not an attitude of conmi tnent to patients without professiona lpossessiveness. Other potential areas of conf l ictoutlined by Batesar eli s t ed in Table 4. Familypractice nurses and physicians
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Differences in Fhvsici/ln Tr"ininQ and rrect tce-
Tr a i nedin hospita l
Struc tureis aut hor i t ari an- top-down Clear ref er ence grO\lpinhos pita l ego - pediat ric house staff
Hospitaliscent e r of pO'ft'"er andknowl edge Role in hospita lclea rlydefine d In huspi te l , elrp!lasis is cn diillgnosis
eed treeteentcr ecute illness
Tratnedto do ce ref ul~hospit a l - typ e~
work up
No tN1ninginpreventive medi cine
Treats"r{'illl".ie .,or gani cillness . The~c1ocl:'."isignored.
Trainedtoworkalone Patientsinhos pi tal ar e there on
hospital's te rms
Pr ac t i ce
~o rk sinhealt h center Str uctureisquasi-e galitarian Uncl ea r re fe rencegroup in health
cent e r-takes outrr.ember sh i p in anew "club'", the healthteam.
Health centeris an outpost Role in health cent erconsta ntly
changing
Inhealth center ,ellf'hasisison treatmentof subacuteillne ss and eenaqceent of chronic and psychosocia 1probkms Conf ront edwithlargenumbersof
pat i ent s . Quidwcrk-up,Are s tenderdsfall ing?
Must learn about preve ntivemedi ci ne, much of which isinspecula t i ve stage
Unending group of peoplewit h psychosocialpr oblees. Tends to use refer r alasen out le t.
t:ust workwithtealll~rs
Culture shock -D'eeting people on their termsinarmulatorysett i ng
• Source: Wise H. (1972)"hePriNry-Care neaj th tees, ArchInte r-nt'.ed130 :441.
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Differences in Nurses' Tr a i ni ng and Pr-act'ice"
Hospi ta l : hie r a rc hy . author;tar-ian; top-down
Roleis submissive
Take sorder s
Ruleshelp in supervision
Tas k- or i ented
Obser ver
Heal th center ;quas i - egalitarian par ti cipa t ory Role is asser t ive
Prob lemsolve r Few rules to assis t in
super vis ionof thefamily health workers Pat ie ntand team-orie nte d Practitioner
"Source: Wise H. (1972) The prima ry-CareHealth Team.
Arch Int ern Med 130 : 441.
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Tabl e 3 Comple~ntaryAspectsof Pri maryand Hospital~re"
PRIKARY CARE SECOI:Q4.RYMiD TERTlr..RY(HOSPITAL) CARE Pat i ent
Patientini t ia t es and motivates care: Pa t i ent volunterl1y abrogatesmany freedoms.
Patient free'dcm high. Patientrre eecerelattve 'lytow.
Patient securein hi sown Pa t i ent insecureinfor ei gn envf rcneent , envtrcreent.
poetors requi redto concentrateextensive resources on rela tivelysroll numbersof pat i ents.
Doctor
Doctor has rel ative ly li t tl e control. Doctorcontrolhigh.
Doctors have to be relativelynon- Doctors have tobeet rec tt ve . directive.
Doctors responsible for a relatively largec~1lUnityofpa ti e nts .
Clini ca l
Triv ia l disea serat e .
Seriousdisease(a)re la t i vel y COUlOOn, (b)pre sentati onconfusedwithother serious dis ease,(c) clinicalpresentetfon more diffe re nt i at ed.
Trivialdis eas efre quent.
Seriousdis ea se, (aJ relative ly rare,-( b)presentationconfused by presenceoftriv ia ,(elcli ni cal presentationundifferenthtedand ear lydiagnosis di f f i cult.
Conti nuity-
Datacoll ec ti onepisode.
Doctor oftenhasno prior knowledgeof patient'sbackground.
Dual eerecontrolled by doctors.
Data collectioncumula tive Backgroundof patient often known to doct orbeforepllti e ntpre sent s . Dual can! often uncontrolled.
CoInprellensiveness
Doctormust know a littleabout Doct or mustknoweverything aboutIIspec l al.
everythi ng. area.
Patiente)(Jlectsdoctor to help with Patfentexpectsdoctortohelp....ith verY wide range of problems . rel at iv el y narrowrangeof prob'lens.
Economics
Patientres pons ib l eforown nursing Hospital has to be funded for nursing accew:modationandupkeep. accOO11lOdatfonand upkeep.
Relatively inexpensive. Rela t i vel y costlyto patientand/orcOllJTlunity•
• Source: Hodgki n ".(1978)Towards Earlier Diagnosis: A Guideto General Practi ce,4t h ed . ,longman, NewYor k.
