UBC Faculty Research and Publications

Who are the primary health care registered nurses in British Columbia? Wong, Sabrina T.; Watson, Diane E.; Young, Ella; Mooney, Dawn; MacLeod, Martha Mar 31, 2006

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
52383-Wong_S_et_al_Who_RNs.pdf [ 3.27MB ]
Metadata
JSON: 52383-1.0048320.json
JSON-LD: 52383-1.0048320-ld.json
RDF/XML (Pretty): 52383-1.0048320-rdf.xml
RDF/JSON: 52383-1.0048320-rdf.json
Turtle: 52383-1.0048320-turtle.txt
N-Triples: 52383-1.0048320-rdf-ntriples.txt
Original Record: 52383-1.0048320-source.json
Full Text
52383-1.0048320-fulltext.txt
Citation
52383-1.0048320.ris

Full Text

March 2006Who are the Primary Health Care Registered Nurses in British Columbia?Sabrina T. Wong RN PhDDiane Watson MBA PhD Ella Young MHADawn Mooney BAMartha MacLeod RN PhDWho are the Primary Health  Care Registered Nurses in British  Columbia?March 2006Sabrina T Wong RN PhDDiane E Watson MBA PhD Ella Young MHADawn Mooney BAMartha MacLeod RN PhDLibrary and Archives Canada Cataloguing in PublicationWho are the primary health care registered nurses in BC? / Sabrina T.Wong ... [et al.].ISBN 1-897085-04-41. Nurses--British Columbia.  2. Nurses--British Columbia--Statistics. 3. Nurses--Supply and demand--British Columbia--Statistics.  I. Wong,Sabrina T.  II. University of British Columbia. Centre for Health Servicesand Policy ResearchRT6 B7.W65 2006           331.7’6161073069209711                  C2006-901344-6 WHO  ARE  T H E  P R I MARY  H EA LTH  C ARE  R EG I S T ERED  NURSES  I N  B C ?CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHTable of ContentsAbout CHSPR ....................................................................... iAcknowledgements ............................................................. iiExecutive Summary ............................................................. iiiIntroduction .......................................................................... 1Methods ................................................................................ 2Findings ................................................................................ 4Vignettes ............................................................................... 13Discussion ............................................................................ 16References ............................................................................ 18Appendix IData Quality and Modifi cations .......................................... 20Appendix IIDetailed Methods and Analysis—The Five-Step PHC-R RN Eligibility Process ............................ 22Appendix IIISensitivity Analysis—Criteria for PHC-R RNs ................... 24Appendix IVDistribution of Possible PHC-R RNs .................................. 27Appendix VAge Distribution of PHC-R RNs and Population ............... 28MARCH 2006WHO  ARE  T H E  P R I MARY  H EA LTH  C ARE  R EG I S T ERED  NURSES  I N  B C ?CENTRE FOR HEALTH SERVICES AND POLICY RESEARCH 4About CHSPRThe Centre for Health Services and Policy Research (CHSPR) is an independent research centre based at the University of British Columbia. CHSPR’s mission is to stimulate scientifi c enquiry into issues of health in population groups, and ways in which health services can best be organized, funded and delivered. Our researchers carry out a diverse program of applied health services and population health research under this agenda.CHSPR aims to contribute to the improvement of population health by ensuring our research is relevant to contemporary health policy concerns and by working closely with decision makers to actively translate research fi ndings into policy options. Our researchers are active participants in many policy-making forums and provide advice and assistance to both government and non-govern-ment organizations in British Columbia (BC), Canada and abroad. CHSPR receives core funding from the BC Ministry of Health Services to support research with a direct role in informing policy decision-making and evaluating health care reform, and to enable the ongoing development of the BC Linked Health Database. Our researchers are also funded by com-petitive external grants from provincial, national and international funding agencies. Much of CHSPR’s research is made possible through the BC Linked Health Database, a valuable resource of data relating to the encounters of BC residents with various health care and other sys-tems in the province. These data are used in an anonymized form for applied health services and population health research deemed to be in the public interest.CHSPR has developed strict policies and procedures to protect the confi dentiality and security of these data holdings and fully complies with all legislative acts governing the protection and use of sensitive information. CHSPR has over 30 years of experience in handling data from the BC Ministry of Health and other professional bodies, and acts as the access point for researchers wishing to use these data for research in the public interest.For more information about CHSPR, please visit www.chspr.ubc.ca.i 5MARCH 2006AcknowledgementsThe methodological advances used to conduct this project rely on previous work by others in the province and new conceptual contributions by Sabrina Wong, Diane Watson, and Ella Young. Mar-tha MacLeod is the author of the vignettes included to offer qualitative insights into the work experi-ence of primary