Nurse Practitioners in Canada — Christine Laliberté and Diana Dima

Alya Niang

Still looking for a family doctor? You are certainly not alone. An estimated 6 million Canadians do not have a family doctor and must rely on walk-in clinics, virtual medicine or visits to local emergency rooms for medical care, if they get it at all. As a result, there is a growing call for more nurse practitioners in Canada to fill the gap.

Today’s podcast focuses on how nurse practitioners are becoming one of the fastest growing health care professions in Canada.

Hello and welcome to the Canadian Health Information Podcast. This is Alya Niang and I’m delighted to host this conversation where we take a closer look at our health care system. Please bear in mind that the opinions and comments of our guests do not necessarily reflect those of the Canadian Institute for Health Information. However, this is a free and open discussion and this episode is about nurse practitioners, a solution to a health care system under great pressure and what is preventing more of them from caring for patients without a family doctor across Canada.

We have with us today Mrs. Christine Laliberté, nurse practitioner specialized in primary care and president of the Association des infirmières praticiennes spécialisées du Québec. Welcome, Mrs. Laliberté.

Christine Laliberté

Hello.

Alya Niang

And Mrs. Diana Dima, head of the department of specialized nurse practitioners at the Centre intégré universitaire de santé et des services sociaux du Centre-Ouest-de-l'Île-de-Montréal. Welcome, Mrs. Dima.

Diana Dima

Hello, nice to meet you.

Alya Niang

So, Christine, I’ll start with you. Many people might not know the role of a specialized nurse practitioner, SNP for short. Can you explain it to those of us who have never been treated by such a person?

Christine Laliberté

Yes, absolutely. I’ll start by telling you about the training. Specialized nurse practitioners have graduate level education. What this means is that they had a bachelor’s degree and worked for a few years. In Quebec, it’s 2 to 20 years of experience before going back to university to get a graduate degree. You need to get a master’s degree and a specialized graduate diploma, after which you will take a certification exam to enter the practice. What makes it special is that our practice is quite autonomous. We can diagnose, and we can also establish treatment plans. This means that we can prescribe medication, lab tests, imaging. Referrals can be made to other specialties as needed.

This is what makes it possible to function for a long time before needing to ask for a medical reference depending on the situation. So, nurse practitioners can be found especially on the front lines. For example, in medical clinics, nurse practitioner clinics, clinics run by nurse practitioners or, in Quebec, LCSCs. They can also be found in hospitals. There are nurse practitioners in several medical specialties. In Quebec, and similarly in other Canadian provinces, there will be nurses in primary care. In Quebec, we refer to this as the front line. In Quebec, some SNPs work in hospitals, such as adult care nurses who can work in various fields: pneumology, cardiology, nephro-oncology, etc. We also have nurse practitioners who work in mental health, pediatric care or neonatal units for babies born prematurely and with complications.

That’s pretty much what we find in terms of the practice.

Alya Niang

And are there limits to what they can do?

Christine Laliberté

The limits are closely linked to the specialty class for Quebec, which is specific to Quebec. But they are very much related to the expertise, the experience and the clinical judgment of the nurse. However, each Canadian province and territory has its own laws and regulations. So, we have limitations related to that.

A lot of it is also related to professional ethics, depending on whether I feel I have the experience to manage the health problem of the person in front of me. So if a person just finished their training a month ago, versus someone who has been in clinical practice for more than 10 years, we’re not necessarily going to have the same approach or provide the same care given the experience level and the amount of continuing education. So, the limitations are really linked to the expertise, even though we remain bound by laws and regulations.

Alya Niang

Perfect, thank you. And do you think there are any benefits to seeing a nurse practitioner rather than a doctor?