- 11-
h!..lc4 fQ.l£!ltialAr£:'_dSof(onf lic tBetweent~.} i ci an
~~C!rc1 mllyPra cticeNlJr se·
S~. ouldthe phys ic ia n aut Ofl'\olticallytakeu?the positionofte am leaderinall sttuettoost
Shouldtht:f<:n'!i1 ypracticenurse'srolebeconfinedto care.comfort, coun5elling, gui dance and helping the patientto cope and not be
involv ed in diagnosis and rreeteentt -
Shouldthe family practi cenur-se spend ecstofterti~as an assistant to the physlchn[recept icnfst,give s shot s .chaperon s ce t vt cs , and ans ...er-sthephone) rather than laking on an expandednursing or family prectt cenur-se role?
Should the'(anlil y practicenurse be one whoe sscssesand managesand
onewhocomforts.supports.andhelps? -
Shouldthe physicianrelinquish any portion of his conventionalrol e- and should his protocolalwayscall forphys icl antnvo tveeentwith the family practicenuese not encouragedto work beyondhis protocol for her?
Shouldthe sharing of,analysisand decision-makingbe viewedas an 1n fr inge~nton the physician-patientrelationshiprather thi!flha vin g an attitudeof cceet teent to patients withoutprofessional possessiveness?
Io:ho shouldcollectpatientdata?
Who shouldmakewhatdeci sions ?
\;ho shoulddecide on whic hmanagement plan?
\\hoshoul dbethe principalproviderforwhich gro up of patients and shouldit be both physician and fallflypractice nurse?
Shoul d the responsibilityof the physician or familyerect.teenurse in theeye s ofthe lawberai sedfrequent ly when decidingon who should do wha t for patients(forexample,takingnig ht or weekend callsor makingdecisions without the physicianpresent) ?
Shouldthe physiciantaketimetoteach the!f01lll11ypracticenurse how to tecoee a sig!'lificantcontrib ut o r in the Il'd nagement of patients and ar.eltberof the practice team?
Shoul dfamil y practice nur se relationswtth hospital and extra- prac t ice perso nnellead to confusion as to tlhet herher roleshould be a conventi onal eedlce'lone or a conventionalnurs ingone?
Should the orectt ce have a policyof handingoverto thefalnily practice nur se all new andunl:ncwn-ettntc" patients forwhich the physician haslitt leint er e s t or tir.e?
Should theuncertaintiesof the far.,ilypracti cenurse's fut ure inthepra c t i ce prevent her fr m soeeactivities?
-s ccree : Oates iL (1975 ): Physiciflnandnorse Practitioner:
Conflict and reward. Ann Inter ntied82: 702·706.
-12-
intendingto work as a team wouldbenefitbydiscussingtogetherthis listof pot ential problemareas. Often these problems exist or are per- ceived toexistbut arenot easily articulatedby the physician or"the nurse.
(iii) Arrer ican Experience
In theUnited States. publichealthnurseshavelong perfonned manyprimarycare duties. The Frontier NursingService of lesl i e County. Kent ucky has since 1925 provide droost of the heal t h care , per-ttc- ularly mat er nal and childcare, to re si dent s.of that county (Isaacs, 1972). TheUnited States Armed Force shave also had conside rab leexper- ienceinthetrainingof Corpsmen to assis t inthe del ivery ofhealth servicestothe Military and its dependents. In the1960 ' s over30,000 of these Corpsmen per year were leavi ngthe services (NationalAcademy ofScience, 1969).
In 1974 Schroede r et al (1974)repor t e d close to 400 education pro- gramsin theUnited States to produce physician assistants (including Medex) and expandedrole nurses for primary care and specialistcare. About 70%are designed to tr ai n primary care personnel. Five organ iz - ations- TheAmer ican Medical Associat ion,the NorthAmerica nAcademy of Sci ences, theAssociationof American Medi cal Col leges ,the American Academy of Pediatricsand the AmericanSocie tyof Int ern al Medi cin e- have joi ntlyproduced guide 1i ne s fordefi ntti on and education of physi ci ans' assistantsand expandedro l enurses (Sadle ret el,1975 ).
One principaldifferenceamongthe mid-levelhealthprofessional educati on prog rams,as of the early1970's,was the extent to which students wereprepared to function independentJy/interdependentlYI dependentl y . The firstprograms preparingassistantsto physicians
- 13 -
pl aced heavy enphast s on this individual asan extender of the physician 's abilities to collectdata through history and physical examinationand to perform routine tasks (see Charleset e l ,1974 : Greenfield et al, 1974;
K.omaraff et al, 1974 ; Sox et al,1973; and Taller and Feldman. 1974 ) . Physicia nswere expected to supervisetheiractions. to review the data collectedbythe m. make alldecisions,andto prescribe all the necessary tre e tnentswhichmight (depending on their compl ex ity) be carriedout byan assista nt (Yankeuer- , 1969 ).
Anothe r emphasi s inthe s eearl y educationprograms tn theUnited States was on the prepa ra t ionofthe individuals to perfor m ce r t ain
"tasks" . Many ofthesewe r e simil ar to those performedby corp smenin the Vietnam war,such as suturingwounds and applyingcasts. Theircur ric ula stressedthe performanceof activit iesthat required psychonotorskills , rather than in-dept h preparationfor evaluation of clinical data or deci sion- maki ng.
