Not what the doctor ordered: A retiring nurse looks at what's wrong with primary care
We would never organize our schools with the same system we use for health care
This column is an opinion by Diane Murray, a registered nurse in New Brunswick. For more information about CBC's Opinion section, please see the FAQ.
In a few months, I will retire as a nurse. Over 40 years I have seen many changes, amazing innovations and great improvements, but health care seems to be in a crisis now.
We are facing a great challenge because we may have arranged primary health care backwards.
Instead of organizing patients into groups and providing services needed for that group or community, doctors are asked to set up individual businesses, each with its own infrastructure.
It's a model that doesn't work properly — and we would never use it, for instance, in the school system.
Communities would never engage a teacher to set up their own classroom, and then have teachers decide how many students they can — and cannot — accommodate when they will teach, while also paying for their rooms, light and heat.
Unfortunately, that is how primary care is arranged for most New Brunswickers. The system has perpetually left many people without primary care because no doctor has picked them.
On Wednesday, the New Brunswick government is rolling out its plans for tackling health-care reform. As we learn the details, I want to lay out what I've learned from my career, and what I would love to see happen.
We've seen great change, but sometimes not enough
In 1981, when I graduated, nurses wore white dresses, shoes, nylons and caps. The first computers were purchased for hospitals, charitable foundations raised money to install the first CT scans, and patients stayed in hospital for a week after surgeries that are now day-op procedures. Nurses counted the drops to regulate an IV drip; now a computerized pump is used.
Some things, though, have not changed.
The current nursing shortage is the third such crisis during my career. When I graduated, all Saint John School of Nursing grads were offered full-time positions at the soon-to-open Saint John Regional Hospital. Opportunities abounded. Some of my classmates ventured off to California or Texas, where they were offered huge signing bonuses. New Brunswick recruited nurses from the U.K.
Nursing shortages are the result of a complexity of problems, most significantly the high cost of educating nursing professionals. Provincial governments fund seats but not enough to consistently meet the demand. Hands-on experience in hospitals, community, long-term and home care is essential to nursing education, and supervision to ensure students provide safe care while learning is costly.
The reality is while there may be short periods of adequate nursing resources, the capacity to produce qualified nursing professionals will often not meet the need.
This problem is not limited to nursing. It is also found with laboratory technicians, diagnostic imaging and other health-care specialties.
Why is a service like this not available here?
Over my four decades, nursing scope of practice has expanded to meet new approaches to care and availability of new treatment options. Nurse practitioners have been introduced in New Brunswick, albeit slowly, compared to other jurisdictions.
On a pre-pandemic vacation in Florida, I required some emergency care and visited a nurse practitioner who worked independently in a nearby strip mall. He assessed, diagnosed, prescribed and followed up the next day.
The service was in the right place at the right time by the right person.
New Brunswickers must wonder why a service like this is not available here.
We all know about long wait lists for a doctor, or what is now commonly referred to as a primary-care provider (which can be either a general practitioner doctor or a nurse practitioner).
Emergency departments are bogged down with people sitting for hours, waiting to see someone because they have no primary provider with same-day access. Urgent care clinics have wait lists for each day and usually do not offer adequate followup, which affects continuity of care.
These problems lead to unsatisfactory experiences for both patients and providers, as well as more frequent admissions to hospitals for acute exacerbations of illnesses that could have been managed earlier.
We see suggestions of change perceived as a loss of something, or a reduction in service. People feel safe having rural emergency departments and hospital beds nearby.
However, the evidence points to the current system as being not only unsustainable with current and expected resources but also not the best way to do business.
A lack of access to primary care doesn't just affect our health. It affects our economy.
If people cannot easily get the care they or their employees need, they are not going to want to move their businesses here. New immigrants will not make New Brunswick home.
Here's how this could work
Instead of looking for more nurses, nurse practitioners or physicians to fill the positions in the over 20 hospitals in New Brunswick, with their overcrowded and overtaxed emergency departments, it is time to expand community health centres or health hubs.
Instead of people shopping for a provider, they could register at the local health centre, some of which were previously hospitals and be provided with preventive, acute and ongoing care. These centres would have expanded hours, so people would not have to go to emergency.
Depending on their need, many people would see a nurse, a respiratory therapist, a dietitian, social worker or physiotherapist — or their primary provider.
Current practitioners, if they wished, could band together, still running their own businesses or health centres in collaboration. These teams could also have access to other professionals to meet the patient's needs.
The key to this type of care is continuity and an interdisciplinary team approach.
The next great changes in health care need to be in the provision of primary health care.
This is the system used in many places in Canada and established with good outcomes in the U.K. and most of Europe.
The providers are employed to meet the needs of the roster of patients. If a practitioner leaves, the patients are not orphaned. Available providers who before did night shifts seeing a couple of patients in a small rural hospital will see those people as part of a team in the health centre.
Serious emergencies are transported to regional hospitals with the resources to deal with complex problems.
In a few short months, I will be officially retired. I will still be a nurse; it is part of my identity. I have seen so much amazing and good change. Care is safer now and of better quality with better outcomes.
I have a passion for seeing quality improvement continue, for communities to be able to offer better services that meet current needs.
The next great changes in health care need to be in the provision of primary health care.
I hope our citizens will see changes as positive, and that instead of losing something, they will be gaining a more effective approach, so that the right care is provided in the right place by the right person at the right time.
ABOUT THE AUTHOR
