The family practice nurse Effective delegation is the hallmark of good business management. Its basic principle is summarized in the sentence, "Never do a job yourself if it can be done as well or better by someone who is paid less." In the efficient management of a high-cost, labour-intensive business such as delivery of health care, it is essential that every opportunity to delegate should be accurately evaluated and then encouraged where appropriate. An excellent example of effective delegation is found in Holland, where all normal deliveries are supervised by nurses; the maternal and infant mortality rates are some of the lowest in the world, significantly lower than those of Canada or the United States, where supervision is largely by doctors.1 In Canada the Boudreau report2 and the Hastings report3 both have encouraged the multidisciplinary team approach using the family practice nurse (FPN). The Boudreau report specifies 12 areas where some or all of the family physician's work could be delegated to a family practice nurse (FPN). This area of health care has been of great interest to Scherer and his colleagues at McMaster University, Hamilton, and their final paper on various aspects of the work of FPNs is published in this issue of the Journal (page 856). Despite the obvious advantages of effective delegation, many family physicians still have misgivings about the widespread use of FPNs. Objections to the use of FPNs are twofold - those based on clinical grounds and those based on grounds of acceptance. The advantages of delegating work of family practitioners to FNPs have been examined in reports of the nurse-practitioner program from McMaster Univer-
sity41' and more recently from Memorial University, St. John's13'14 (L.W. Chambers: personal communication, 1976). Few practitioners deny that a proportion of their work can be safely and effectively delegated to a nurse. Crombie and Cross15 demonstrated that a nurse could safely accept full responsibility for 16% of all patient contacts and could assist in a further 24%. Cartwright and Scott1 found that a nurse helped in the clinical examination of 41% of consultations. In isolated areas such as the Northwest Territories, Labrador and Newfoundland, nurses have for years been safely accepting many responsibilities traditionally taken by family and general practitioners. In more developed areas, such as Britain, FPNs working alongside physicians either singly or in groups saved practitioners 4 to 8% of their time by working 8 hours each week, and increased the average consultation time of the physicians.17 The McMaster University and Newfoundland studies analysed the clinical contribution of FPNs and compared it with that of the physicians for whom they were working, and with that of family physicians in the same area working alone. Sackett and associates, Spitzer and associates5 and Sibley and colleagues4 compared the clinical work of FPNs and physicians over a range of common conditions in relation to diagnosis, referral, the use of drugs and other measures of adequate care. They found that in the previously specified areas of activity the FPNs performed as well as the physicians for whom they were working and possibly a little better than randomly selected family physicians working without nurses. The Newfound-
land studies of Chambers, Suttie and Summers14 have confirmed these findings in both rural and urban settings. It appears that family physicians can safely delegate much clinical work to suitably trained FPNs in specified areas of practice. These areas include a) preand postnatal care, b) pediatrics, c) geriatrics and chronic care, d) preventive medicine (immunization, family planning etc.), e) health education and f) nutrition. An important consideration is acceptance of FPNs by others. (There is little doubt that FPNs themselves are satisfied, for the Canadian studies8.'1'14 disclose increased job satisfaction among the nurses, who uniformly appeared to enjoy the extra clinical responsibility and the income incentives.) With respect to acceptance of the FPN by patients, perhaps the commonest objection given by physicians is that their patients would not accept a nurse. This objection, however, is not supported by published work. When family physicians delegate suitably specified clinical work to nurses most patients appear less worried than either the physicians or the nurses.8'1'17 Clearly, acceptance by the patients requires that both physician and nurse cooperate but, given such cooperation, patients appear to appreciate the longer consultations even if they do not always see their own doctor. Acceptance of the FPN by the family physician is critical to the success of any FPN attachment program. If the family physician does not wish to delegate responsibility no such scheme will work. Reasons for a physician.s unwillingness to delegate fall into four categories: 1. Personality clashes between the physician and the FPN. The Canadian