Physici ansassistants programslately have changed the i r philosophy and assumpt io ns unde rl yi ng thei reducational objectives downplayingthe character is ticsdescribed. Gr aduatesare beingpreparedto process informationand make decisions.as well as to collectdata andper fo rm certain skills. Arecent art ic le in the NewEnglandJour nal (Role s, tasksand practiti oner s, 1977 ) pointe dout that thi snewdirecti onofthe programsclo udthedist i nc tionbetween physi c i a n andnonphys i ci an .
Inthe UnitedStates (and in Canada), nursepractitioner programs have enphasi zed aspects of patient care that involve psychosocial inter - ventions. suchas healtheducatio nand counselling. In early education prog rams(except for northern nurse programs that included mtd- vtfery}, verylittle enches ts was placedon the surgicalaspects of medical
- 14 -
practice. Increasing numbers of programs are empha sizingcourses
for clinical nursing specialists. supp lenented bytr a i ni ng inphysical diagnosis and nedt ce l management.
A third type of mid-level health professional education program operating in the United States include such programsas the child health associate, the family planning specialist, and thepr i ma ry - ca r e associate.
These practitioners possess a blend of skills and abilities of physicians' assistants and nurse practitioners. However often these education pro- grams do not require previous training or experience in the health sciences.
(iv) Programs Outside North America
The concept of the Physician Assistantfs of course not new.
The Russian Feldsherdescribed by Sidel (1968) and others (Field, 1966;
The training and utilization of feldshers in the U.S.S.R.,1974; and U.S.S.R .,The ordinary or general feldsher, 1971)was activein the 1700 's. In the United Kingdom there has been an i ncreas i ng trend to the attachment of members of the domiciliary nursing services to general practitioners . This began in 1963 following the Gill ie Sub- conmtttee recomrrendations. Lega1 problems were removed by the Health Services and Publ ic Health Act of 1968. However, it has been found necessary to stress that "where nurses make a first visit to the patient,it must be understood that this visit is not for the purpose of diagnosis. The doctorrema i ns accountable and the attachment schemes are not anattempt to re li e ve the general practitioner of responsibil- ity, but to make more effective use of existing medicaland nursing Skills" (Gish,1971). Itis interesting, then,that attached personnel of this type in the United Kingdom are neither physician assistantnor
- 15-
expanded role nurs esas understoodin the North American context.
Robinson (1977) recently reviewed the major differences in the style andcontent of primary medical practice inNorth Americacompared with the United Kingdom. In the United States. he argues, eechests ts on diagnosis. In the United Kingdom emphasis is on continuity and home-based care supported by a nationwide network of paramedical and social services.
Beyonda concern that these services be continued at existing levels.
primary care physicians in the United Kingdom remain uninterested in
actual delegat ion of their diagnostic responsibilities despite the reported efficiency of trained nurses in mak.ing decisions inhousecalls (Moore et all 1973). They are also apparently uni"llressed by enthusiastic reports from the Uni t ed States about the potential of mid-level health pro- fessionals (An assistant in the house? 1975).
Ethiopia. Uganda.Sudan. Tanzania.Kenya,Malawi, and NorthernNige ria all deploy varietiesof medicalauxiliaries(Fendall , 1972) . Thailand.
several of the South American republics and Iran are either actively con- sidering or have been elTl'loying categories of Assistants to the Physician (Fendall, 1972). Fiji trains Assistant Medical Officers 1n a five year program. and the People'sRepublic of China is currentlytraining
"Barefoo t Doctors" {Fendall,1973;and Wen andHays,1975). Thereseems little merit here indiscussing in detai lthe many interesti ngdevelop- ments in these countries-countries which have marked differences from Canada in their political,social and economicenvf ronnents,and health care systems.
(v) Nurse Practitioner Prog rams;n CanadiY
A varie tyofprograms(Depar tmentof National Health andWelfare.
- 16-
1973)existacross Canada aimed at preparing nurses for anexpanded role.usually ina primarycarecontext. frequentlyfor arural or northernenvironment.and seldomwitha defendab le evaluative component.
