A vision of primary health care for RNs

President’s update: A vision of primary health care for RNs

Besner, Jeanne


A Vision of Primary Health Care for RNs


Photo [Not Transcribed]

FOR me, primary health care is more than a model of delivering health care services. It is an approach which, among other things, gives us an opportunity to use the knowledge, skills and education of registered nurses for the greatest benefit of patients and the health care system. More than that, it is an approach built on the foundations of the nursing profession.

I am going to trace the relationship between primary health care and the roots of nursing. Then, I will discuss the implications for registered nurses today. Finally, I will share my vision of primary health care as an opportunity to revitalize register nursing in Alberta.

In the 1980s, there was a popular movie titled “Back to the Future.” I invite you to “go back to the future” with me because primary health care is really nursing principles in action. As British nurse Edith Cavell said, “If I speak concerning the past, it is because it is sometimes wise to look behind on the road we have traveled, and to take account of our errors as well as our progress.” The future of nursing depends on our ability to recapture the vision of our founders.

Professional nursing began in mid-19th century England as a consequence of the industrial revolution. At that time, the relationship between poverty and ill health was evident, along with the need for social reform.

Florence Nightingale was convinced of the importance of preventive social policies and certainly saw that health depended on the whole environment, not just the state of the body.

In 1861, she wrote: “It is mere childishness to tell us that it is not important to know what houses people live in… the connection between health and the dwellings of the population is one of the most important that exists.”

She clearly defined health as more than the absence of illness. In fact, her definition of health predated by over half a century that which emerged from the 1978 primary health care conference in Russia…although it was remarkably similar. In 1893, she wrote: “Health is not only to be well, but to be able to use well every power we have.”

Although she clearly saw a difference between nursing and medicine, she made little distinction between nursing and health. In Notes on Nursing [what it is and what it is not], she said: “The same laws of health or of nursing, for they are in reality the same, obtain among the well as among the sick.”

American nurse Lillian Wald shared Nightingale’s belief that health was a community responsibility which warranted the same level of government support given to the care of the sick. Wald was a master at putting health on the agenda of policy makers. Like Florence Nightingale, her accomplishments were awesome and her influence extended well beyond the realm of nursing. Here are just a few of her achievements:

* Establishing the first municipal playground in New York City

* Introducing hot lunches for school children

* Improving attendance at school given that illiteracy was a major concern of hers

* Introducing special education for mentally handicapped children

* Abolishing physical abuse of children in institutions for the handicapped, and

* Working to develop legislation to prohibit labour abuse of children.

Nightingale and WaId shared a common understanding of the purpose of nursing. Nightingale defined nursing practice as “putting people in the best possible condition for nature to restore or to preserve health.”

Nightingale’s definition is once again very similar to the 1978 World Health Organization (WHO) definition of health promotion: “The process of enabling people to increase control over and improve their health.” In other words, nursing and health promotion are one and the same thing!

The fundamental truth that there is more to health than health care is at the very core of the primary health care concept. The very words primary health care are often misused in today’s health care debate. They encompass more than primary care which is generally understood to mean the first contact people have with the health care system in their community.

The AARN was very pleased by the recent federal provincial health accord, with its increased funding for primary health care initiatives. However, we need to make sure that funding allocated for primary health care reform is actually used for that purpose instead of being used solely to address primary care issues.

Primary health care will include the following elements:

* Inter-disciplinary teams which could include physicians, registered nurses, dietitians, home-care workers, physio-therapists, social workers, nurse practitioners, licensed practical nurses and many others. These teams of providers are assembled based on the needs of the individual, family or community.

* People can access health services through members of the team as appropriate. Although physicians continue to play a key role in service delivery, they need not be the first or only point of access to the health care system.

* The health system shifts to a greater focus on health promotion and illness prevention, without sacrificing excellence in treatment and rehabilitation, which will always be an important and necessary element of the health system.

* Services are provided based on the needs of a defined population.

The problem with the current medical model for health service delivery is that it has failed and continues to fail in improving overall population health, despite dramatic advances in technology and exponential increases in costs.

There exists considerable variation in health among people in the same socio-economic group, even when they have similar access to health care resources. Clearly, professional knowledge and expertise applied to solving health problems are not sufficient by themselves in achieving improved population health, even though they are of course necessary.

The question we must now address is how to achieve the desired gains in population health within the resources available to us. How can we make our health system sustainable over the long-term and ensure its viability as a publicly funded system for our children and grandchildren?

Primary health care highlights the complexity involved in any effort to improve population health and recognizes the need to address the broad determinants of health. These determinants include income and social status, social support networks, education, employment and working conditions, physical environments, biology and genetic endowment, personal health practices and coping skills and, yes, the health system itself.

There are already several primary care pilot projects in the province such as the Crowfoot Village Family Practice, Northeast Community Health Centre and Bassano Health Centre.

