Nurse Practitioners in Canada — Cindy Fehr and Stan Marchuk

Avis Favaro

Can’t find a family doctor? You’re not alone. There are some 6 million Canadians who don’t have a GP, who rely on walk-in clinics, virtual medicine, or head to the local emergency unit for medical care, if they get care at all. And that’s why there are growing calls to expand the numbers of nurse practitioners across the country.

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

Stan Marchuk

I’d say that we grow around 10 to 12% per year.

Avis Favaro

How some saved a rural hospital in Manitoba from closing down.

Cindy Fehr

It’s a primary care crisis. We’re needing more feet to the ground and more providers to provide access to primary care across this country.

Avis Favaro

Hello and welcome to the Canadian Health Information Podcast. We call it the CHIP, for short. I’m Avis Favaro, the host of this conversation. A note: the opinions expressed here don’t necessarily reflect those of CIHI, but it is a free and open discussion. And this show is about nurse practitioners: one solution to a health system under severe stress, and what’s stopping more of them from caring for orphaned patients across Canada.

Joining us today is Stan Marchuk, a nurse practitioner in Vancouver and President of the Canadian Nurse Practitioners Association of Canada.

Hi, Stan.

Stan Marchuk

Hi, Avis.

Avis Favaro

And joining us from Swan Lake, Manitoba, Cindy Fehr. She’s also a nurse practitioner and CEO of the Nurse Practitioners of Manitoba. And you will want to hear her story later.

Hi, Cindy.

Cindy Fehr

Hi, Avis. Hi, Stan.

Avis Favaro

Hi. So I want to start with you, Stan. When I told my husband that we were doing a podcast on nurse practitioners and I said, do you know what they do? And he said, I don’t. How many Canadians do you think know what nurse practitioners are?

Stan Marchuk

Probably, a good percentage of Canadians don’t know what a nurse practitioner does. Only those who have had the opportunity to have one as a provider really have experienced what they do.

Avis Favaro

I discovered that nurse practitioners were first introduced in Canada in 1967. That’s 50 years ago. But a lot of people don’t know what you do. Why is that, Stan?

Stan Marchuk

So, if we go back to the ’60s and look historically why the role came to be, the role really came to be because of Canadians who lived in rural, remote Canada who didn’t have access to health care.

And so, it isn’t until the 1990s that we really gained significant momentum in the country to really advance it.

And as we all know, in today’s climate where we have significant issues around access to primary care, nurse practitioners are very much fitted to help address that issue.

Avis Favaro

So maybe I’ll go to Cindy with this. Like what do you as a nurse practitioner do in terms of giving patients care? And what’s the difference between a nurse and a nurse practitioner?

Cindy Fehr

We all start out as nurses. And so that’s the foundation for a nurse practitioner, that you must have graduated from nursing school; practised for a minimum of 2 years is what the standard is out there, full-time equivalent; and then applied to nurse practitioner school.

The graduate program is anywhere from about 2 to 3 years full-time to part-time, which can be up to around 5 years or so. And then out into practice.

We don’t take medicine, like a medical degree, but we learn the foundations of how medicine applies to the practice of health care.

Stan Marchuk

Nurse practitioners diagnose various health conditions. They prescribe medications. They order diagnostics and laboratory tests. They refer to specialists when required. They are part of the health care team. So it’s a well-rounded role that, in my opinion, is very underutilized in our country.

Avis Favaro

Right. So help me understand where they fit in the ladder of health care. Because a lot of what you’ve said actually sounds a bit like what doctors do.

Stan Marchuk

We’re not physicians. No. We don’t carry that title and we’re not educated as such. But we do share some of the same knowledge and expertise. There is an overlap in scope of practice.

Avis Favaro

There are, based on CIHI data, some 7,400 across the country. Where are they?

Stan Marchuk

The majority, I would say, are working in primary care, actually in a primary care practice.

Avis Favaro

So family clinics?

Stan Marchuk

Yeah. Some of those clinics are NP-led, like some are within a larger team or structure. Some are integrated within health authority or health systems structures.