Deati le d task inventories have been developed for the SaskatchewanNurse Prac t i t i onerDemonstratio nProject (Cardenas, 1975) whose graduates have been placed in nor t he r n Saskatchewan or to practi ce inis ol ate d nursing sta t i ons who trainedinthe specieTly sponsored Medical ServicesBranch (Healthand Welfa re.Canada) education programsat the Universitiesof Sher br ooke , McGil l.Toronto,Wes t e rn Ontario,Manitoba andAlberta (Hazlett, 1975) . However.empiri ca1 stud;es of roon;tori n9 these graduate sinthe fie l dhave yet to berepor t ed. Sophisticatedevaluation studies, done atMcMa s t er Unive rsity ,hav~been repor t ed on the nurse practitionerin Canada. TheMcMaste r studies (Batchelo ret al,1975;
Chenoyettel , 1975 ; Sackett et al,1974 ; Schereret al, 1977; Sib leyet al,1975; Spitzer and Kergin , 1973 ; andSpitzeret al , 1973, 1974, 1976a , 1976b),where nur se practitioners have been ca refullyobserved inthe; r dail ywork (primar ilyinur ban medical practice)have reported that nursepractitione rsconduct numerous medical procedures, teachpatients howto handle orpreventillnes s and diseasesymptomsand decide which pati entsare in genuine need to seethe physic ia n. The McMaster studies ofthe nurse-practitione r -phys icianpairs have found: without increasing theirbilling,the nurse-physicianteams gave 24%oore service ,were able to care for 40%more familiesand reducedper person hospital izationby 31% . In one corrmunity clinic,annualhospital izationcosts were reduced by77%. Nurse practitionerswere able to handle67%ofpatients ' cell s andvis i ts without involving the physician ,whowaseither leftfree to
- 17 -
give better quality care to pat ientsrequiring the help of someone with his levelof trainingor toincr ease the number of patients seenin the practice.
With the exception of the present Newfoundlandstudy , therehasbeen noprogram involVi ngtraini ngor evaluationof nurse pr-actit'ioner-s in an ur banprimary care settingoperatingor planned in any of the four Atlantic Provinces .· This is surpris i ngas in rural and nort hern areasof the At- lantic Region. particularly Newfoun dlandandLabrador,nurseshave been functioni 09as physictan surrogates(seedef -initionabove) for many year s-- albe itwithoutspecific preparat io nfor that rol e (lady Har r i s, 1921) . Due to Newfoundland 'sgeograp hyandcl imat ic conditi ons .nurses havehistorical ly,andin most cases without formal tr a i ni ng, provided primaryhealthservices out ofcottagehospi t al s andnur s i ng stations scatteredthroughout the Pr ovi nce (Mille r , 1974). Famil y physic ianscon- stitute 52%of all regi s ter-edphystciansin Newfoundlandindicating that healthcare is still oriented towar d familyphysicians. In January1976 , -t hefamilyphysicianto popula t ion rati owa s1to 1811but they are
une venlydistributedso that many rur al andsmall outportfamilyphysicians areoverburdened'( Gove r nment of Newfoundl and , 1971). Whil e in the past Newfoundland ha s been plaguedwitha shortageof nur se s, recent fi sc al constra'intsprimar ilyon the la r ge acute care hospitals have reversed this resultingin aninc re ase inthe number of wel l trai ned ,experienced New- foundlandnur se s who are lookin g for work. Dr.Le ona r d A.Mi ller,former Newf oundland DeputyMini ste r ofHealthandconmtssfoner oftheRoyal Cornmi ssionon Nurs i ng Education , has reconvnended that nurs i ng education progra msin the provincebe tailored(in te rms of length and orientatio n) to theneeds of the provin.ce(Government of Newfound land , 1974 ).
(vi)
- 18-
The~'errorialUniver sityof Newfoundland and Family Practice
NurseEducat lo nProgram.
In 1971the Facul tyof MedicineandSchool of Nursingat IoEmorial Univers ity of Newf oundla nd agreed to offerjointlya pttot family pract i ce nurseeducationprogra m. The pilotprogra mreceivedthe suppor t of theNewfoundlandBranch of the Collegeof Family Phys tcf ens , theNewfoundl and!"edical Association. the Provincial Department ofHealth and the Associationof Registered Nurses. He a lth andWelfa re Canada 's HealthResearc handDevelopment Pr ogr ams D; rec~o ra te of fered tofund thepilot educationprog ram pr ovi deditwas evalua tedby rrethods accepta ble to them.
Developrrentof the concept of the Memor ia l University ofNewfoundland familypracticenurs e role wasinfl ue nce d by recentCanadian expanded role nur seand pr-tna ry care reports and prog ramswhile st r ongl y recognizing the need in Newfound'l en d • The role of the family practicenurse has beenpurposelyde f inedto allowforadegre eofflexibi lityin its appli ca ti on both in the EducationProgramand in primary carepractices which haveProgram graduates attachedtothem. The"Boud re auCorrmittee on theNursePract itioner" (Depa r tme nt ofNational Healthand Wel fare 1972b) and othe rs (Spitzer and Kerqt n , 1973 ) ha veacce pte d the followi ng definitionof the family prac t icenurs erole: "A NursePracti t io ner (Family PracticeNurse) is a nurseinanexpanded roleoriente dtothe provisionof primaryhealth care as a merrberof a team of health profe s s i onals .relating to famili es on a long-t e r mbas i s andwho . througha combinationof specialeducation andexperi e nce beyond a bacca- laur eatedegreeora diploma.isqualifiedtofulftlI theexpe c t at ions of this role-[Depar-tnentof National Hea lth and Welfare.1972b). The
- 19 -
Hastings COOITIittee on Conmunity Health Centres in Canada (Report of the Coemanity Health Center Project to the Conference of Health Min- isters.1972) adopted the following as teoort.ant characte rist icsof primary care: first contact,accessibil ity,comprehens iveness (wide rangeof health servicesand ski llsprovided or arranged by the health care team), co-ordinationofcare.continuity of care. andfamily orientation.