The first example, the Crowfoot/Calgary Regional Health Authority partnership project, was made possible by implementing a major change in the way physicians are remunerated for their services. Alberta Health and Wellness reimburses the physicians on the basis of the number of rostered clients enrolled with the practice, rather than using the traditional fee-for-service scheme.

The clinic is paid a monthly fee per patient based on a formula determined by each patient’s age and gender and the fee covers all primary health care services. A public health nurse, a home care nurse, office nurses and others work collaboratively with Crowfoot physicians and their patients in the provision of a comprehensive range of services including prevention, promotion, treatment, support, rehabilitation and supportive services. In addition to receiving services, patients are encouraged to engage in a proactive approach to managing their health.

Registered nurses provide on-call support or “nurse triage” to the practice from 1700 to 0800 hours Monday through Friday, and for a 24-hour period on weekends and statutory holidays. The nurses answer patient questions about common conditions such as colds, coughs, low-level fevers and flus as well as more complex but easily identifiable illnesses such as urinary tract infections, whose symptoms and treatment are well-defined.

For patients, telecare reduces the inconvenience of waiting in the doctor’s office for minor ailments. It also allows nurses to schedule priority office visits for patients who need them. Information technology allows appropriate information to be shared among team members to support integrated service delivery.

This primary health care initiative is an example of a multi-disciplinary team which is using registered nurses to their full scope of practice, and which includes health promotion and illness prevention activities in order to increase the health of clients. The Crowfoot example has achieved significant efficiencies and is cost-effective.

Another example of primary health care in action is the Northeast Community Health Centre in Edmonton (NCHC). NCHC also provides primary health care services using integrated, multi-disciplinary teams of health care providers, including nurse practitioners.

Client needs determine the composition of a health care team and teams are assembled from existing resources to meet the specific needs of a family or individual. For example, a basic family or child health team could consist of a physician, nurse practitioner and registered nurses while a mental health team could be comprised of a social worker, registered psychiatric nurse, registered nurse, and addiction counsellor.

A client can access the services of the NCHC directly through any of the members of the health care team, allowing all providers to work to the full scope of their education and training. Like Crowfoot Village Family Practice, physicians are remunerated through alternate payment plans, not fee-for-service.

The NCHC serves a challenging demographic area with one of the highest percentages of first generation immigrants in the region as well as a high proportion of single, female parent families and areas of poverty. It has become expert at working with complex, vulnerable populations and is directly addressing issues associated with determinants of health. The centre partners with organizations such as the Alberta Alcohol and Drug Abuse Commission (AADAC) to ensure that the right care providers are available to meet medically and socially complex patient needs.

Primary health care initiatives in Alberta are not limited to the major urban centres. The Bassano Health Centre consists of eight acute care beds, one of which is designated as a palliative care suite, and seven continuing care beds. There is also a 24-hour emergency room. Facilities include a clinical area and offices for members of the integrated multi-disciplinary team. The centre provides a broad range of primary health services to the Bassano community.

The fourth example I want to highlight this morning is Provincial Health Link. Telehealth now offers 24/7 access to health information provided by registered nurses. It began in Edmonton, is now established in Calgary and is expected to be implemented province-wide by the middle of this year.

Health link makes registered nurses the point of access for people who need health information and advice. The nurses can refer callers to physicians or other health providers or provide self-help advice.

One point I want to emphasize is that efforts to improve population health should not be approached from the point of view of “blaming the victim.” Individuals should not be penalized for becoming ill or disabled. This fundamental principle is the reason that AARN opposes health reform recommendations, such as medical savings accounts, which would end up penalizing people who become ill.

Inherent in my beliefs about the role of nurses in a primary health care focused system is the understanding that nurses have a responsibility to help increase people’s awareness of the factors that contribute to health. Registered nurses also have a responsibility to plan and deliver services that address such important determinants of health as the social and physical environment, coping skills, personal characteristics and lifestyle.

In nearly every conversation that I have with members about primary health care there is one question that always surfaces: What does primary health care mean for registered nurses who work in tertiary care settings?

A commitment to primary health care means returning to the roots of nursing… and not allowing nursing to be situated primarily within the medical model, which focuses on fixing illness without sufficiently addressing the underlying causes of disease or ill health.

Nurses in Alberta today work in settings where the medical paradigm predominates and frequently perform tasks of a medical nature. That does not mean, however, that they should operate from within the medical paradigm while they are performing those tasks.

I want to share my understanding of what a primary health care approach means for RNs in each and every practice setting. o It means less concern about who is doing specific tasks and more focus on the patient

* It means a conscious decision to apply the nursing model to every interaction with a patient, and

* It means thinking beyond the required intervention to the implications for the patient’s total health.

Unfortunately, the popular tendency is to think of health as something at one end of an illness-health continuum. This has clouded the role that nurses should play in promoting health during all interactions with people experiencing illness, crises or life transitions.