Avis Favaro

Do they assist physicians? Or they take the place of physicians in some cases?

Stan Marchuk

It’s not about assisting necessarily, and it’s not about necessarily replacing. I think it’s an adjunct to the system. So nurse practitioners will, just like physicians, roster their own patients. And so they can have their own practice. And when a condition or an issue is outside of their scope or practice, they would refer on to a specialist for their knowledge and expertise, just like a family physician would do.

Avis Favaro

What is it that drew you to this practice?

Stan Marchuk

So I had been a nurse for, oh, probably, what, some 17 years and then decided — or kept seeing that I really wanted to do more for patients. And I saw that people weren’t getting the access to the care that they needed. And I felt that there was an opportunity for me.

And I got exposed, when I was visiting a colleague in the U.S. who was a nurse practitioner, and really, that really tweaked my interest to say, what do you do? And so I really was able to see that I could use my nursing knowledge.

Avis Favaro

Right. And, Cindy, was there an aha moment where you went, I need to do more than nursing, but I don’t want to be a doctor?

Cindy Fehr

Right. And that was an opportunity for me to go to medical school. But I didn’t — I really like the nursing foundation. That is something that I have a passion for and that connectedness with patients.

For me, it was really about the illness care that I was seeing in the system and wanting to get ahead of that to really promote wellness.

Avis Favaro

What does illness care mean?

Cindy Fehr

Really, just seeing people coming into the hospital sick and where I thought, what if we kind of backed up the train and help them have better health habits, have more education to be able to take ownership of their health earlier rather than waiting ’til the illness kind of took over? How do we help people stay well rather than just intervene when they’re ill?

So, that was really the aha moment for me was, how do I do that as a nurse? And the nurse practitioner role was really something that looked like an opportunity to really look at the primary care and that wellness model of helping people stay well.

Avis Favaro

What is it about nurse practitioners that lets you do that more or differently than physicians?

Cindy Fehr

Primarily, when they’re a fee-for-service physician, the system drives the method of which they are able to work. And so, as nurse practitioners, we’re primarily employed in a salary or an hourly kind of wage. And so, with negotiations with our employers, we have longer times typically with our patients. So instead of a 10- or a 15-minute appointment, you’ll see a nurse practitioner has 20 or 30 minutes.

And so, we have just a little bit more time to be able to get to know our patients a little bit more intimately, get to see them over time for a multitude of different things; but also, just develop that relationship, learn from them what their needs are, provide the education because we have the time to, and really look at the patient from a holistic perspective, the whole being, and not just little bits and parts that we are taking care of when they come in.

Avis Favaro

Have there been studies to show that nurse practitioners offer different care or better care?

Stan Marchuk

There’s 50 years of research and we’ve probably been one of the most studied health professions around just because of that, because it’s been quite contentious over the years.

And if we look at all of the research that’s been published, study after study shows that nurse practitioner care is equivalent or if not better than our physician colleagues. And patients have a very high degree of satisfaction with the care that we provide.

Avis Favaro

You mentioned the word contentious, though. Explain that.

Stan Marchuk

Well, I would say it’s contentious simply because, unfortunately, our current health system is, in terms of the payment system, creates that because of the fee-for-service system is about volume. And there’s always a concern about who’s going to get paid and how much are they going to get paid.

Nurse practitioners aren’t fee-for-service in Canada. They’re either on a contract model or on an hourly model or a salary. So, just like that, we have the opportunity to offer that holistic approach. It’s not like one problem, one visit. It’s like — so Avis, you come to see me, and you can talk about your problems in your visit because you have enough time to do that, and we have enough time to explore what’s meaningful to you.

Avis Favaro

So you’ll listen, is what you’re saying. You have time to listen?

Cindy Fehr

Yeah. We have 2 ears and one mouth. That is the way we should be doing it, is listening twice as long as we are talking. So it may be that they come in and mental health is a huge issue. How do you do that in 10 minutes, deal with a mental health crisis that somebody has? Or that they’re having issues with finances that’s affecting how they are able to purchase the medicine that they need to keep them healthy or be able to attend counselling sessions?