The followingare the range of possible activities which the plan- ners of the education program considered as included in the rol e of the family practice nurse. Underthesupervision of a physician the role of the familypracticenur se can:
act as initialcont ac t for persons entering thehealth care system
assess the health status of the individual andthe family detenninethe requiredresponse from the health care system. e.g. initi ationand maintenance of treatment for patients with heal th problems which the famil y practice nurse has been prepared to handle,referral oftile patient after work-up to appropriate health care personnel
provi de health counsell i ng to all age qrouos and to a 11 sod 0- economic strata, with particularreference to the adolescent and the ger iatricpatie nt
provide healtheducation,rein fo rc ing the individual 's andthe famil y' s knowledge andabili ty in the mai nt e nance of health . in the pr e ven t i onofill nes s. inself-careand ca reoffamil ymembers in the home in theevent of illnes s
give pre-andpost-natalcare of the nonnal healthymother , excludingdelivery
conduct preventive programs,e.g.infant and pre-schoolexam- inations, ir.rnunizations,geriatric health ea intenance clinics follow up patients with long-termillness. adjusting theraoy, oftenon her ownini t i a ti ve . but always in consultationwith the physician
- 20-
co-ordinate thehealth care of indi vi dual s and famili es intervenein errergencysituati ons
Broad instr-uct!ana 1 object; yes of the '''emar;a1 Universi tyof NewfoundlandFami1yPracticeNurse Education Programwere de vel oped before the st artof the Pro gram. These objectives weredevel opedbyan adviso ry andpla nni ngcommittee wit hrepr e se nt a tive s fromtheNewfound- land Branchofthe CollegeofFamil y Physicians. the Newfo undland Medical Association. the Facultyofledi ctneand the Schoolof Nursing.
In order tofulfill the rol e expectations placed on thefami ly pr actice nurse , itwasfelt that thenurses woul d nee d tosupplement theirback- groundknowl edqeand abilityto the exte nt thatthey woul dpossess the following:
(1) Knowledge of the purposes. techniques,and limitations of i ntervi ewingand history -tak i nq, i ncludi ng physte a1assessment techni ques whic h would equip them to re cogni zeabnormalities that would just ifyinterv e nti onbythefamil ypracticenurses, whether preventi veor cura tive .
(2) Knowledgeofnutrition.the life cycle.conmon illnesses and therapeutics infamil y practice in orderto part icipatein over - all patient manaqenentand co-ordinationof aninte r di sci pl i na ry team plan ofpatientcare.
(3) Abil i ty to apply ef f ec tive ly this knowledge toclinical wor k sit ua t ions duringthe educat io nprogram.
(4) Apprec iat io nof theimportance ofrelat ionshipswith patients, oth e rhea Ithpr of es si ona1s, hospitals and government and the possib ilitiesof self-evaluationin these areas.
TOpics covered in the courses offered in the Faculty of Medicineand theSchoolofNurs i ngincl uded: famil y medicineskills revi ew,cur re nt conceptsinnursing,1; fe eyele andcommon illnes ses, thera peuti cs and nutrition. Studentswithout degrees innur sfnc sere requi redto take COurses in sociologyand psychology fr-om the respective University
- 21-
departllEnts. An important ccneonent of the program included clinica l experience with patients in cottagehospitals.the Univers ity famil y precttce units. children's hospita 1 out -patient depa rtment andhomes for the aged. Alsoduring the education program the supervising physicians were asked to attend eeetinqs with the st ude nt s to discussthe objectives of the program and to rev i ew the progress of the students . Thesealso served as inf or mal socia lmeetings givi ngthe nurs e s anoppor tun ity to share the;rownexpe r ienceswith the ;rsuper-visiog physict an.
tn additio n tobei ng one of thelonges t educat io n progra msfor famil ypra cticenurse s inNorthAmer ic a, (oeoert.ren tofNat i onal Hee l th and Welfa re . 1973). the MelOOria l Unive rs ityofNewfound l and Famil y PracticeNur-seEducatio nProgram is uniquein its emphasis ontherapeut ics.
The coursehas been the joint responsibility of a phannacologist anda family physician. The instructional objectives of the therapeutics course incl uded: (1)abi 1i ty to ide nt ;fy drugs and tablets orescr ibed mast often to patie nts in familypractice.(2) appreciationof the the r apeu ti cvalue s andside effe cts ofthose drugs JOOstcorrrnonly us edin family pr ac t icesuch as antib io t ics .othe rproprietary dru gs . ana lgesics, and drugs givento patie ntswithchro nic conditions.