health care (PHC) registered nurses (RNs) in BC. Diane Watson was instrumental in obtaining the funding and ethics approval. Other assistance was provided by Rachael McK-endry, who edited drafts, and Dawn Mooney and Peter Schaub, who assisted in validation work to assign RNs to geographic locations. Dawn Mooney created the graphics and maps.The Michael Smith Foundation for Health Research provided a grant to support this project through a funding program offered at the University of British Columbia to new faculty. The BC Ministry of Health also provided funding under the Primary Health Care Transition Fund. The Behavioural Research Ethics Board of the University of British Columbia approved this study, and the College of Registered Nurses of BC approved the use of their data, provided assistance in interpreting how data were coded, and provided verifi cation of our interpretation of the data. In August of 2005, the Registered Nurses Association of BC (RNABC) became the College of Regis-tered Nurses of BC (CRNBC). For simplicity, we refer to CRNBC throughout the report.This report’s results and conclusions are those of the authors and no offi cial endorsement by the Ministry, Foundation or the College is intended or should be inferred. All analysis and interpreta-tion, and any errors, are the sole responsibility of the authors. iiWHO  ARE  T H E  P R I MARY  H EA LTH  C ARE  R EG I S T ERED  NURSES  I N  B C ?CENTRE FOR HEALTH SERVICES AND POLICY RESEARCH 6Registered nurses (RNs) represent the largest occupational group delivering health care in British Columbia. Gaining a better understanding of the composition and distribution of the province’s nursing resources in primary health care (PHC) is crucial to better inform health human resources planning, and to provide a benchmark for PHC renewal ef-forts designed to increase the number of interdisciplinary teams and RNs working in this area of health care.Th is report describes the population, system distribution and geographic location of RNs working in primary health care-related (PHC-R) roles in BC, and assesses the useful-ness of existing data sources in identifying these health professionals. To categorize and identify RNs presumed to be practicing in a PHC-R role, we analyzed self-report registration information collected by the College of Regis-tered Nurses of British Columbia (CRNBC) in 2000 using a combination of variables – place of work, area of respon-sibility, position and work status. Of the 27,570 practicing RNs in British Columbia in 2000, 3,179 (12%) were identifi ed as providing PHC-R services. When factored as a ratio of workforce to population, this equals 78 PHC-R RNs per 100,000, or 1,277 people per PHC-R RN (compared to the complete nursing workforce in the province of 679 RNs per 100,000 or 147 people per RN). Th e PHC-R RNs represent 43 per cent of BC’s PHC workforce of physicians and nurses.Th e supply of PHC-R RNs varied across health service delivery areas (119 per 100,000 population in Kootenay Boundary to 56 per 100,000 in Fraser South) and local health areas (244 per 100,000 in Castlegar to zero in Arrow Lakes and Armstrong-Spallumcheen). In 2000, there was no association between the supply of PHC-R RNs in a geographic area and that area’s health status, as measured by premature mortality rate. Th is was the case at both the health service delivery area level and local health area level. Similarly, we found no association between the supply of PHC providers (PHC physicians and PHC-R RNs combined) and premature mortality. For the PHC system to off er equitable access, we would ex-pect local health areas with low health status to have more PHC providers. While previous work by CHSPR found no association between the geographic distribution of PHC physicians and population health status, it did document equity in the utilization of PHC services. Th ese results sug-gest that people move across jurisdictional boundaries to obtain the PHC services they need.In order to illustrate the kind of work PHC-R nurses undertake, this report includes three vignettes drawn from 24 in-depth interviews collected in the study, Th e Nature of Nursing Practice in Rural and Remote Canada. Th e vignettes reveal that RNs are involved in core activities of PHC, suggesting that RNs are part of a PHC network that patients depend upon in order to meet their health needs.While this report does utilize new concepts to categorize CRNBC data, current PHC policy and planning activities require more up-to-date and more detailed information. Th ere is still much to learn about the health of British Co-lumbians and the PHC system, and much work to be done to improve the administrative data infrastructure that can inform PHC planning and evaluation in the province.  