CMA JOURNAL/APRIL 23, 1977/VOL. 116 829
studies report a small number of such difficulties. In their study of 79 attachments Scherer and colleagues (page 856) report that, after 5 years, 92.7% of nurses were currently employed and that 82.5% continued in their original practice. 2. The inability or psychologic unpreparedness of the physician, often working on his own with a relatively small workload, to delegate work. Such situations have arisen only occasionally in Britain, where financial inducements to encourage widespread attachment of FPNs to general practitioners have been in operation for several years. This is confirmed by Scherer and colleagues. 3. The physician's fear of the dangers of litigation as a result of the delegation of responsibility. In the studies reported from McMaster University and Memorial University, legal cover was provided but litigation remained a theoretical rather than a practical difficulty. The situation appeared little different from that in hospital, where similar delegation of responsibility to nurses and interns has been practised for many years. Both family physicians and FPNs require some insurance protection against malpractice litigation, and this should be encouraged by the community or province if work is to be delegated. 4. Financial barriers to acceptance of the FPN. These appear crucial. Spitzer and colleagues11'12 showed that the use of the FPN leads to overall financial savings to the community not only in terms of physician payments but also in relation to hospital and extended-care costs. These savings far outweigh the expense of the FPN's salary. By contrast, the acceptance of FPNs by family physicians depends mainly on whether the physician himself suffers financially. In Britain, where all doctors are paid by salary plus capitation fee, delegation to FPNs is naturally encouraged by the mode of remuneration and, once accepted, attachment tends to become permanent and is now almost universal. Scherer's study at McMaster University shows that the nurse's activities resulted in appreciable financial disadvantage to the family physicians concerned, because their income was largely fee-for-service. Physician acceptance of the FPN was here dependent on the extent to which this loss could be avoided either by direct subsidy or by a physician workload heavy enough to ensure that the FPN generated more income than her salary. A similar pattern was observed in fee-for-service urban practices in Newfoundland (L.W. Chambers: personal communication, 1976). Where family physicians are paid by
salary, as in parts of Newfoundland, physician acceptance of the FPN, once started, tended to become permanent, as it has in Britain. Thus, in certain large and well specified areas of primary care the clinical and economic effectiveness of the FPN has been clearly demonstrated. The only barrier to widespread acceptance appears to be the threat to the income of physicians paid by fee-for-service. In Canada, where fee-for-service is the mode, changes in the methods of financing of family physicians will be needed if the good business principle of effective delegation is to be encouraged in the delivery of health care. In the meantime the studies of Spitzer's group and those of his colleagues have proved of much interest and their implications for health care in Canada must be considered carefully. KEITh HODGKIN, BM, B CH, FRCP[C], FRCP Professor and chairman, general practice Faculty of medicine Memorial University of Newfoundland St. John's, Nfld. References 1. MAXWELL R: Health Care: the Growing Dilemma. Needs v. Resources in Europe, US. and U.S.S.R., 1974, New York, McKinsey, 1974 2. BOUDREAU TJ (chrun): Report of the Committee on Nurse Practitioners, Ottawa, Health and Welfare Canada, April 1972
3. HASTINGS J (chmn): Report on Community Health Centre in Canada, Ottawa, Health and Welfare Canada, 1972 4. SIBLEY JC, SPITLER WO, RUDNICK Ky, Ct al:
Quality of care appraisal in primary care: a quantitative method. Ann Intern Med 83: 46, 1975 5. Sprrz"a WO. SACKETr DL. SIBLEY JC, et al: The Burlington randomized trial of the nurse practitioner. N Engi .7 Med 290: 251, 1974 6. SACKETT DL, SPITLER WO, GENT M, et al: The Burlington randomized trial of the nurse practitioner: health outcomes of patients.
