Transforming Healthcare, Without Nurses?

In March, the province released its budget for the 2023 fiscal year, announcing a $3.9 billion investment in health care, $60 million of which will be allocated towards “transformative initiatives” meant to demonstrate its “commitment to reimagining health care.” Whatever this new vision of health care is going to be, it does not include registered nurses (RNs) and nurse practitioners (NPs). 

How can healthcare be “transformed” without the inclusion and participation of RNs and NPs? 

The Government is Giving Nurses the Silent Treatment

There are approximately 220 NPs and 5000 RNs in Newfoundland and Labrador. Together we make up most of the health care workers in this province. While this latest budget claims to integrate all aspects of health care, its omission of nurses and nurse practitioners is glaring, disheartening, and insulting. 

The province states they are “driving meaningful change across the health care system that will improve access to primary care.” In Newfoundland and Labrador, “primary care” has historically been delivered by nurse practitioners and physicians, and now through the new family care teams. Yet our government only refers to physicians. Problems of access to primary care continue to be expressed in terms of a shortage of family doctors, and according to this logic, the only way to solve this ongoing problem is to devote more resources to recruiting and retaining physicians. 

The thing is, nurse practitioners are also primary care providers. We have been on the forefront of the family care teams. We provide the same primary health care services and do the same work. Currently, NPs are improving access to primary care, by staffing and running clinics and seeing patients. Our health authority uses our skills, services, and contributions but it does not acknowledge us in name, nor does it equitably support our efforts. 

The Unique Role of NPs 

The nurse practitioner role is unique in health care. The language can be confusing. An NP is different from an RN. A registered nurse must complete a Bachelor of Nursing degree (BN) and pass a national exam to be granted their title. If an RN wants to become an NP after they complete their BN, they need a minimum of two years of full-time work experience as a registered nurse. Only then can they apply to the NP Master’s of Nursing (MN) program. After they complete their Masters’ degree, they have to pass a national licensing exam to be granted the title of NP. 

NPs work under our own licenses. We do not work under the direction of a physician. We are not junior physicians. We are not physician assistants.  We are not RNs with prescribing privileges. We are advanced practice nurses and independent care providers. We are not allied health workers. 

NPs independently assess and treat patients. We conduct medical histories and physical exams, we order and interpret diagnostics like x-rays and blood work, we provide referrals to other health care providers and make diagnoses. We order medications, write prescriptions, and are solely responsible for the care of the patients we see. We are primary care providers, just like our primary health care physician colleagues. While many people in the province have been struggling to get access to primary health care, NPs have been working on the forefront as part of the solution to this. We have been holding down our hospitals and acute care, we have been at the helm of the new family care teams. But still not one mention of us in the budget. Really?! 

NPs care for patients in every aspect of our health care system, and yet, our work is not equitably included in or appropriately valued by this government. It is appreciated by the patients we see and care for every day. That’s what keeps NPs here in spite of the blatant disrespect from our government. But now, enough is enough. 

GPs and NPs: Same Work, Different Pay

Based on the work they do, an NP can often be mistaken for a physician by patients. But the province of Newfoundland and Labrador makes no such mistake. And NPs have the bank statements to prove it. 

The only way for NPs to actually work in the public health care system is to be hired by the health authority directly, and work for the hourly wage negotiated. This pay is a fraction of what MDs are paid. Our health authority pays salaried NPs less than half of what they pay salaried GPs to do the same jobs, and staff the same primary care clinics. The work expectation is the same. The responsibility is the same. 

It’s not just a matter of salary, but also of billing. Currently, physicians can bill MCP for the patients they see. By making it easy for them to bill MCP directly, the system validates, supports, and indeed prioritizes physician-centred care. 

Nurse practitioners, by contrast, are paid an hourly wage for their time, which is negotiated by the union that includes both NPs and RNs. The scope of an NP’s work has been increasing in tandem with changing needs, and the job responsibilities are evolving. NPs have been fighting for years to be able to bill MCP as well, but they are still being told it is far too complicated. 

This is hard to believe when the provincial health care authority has readily accommodated the complex MCP-billing needs for the growing number of physicians who are offering remote telehealthcare. They have recently found a way for pharmacists to bill MCP. Why not NPs? 

The government is, however, trying to shift to a blended capitation model so that physicians won’t be paid more to see more patients. Unless they want to! The assumption is this will improve quality and not quantity of care, and increase job satisfaction for MDs. NPs have put forward a series of proposals on blended capitation models too, but these requests have been declined. 

We don’t want to be hired by a physician to work alongside them. This sets up an unnecessary power imbalance. The Registered Nurses’ Union has put forward proposals for NP-led clinics which have also been ignored. In reality, NPs are in fact leading clinics, just without acknowledgement, and for a fraction of the pay. It’s disheartening. 

Raising Up MDs, Keeping NPs Down 

In this health care budget, our government announced 20 per cent salary increases for family physicians and a $25,000 retention for family doctors. There were no raises or incentives announced for the NPs working side-by-side with these MDs, doing the same job, seeing the same patients. 