Executive Summaryiii 1MARCH 2006Over the last fi ve years, the federal government has estab-lished a policy and funding framework to support PHC re-newal in Canada through the Primary Health Care Transition Fund (PHCTF). Among the Fund’s objectives are the estab-lishment of “interdisciplinary primary health care teams of providers, so that the most appropriate care is provided by the most appropriate provider,” and new collaborations among these teams to “facilitate co-ordination and integration with other health services, (e.g. in institutions and in communi-ties).” Interdisciplinary collaboration in PHC is also explicitly mentioned as a goal of the First Ministers’ Accord1 and the Ten-year Plan for Health Care in Canada.2 All provinces now include this as one element of their goals and objectives state-ments for PHC renewal.3In British Columbia (BC), the government committed to investing $74 million between 2002 and 2006 to “strengthen family practice and reduce pressure on the acute care sys-tem; improve health care delivery and health outcomes; and provide patients with a wider range of options for accessing services at the local level.” Th is commitment includes, among other things, support for primary health care organizations (PHCOs) that provide access to comprehensive, coordinated primary health care. As early as 1997, PHCOs required physi-cians to work in groups and to move toward multidisciplinary teams as a precondition for funding.4Th is report describes the population, distribution and geo-graphic location of RNs presumed to be working in PHC or a PHC-R area in BC. It also assesses the feasibility and useful-ness of existing population-based data sources to identify these health professionals. Our intent is to inform health human resources planning and to off er baseline information against which to benchmark PHC renewal eff orts directed toward increasing the number of interdisciplinary teams and volume of RNs working in this sector. Since RNs are the larg-est occupational group delivering health care in the province, it is essential to understand their situation for future planning. In 2004, we published information regarding the geographic distribution of RNs and coupled this information with data on the distribution of inpatient services. Th is information is Introductionavailable on our website (www.chspr.ubc.ca) and in the report Planning for Renewal: Mapping PHC in British Columbia.5 Th is report builds on that work. Primary Health CarePHC is where patients and health care providers interact to resolve short-term health issues and manage chronic health conditions. It is also where clinical disease prevention and health promotion activities are undertaken, and where pa-tients in need of more specialized services are connected with secondary care. Th e unique and distinguishing features of this part of the health care system are its responsibility for deliver-ing fi rst contact care, and for delivering services considered to be responsive, comprehensive, continuous and coordinated.6 While primary care activities are seen across diff erent health care sectors (e.g. acute care), these activities, by themselves, are not the defi ning features of the organization and delivery of PHC.  For most people, the fi rst point of contact with the health care system is a family physician. Family physicians oft en fulfi ll the role of a generalist family doctor, but some of these providers may elect to focus their clinical activities on special-ized services or deliver care exclusively in tertiary settings. Conversely, RNs, paediatricians, geriatricians, and other health professionals may off er fi rst contact care, and services considered to be comprehensive and continuous, yet provide specialty (or secondary) care exclusively.7 Likewise, RNs may elect to focus their practice in a specialty area or provide more comprehensive services. Th is care could be considered fi rst contact, or continuing in nature. Since PHC is more of a service function than a professional discipline or place of care, the challenge is to identify RNs who deliver these services as the majority of their work. Only then is it possible to describe this segment of the nursing workforce. Since there are no data sources in BC explicitly designed to identify PHC RNs, we used readily available data to extrapolate which RNs work in this sector and called these nurses primary health care-related (PHC-R) RNs. WHO  ARE  T H E  P R I MARY  H EA LTH  C ARE  R EG I S T ERED  NURSES  I N  B C ?CENTRE FOR HEALTH SERVICES AND POLICY RESEARCH 2Methods Administrative Data AnalysesWe used 2000 self-report registration information collected by the CRNBC, and identifi ed a combination of variables in the data that would allow us to identify RNs presumed to be practicing in a PHC-R role. We elected to conduct the analy-ses using data from 2000 for two reasons. First, 2000 pre-dates PHC renewal initiatives funded through the PHCTF and thereby off ers a baseline against which change can be compared. Second, 2000 represents the period for which a full complement of administrative data are available at the University of British Columbia to identify and describe the PHC physician workforce. Part of the analyses in this report relies on information from those data sources.      In order to avoid under-reporting PHC-R RNs, we used a fairly broad defi nition to identify this group. Neither the annual RN license renewal registration form nor the resul-tant electronic version of this information had categories, codes, or fi elds that would allow a straightforward method of identifying which RNs practice in the PHC sector. A list of all available fi elds and their reported frequencies can be found in Appendix I. We undertook numerous iterations of data analysis in order to identify the population of PHC-R RNs in 2000, and conducted sensitivity analyses regarding key decision points. Detailed information about these steps is included in Appendix II.  