Ann Intern Med 80: 137, 1974 7. SPITZER WO, KJtROIN DS: Nurse practitioners in primary care. I. The McMaster University educational program. Can Med Assoc I 108: 991, 1973
8. CHENOY NC, SPITzER WO, ANDERSON GD:
Nurse practitioners in primary care. II. Prior attitudes of a rural population. Ibid, p 998
9. SPITZER WO, KItROIN DJ, YOSHIDA MA, et
al: Nurse practitioners in primary care. III. The southern Ontario randomized trial. Thid, p 1005
10. BATCHELOR GM, SPiTzER WO, COMLEY AE, Ct
al: Nurse practitioners in primary care. IV. Impact of an interdisciplinary team on attitudes of a rural population. Can Med Assoc .7 112: 1415, 1975
11. SPITZER
12. 13. 14.
15. 16. 17.
WO,
ROBERTS
RS,
DELMORE
T:
Nurse practitioners in primary care. V. Development of the Utilization and Financial Index, to measure effects of their deployment. Can Med Assoc .7 114: 1099, 1976 Idem: Nurse practitioners in primary care. VI. Assessment of their deployment with the Utilization and Financial Index. Ibid, p 1103 BLACK DP, RIDDLE RI, S.asPSON E: Pilot project; the family practice nurse in a Newfoundland rural area. Ibid, p 945 CHAMBERS LW, Surrm B, SUMMERS V: Expanded role nurses: an educational program in Newfoundland and Labrador. Can .7 Public Health 65: 273, 1974 CROMBIE D, CRoss K: The nurse in general practice. Br .7 Prey Soc Med 2: 41, 1957 CARTWRIGHT A, Scoi-r R: The work of the nurse employed in a general practice. Br Med .7 1: 807, 1961 Royal College of General Practitioners: Reports from General Practice, no 10, the practice nurse, London, Sept 1968
830 CMA JOURNAL/APRIL 23, 1977/VOL. 116
'STEMETIL prochiorperazine
Indications: nausea and vomiting of various etiologies: gastrointestinal disorders, drug intolerance, motion and radiation sickness, post-operative conditions, pregnancy, vertigo and migraine. Dosage: Adults, oral route - Usual effective dosage is 5 to 10 mg, 3 or 4 times daily; in very mild cases, a single dose of 5 to 10 mg is often adequate. 'Spansule' Capsules: one or two every twelve hours. This dosage may be increased as required by increments of 10 mg every 2 or 3 days until symptoms are controlled. For maintenance therapy the dosage should be reduced to the minimum effective dose. Because of the lower pediatric dosage requirements, the 'Spansule' Capsules are not intended for use in children. Rectal route - 1 or 2 suppositories of 25 mg per day. Children: oral andr.tal routes-up to 10mg per day in divided doses according to body weight. Parenteral route (not to exceed 40 mg per day) - In general practice: 5 to 10 mg l.M., 2 or 3 times a day. In surgery: 5 to 10 mg l.M., 1 to 2 hours before anesthesia. Repeat once during surgery if necessary. Post-operatively, same dose of S to 10 mg l.M., repeated every 3 to 4 hours. May be given IV. during and after surgery in the infusion solution at a concentration of 20 mg per litre. In obstetrics: 10 mg IM. during first stage of labor; subsequent 10 mg doses as needed. Post partum: the usual total daily dose is 15 to 30 mg orally or IM. Contraindications: Comatose or deeply depressed states of the CNS due to hypnotics, analgesics, narcotics, alcohol, etc.; hypersensitivity to phenothiazines; blood dyscrasias; bone marrow depression; liver damage. Warnings and precautions: etiology of vomiting should be established before using the drug as its antiemetic action may mask symptoms of intracranial pressure or intestinal obstruction. Patients with a history of convulsive disorders should be given an appropriate anticonvulsant while on therapy. Tardive dyskinesia may occur in patients on long-term therapy. If used with CNS depressants, the possibility of an additive effect should be considered. Use with great caution in patients with glaucoma or prostatic hypertrophy. The drug may impair the mental and/or physical abilities required for the performance of potentially hazardous tasks such as driving a car or operating machinery, especially during the first few days of therapy. Keep in mind that all medications should be used cautiously in pregnant patients, especially during the first trimester. Side effects: extrapyramidal reactions, disturbed temperature regulation and seizures have been encountered. Other side effects due to phenothiazine derivatives should be borne in mind; for complete list, see product monograph. Overdosage: no specific antidote; symptomatic treatment. If a pressor agent is required, norepinephrine may be given (not epinephrine as it may further depress the blood pressure). Dosage forms: tablets 5, 10 and 25 mg; ampoules 2 mI/l 0 mg; liquid 5 mg and 15 mg per teaspoonful (5 ml); suppositories 5, 10 and 25 mg. 'Spansule' Capsules, 10 mg. Complete information upon request MEMBER