It’s really — health is so complex and giving a 10-minute visit is doing a disservice to the person. And it’s disrespectful because they’re more than that. I mean, there are — definitely, if you’re coming in for an immunization, that might be an in-and-out. But I also take it as an opportunity to discuss just health in general. How are things going for you? How is your home life? How are your kids?

Avis Favaro

So my question now is COVID hit. And now it seems like everybody’s talking about nurse practitioners. But if you look at recent articles from various provinces, Newfoundland is looking for nurse practitioners, New Brunswick, Ontario; Quebec has just set up nurse practitioner clinics in Montréal to deal with the surge of cases because the ERs are swamped. It seems to me that COVID, even though it’s a crisis, has become a call-out for more nurse practitioners.

Stan Marchuk

Most definitely. And I’ll give you an example of where, during the COVID time, in one of our provinces, nurse practitioners, although they were not recognized to provide the care, they rolled up their sleeves and they did it for free because they felt that they needed to actually meet the needs of their community.

So, I just think that that’s the way we need to get in front of it. And we need to continue to do that.

I think the other part was, we need to continue to tell Canadians about what we do and how we do it.

Avis Favaro

So, Cindy, that brings me to your recent experience. So you work in Swan Lake and there was a hospital, and you were telling me about how the 2 physicians who worked there left. And this was early in the pandemic.

Do you remember what you thought when you heard that? And what it meant for the community?

Cindy Fehr

I also live in the community. So that was a double whammo for me. So, the first instinct for me was a little bit of panic. Giving perspective, Swan Lake has a population of just over 300 people, but our draw of our community is about 3,000 patients because it’s a rural farming kind of area.

Avis Favaro

So this is a very, very critical hospital service.

Cindy Fehr

That’s right. We are an 18-bed hospital. We had full emergency services and inpatients. And so that was a huge hit. And the recruitment drive did not succeed in being able to recruit new physicians. There was just none to be had. And so the choice was, close everything down and redistribute services elsewhere in the area, or look at a new model.

And under the leadership of our chief medical officer, we decided to move forward with the nurse practitioner-led model for our hospital and our 2 primary care clinics.

Avis Favaro

It’s got to be one of very few hospitals in the country run by nurse practitioners.

Cindy Fehr

Well, it’s the first one in Manitoba. And so, yeah, we have 5 nurse practitioner positions. We have currently 4 nurse practitioners that are working in that model and providing the 2 clinics with primary care services and the hospital with the transitional convalescent care, so low-acuity care.

And then, outpatient services. So, if somebody needs blood, we help them get blood if they come in. And we’re all trained with high needs or high emergency care. So if somebody came in having a stroke, we can manage that until we can get them out to the most appropriate care.

Avis Favaro

How does the community react to the nurse practitioners coming in and saving the hospital?

Cindy Fehr

Well, there’s still always a want to have a physician. For some, I guess it’s just a historical thing. They still want a physician, but are very, very happy with the nurse practitioners and thankful that we came in to actually save the hospital and primary care clinics, that they weren’t closed. And so we have got a lot of respect from our community members for that, but yeah. Is it perfect? No. It’s a work in progress. And it’s, like any other new model, there’s lots of kinks and we’re learning as we go. But primarily, it’s serving the communities while they’re getting the care that they need where they need, and especially in a time where human resources is lacking.

Avis Favaro

Could nurse practitioners help bolster the health care system right now?

Stan Marchuk

Most definitely. You know, nurse practitioners need to be integrated into the health system, full stop. The barriers have really been around, how do you get access to the funding in order to do that, and everybody is trying to figure that out.

There’s been a number of different opportunities or initiatives, projects that have been trialled across Canada. Ontario, in 2007, initiated the first nurse practitioner-led clinic in Sudbury. That was hugely contentious in the community, but a thriving clinic that is really working well for the community.