Of the 33,099 RNs registered in BC in 2000, 5,529 were ex-cluded because they either reported not actively practising, had missing employer information, were identifi ed as being out of province* or only worked on a casual basis±. Th e resulting total number of practicing RNs in BC was found to be similar to what is reported in the Canadian Institutes for Health Information report, Supply and Distribution of Reg-istered Nurses in Canada, 20008 and the Centre for Health Services and Policy Research report, RollCall Update 00.9  Figure 1 shows that our sample was selected based on simultaneously meeting four eligibility criteria: 1) place of work, such as a community health agency or home care agency; 2) area of responsibility, such as community health, home care, or occupational health; 3) position, such as staff  nurse, home care, community nurse or offi  ce, occupational, industrial nurse; and 4) work status of full time or part time. A more detailed discussion of these eligibility criteria can be found in Appendix III. Figure 1: Eligibility CriteriaTh e places of work considered PHC-R include: nursing station/outpost/nurse clinic; private nursing agency/pri-vate duty; business/industry/occupational health; self-em-ployed/private practice; mental health centre; physician’s offi  ce; home care agency; and community health agency/centre. Th e areas of responsibility considered PHC-R include: rehabilitation; occupational health; mental health; home care; emergency care; and community health. Th is variable attempts to measure the type of health service provided by each provider.* Th e positions identifi ed as Place of workPosition Work statusArea of responsibilityPHC-R*  Living and working out of province, or living out of province and only reporting casual work status or living in province but working out of province part or full time±  If the ‘fullpart’ fi eld entry was C, meaning casual work status * Among the entire population of practicing RNs in 2000 (n=27,570), most provided medical/surgical services (n = 5,773 or 21%). A further 3,972 (14%) provided geriatric/long-term care services, and a further 1,815 or 7% provide community health ser-vices. Th ere were 27 possible areas of responsibility listed in 2000. 3MARCH 2006PHC-R because they involve direct interactions with the public include: consultant; staff  nurse/home care/com-munity nurse; offi  ce/occupational/ industrial nurse; and manager/assistant manager/supervisor. Only records in-dicating part-time and full-time work status were includ-ed. Because it was not possible to determine how many hours were worked (the ‘number of hours’ fi eld contained a value less than one-third of the time; see Appendix I), casual work status was considered unreliable, and there-fore excluded.Each RN may state their primary, secondary, and tertiary employer on their registration form. If an RN reported working on a casual basis for a primary em-ployer not considered PHC-R (e.g. hospital) but also reported working full time or part time for a second-ary employer that was considered PHC-R, they were considered to be a ‘possible PHC-R RN’. We identified 590 possible PHC-R RNs.In order to better understand the features and geographic dispersion of the PHC-R RN workforce, we describe the demographic characteristics of this group and calculate crude ratios per 100,000 population. Denominators were derived from BC Stats PEOPLE 28 estimates for 2000. Information is provided for each of BC’s 16 health service delivery areas (HSDAs) and 89 local health areas (LHAs). In order to protect confi dentiality, ratios are not reported in areas where both the total number of practicing RNs and the number of PHC-R RNs are very low (e.g. less than fi ve RNs). PHC-R RNs were assigned to jurisdictions on the basis of self-reported work addresses, and when not available, their home address. We then combined counts of PHC-R RNs with counts of PHC physicians7 at the HSDA level to calculate crude ratios of the PHC workforce per 100,000 population. We also calculated the ratio of PHC-R RNs to PHC physicians to understand how supply rates of the providers interact across the province. PHC-R RN-to-population ratios were not adjusted to ac-count for diff erences in age, gender or case-mix structure of the regions. However, we conducted analyses to assess the distribution of PHC-R RNs and distribution of PHC providers relative to population health status. A key aspect of planning for PHC renewal is to understand how well the current system responds to the health service needs of the populations it serves. Th erefore, to assess equity in the geographic distribution of PHC providers, we measured the association between supply-to-popu-lation ratios relative to the health service needs of the populations who reside in the same jurisdiction. We used premature mortality rate as the central measure of need for health care, since it is generally recognized as the best indicator of population health status10 and has a high level of association with other measures of morbidity.11,12 We measured local supply of PHC-R RNs and premature mortality rate at concurrent points of time and used the Pearson correlation coeffi  cient to assess the degree of as-sociation. Scatter plots illustrate these relationships. Th e level and geographic distribution of premature mortality rate in BC, and its association with other measures of health, are described in previous Centre for Health Ser-vices and Policy Research publications:•  British Columbia Health Atlas (Second edition)11•  Planning for Renewal: Mapping Primary Health Care in British Columbia5  VignettesIn order to better illustrate the work done by PHC-R RNs, three vignettes were drawn from in-depth interview data collected from RNs in BC who participated in the na-tional study, Th e Nature of Nursing Practice in Rural and Remote Canada.13, 14  RNs were recruited for the narrative portion of the study through advertisements in provin-cial and national nursing magazines and newsletters. Th e interviews were conducted by telephone and lasted, on average, 70 minutes (range= 45 to 180 minutes). Inter-viewees were asked to describe various scenarios, such as a typical or ordinary situation, a situation where they made a diff erence in a client outcome, or a situation that did not go as well as expected. Th e goal was to articulate the meaning of being a RN in rural and small town Can-ada. Rural was defi ned as communities of 10,000 or less, outside the commuting distance of large urban centres.15 Th e vignettes in this report arise from interviews with 24 RNs from BC who work in public health, community health, acute care, and home care roles. Pseudonyms have been used to protect anonymity.WHO  ARE  T H E  P R I MARY  H EA LTH  C ARE  R EG I S T ERED  NURSES  I N  B C ?CENTRE FOR HEALTH SERVICES AND POLICY RESEARCH 4FindingsIdentifying PHC-R RNsIdentifying variables to use in order to determine PHC-R places of work, area of responsibility, position, and work status was based on a review of the relevant literature8, 9, 16, 17 and consultation with nurse managers working in community health centres, health authority representatives, and nurse researchers with PHC as a substantive area of expertise.A fi ve-step process was used to classify PHC-R RNs (Figure 2) within the total population of RNs registered in BC in 2000 (n=33,099). First, RNs who were not practicing or were not in BC were excluded. RNs were next identifi ed by their place of work.  Eighty-one per cent of all RNs reported working in one of three settings: 63 per cent (n=17,265) in a hospital, nine per cent (n=2,498) in a community health agency or centre, and nine per cent (n=2,399) in a long-term care home.  Of the 33,099 RNs registered in BC, 5,793 were identifi ed as working in PHC-R places. Th ese PHC-R places may be found in Appendix II, and were chosen based on consultations with health authority and CRNBC representatives about locations in which RNs provide direct, episodic patient care.Th e third variable considered was the area of responsibility reported, which attempts to capture the workplace depart-ment in which the RN works. Of the 5,793 RNs identifi ed by place of work, only 4,249 RNs met the additional criteria of also having a PHC-R area of responsibility. Areas of respon-sibility were determined to be PHC-R according to the same consultations used to determine PHC-R places of work.  The fourth step involved the selection of RNs based on their reported position. This variable is designed to mea-sure each provider’s role within an organization. Eighty per cent of all RNs reported that they held positions as staff nurses. Of the 4,249 RNs who had a work place and area of responsibility deemed to be PHC-R, we were left with 4,011.Th e fi nal criterion classifi ed RNs according to their work status. Th is variable attempts to capture the number of hours worked by the RN by approximating full-time, part-time, or casual status. Among the group of 4,011 RNs who had a workplace, area of responsibility and position deemed to be PHC-R, 3,179 worked full or part time. Consultations revealed that casual status is associated with a highly vari-able number of hours worked—typically just a few hours a month, but also ranging in exceptional cases to more than full-time hours. As with other aspects of the eligibility criteria, we chose to be conservative in order to have a more accurate picture of the number of PHC-R RNs in BC and therefore, did not include the highly variable casual work status.Th e resulting population of 3,179 PHC-R RNs is composed of providers who met all criteria for all their employers. We estimate that PHC-R RNs represented 12 per cent of practicing RNs in BC in 2000.Figure 3 categorizes each of these 3,179 PHC-R RNs according to their place of work, position, and area of re-sponsibility. Approximately 72 per cent of PHC-R RNs are accounted for in two categories: 1,347 or 42 per cent are staff  nurses (position number 11) providing either com-munity health or home care services in community health centres, and another 962 or 30 per cent are staff  nurses providing emergency care in hospitals.RNs Deemed to be Possible PHC-RWe identifi ed an additional 590 RNs deemed to be possible PHC-R, representing two per cent of the practicing RNs in BC in 2000. Th e distribution of place, position and area cat-egorizations in this group is quite similar to that of the PHC-R RNs. Th e largest proportion (n=183 or 31%) are staff  nurses working in community health agencies providing either community health or home care services. Seventeen per cent are staff  nurses working in hospitals providing emergency care services. Another 15 per cent are staff  nurses working in hospitals providing other services. Th us, these three areas account for about 65 per cent of the possible PHC-R RNs. A detailed graph showing their distribution is in Appendix IV. 5MARCH 2006Figure 2: Detailed Five-Step