Super nurses: a missing piece of Quebec’s health care puzzle
Ranks last among provinces for nurse practitioners per capita
Yannick Melançon Laître treats patients with all kinds of medical conditions at his clinic in Berthierville, a small town in the Lanaudière region northeast of Montreal.
His youngest patient is only two months old, and at the other end of the life cycle are a few nonagenarians he follows, making sure that their blood pressure is under control. In total, he has 650 patients, not counting the walk-ins during the afternoons.
“Every professional in our health network must be used to the maximum of his or her abilities,” he says after a busy morning at his clinic.
Most people would easily mistake the 32-year-old McGill University graduate for a rural family doctor. Except Melançon Laître isn’t; he’s a specialized nurse practitioner, one of 485 in Quebec — the so-called super nurses.
“Although all my patients are registered with a doctor from the point of view of the government, I actually ensure the care of these patients in an autonomous manner,” he adds, explaining that nurse practitioners can prescribe medications, order X-rays, initiate treatment plans and perform minor procedures like stitching a cut.
QUEBEC FAR BEHIND
Super nurses have long been hailed as the missing link in Quebec’s overburdened health-care system. Health Minister Gaétan Barrette lauded nurse practitioners last year for their “undeniable positive contribution to our network.”
Yet despite those words of support, Quebec ranks last among all provinces in its ratio of nurse practitioners per 100,000 population, according to a study last December by the Canadian Institute for Health Information. By comparison, Ontario boasts more than 3,300 super nurses — four times the number per capita than Quebec.
In the last election campaign in 2014, the Quebec Liberal Party promised 2,000 nurse practitioners as part of a three-pronged strategy of superhospitals, super clinics and super nurses. Since then, the number of nurse practitioners has risen from 230 to 485.
To put those numbers in perspective, there are 64,000 registered nurses in the province and nearly 21,000 active physicians.
In the provincial budget unveiled last month, the government set aside $20 million for the training and hiring of nurse practitioners, setting a goal of reaching 2,000 within six years.
Critics, however, are skeptical. “We’re very far behind,” said Diane Lamarre, of the opposition Parti Québécois, calculating that at the current pace of graduating nurse practitioners it will be impossible to achieve that objective.
Forty-five nurse practitioners obtained their diplomas in 20162017. Given that Quebec is currently 1,515 super nurses short of its goal, the province’s universities would have to graduate more than 250 per year by 2024.
Lamarre accused Barrette of paying lip service to super nurses as he spent most of his mandate forging ahead with an austerity agenda of merging the management of hospitals to slash costs.
At the same time, Barrette — a former radiologist — has maintained an agreement struck by the previous Liberal government to pay doctors $60,000 a year for each super nurse they supervise. In contrast, doctors in Ontario are not paid to supervise nurse practitioners, who can even run their own clinics.
“So we’re paying double,” Lamarre said. “We’re paying the super nurse and we’re paying the doctor to supervise the super nurse. This is nonsense.”
(Nurse practitioners earn up to $94,000 a year in Quebec, compared with $122,000 in Ontario.)
Still, the Quebec Order of Nurses praised the government for adopting regulations last month that will expand the scope of practice for super nurses, making the profession more attractive to potential candidates.
REGULATIONS CHANGING
As of March 8, nurse practitioners have been granted the legal right to initiate treatment in stable patients, independently of a doctor, for diabetes, high blood pressure, high cholesterol, asthma, hypothyroidism and chronic obstructive pulmonary disease. What’s more, Quebec became the first province in Canada to allow nurse practitioners to treat mental illness.
“One of the things that we’re most proud of with the new regulations is that specialized nurse practitioners can now initiate treatment as soon as they examine the patient and this will contribute to the improvement of care,” said Lucie Tremblay, president of the Order of Nurses.
“But that means that out there in the field, nurses and their physician partners must put into practice these new regulations, and that’s something that we will have to work on in the coming weeks and months.”