EEEJ
'p
sity41' and more recently from Memorial University, St. John's13'14 (L.W. Chambers: personal communication, 1976). Few practitioners deny that a proportion of their work can be safely and effectively delegated to a nurse. Crombie and Cross15 demonstrated that a nurse could safely accept full responsibility for 16% of all patient contacts and could assist in a further 24%. Cartwright and Scott1 found that a nurse helped in the clinical examination of 41% of consultations. In isolated areas such as the Northwest Territories, Labrador and Newfoundland, nurses have for years been safely accepting many responsibilities traditionally taken by family and general practitioners. In more developed areas, such as Britain, FPNs working alongside physicians either singly or in groups saved practitioners 4 to 8% of their time by working 8 hours each week, and increased the average consultation time of the physicians.17 The McMaster University and Newfoundland studies analysed the clinical contribution of FPNs and compared it with that of the physicians for whom they were working, and with that of family physicians in the same area working alone. Sackett and associates, Spitzer and associates5 and Sibley and colleagues4 compared the clinical work of FPNs and physicians over a range of common conditions in relation to diagnosis, referral, the use of drugs and other measures of adequate care. They found that in the previously specified areas of activity the FPNs performed as well as the physicians for whom they were working and possibly a little better than randomly selected family physicians working without nurses. The Newfound-
land studies of Chambers, Suttie and Summers14 have confirmed these findings in both rural and urban settings. It appears that family physicians can safely delegate much clinical work to suitably trained FPNs in specified areas of practice. These areas include a) preand postnatal care, b) pediatrics, c) geriatrics and chronic care, d) preventive medicine (immunization, family planning etc.), e) health education and f) nutrition. An important consideration is acceptance of FPNs by others. (There is little doubt that FPNs themselves are satisfied, for the Canadian studies8.'1'14 disclose increased job satisfaction among the nurses, who uniformly appeared to enjoy the extra clinical responsibility and the income incentives.) With respect to acceptance of the FPN by patients, perhaps the commonest objection given by physicians is that their patients would not accept a nurse. This objection, however, is not supported by published work. When family physicians delegate suitably specified clinical work to nurses most patients appear less worried than either the physicians or the nurses.8'1'17 Clearly, acceptance by the patients requires that both physician and nurse cooperate but, given such cooperation, patients appear to appreciate the longer consultations even if they do not always see their own doctor. Acceptance of the FPN by the family physician is critical to the success of any FPN attachment program. If the family physician does not wish to delegate responsibility no such scheme will work. Reasons for a physician.s unwillingness to delegate fall into four categories: 1. Personality clashes between the physician and the FPN. The Canadian
CMA JOURNAL/APRIL 23, 1977/VOL. 116 829