A detailed report and recomrandatf ons on the Hemorial Universityof Newfo undla nd Fami1yPrac ticeNurse Educa t i onProg r amwasincludedin the January1976 section of the projectsubmittedto the HealthResea rc h ProgramsDirectorateof HealthandWelfareCanada (Departmentof National Health andWelfare, 1976 ) .
(Vii) The Students
Ofthe fourteen studen tswho enrolled in the educationproq ram,
- 22 -
seven had been previously enp loyed by rural hospitals or the Provincial Departmentof Health and were selectedbythese organizations to attend the prog ram. All applicantswere required to be degree ordiploma- hold i ng nurse s andto have two years ofnursingexper ience.
Table 5 gives the profiles of ten nur ses who were enro lled in the 1974-75 academic year. One student began worki ngas anur se in1972 while some of the others had been nursing for up to twenty years.
As shown in the map on Figure I.all fourteen students ,upon conctet ton of the educationprogram, began working in the role of family practicenur ses . Sevennurses were attached to primary care settings in rural Newfoundland. Inall rural cases. the familypractice nur s eis attache d to a cottagehospi taland under thesuperv is io n of asal ari ed physic i a n. There na tntnq sevengraduates .upon graduation.were attached to urbanpractices either in the cities of St. John's or CornerBrook.
Early in the attachment of one of the St. John's practices.largely be- cause of ill nes s of the physician ,one family practice nurse was placed in the walk-in clinic of the children's general hospital in St. John's.
(viii) Legal Aspects
A seriesof steps wereunde r t a ken and exploredin Newfoundland in order to minimizepossi ble medico - lega l diffic ulties which gra dua tes ofthe Memorial UniversityofNewfoundla nd Fa mil y Practice NurseEducation Program may have encountered once they were attached to a practice (Personal coeeuntcetion with L.E. Rozovsky, 1974).
(1) Graduates of the MelOOrial University of Newfoundland Family Practice Nurse Education Program. like graduates of other health professional train- ing programsarele gall y el igibleto perform procedures and funct io nswhich
23
" <
~
FIGURE1
- 24 -
In Newfoundlan d 1975-7 6 Famil y PracticeNurses
. PRACTICE NURSE ONEFM'.I~~PRACTICE
<:)INA UR
AMllY PRACTI CENURSE 1jII)
~::/
RURALPRACTlC~
00
o
u. ~"00
- 25-
have been covered in the Education Program. Although expl i c it ly define d anddetai1edgui de1ine s writte nint othelaw cutli0;" 9the s e pr oce dures and function swould leave littleroomfordevelopment andchangetnthe poss i bleact i vit iesofexpanded rol e nurses.aformal stateme nt ofgui de- 1i nes out1i nt09 procedures andfunctions of Hemoria1llnivers ity of New- foundla nd Famil y PracticeNurse EducationProgramgraduatesas Il'Embers of a healthcare team was considered necessary. A conmtt tee on thelegal aspec tsof thefamily practicenurseconsistingofmerrbersrepre sent in gthe Faculty ofMedi ci ne. Schoolof Nursin g, the As sociati on of Regi stered Nurses of Newfoundla nd. theNewfoundland Hospita1 Associ ation, the Newfoundlan dtI.edical Associat ion .the Departmentsof Health andJustice. produced these guide l ines (See Appendix A).
(2) Mainte na nceof patient records not only reduce s the chanceof injury of patients due to poor conmmtcettcn, but adequate pat ie nt recor ds are a cruc i a1 means of defe nse ifthe qual1ty of careis cuesttoned ina court oflaw. For the s ere as ons. emphasis was placed inthe Programonthe tnoor-tance ofmaintenanceofpatient records by physicianand the nur se . (3) In the event that a malp racticesuit arose as a resul tof the ac ti v- itiesof afamil y practice nur se, both theemploye rand the enployee wouldbeliabletogether . Physicians prac ti c in gin Canada can be insure d again st suchoccurrences throuqh the Canadian Medical Protect ive Association. At pre s ent in Canada ,othe r hea lt h professionstend not to becovered. Nurses not esployed by the Newfoundland government purchased rna1precttce insurancepremi ums from a loca 1 insurance fi no.
Ma l pr acti ce coverage ofal l nurses inthe provincebeganon January1.
1977thr oughthe Associa t i on of Regi steredNur s es ofNewfo undl and.
-26 -
(4) Asin ot he r prof es s i ons . onenethod of setti nga mi nimumstandard of ccro etencefor familypractice nurse s canbe ettencted thro ugh the establ ishment ofspecialistlicensure for graduates of the Memoria l University of Newfoundland Family PracticeNurse EducationProgram.
Also·,since the standards by which a professional is judged are the standards of the ti methe act complainedof occurred ,andnot standards at the tine theprofessional grad.uated .programs for cont in uingeducation aftergraduation .andthe pos s i bili tie s of limi te dli ce nsurewill have to be contempla te d for "long-term" gra duatesoftheMemori a l Uni vers ityof Newf oundland Family Pra ctice Nur seEducation Progra m.
