Trenton nurse practitioner role breaks down barrier

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A new role for a nurse practitioner in Trenton could be a sign of changing times for Quinte Health Care, senior staff say.

Johanna Leonhardt is the corporation’s first nurse practitioner with the role of “most-responsible provider.”

It means she can work independently without consulting with or being supervised by a doctor.

Leonhardt works in the regional complex continuing care unit at Trenton Memorial Hospital.

Her status as most-responsible provider required approval by QHC’s board. That came Nov. 24, and also led to board members updating their bylaws to extend admission and discharge responsibilities to nurse practitioners in specific situations.

“It’s pretty exciting,” said Leonhardt, a former army nurse who lives north of Napanee and who has been in the Trenton job for less than two months.

Breakthrough role

It’s her first job as a nurse practitioner. The additional duties were in the job description, but they’re not common. She said she’s one of only a few nurse practitioners in the province working as a most-responsible provider.

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Chief nursing officer and vice-president Carol Smith Romeril said the new approach is “one of the silver linings” of pandemic-related planning to address capacity problems.

Many Ontario hospitals are working beyond their capacities. That includes those of QHC, which have seen few patients with COVID-19 but surges of other patients. They’re also preparing for further surges.

Ontario nurse practitioners’ scope of practice allows them to work independently, but it’s taken years to get to this point.

“This has been a goal for almost my entire career,” Smith Romeril said, adding she was “delighted” by the change.

“It’s taken two decades for those barriers to be whittled away.”

Lightening the load

Patrick Johnston chairs the board’s quality of patient care committee. His written report explained the hospital’s need.

“This change is being requested urgently to deal with significant workload pressures in Trenton,” Johnston wrote.

“The Trenton family medicine group has not been able to achieve full staffing complement for an extended period of time. It has been relying on a capable physician assistant who has recently resigned.”

The group noted “the complexity of the cases and layers of support for patients and families requires a great deal of time,” Johnston added.

Compensation from the Ontario Health Insurance Plan (OHIP) doesn’t cover all of that time, he continued, and physician assistants require full supervision by doctors.

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Ontario is among the provinces and territories granting full hospital privileges to nurse practitioners , the Canadian Institute for Health Information noted in this year’s study of nurse practitioner scopes of practice in Canada. The study showed privileges in 30 of 38 duties studied differed by province and territory.

Johnston told the board nurse practitioners were an option for Trenton, but “our bylaws, which are really based on a template that the Ontario Hospital Association has provided, have not really kept up … and are more restrictive than they need to be.”

Nurse practitioners are paid directly by Ontario. Unlike doctors, they can’t bill OHIP, so they can’t have their own offices in which they’re the most-responsible providers “because we have no way of billing for that,” Leonhardt said.

Smith Romeril said QHC, which receives all operating funding from the province, could fund the nurse practitioner job with money available due to a vacancy.

Successful first month

Leonhardt spent 16 years in Canada’s military, first in communications, then in nursing. She graduated in 2013 from nursing school and then specialized in critical care, working in the intensive-care unit of Kingston General Hospital.

She said so far the new method in Trenton has been “excellent.

“I have been really well-received here, not only by the patients themselves, but by all of the staff, including the physicians,” she said. “I’m very thankful that I have a lot of support around me.”

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Midwives have in recent years also lobbied QHC successfully for further privileges.

“Allowing a nurse practitioner or midwife to work to their full scope can only be beneficial for the health care system in order to provide the patient with the best quality of care,” said Leonhardt.

“I really appreciate it, because it gives me not only that responsibility, but there’s an expectation there that I step up to the plate and provide top-quality care for these patients.”

She said most of her patients’ medical conditions are stable. Leonhardt said the job is similar to nurse practitioners’ work with family health teams and includes treatment and adjusting medications.

More changes possible

Smith Romeril said the Trenton position is unique within QHC. A similar process of board approval would be required for more nurse practitioners to do similar work elsewhere in the corporation, she said.

In each case, the roles and relationships with doctors would first have to be defined, with human-resources planning dictating if and when more changes are needed, she said.

Smith Romeril said QHC does, however, have a nurse practitioner working in the emergency department of Prince Edward County Memorial. That practitioner is employed by the Prince Edward Family Health Team.

During November’s board meeting, senior leaders were supportive of the change for Trenton.

“I think we’re setting ourselves up for success,” chief of staff Dr. Colin MacPherson said.

“This is huge progress,” added chair David MacKinnon.

In a later interview, Smith Romeril said similar roles may lie ahead.

“I think after we test-drive this model in Trenton we’d be open to looking at doing more.”

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