studies report a small number of such difficulties. In their study of 79 attachments Scherer and colleagues (page 856) report that, after 5 years, 92.7% of nurses were currently employed and that 82.5% continued in their original practice. 2. The inability or psychologic unpreparedness of the physician, often working on his own with a relatively small workload, to delegate work. Such situations have arisen only occasionally in Britain, where financial inducements to encourage widespread attachment of FPNs to general practitioners have been in operation for several years. This is confirmed by Scherer and colleagues. 3. The physician's fear of the dangers of litigation as a result of the delegation of responsibility. In the studies reported from McMaster University and Memorial University, legal cover was provided but litigation remained a theoretical rather than a practical difficulty. The situation appeared little different from that in hospital, where similar delegation of responsibility to nurses and interns has been practised for many years. Both family physicians and FPNs require some insurance protection against malpractice litigation, and this should be encouraged by the community or province if work is to be delegated. 4. Financial barriers to acceptance of the FPN. These appear crucial. Spitzer and colleagues11'12 showed that the use of the FPN leads to overall financial savings to the community not only in terms of physician payments but also in relation to hospital and extended-care costs. These savings far outweigh the expense of the FPN's salary. By contrast, the acceptance of FPNs by family physicians depends mainly on whether the physician himself suffers financially. In Britain, where all doctors are paid by salary plus capitation fee, delegation to FPNs is naturally encouraged by the mode of remuneration and, once accepted, attachment tends to become permanent and is now almost universal. Scherer's study at McMaster University shows that the nurse's activities resulted in appreciable financial disadvantage to the family physicians concerned, because their income was largely fee-for-service. Physician acceptance of the FPN was here dependent on the extent to which this loss could be avoided either by direct subsidy or by a physician workload heavy enough to ensure that the FPN generated more income than her salary. A similar pattern was observed in fee-for-service urban practices in Newfoundland (L.W. Chambers: personal communication, 1976). Where family physicians are paid by
salary, as in parts of Newfoundland, physician acceptance of the FPN, once started, tended to become permanent, as it has in Britain. Thus, in certain large and well specified areas of primary care the clinical and economic effectiveness of the FPN has been clearly demonstrated. The only barrier to widespread acceptance appears to be the threat to the income of physicians paid by fee-for-service. In Canada, where fee-for-service is the mode, changes in the methods of financing of family physicians will be needed if the good business principle of effective delegation is to be encouraged in the delivery of health care. In the meantime the studies of Spitzer's group and those of his colleagues have proved of much interest and their implications for health care in Canada must be considered carefully. KEITh HODGKIN, BM, B CH, FRCP[C], FRCP Professor and chairman, general practice Faculty of medicine Memorial University of Newfoundland St. John's, Nfld. References 1. MAXWELL R: Health Care: the Growing Dilemma. Needs v. Resources in Europe, US. and U.S.S.R., 1974, New York, McKinsey, 1974 2. BOUDREAU TJ (chrun): Report of the Committee on Nurse Practitioners, Ottawa, Health and Welfare Canada, April 1972
3. HASTINGS J (chmn): Report on Community Health Centre in Canada, Ottawa, Health and Welfare Canada, 1972 4. SIBLEY JC, SPITLER WO, RUDNICK Ky, Ct al:
Quality of care appraisal in primary care: a quantitative method. Ann Intern Med 83: 46, 1975 5. Sprrz"a WO. SACKETr DL. SIBLEY JC, et al: The Burlington randomized trial of the nurse practitioner. N Engi .7 Med 290: 251, 1974 6. SACKETT DL, SPITLER WO, GENT M, et al: The Burlington randomized trial of the nurse practitioner: health outcomes of patients.
Ann Intern Med 80: 137, 1974 7. SPITZER WO, KJtROIN DS: Nurse practitioners in primary care. I. The McMaster University educational program. Can Med Assoc I 108: 991, 1973
8. CHENOY NC, SPITzER WO, ANDERSON GD:
Nurse practitioners in primary care. II. Prior attitudes of a rural population. Ibid, p 998
9. SPITZER WO, KItROIN DJ, YOSHIDA MA, et
al: Nurse practitioners in primary care. III. The southern Ontario randomized trial. Thid, p 1005
10. BATCHELOR GM, SPiTzER WO, COMLEY AE, Ct
al: Nurse practitioners in primary care. IV. Impact of an interdisciplinary team on attitudes of a rural population. Can Med Assoc .7 112: 1415, 1975
11. SPITZER
12. 13. 14.
15. 16. 17.