Primary Health Care-Related (PHC-R) Registered Nurse (RN) Identifi cation Process Rehab/convalescent centreAll RNs (N=33,099)N=27,570 PHC-RPracticing in BCNon-practicingIn BC, but no dataNot in BCPlace of workN=5,793 PHC-RCommunity health agencyPhysician’s officeMental health centreBusiness/industry/occupational healthHospital - non ERLong term care/nursing homeExtended careOtherEducational institutionAssociation/governmentHome care agencyHospital - ERArea ofResponsibilityN=4,249 PHC-RCommunity healthEmergency careHome careMental healthOther direct careOccupational healthRehabilitationPart timeFull timeCasualPositionN=4,011 PHC-RStatusN=3,179 PHC-RStaff nurse/home care/community nurseManager/supervisorSelf-employed/private practiceNursing station/outpost/nurse clinicPrivate nursing agency/private dutyOccupational nurseConsultantFinalsample:N=3,179PHC-RRNsNumber of PHC-R RNs5,00010,00015,00020,00025,00030,00035,000������ ������ ������ ������ ������RN counts: Registration Database (2000), RNABC (now CRNBC). WHO  ARE  T H E  P R I MARY  H EA LTH  C ARE  R EG I S T ERED  NURSES  I N  B C ?CENTRE FOR HEALTH SERVICES AND POLICY RESEARCH 6Demographic StructureTh e majority of PHC-R RNs working in BC in 2000 were female (96%). In terms of age structure, 70 per cent were between the ages of 40 and 59 years, 25 per cent were under 40 years, and only fi ve per cent were 60 years or older. Just under half (49%) worked full time and 35 per cent worked part time in a PHC-R role for their primary employer. Figure 4 illustrates the age distribution of the PHC-R RN workforce compared to that of the general population of BC. Th e median age of PHC-R RNs is seven years older than that of the general population. Appen-dix V provides a similar bar chart for each of BC’s fi ve health authorities. Figure 5 illustrates the age of PHC-R RNs compared to other (non-PHC) practicing RNs in BC, showing that RNs in the PHC sector are older than their non-PHC-R counterparts. Compared with the median age of the working age population, PHC-RNs are older (data not shown).  Figure 3: Primary Health Care-Related (PHC-R) Registered Nurses (RNs) by Place of Work, Position, and Area of Responsibility Geographic Depiction of PHC-R RNs in BC in 2000In order to examine the geographic dispersion of the PHC-R nursing workforce, maps are presented in a simi-lar format to that used in Planning for Renewal: Mapping Primary Health Care in BC.5 Since the gain-loss of PHC-R RNs could have a substantial impact in some commu-nities, a sensitivity analysis was conducted considering PHC-R RNs and the possible PHC-R RNs. No substantial variations in the results occurred. Th erefore, we present only the PHC-R RNs by Health Service Delivery Areas (HSDAs) and Local Health Areas (LHAs).    In 2000, according to our definition, there were 3,179 PHC-R RNs licensed by CRNBC, which equates to 78 per 100,000 population. Across HSDAs, this ratio varies from a high of 119 per 100,000 in Kootenay Boundary to a low of 56 per 100,000 in Fraser South (Figure 6).Across LHAs, this ratio varies from a high of 244 per ���������������������������������������������������������������������������������������������������������� �� ���� �� ������������������������������������ �� ���� �� �� ���� �� ���� ���� �� �� ���� �� �� ������������������������������������������������������������������������������������������������������������������������������������������ �����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������RN counts: Registration Database (2000), RNABC (now CRNBC).  7MARCH 2006Figure 5: Primary Health Care-Related (PHC-R) Registered Nurses (RNs), by Age, with Non-PHC-R RN Age DistributionFigure 4: Primary Health Care-Related (PHC-R) Registered Nurses (RNs), by Age, with Population Age Distribution100,000 in Castlegar (#9) to a low of zero in Arrow Lakes (#10) and Armstrong-Spallumcheen (#21) (Figure 7). Several other LHAs also report very high or very low rates; these have been aggregated because they have small numbers of both PHC-R RNs and total practicing RNs. The high ratio of PHC-R RNs to popu-lation in Kootenay Boundary HSDA and Trail (#11) and Castlegar (#9) LHAs reflects a group of providers who work in large acute and community care centres in Trail and Castlegar (see Figures 6 and 7 for more detail).Geographic Depiction of PHC-R Providers in BC in 2000In BC, the crude ratio of the sum of PHC-RRNs (N=3,179) and PHC physicians (N=4,152)7 to 100,000 population was 180 in 2000. Across HSDAs, this ratio varies from a high of 261 per 100,000 in Vancouver to a low of 125 in Fraser South (Figure 8). By combining counts of PHC-R RNs and PHC physicians, the extent of variability in supply is attenuated. However, the ratio of PHC-R RNs to PHC physicians shows that the supply of RNs may be related to the supply of physicians (Figure 9). Where there are fewer PHC physicians, there are more PHC-R RNs (Northeast).  ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������RN counts: Registration Database (2000), RNABC (now CRNBC). Population counts: PEOPLE 28 (2000), BC Stats. WHO  ARE  T H E  P R I MARY  H EA LTH  C ARE  R EG I S T ERED  NURSES  I N  B C ?CENTRE FOR HEALTH SERVICES AND POLICY RESEARCH 8Vancouver         IslandNorthernPart ofVancouverCoastalInteriorVancouverCoastalFraserCoastalNorthern InteriorNortheastNorthwestThompson - CaribooEastKootenayKootenay -BoundaryOkanaganPart ofNorth Shore -Coast GaribaldiNorth IslandCentral IslandNorth Shore -Coast GaribaldiNorth Shore -Coast GaribaldiFraser NorthFraser SouthRichmondVancouverFraser EastSouthIslandFraserVancouverThe crude ratio of primary health care-related (PHC-R) registered nurses per 100,000 population was calculated by dividing the number of these nurses in each health service delivery area by the total population in that area. PHC-R RNs were identified based on their primary place of work, area of responsibility, position and work status. We used the address of the primary employer for the 84% of PHC-R RNs who reported one to determine their residency.  For the remaining 16% their home address has been relied upon.Health service delivery areaHealth authority12060708090100110Kootenay BoundarySouth IslandNorthwestVancouverNorth IslandThompson CaribooOkanaganCentral IslandNortheastNorthern InteriorN. Shore - Coast Gar.Fraser EastFraser NorthRichmondEast KootenayFraser South11910610298868484847875686666595756Data classified by natural breaks (manually)Health service delivery areaNameCrude Ratio of PHC-R RNs per 100,000 pop.Figure 6: Crude Ratio of Primary Health Care-Related (PHC-R) Registered Nurses (RNs) per 100,000 Population by Health Service Delivery AreaRN counts: Registration Database (2000), RNABC (now CRNBC). Population counts: PEOPLE 28 (2000), BC Stats.  9MARCH 20063537384342414045 44161-166816059575651/87/94545388/92505280 552883 492725293024/26181946/710351112/1314/1615232220782131771775/7642434669706261636465/666768714772/84854833343532921201/202Part ofVancouverCoastalNorthernInteriorVancouver         IslandVancouverCoastalFraserFraserVancouverCoastalThe crude ratio of primary health care-related (PHC-R) registered nurses per 100,000 population was calculated by dividing the number of these nurses in each local health area by the total population in that area.PHC-R RNs were identified based on their primary place of work, area of responsibility, position and status. We used the address of the primary employer for the 84% of PHC-R RNs who reported one to determine their residency.  For the remaining 16% their home address has been relied upon.Data classified by natural breaks (Jenks optimization algorithm)2450285595200150Local health areaCrude ratio of PHC-R RNs per 100,000 population72/84Local health areaAggregated local health area Health authorityEach circle represents one local health area (LHA)Figure 7: Crude Ratio of Primary Health Care-Related (PHC-R) Registered Nurses (RNs) per 100,000 Population by Local Health AreaRN counts: Registration Database (2000), RNABC (now CRNBC). Population counts: PEOPLE 28 (2000), BC Stats. WHO  ARE  T H E  P R I MARY  H EA LTH  C ARE  R EG I S T ERED  NURSES  I N  B C ?CENTRE FOR HEALTH SERVICES AND POLICY RESEARCH 10Vancouver         IslandNorthernPart ofVancouverCoastalInteriorVancouverCoastalFraserNorthern InteriorNortheastNorthwestThompson - CaribooEastKootenayKootenay -BoundaryOkanaganPart ofNorth Shore -Coast GaribaldiNorth IslandCentral IslandNorth Shore -Coast GaribaldiFraser EastSouthIslandCoastalNorth Shore -Coast GaribaldiFraser NorthFraser SouthRichmondVancouver FraserVancouverThe crude ratio of the sum of primary health care-related (PHC-R registered nurses and primary health care physicians per 100,000 population was calculated by adding the number of regis-tered nurses practicing primary health care to the number of primary health care physicians in each health service delivery area, and then dividing by the total population in that area. Health service delivery areaHealth authorityNameVancouverSouth IslandKootenay BoundaryNorthwestNorth IslandCentral IslandOkanaganN. Shore / Coast Gar.East KootenayThompson CaribooNorthern InteriorNortheastFraser NorthFraser EastRichmondFraser South 261  242  236  219  188  183  182  180  176  175  162  148  143  139  139  125 Crude Ratio of PHC-R RNs + PHC physicians per 100,000 pop.260120180200220240140160Data classified by natural breaks (manually)Health service delivery areaFigure 8: Crude Ratio of the Sum of Primary Health Care-Related (PHC-R) Registered Nurses (RNs) and Primary Health Care Physicians per 100,000 Population by Health Service Delivery Area RN counts: Registration Database (2000), RNABC (now CRNBC). Population counts: PEOPLE 28 (2000), BC Stats. Physician counts: MSP practitioner information fi le, MSP payment information master fi le (for fee for service data), hospital, primary health care organizations and alternative payments to physi-cians data, all BC Ministry of Health 2000/01 data; CPSBC (2000/01).  11MARCH 2006Vancouver         IslandNorthernPart ofVancouverCoastalInteriorVancouverCoastalFraserNorthern InteriorNortheastNorthwestThompson - CaribooEastKootenayKootenay -BoundaryOkanaganPart ofNorth Shore -Coast GaribaldiNorth IslandCentral IslandNorth Shore -Coast GaribaldiFraser EastSouthIslandCoastalNorth Shore -Coast GaribaldiFraser NorthFraser SouthRichmondVancouver FraserVancouverThe ratio of primary health care- related (PHC-R) registered nurses to primary health care physicians was calculated by dividing the number of these nurses by the number of these physicians in each health service delivery area.Health service delivery areaHealth authority1.100.400.700.800.901.00Name0.500.60NortheastKootenay BoundaryThompson CaribooFraser EastNorthwestOkanaganNorthern InteriorFraser NorthCentral IslandNorth IslandFraser SouthSouth IslandRichmondN. Shore / Coast Gar.VancouverEast