The medical establishment in Quebec hasn’t always been so accepting of nurse practitioners. In August 2016, Barrette chastised the Quebec College of Physicians for refusing to cede to super nurses the right to initiate treatment for chronic conditions, according to Le Devoir. Quebec at the time was the last province to do so.
And although nurse practitioners now have the right to start treatment, they cannot use the term “diagnosis.” That choice word can be uttered only by a doctor. Instead, nurse practitioners can give a “clinical impression” or a “diagnostic impression.”
Dr. Barbara Hogenbirk, of the Brunswick Medical Centre in Pointe-Claire, acknowledged that super nurses make a real difference in her practice.
“Oh, 100 per cent,” Hogenbirk said. “A good, thorough nurse practitioner can spend a lot more time with the elderly patients and the psychiatric patients that need more time. There’s no doubt about it.”
But she insisted that nurse practitioners must be supervised by a physician.
“I have a nurse practitioner under me, and she comes for advice all the time. So what is that going to be — a free thing ?”
Melançon Laître, who has worked as a nurse practitioner since 2011 and who teaches at McGill, does consult with one of the six family doctors at his clinic, but sparingly.
“I work in partnership with the doctor,” he said. “During the afternoon when we accept patients without an appointment, I will consult with my partner doctor from time to time to validate an impression, especially if I have less knowledge on a particular subject. In my case, it’s 15 minutes a week at the maximum.”
(Among the patients he follows in the mornings, Melançon Laître routinely refers a small number to doctor if their conditions deteriorate or they’ve become unstable.)
OBSTACLES AHEAD
Norma Ponzomi, a program director at the Ingram School of Nursing at McGill, suggested that the expanding field of nurse practitioners is one of the true success stories in Quebec despite burntout workers, ER congestion and lengthy wait lists for surgery. But she conceded that some obstacles still lie ahead.
“Probably the most important one in my mind is space limitations,” she said, explaining that nurse practitioners must share a limited number of exam rooms with doctors, reducing the number of patients who could be seen in a day.
“These clinics don’t necessarily increase the number of exam rooms and space. Even though there is this investment in hiring people, there’s no space created for them. So that’s a huge problem.”
Half of the $60,000 that a doctor is paid annually to supervise a nurse practitioner is supposed to be set aside for extra space in a clinic.
Another impediment is that the potential pool of nurse practitioner candidates is lower than in other provinces because more than half of all nurses in Quebec have only a CEGEP diploma. In order to qualify for a master’s degree as a nurse practitioner, one must possess an undergraduate degree. In the rest of Canada, nurses have bachelor’s degrees, and that means all can apply for a nurse-practitioner program.
“Only 48 per cent of nurses in Quebec have a degree from university and we can only pull from that 48 per cent,” Ponzomi said. “There’s not a critical mass of undergraduate-prepared nurses. So even if the government increases funding, it’s still difficult.”
Ponzomi and the Order of Nurses have recommended to the government that all future nurses must earn a three-year bachelor’s degree. Catherine W. Audet, Barrette’s press attaché, told the Montreal Gazette on Thursday that “it’s not in the pipeline for the ministry to require a bachelor’s for nurses.”
CLINIC BENEFITS
In Berthierville, a town of just over 4,000 residents with only one medical clinic, the addition of two nurse practitioners has been nothing short of a godsend. Initially, some residents were a wary of them, but Melançon Laître and his fellow super nurse eventually won them over.
“They ’re a great help in our town,” said Marilyn Rocheleau, 39, whose
two teenage daughters started being followed by Melançon Laître after their pediatrician retired.
“My daughters were intimidated to see a doctor, but not so with Yannick,” she recalled. “He listens and explains things well to them.”
He’s treated them for strep throat and gave one daughter a tetanus shot after she was bitten by a cat.
“Of course the doctors recognize how important the nurse practitioners are,” Rocheleau added. “Every clinic should have one.”
So we’re paying double. We’re paying the super nurse and we’re paying the doctor to supervise the super nurse. This is nonsense.