Nova Scotia offered a $20,000 incentive for NPs and RNs to stay in the workforce. Meanwhile, even New Brunswick pays NPs 20 per cent more than Newfoundland and Labrador does.

In Newfoundland and Labrador, a physician can be paid anywhere from two to five times more than an NP to do the same work from assessment and diagnosis to follow-up. How can this be? A pap test is worth what a pap test is worth. A medical exam is worth what it’s worth. Managing diabetes or doing a well-baby check costs what it costs. So why isn’t an NP’s work worth the same as a physicians? If the expectation of care is the same, if the responsibility is the same, if the skills and capacity are the same, then the compensation should be the same, or at least comparable. 

The fact that it’s not, can mean only one thing: our government assumes the work of physicians is worth more than that of NPs. This not only diminishes the hard work of NPs, it is insulting to our profession, and to our patients receiving our care. The patients receiving our care value and appreciate us. That is what has been keeping us going.  But we are tired, and this latest budget is the straw that is breaking the camel’s back.

Women’s Work? 

Clearly, from a resource allocation perspective, the work of nurses is not valued. Nursing, it seems, is still perceived as a predominantly female profession. Thus, the care nurses give is assumed to be something they will offer freely anyway, whether they get paid for it or not. Often, RNs and NPs do go over and above what is required to meet the emerging needs of patients. They fill in gaps where no one else can. 

This is the work that holds health care together. It’s the backbone of quality care–but you would never know it from looking at the province’s budgetary priorities, or its messaging. By all appearances, Newfoundland and Labrador is leveraging the unpaid caregiving of its nurses, NPs and RNs alike, to keep the system going while it directs resources elsewhere. 

The health accord includes plans of integrating NPs into primary health care. But NPs are not even named anymore by our premier or our health minister, let alone counted in the 2023 budget. 

The voices of NPs are not being heard, their experiences are not being counted. The Newfoundland and Labrador Nurse Practitioner Association (NLNPA) is run by volunteers. There is no office, there are no paid employees. Busy NPs have to give their time between work and life to advocate for themselves, their colleagues, and their patients. This advocacy is especially hard when the province is not listening anyway. 

NPs are leaving in droves, and who can blame them? Nurse practitioners in Newfoundland and Labrador have the highest scope and the lowest pay in Canada. It would be one thing if resources were scarce, but when the province is contributing $60 million towards health care, the lack of anything even close to pay equity is an insult. 

If we are going to have any hope of keeping NPs employed in public health care, and improving patient access to primary care, this has to change. 

High Expectations, Low Remuneration  

I worked every shift I had during COVID, I worked more overtime than I ever have before in my career. All of us nurses and nurse practitioners worked long hours. We had our holidays canceled or clawed back. We were understaffed and overextended. There was no coverage for shift breaks or sick days. We still showed up because we care about our patients and each other. 

The only thing that changed for me in my work environment during that time was what I wore. Was it N95s, gowns, gloves, and face shields? Or just gowns and gloves and surgical masks? Was it point-of-care-assessments? It was a confusing and complicated time, and the rules changed daily. There was no option for us to do virtual work because our in-person care is essential. Ultimately, you cannot take care of people without seeing them and touching them. 

During this chaotic time, physicians were given the ability to work virtually. Not only were they able to bill MCP, they were actually able to bill more for such patient “visits.” 

Now, in 2023, everything is open again, from malls and offices to schools. NPs continue to work in much of the same conditions as they always have. Physicians, however, are still getting paid to do virtual visits, just as patients are growing desperate for in-person ones. Virtual care has its place, but it does not and should not replace hands-on care. 

NPs like me remain on the ground offering primary care, working face-to-face with patients. We continue to do the same work for less pay with less flexibility–and on top of it all, without any mention from our government. 

Equity Now

The language and messaging needs to change. There is a shortage of primary care providers in this province. There is a shortage of family doctors. There are also shortages of NPs and RNs too. But while the province devotes time and energy into finding more physicians, it is neglecting and undervaluing its nurses. 

In yet another case in point: this week, the government put out a call for physician assistants (PAs) as part of a “Physician Assistant Pilot program.” While NPs have masters’ degrees and work under their own licenses,  PAs complete a two-year college program and work under physicians’ licenses. The province is not only offering to pay them $30,000 more than it pays NPs, it is also giving PAs a $30,000 signing bonus. 

A more equitable distribution of resources to registered nurses and nurse practitioners would not only boost our morale. It would also improve the retention and recruitment of RNs and NPs, increase the resilience of our health care system, and expand access to quality health care for all Newfoundlanders and Labradorians. 

If the province is truly interested in transforming its health care system, it needs a strong human foundation to support these changes. Registered nurses and nurse practitioners are essential to this foundation, and our provincial budgets must reflect that. The government is taking us for granted. Maybe they think if they ignore us we will just go away. I’m afraid they might be right.