{tx}St udyDesi gnandSal!!lle
Selectio n of the sample beganwith theuniv ers e of14famil y practice nurses whohad graduated from theMe~r:ia l UniversityofNewfound lan d Family PracticeNurse Educa t ion Programin May,1974 or: May,1975. In this report, the family practice nurse 'stepect is examined in urban fee- for-serviceprimary -carepractices. Thro ughthe excelle nt co-operationof one rural hos pita l ' s nedtcel and administrative staff, thetnoac t of one rural familyprac tice nurs e was exami nedand has bee nreported elsewhere (Chambers et al , 1977) .
Toens ure homogeneity among the practices inwhich familypractice nurses wor ke d, eight famil ypracticenur s esnot enployedin urban, fee-for- service, pr imary -careprac ticeswere excluded. The st udysample included the sixfamily prac ti ce nur s es whower e enployedin primary ca re practices beginni ng in June,1975 andwho were monitoredovera one yearper io d.
Permissionto conductdetailedeval uationstudies inthese practiceswas possible because they were offeredfree the servicesofa famil y practice nurse{a t conside rablecost to the National Health Researchand Develop-
-27-
-ment.Program}. The cOlmIi tment of resources to these pre ct.tces and the genera l diff i culti esin convin cin gotherphysicia ns of the mer i ts of being simil ar ly evaluat edas cont ro ls without family practice nursesres ulted inmost concer t sons being made onlyona before andafte rbasis. Access to the Medical Care Plan computerfile enabled soee compar isons between the stxphystct ens and all otherfamily physicians in theprovi nce whose mainsourceofincomewasfromfees-for- servi ces covere d in the physi ci an payment schedule oftheMedical CarePlan.
Ratherthan cOll"paringafewva r i abl esa~rossmanypractices(or saJ11l1i ng units ) as is usuallydone in epid emi ol ogi c studies .this repor t ccnca re s many variablesacro ss afew pr acti ces . Theevalu ati on of sixphysici an/famlly pra c t i ce nurseteamson a practiceby pr act ice basisinvolv edlar ge nuncer-s ofobser vatio ns. For example ,868 patients were interviewedattwo points intime aft erbei ngrandoml y allocatedto eitheran exper t rrental group receiving care mainlyfr oma famil y practic e nur seor a cont r ol group recei vingcare mai nly from a phys icia n. In conductin g thequalityof carecormonent of thest udy,4401episodes of care provided by physiciansand famllypracti ce nurses were assessed before andafter theintroduct i on offamily prac ticenurses into the prect.tce . Util iza tion and fin anci al assessments in all sixpracti ces were basedon total year . before / aftercompari sonsof servic es whi chaveraged 10 .000 pat ientserv icesperpr ac t ice per year. The re fo re, despite the limitationsin making'among' practicecoeoer-tsons,ithas been possible to conduct hi ghly detailed 'with in 'prac t i ce assessments.
(x) Org ani zationof the Thesi s
Chapters II. III. IV and V of the thesi s repor -ton the eval uat i ons of thetnoact of thefamilypracti cenur se onurbanfee-for - se r vic e
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practicesfrom four points of view respectively.
II. TheillJ? dc t of the family practice nurse on the effectiveness of the care provided. Patientoutcomes such as physical .social. and emotiona l functionwere determined with questionnaires administeredin thepatient 's hones. These questionnaires also enquiredabout the patie nt's accept ance of the nurse in certainexpanded role act i vi ties .
III.The;lTJldct ofthe famil y practicenurse on thequal ityof care pro vi de d . Writtencl i nical decis io n-maki ngoutl i nes we re de - veloped by a peer advisorygro up(consist i ng ofthreenon- uni versity af f il i ated prac t i sin g corrrnunityphys ic ia ns) for twelve indicator condi t io ns and fourtee n drugs COllll1001yused in generalpractice. Scalesofmeasurement for each indi cator condition and dr ug were descr ibe d in these out li nes. With the assistance of nurses anda medica l recordlibra rian.data was extracted from the medical records and eachpracticewas scored quantitativelywith the scoringsystem setout in the clinic al decision-makingoutl i ne.
IV.Theil!J)act of the family practice nurseonthe serviceoutput andorganizationof anurbanfee- fa r-s er vi ce medica l pr ac t ice. The prac tt ces weremonitore d usin g Medical Care Plan ofNewfo undl andcl a im forms. familypract i ce nur sedaybookdiar ies andaddi t i onal questi on- nai res to meas ure thenumberandtypesofpatientscare dfor ,phys ician delega tion offunctions tothe family pract ice nurse. and practice personnel professionalsatisfact ion.
V. Theinpact ofthe fami l y practice nurseon thefinanci al profitabilityofanurbanfee- f ar- s e r vi ce medical practice. Medical Care Pla nof Newfoundla nd andthephysicians' financial accounts were
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usedto analyzetheilllllica t i ons of employing fam;1ypract i ce nurses when taking intoaccountsalary and overheadcosts of the family practicenurse .