Christine Laliberté

There are benefits to consulting both. I think it’s about accessibility, but it’s also about working together. We must always think of using the best resource to offer the service in order to improve access. So if the nurse practitioner can manage one situation and free up the physician to manage a more complex one, there is a benefit to working collaboratively. So yes, there are advantages, we’ll give some examples later of what we can do as specialized nurse practitioners. I would say there is complementarity in terms of care and services. We also have a different approach for everything related to prevention, health promotion and education, in conjunction with the medical teams. There is a difference for the patients in the level of care they will receive. We also help patients to better manage their health condition, to better understand it. So there is definitely an advantage to working with both, but clearly SNPs can bring a lot to the population.

Alya Niang

Absolutely. Diana, let’s turn to you. You’re not an SNP, but as the department head of the nurse practitioner specialty workforce, can you tell me a little bit about your day-to-day role?

Diana Dima

Yes. So as a manager, I’m mainly involved in the administrative side, the day-to-day management of the nurse practitioners in each of their specialties. For example, in our CIUSSS, we have 4 of the 5 specialties that exist in our province. I am also in charge of recruiting and hiring new front-line SNPs for all the specialties. I also oversee employee retention for existing SNPs and ensure the proper integration of new hires. I am currently in charge of all the planning and onboarding of interns. I also oversee the development of the SNP role in conjunction with the Ministry, of course, in order to reach the pre-established targets that are given to us by the Ministry to improve access to care for the population.

I also help develop new positions based on these SNPs as well as their specialties and different environments. We work with various boards and physicians as well to create a response to the population’s needs.

Alya Niang

Diana, can you tell us a little bit about the QFDF, which is the Quebec Family Doctor Finder, founded in June 2021? What is the real purpose of this clinic?

Diana Dima

So this clinic is called the QFDF. It is on the front line, and its primary goal is prevention and health promotion. We do primary, secondary and tertiary prevention for orphaned patients, as we say here in our province, meaning those who don’t have a family physician. So, those who are on the Quebec Family Doctor Finder’s waiting list.

In our territory, at the moment, there are approximately 80,000 people on this list. We offer a service that is, as I said, focused on prevention. There are 2 components. We have nursing assistants, clinical nurses and specialized nurse practitioners on the front lines.

So the first component is screening, which is done by the clinical nurses for patients on the QFDF list. They really do a screening assessment including collective prescriptions and referrals to professionals when patients need it. And sometimes they refer some of these patients to an SNP who works in the same clinic.

The second component is the short-term stabilization for chronic problems and new diagnoses that have been made by the clinical nurses. This is done by the front-line SNPs.

The objective is really to avoid complications and to avoid these patients ending up in the emergency room. While waiting for a family doctor, patients who have chronic or complex diseases are managed and stabilized by the front-line SNPs who diagnosed the problem.

Alya Niang

So you could say that this clinic has been really helpful for patients without a family physician.

Diana Dima

Absolutely. We proceed by patient groups. Since we’ve launched in June 2021, the SNPs have seen more than 2,800 patients. The clinic has done more than 5,000 diagnostic tests. Of all these tests, 87% came back positive, meaning that something abnormal was discovered. So, there are a lot of problems on the front line that need to be addressed and it’s clear that if these people had not consulted, they could have ended up in the emergency room or in emergency clinics elsewhere. So, it has certainly greatly benefited people who are waiting for a family doctor.

We know that the average time, here in Quebec, is about one year before getting a family physician.

Alya Niang

Back to you, Christine. We found out that specialized nurse practitioners were first introduced in 1967, but it is only recently that the numbers have increased. There are 7,400 across the country, and they had the largest increase compared to other nursing professions, 10% between 2020 and 2021. What does that tell you?

Christine Laliberté

I feel that there are several factors that can explain the situation. The first was the evolution of the role. When the first cohorts of nurse practitioners start their training, it takes time in each province and territory for them to gain experience and expertise to train others. So, there is the issue of initial numbers. There is also the fact that the needs of the population are growing. The needs increased even more so during the pandemic, and highlighted the need for our health care system to change to better meet population needs.