There is no doubt that registered nurses in this province are facing significant challenges. Here are just a few of them:

* The amalgamation of 16 health authorities into nine larger regions raises issues of potential job losses or redeployment to unfamiliar or out-of-the-way work sites

* There are fears that staff mix changes in some settings are being driven by pressures to improve the bottom line, rather than concern about provision of high quality care by the most appropriate health provider

* Despite the ongoing nursing shortage, students in most parts of the province face the prospect of securing nothing but casual employment when they graduate

* Nurses still do not feel valued for their contribution to the health system and, they do not believe that employers understand nursing.

Despite these very real concerns, RNs remain hopeful about the future and confident that they can help create a health system that will truly meet the needs of the public we serve.

In view of these issues, it becomes all the more essential for registered nurses to demonstrate the added value we bring to the health system. It is up to us to demonstrate through our words and actions the difference that we make by complementing medical care with health care.

If we see ourselves too closely defined by the activities we are currently performing, we will be less able to see what we could or should be doing.

As registered nurses, we must strive to the highest professional standards in our treatment of the people we serve and in our relationships with colleagues.

Like other professionals, when nurses do their work they aren’t necessarily thinking about all the knowledge and experience that goes into it. We need to reflect on our own work and that of the registered nurses we work with.

In their book, From Silence to Voice, authors Bernice Buresh and Suzanne Gordon comment on the negativity that creeps into the nursing profession. This leads to the comments we have all heard that “nurses are too hard on each other,” that “nurses are their own worst enemies,” or that “nurses eat their young.”

Buresh and Gordon suggest a simple technique for countering that negativism. They ask nurses to consciously and regularly compliment their nurse colleagues for something they have done in their work. Their colleagues are often startled at first and then heartened by the experience. The nurse who compliments also feels buoyed and shifts his/her focus from negative to positive.

This shift in focus is critical. It is critical for helping maintain morale among a stressed nursing workforce. It is also critical that registered nurses behave professionally towards each other as well as towards their clients and other healthcare professionals.

It is critical that we understand what it means for us as registered nurses to work to full scope of practice. It means we work collaboratively with other categories of nurses, other health care providers and employers so that we actually can work to full scope of practice.

As a profession, we need to enhance the credibility of our profession and the professional standards we value. We need to demonstrate the added value registered nurses bring to clinical practice as well as our contributions to education, research and administration…and we have the education, knowledge and heritage to achieve this goal.

This brings me to the final theme in my remarks this morning… the challenge of implementing primary health care reform.

The essence of nursing is embodied in every aspect of the primary health care model. We must work individually and collectively to educate Albertans about the importance and value of the work that is carried out by registered nurses in improving the health of individuals, families and communities.

As registered nurses assume a pivotal role in the revitalisation of the health system, we can draw on the rich tradition of nursing leaders who had the vision and commitment to respond to the social needs of their time, including the need to develop the health system that we enjoy today.

Florence Nightingale saw concern for humankind and social reform as key features of the work of nurses in her day. That is no different in today’s environment.

Registered nurses are poised to play a significant role in transforming the health system, by using knowledge gained through their contacts with people in homes, schools, work-places, institutional and other community settings to contribute to improved access to health for all citizens.

First, we must rekindle the passion in registered nurses whose morale has been diminished by job cuts, workplace issues and time.

We must elevate the nursing profession in the eyes of decision-makers …ensure that we are viewed as part of the solution to the problems facing the health system, not as part of the problem.

As a profession, we have a responsibility to make the voice of nursing heard in setting the vision for a sustainable, high quality, publicly funded health system in Alberta.

The AARN, as the professional voice of nursing in Alberta, will remain vigilant in monitoring changes in the health care system and articulate in reminding decision-makers of the importance of retaining a vibrant and satisfied nursing workforce.

It is time for registered nurses in Alberta to “go back to the future”…to renew our enthusiasm for the ideals which are the basis of our profession…to promote the highest standards of practice and professional behaviour…and to serve the people who trust us to advocate for them.

Primary health care is no more, nor less, than shifting our health system towards a greater focus on health versus illness, being patient centered versus task focused, about all members of the multi-disciplinary team working each to their full scope and collaboratively to ensure sustainability of our health system.

I look forward to working with you in creating a vibrant future for registered nurses in Alberta.


The fundamental truth that there is more to health than health care is at the very core of the primary health care concept.


Registered nurses are poised to play a significant role in transforming the health system, by using knowledge gained through their contacts with people in homes, schools, workplaces, institutional and other community settings.


President Jeanne Besner’s presentation at the 2003 Annual General Meeting and Conference on April 30, 2003.



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Copyright Alberta Association of Registered Nurses Jun 2003

Copyright Alberta Association of Registered Nurses Jun 2003

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