Thelast chapter of thethesi s surrma r izes the findin gsfromthe previo usfour chapters. Conclu sionsaredrawnfromthesefindings regardi ng the feasibilityand futur efor family pract icenurses.
Anannota te d bibliogr aphy of articlesprimarily focusingon the mate r ia l co ve red inchaptersIV andVis provided in AppendixB.
Appendix Cis a report on theee thods used to collect family pr actice nurse daybookdata and the linkage ofthisdata-to the I"edical Ca re Planof Newfoundl and data.
Appendix 0 consis ts ofcopiesof theinst rument s used in this st udy.
AppendixEconsi sts ofadditi onal tables ofserv iceandpat ien t vol ull'edata which were surrma r tz edfrom the Medical Care Plan computer file onthe sixpract ice s.
CHAPTER II
HOWEFFECTIVEAND SAFE IS THE FAMILYPRACTICE NURSE
HEALTHOUTCOMES OFPATIENTS IN THE ST. JOHN' S RANDOMIZEDCONTROLLEDTRIAL
OFTHE FAMI LY PRACTICE NURSE
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A fundamental assumptionin the concept of the family practicenur se model is that inany primary care practice there is a large number of patients whose problemsdo not require the skills and talents of the physician for effective management.
and. furthe rmor e , that aregi s t e r e d nurse with additional training primarily in preventive medicine. physical diagnosisand medica l management wil lhave the skills needed to provide effective (White. 1976). safe care to these patients which is equivalent to the care a physician would provide in a conve ntio nal model. This chapterdescribesan evaluationof theeff ecti vene ss of the family practice nurse on patients' chys tce l function.
emotiana1funct ion .and socia 1func tion components of health out - lined in the \<:orld Health Organization definition of health (The FirstTen Years of the World Health Organization, 1958). The evaluatio nwas conducted with patients in one of the family practices inSt. John's where a family practice nurse was introduced.
(t) Pa rt ; ciEat in9 Personne1 and Background
The family practice under study previously had no affiliation with auni ve r s ity or other institution. The organizationof medica l care in Newfoundl andwas wel lsuited to ourstudy as patie nts were freeto seek any desired source of primary care,and the costs of care regardless of source werecomplete lycovered by the NewfoundlandMedical Care Plan.
The family physician had received his medical degree in 1961 from the University of Tai wan and had practiced in St. John's for 15 years. The nurse had received her RegisteredNurse diploma in
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1955andhad been an employeeof the physicianfor four yearsbe f or e becominga family practice nurse.
Before the study began, the nurse attended a special education programfo rfamily practice nurses conducted by the schoolsof nursing and medicine at Hemorial University of flewfoundland as described in Chapter l . During the nine month education program, decis io n-makingandclinicaljudgement were stressedinclass room and prac t icalwork. The students were taught socialhistory taking.
physical exemtnat tonsand the ability to distinguish between abnormal and normal patient symptoms and s tqns as skills to be appliedin cl inica l sett i ngswhere the responsibilityofconti nui ngca re of patients is shared with a family physician. In establishing reciprocal confidence in each other's work. the physician and fami ly practice nurse arr ive at a poi ntwhere the family practice nurse is delegated the responsibility of choosing between three possible courses of action: providing specific treatment;providing reassurance al one.wi t hout speci fic tre at men t; or refe r r i ngthe patient tothe associatedfamily physician.to anotherc1inician or to an appropriate serviceagency.
(ti) Methods
(a) The StUdy Population
The study physician's practicerec or d s were organizedby family because many clinical problems in primary care involve families.
'fami ly ' in the studyprac ti ce was defi nedas a person or group sharing a coemon addressand typtce 11yinc l uded br-eedwinner,spouse.
and dependentchildren. Familte s as defined in the practice records
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Persons judged eligible for the trial were those whose famil ies had an ongoi ngmedical re l a t i on with the studyphysician.
Records of families who had not visited the study physician for anumber of years were not easily identified from patientrecords with i n the practice. Using computer records of the Newfoundland Medical Care Plan which have unique identifying numbers assigned to individual residents. 3090 patients who had visited the study phys ici anprior to the trialwere init i all y identified. Within the groupof 3090 patients,1325 had 60sof their general practitionerservices fromone physicianor75~of such services from the thr ee man clinicof which the study physician wasamember.
These patients were from 877 fa mil tes . (b) Randomization
Withthe assumption that a case load half that of a family physicia n was manageable for a family practice nurse, the eligible famil ies we r era ndomly allocatedin ara t i o of 2:1. They formeda randomizedconventionalgroup,assigned to continuing primary clinical services from a family physician (control group) and a randomized famil y pr act ice nurse gro up whose first-con t act prima r y clinical services were to be provided by the family practicenur se (experimental group). The resulting control group contained 585 familiesandthe experimentalgroup comprised 292 families.
After assignmentof the patients' cha r t s within the practice, the receptionist scheduled patient appointments after June1, 1975