There was also an increase due to laws and regulations. Across provinces, and I’ll speak for Quebec because that’s where I’ve had to work the most, but it took many years to get the role of the nurse practitioner to where it should be. We have only been able to make diagnoses since January 2021, despite being in the Quebec network since 2005. In comparison, our colleagues in other Canadian provinces and territories have been able to make post-assessment diagnoses from the beginning.

So this long journey created delays. There is also the question of understanding and recognizing the role, and exchanging with the different professional groups to advance this profession. I think we have reached a point of no return, because we can see that the population needs are there, and we have to think about how we can better leverage all the resources in the health network. Today we’re talking about nurse practitioners, but the same goes for all professionals who are often underutilized and who could be leveraged to offer better access to the population through enhanced collaboration between different professional bodies, in order to better meet people’s needs in a timely manner.

I think a lot of factors like that have come to influence this evolution. But this is really good news!

Alya Niang

Absolutely. And you kind of touched on my next question by talking about COVID. Has COVID-19 been a factor in the growing importance of SNPs?

Christine Laliberté

Yes and no. No during the pandemic crisis. In fact, there are instances where the role of nurse practitioners was really underutilized, but probably out of a lack of understanding of how much more we could have done for the population at that time. However, coming out of the pandemic, it’s like the opposite. Now we see the added value. The role has also evolved. Here in Quebec, the whole issue of making diagnoses happened during the pandemic, right in the middle of a parliamentary commission. It was decided after that. Some places have actually relied more on the expertise and skills of these nurses to enhance every role, because we also work in collaboration with our nursing colleagues. We can support each other in the form of mentoring, supervision, improving everyone’s skills. And it seems that the pandemic has allowed us to see this possibility that we could have different levels. And there are places too that have used nurse practitioners to run new clinics, run new centres for the elderly.

So, we really made the most of what we could do in terms of the nurse practitioner role. So, on some levels, yes, it has advanced the profession.

Alya Niang

Christine, given the many problems in the health care system, do you think that more SNPs could be a solution to the staffing shortages and emergency room closures?

Christine Laliberté

Yes, at many levels, and not just nurse practitioners. Obviously, I would say we need to increase the number of all professionals. As I mentioned earlier, I think their skills are underutilized. But nurse practitioners have greatly contributed to relieving the pressure in emergency rooms through outside work, namely nurse practitioners in front-line care, such as the new clinic that has opened in Montréal. In fact, they can really help relieve the pressure. We not only see patients with ear infections, sinusitis or colds, we can really go further with vertigo, dizziness and abdominal pain.

People don’t know how far we can go in terms of our role and we have contributed a lot, and even more so by following up with patients, precisely to prevent them from returning to the emergency room.

So, if a chronic condition is discovered, we can follow up with patients to prevent deterioration of their state of health, but we must also think of our colleagues in hospitals who, at several levels, particularly in Quebec, but also in other parts of Canada, cannot admit and discharge patients, so that there are hours of waiting to discharge patients, which is preventing someone in the emergency room being hospitalized.

So if we used the full potential of all SNP specialties, we would be able to relieve pressure in the emergency department and give patients the benefit of additional accessibility. The priority is to avoid having people who can’t get an appointment outside being forced to go to the emergency room. And it was a good idea to create these amazing nurse practitioner clinics that will make it possible to meet this need.

Alya Niang

What do you think about immigration? Would it be a good idea to import SNPs from other countries?

Christine Laliberté

I think so. In fact, we need to. When it comes to nurse practitioners, we’re talking about an advanced-level practice. To get there, we need a lot of nurses with a bachelor’s degree, which means they have completed their undergraduate education. So if the bachelor degree eventually becomes mandatory, including in Quebec, it would increase the pool of available nurses in addition to people from other countries who already have these skills and who could access the training of nurse practitioners, it would really be worth it.

Alya Niang

As you mentioned earlier, Christine, a new SNP clinic was opened recently on December 1 to relieve the pressure in emergency rooms, and is a first of its kind in Montréal. Can you tell us a little more about it?

