Last August, Diane Gudmundson left the public health system, disillusioned with it. The nurse practitioner felt away from its constraints, she could deliver better patient care — even though it meant charging people directly.
"I would get this restless feeling like, ‘We should be doing more,’" said Gudmundson, who has more than two decades of nursing experience. "We could be doing better, we should be able to do different things."
It’s a feeling echoed by Donna Alden-Bugden, another nurse practitioner scaling back her work for the Winnipeg Regional Health Authority while building up a roster of private clients.
The two women are among a cohort of nurse practitioners, NPs for short, currently branching out into the private sphere, according to the chairwoman of the Nurse Practitioner Association of Manitoba.
"These nurse practitioners are visionaries who have identified a client need that’s not fit by the traditional funding model," said Ashley Pylypowich, herself a practising NP. "They’ve developed new pathways to optimize client care."
The timing has proved advantageous.
Gudmundson opened NP on Wheels last August — before the first Winnipeg emergency room conversions, before the QuickCare closures bumped NPs out of long-held roles, when confusion and concern seemed to be steadily mounting. Demand has continued to grow, such that she’s had to add to her roster of fellow nurse practitioners to meet it. In a few weeks, her clinic will have its grand opening.
'These nurse practitioners are visionaries who have identified a client need that's not fit by the traditional funding model'— Ashley Pylypowich, chairwoman of the Nurse Practitioner Association of Manitoba
Gudmundson’s practice is designed for ease of access and to ensure continuity of care, she said. The patient decides how often they want visits and for how long, whether they want a home visit or the clinic.
Whatever they decide, she said, registration is all done online through a secure network. People can fill out full histories, family histories and medication information, as well as answer a questionnaire about what’s bugging them to make sure the appointment addresses their concerns.
"I wanted to give people control back," Gudmundson said.
A surprising request she said she fields is for help navigating the public system.
"They say, ‘Can you come and give me your thoughts, because I’ve been through this and this and this and we’re thinking of going to Mayo (Clinic), but we thought we’d try you instead,’" she said.
It’s become so common, Gudmundson said, she’s considering adding "advocacy" as a service offering. It’s something the two nurse practitioners she employs part-time are able to help with.
"They are still in the public system, but they help me out after-hours," she said. "That’s pretty much how we all start."
That’s how Alden-Bugden is starting.
A nurse practitioner since 2003, Alden-Bugden works a few days a week for the WRHA and is self-employed the rest. She has a small room in a shared office in downtown Winnipeg, but also does house calls, seeing an average of 20 or so patients each week.
"I wanted to be able to have some independence over how I care for patients," she said.
Like Gudmundson, Alden-Bugden is fielding more and more requests each day. They tell her the appeal is ease of access, she said, especially when they realize nurse practitioners can do almost as much as a family doctor can: prescribe medication, order tests and diagnostics, as well as incision and drainage of an abscess.
"They’re frustrated with the health-care system," she said.
So are nurse practitioners, Gudmundson said, especially when it comes to "bumping," the process whereby NPs were reshuffled during the QuickCare closures.
"It’s a very serious issue right now," she said.
It’s also, in large part, a union one. Per the collective agreement, seniority is calculated based on total hours worked. A nurse practitioner with more NP experience could be bumped by one with less experience, as long as that person has more overall nursing hours.
"That is just a fact of the way we need to do business," said Lori Lamont, WRHA acting chief operating officer.
While the region wasn’t able to give all the NPs bumped during the QuickCare closures permanent jobs, she said many are filling other roles on a temporary basis. Generally speaking, Lamont said the WRHA is supportive of nurse practitioners and integrating them into the system (they have a toolkit to that effect available online).
"It’s important for everyone to work to their full scope of practice, and certainly that is the desire for nurse practitioners working within our system," she said.
Per the latest figures, there are some 200 nurse practitioners working in Manitoba, three-quarters of whom are members of the Manitoba Nurses Union. However, MNU president Sandi Mowat said it’s hard to get a sense of how many are also working private practice.
The Nurse Practitioner Association of Manitoba (NPAM) estimates 30 or so NPs work part-time or full-time in private practice.
Last month, nurse practitioners brought forward a resolution to the union to revisit that facet of the collective agreement. It failed, although Mowat said "that doesn’t mean they shouldn’t bring it back again in the future."
Mowat empathized with the nurse practitioners frustrated with their jobs.
"They provide a very valuable service," she said. "If there’s work for them in setting up these private clinics, we should be looking at adding that to the public sector."
Pylypowich said NPAM has had some very constructive discussions with Manitoba Health and Shared Health about where nurse practitioners fit in the system. "We’re in a period of health-care restructuring right now that creates some uncertainty," she acknowledged, but "I think right now we have to kind of sit tight."
It’s too early to tell how private clinics like the ones Gudmundson and Alden-Bugden are setting up might eventually work in conjunction with the public system, Pylypowich said. Gudmundson, in particular, has been building the digital side of NP on Wheels so it could feasibly be integrated with Manitoba Health’s digital systems.
"I look forward to seeing what comes out of private practice, and what that means for patient care," Pylypowich said.
Read more by Jane Gerster.
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