WO,
ROBERTS
RS,
DELMORE
T:
Nurse practitioners in primary care. V. Development of the Utilization and Financial Index, to measure effects of their deployment. Can Med Assoc .7 114: 1099, 1976 Idem: Nurse practitioners in primary care. VI. Assessment of their deployment with the Utilization and Financial Index. Ibid, p 1103 BLACK DP, RIDDLE RI, S.asPSON E: Pilot project; the family practice nurse in a Newfoundland rural area. Ibid, p 945 CHAMBERS LW, Surrm B, SUMMERS V: Expanded role nurses: an educational program in Newfoundland and Labrador. Can .7 Public Health 65: 273, 1974 CROMBIE D, CRoss K: The nurse in general practice. Br .7 Prey Soc Med 2: 41, 1957 CARTWRIGHT A, Scoi-r R: The work of the nurse employed in a general practice. Br Med .7 1: 807, 1961 Royal College of General Practitioners: Reports from General Practice, no 10, the practice nurse, London, Sept 1968
830 CMA JOURNAL/APRIL 23, 1977/VOL. 116
'STEMETIL prochiorperazine
Indications: nausea and vomiting of various etiologies: gastrointestinal disorders, drug intolerance, motion and radiation sickness, post-operative conditions, pregnancy, vertigo and migraine. Dosage: Adults, oral route - Usual effective dosage is 5 to 10 mg, 3 or 4 times daily; in very mild cases, a single dose of 5 to 10 mg is often adequate. 'Spansule' Capsules: one or two every twelve hours. This dosage may be increased as required by increments of 10 mg every 2 or 3 days until symptoms are controlled. For maintenance therapy the dosage should be reduced to the minimum effective dose. Because of the lower pediatric dosage requirements, the 'Spansule' Capsules are not intended for use in children. Rectal route - 1 or 2 suppositories of 25 mg per day. Children: oral andr.tal routes-up to 10mg per day in divided doses according to body weight. Parenteral route (not to exceed 40 mg per day) - In general practice: 5 to 10 mg l.M., 2 or 3 times a day. In surgery: 5 to 10 mg l.M., 1 to 2 hours before anesthesia. Repeat once during surgery if necessary. Post-operatively, same dose of S to 10 mg l.M., repeated every 3 to 4 hours. May be given IV. during and after surgery in the infusion solution at a concentration of 20 mg per litre. In obstetrics: 10 mg IM. during first stage of labor; subsequent 10 mg doses as needed. Post partum: the usual total daily dose is 15 to 30 mg orally or IM. Contraindications: Comatose or deeply depressed states of the CNS due to hypnotics, analgesics, narcotics, alcohol, etc.; hypersensitivity to phenothiazines; blood dyscrasias; bone marrow depression; liver damage. Warnings and precautions: etiology of vomiting should be established before using the drug as its antiemetic action may mask symptoms of intracranial pressure or intestinal obstruction. Patients with a history of convulsive disorders should be given an appropriate anticonvulsant while on therapy. Tardive dyskinesia may occur in patients on long-term therapy. If used with CNS depressants, the possibility of an additive effect should be considered. Use with great caution in patients with glaucoma or prostatic hypertrophy. The drug may impair the mental and/or physical abilities required for the performance of potentially hazardous tasks such as driving a car or operating machinery, especially during the first few days of therapy. Keep in mind that all medications should be used cautiously in pregnant patients, especially during the first trimester. Side effects: extrapyramidal reactions, disturbed temperature regulation and seizures have been encountered. Other side effects due to phenothiazine derivatives should be borne in mind; for complete list, see product monograph. Overdosage: no specific antidote; symptomatic treatment. If a pressor agent is required, norepinephrine may be given (not epinephrine as it may further depress the blood pressure). Dosage forms: tablets 5, 10 and 25 mg; ampoules 2 mI/l 0 mg; liquid 5 mg and 15 mg per teaspoonful (5 ml); suppositories 5, 10 and 25 mg. 'Spansule' Capsules, 10 mg. Complete information upon request MEMBER
EEEJ
'p