Christine Laliberté

Yes, it was an excellent initiative. It is brand new. Several nurse practitioners are involved, and I would like to take this opportunity to acknowledge them and congratulate them because I have not had an opportunity until now. We were able to carry out this innovative and forward-thinking project, which also complements the other existing models. When it comes to nurse practitioner clinics, we want them to have all the necessary support as well as complementary resources, psychologists, social workers, physiotherapists and nurse practitioners specialized in mental health in order to have interdisciplinary clinics, to really give them the means to further enhance accessibility and offer complementary services to patients.

So, this is one way to think forward, and I think the important thing is that we all work together, including the collaborating physicians who are with us in these projects, to really offer the best services to the population.

Diana Dima

I can tell you that a mental health SNP will join the QFDF clinic’s team in January as well as a physiotherapist to do all the interdisciplinary work. We will also have walk-ins, and we’ll be able to respond to demands from the Primary Care Access Point, which is a particularity in our province too. We are expanding in order to provide walk-in options for people who are waiting for a family doctor to relieve pressure in the emergency room in our own way and through interdisciplinary work. The purpose of this clinic and what it has really accomplished is the full utilization of the scope of practice of each of the nurses. Nursing assistants are doing all they can, clinical nurses are also working to full extent of their practice and do everything they can, including collective prescriptions, and the same goes for specialized nurse practitioners.

And so, we are trying to fill the gap on the mental health side with the addition of a mental health SNP in a front line context.

Alya Niang

That’s a great idea.

Christine Laliberté

We also have models in Quebec City, such as the SABSA clinic and the Archimède clinic which works in the same way. These rely on the role of nurses and other professional resources, and, based on the reason for the consultation, provide the best resource based on the population’s needs.

If we had more clinics like the ones Diana mentions, in addition to existing clinics, we could manage a patient’s health while they’re waiting for a family physician. Is that what is required, or are we instead responding to the population’s needs? And then there’s a point where the issue requires the physician who is part of our team as well, who comes in and complements the care.

In reality, you could have lots of clinics like Diana mentions, so the population would receive all of these services by the best provider based on their needs.

Alya Niang

Perfect. So clearly, many people right now don’t have a family doctor. So, if one of our listeners does not have a physician, should they consider seeking an SNP? And if so, what is the best way to find one?

Christine Laliberté

Well, in fact, in several Canadian provinces and territories, there are already websites available for patients to look for a doctor or a nurse practitioner to do their follow-ups. In Quebec, we haven’t reached that point yet, we are slowly getting there, probably in 2023. But patients in Quebec who would like to see a nurse practitioner often go to offices where there are already nurse practitioners present or to clinics like the one Diana talked about, where they have direct access when they don’t have a family doctor. This is the primary method right now.

But in 2023, we will probably have a system that will allow people to choose a doctor or nurse practitioner for their follow-ups and that accessibility will be similar to the other Canadian provinces and territories.

Alya Niang

Would you like to add anything, Diana?

Diana Dima

It would be great if it worked in the same way, that’s for sure. I can tell you that at the QFDF clinic, we call patients who are on the waiting list for a family doctor to ask them if they want to see a clinical nurse or a front-line SNP. If they have any known diseases, it depends on their category.

So that’s how we operate. We work by age group, so they can access the clinic.

Alya Niang

Thank you, Christine, thank you, Diana, for clarifying the issues surrounding SNPs, a timely and also very important topic. Thank you very much.

Christine Laliberté

Thank you, have a nice day.

Diana Dima

Have a nice day.

Alya Niang

Studies show that the demand for specialized nurse practitioners is expected to increase by more than 50% over the next decade. We hope you have learned more about what they do and how they can help patients across Canada. Thank you for joining our discussion.

Our executive producer is Jonathan Kuehlein and special thanks to Ieashia Minott and Avis Favaro, the host of the CIHI podcast in English.

Don’t forget to subscribe to the Health Information Podcast and listen to it on the platform of your choice. I’m your host Alya Niang, see you soon.