Avis Favaro

Okay. Contentious. Again, why? Is it because people wanted doctors and they weren’t used to having nurse practitioners?

Stan Marchuk

Exactly. And there was a strong physician lobby against it.

Avis Favaro

Why is that, do you think?

Stan Marchuk

I think we all know that money plays into it and there’s a lot of challenges around that it’s going to dry up. As one of my colleagues would say, there’s more than enough pain and suffering to go around for all of us.

And the reality is, is that we have to take the hierarchy of health care away and we need to move it more to a circular model of participation and collaboration. It’s not about one particular person being the be all and end all for the person. That’s not possible.

Health care is far more complex than it was in the ’60s. With new advances happening every week and every day, to stay abreast of that, no one profession can do that. So we need to work collectively to do that together.

Avis Favaro

So when you hear that there are 6 million Canadians without primary medical care, are you frustrated?

Cindy Fehr

It’s a primary care crisis. We’re needing more feet to the ground and more providers to provide access to primary care across this country. Nurse practitioners can be educated quickly or quicker than our physician counterparts and integrated within the system quicker. We can be produced quicker.

And I don’t often like to compare that we’re not physicians, but we service a good — we’re a good opportunity to fill some of the need that Canadians need for access right now to primary care.

Stan Marchuk

And we, as the National Nurse Practitioners Association, have lobbied in many different ways to say, we need to work to ensure that nurse practitioners are gainfully employed. Many are underemployed in some of our rural communities, which is a real tragedy.

Avis Favaro

What do you mean by that? You mean there’s nurse practitioners who don’t have jobs?

Stan Marchuk

That’s correct. Yes

Avis Favaro

How is that possible?

Stan Marchuk

Well, if the health system doesn’t create a position for you and you’re not permitted to bill fee-for-service because that doesn’t exist, then those nurse practitioners are often working as registered nurses or not at all.

So, we have to do better. We have to ensure that there is the mechanism there to ensure that nurse practitioners, when they graduate, have an opportunity to be employed.

Avis Favaro

How many nurse practitioners do you figure are out there underemployed or not employed at all?

Stan Marchuk

It’s a good question because we really don’t have good health human resource data. But we do know from the sampling that we have done that probably anywhere, it’s between at least 10 to 15% or maybe upwards of 20% of nurse practitioners don’t have employment.

Cindy Fehr

I hear often a nurse is a nurse is a nurse, and we’ll just take you from one position and put you in another position. That doesn’t fly with nurse practitioners. We work in family practice. We have panels of patients that we get connected to and who are connected with us over years and years. And then to take that person out of that position to put them in another area of need is a disservice to those panel of patients.

We would never think to do that for a physician in a family practice, but yet, we’re seeing that in the system where we’re still treated as a nurse is a nurse is a nurse. We need to change that attitude so that we are given the respect for the role that we provide. We’re not physicians, but we need to be treated with the same respect as the physicians are in this health care system.

Avis Favaro

One of the phrases you used when we first spoke, Cindy, was grow your own.

Cindy Fehr

Well, how are you going to attract a nurse practitioner who’s gone — or a physician in a small rural community, if they have no connections there, and if they’ve grown up and worked in a large city? It’s not something that is an easy transition.

The nurses that are already there may have a passion for or an interest in going to school, learning to be a nurse practitioner, and then going back to that community and being that primary care provider or group of primary care providers.

So growing your own is really about thinking — not about taking somebody from a different community and plunking them into the area of need, but really growing your community of providers from within. And so, giving them support by financing them; giving them a salary while they’re going to school; ensuring that there’s a position there for them when they finish their education.

Stan Marchuk

There are published papers that show that nurse practitioners who live in a community and are educated are more likely to return to that community and stay within a community to support it.

Avis Favaro

What would you like governments to do to get more nurse practitioners in the field?

Stan Marchuk

Dedicate some funding directly towards nurse practitioners. It’s that simple.

Cindy Marchuk

Yeah. Don’t just throw it in the health care system. Dedicate it. Tie it directly to nurse practitioners.

The challenge is a lot of the provincial budgets are either physician or nursing. And when you add more to the nursing, what happens is a lot of that funding then gets diverted to the registered nurse role or the LPN, the licensed practical nurse.

And that’s fair enough; there’s a need for those as well. But that is a disservice and, frankly, a disrespect again to the nurse practitioners. We need to be recognized that our role is important and that we need to have dedicated funding, that there’s some accountability that it’s going to be spent for nurse practitioners, not diverted to physician dollars or diverted to registered nursing dollars. It needs to be earmarked specifically for nurse practitioner positions.

Avis Favaro

I have heard something intriguing in Manitoba, though, Cindy, where some nurse practitioners are going out and doing private practice. Is that a trend?

Cindy Fehr

So we are seeing a larger number of nurse practitioners that are leaving the system or partially leaving the system and providing their own independent practice for people that have the funds to be able to do that.

But they’re paying out of pocket for that and at a good price, really. But it’s filling a niche in the market that — or in the health care system that’s not currently being able to be provided to patients.

Stan Marchuk

I would just add, Manitoba is not the only province. New Brunswick has done that. Because in its time, there were nurse practitioners who graduated, there were no health system positions. So, yes, they opened up their own practice and charged patients for the visit because they wanted to stay in their community and provide care to people in the community.

The government didn’t like that and still doesn’t like that. But once again, if they want to change that, they need to get out in front of that and change that to create opportunity.

If the system isn’t going to work with you, you need to figure out another way to kind of either go around it to serve the needs. I agree that nurse practitioners should be part of the health system. But as you know, nurse practitioners aren’t part of the Canada Health Act. Physician and hospital services are what’s covered. So, if you graduate as a nurse practitioner, there should be an opportunity for you to provide health services to Canadians.

Avis Favaro

If someone is listening to this and they don’t have a doctor, how do they find a nurse practitioner?

Stan Marchuk

Some provinces have a central registry where you sign up and, as many people have told me, could be waiting on that list for years and still never get someone, which is really not effective.

Some individuals have put out ads seeking for a provider, as we all know, and we’ve seen that in the media as well. But we don’t have a really good national way of actually articulating or asking who’s available.

And I think that, in terms of when we move forward in our — hopefully, in our health human resource redesign or improvement, that we would look to say, how could we have a portal, a one-stop shopping that, if I needed a provider, an NP or a physician, that I could go to and I could sign up in my community. Like that just doesn’t exist currently.

Avis Favaro

So, I hear nurse practitioners are ready and willing to help, but there’s a few barriers in the way.

Stan Marchuk

Those barriers are, by and large, policy or government-type barriers that really need to be addressed. Those barriers include data funding for nurse practitioners in terms of employment, but also for the education side. And the other part is the retention side; to make sure that we can continue to keep them working in the system and not burn them out.

Avis Favaro

Are you hopeful?

Stan Marchuk

Absolutely, I’m hopeful. I look at the history and I see that we grow around 10 to 12% per year.

Cindy Fehr

I would totally agree. I’m always hopeful and optimistic about the future. A real significant part is educating the public about what we do so that they can say that this is the option they want and that they as well can advocate for more nurse practitioner positions to the government.

Avis Favaro

All right. Well, I’m going to wrap it up there.

I want to thank you, Cindy, and thank you, Stan, for talking about nurse practitioners in Canada right now. And I hope that people have learned about what nurse practitioners do. Thank you, both.

Cindy Fehr

Thank you for the opportunity.

Stan Marchuk

Thank you, Avis.

Avis Favaro

Studies show the demand for nurse practitioners is projected to grow by over 50% over the next decade.

Thank you for joining our discussion. Our executive producer is Jonathan Kuehlein. Special thanks to Ieashia Minott and Alya Niang, the host of our French CIHI podcast.

If you want to learn more about the Canadian Institute for Health Information, please go to cihi.ca — that’s C-I-H-I-dot-C-A — and subscribe to the CHIP wherever you get your podcasts.

I’m Avis Favaro. Talk to you next time.