Kootenay1.111.020.930.910.880.860.860.850.850.840.800.780.750.610.600.48Crude Ratio of PHC-R RNs to PHC physiciansData classified by natural breaks (manually)Health service delivery areaFigure 9: Crude Ratio of Primary Health Care-Related (PHC-R) Registered Nurses (RNs)to Primary Health Care Physicians by Health Service Delivery AreaRN counts: Registration Database (2000), RNABC (now CRNBC). Population counts: PEOPLE 28 (2000), BC Stats. Physician counts: MSP practitioner information fi le, MSP payment information master fi le (for fee for service data), hospital, primary health care organizations and alternative payments to physi-cians data, all BC Ministry of Health 2000/01 data; CPSBC (2000/01). WHO  ARE  T H E  P R I MARY  H EA LTH  C ARE  R EG I S T ERED  NURSES  I N  B C ?CENTRE FOR HEALTH SERVICES AND POLICY RESEARCH 12PHC-R Provider Ratios Versus Population NeedIf PHC-R providers were equitably distributed across the province, we would expect areas with low popula-tion health status (high premature mortality rate) to have a higher level of provider supply to meet addi-tional needs. Conversely, areas with high population health status (low premature mortality rate) would have lower levels of provider supply. This would result in a strong, positive association between the PHC-R RNs to population ratio and premature mortality rate, as well as between PHC-R providers to population ratio and premature mortality rate. In 2000, there was no association between the supply of PHC-R RNs and premature mortality rate at the HSDA level across the province (Pearson coefficient = 0.48, p = 0.06) or at the LHA level (Pearson coefficient = 0.19, p = 0.11). Similarly, we found no association between the supply of PHC-R providers (the sum of RNs and physicians) and premature mortality rate across the province (Pearson coefficient = 0.33, p = 0.21). Figure 10 illustrates the relationship between the ratio of PHC-R RNs and standardized premature mortality rate at the HSDA level. Figure 11 illustrates the relationship between the ratio of PHC-R provid-ers and standardized premature mortality rate. There seems to be no clear link between the geographic distribution of PHC-R RNs relative to the health care needs of populations who reside in those jurisdictions.Figure 10: Primary Health Care-Related (PHC-R) Registered Nurses (RNs) and Premature Mortality Rate Figure 11: Sum of Primary Health Care-Related (PHC-R) Registered Nurses (RNs) and Primary Health Care Physicians and Premature Mortality Rate 02040601001201400 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0Premature mortality rate per 1000 pop.Age/sex-standardized rate; 1996-200080PHC-R RNs per 100,000 pop.Crude ratio; 2000 14 4243525313124151322122333123 11East KootenayKootenay BoundaryOkanaganThompson CaribooFraser EastFraser NorthFraser SouthRichmondVancouverN. Shore - Coast Gar.South IslandCentral IslandNorth IslandNorthwestNorthern InteriorNortheast11121314212223313233414243515253�����������������������������InteriorFraserVancouver CoastalIslandNorthernAge/sex-standardized rate; 1996-2000Sum of PHC-R RNs and primary health care physicians per 100,000 pop.Crude ratio; 20000501001502002503000 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0Premature mortality rate per 1000 pop.3241125143115214534213332231 2123East KootenayKootenay BoundaryOkanaganThompson CaribooFraser EastFraser NorthFraser SouthRichmondVancouverN. Shore - Coast Gar.South IslandCentral IslandNorth IslandNorthwestNorthern InteriorNortheast11121314212223313233414243515253�����������������������������InteriorFraserVancouver CoastalIslandNorthernFigure 10: RN counts: Registration Database (2000), RNABC (now CRNBC). Population counts: PEOPLE 28 (2000), BC Stats. PMR: BC Vital Statistics Agency; Hospital separations data, BC Ministry of Health; PEOPLE 28, BC Stats, all 1996-2000 data. Figure 11: RN counts: Registration Database (2000), RNABC (now CRNBC). Population counts: PEOPLE 28 (2000), BC Stats. Physi-cian counts: MSP practitioner information fi le, MSP payment infor-mation master fi le (for fee for service data), hospital, primary health care organizations and alternative payments to physicians data, all BC Ministry of Health 2000/01 data; CPSBC (2000/01). PMR: BC Vital Statistics Agency; Hospital separations data, BC Ministry of Health; PEOPLE 28, BC Stats, all 1996-2000 data.  13MARCH 2006Th is section presents the qualitative results from inter-views conducted with practicing RNs who identifi ed themselves as providing PHC. Th ese descriptions of PHC delivery are representative of the experiences and issues of PHC-R RNs. All names are fi ctitious. 1.  Promoting Health, Troubleshooting Health Issues: Public Health/Community Health NurseAnne has worked for most of her career in the small community in which she lives. She has been a RN for 20 years, ten of them as a public health nurse. Anne’s focus is health promotion at the community level. She achieves this not only through planning and implementing pro-grams at a group or community level, but also through working with individuals in ways that help them address their own health needs. She describes this as ‘trouble-shooting.’ Anne works to promote health and prevent ill-ness through early identifi cation of health or health-relat-ed issues, and assisting individuals and families to address these issues, oft en with a referral to other services. One such area is perinatal care. Anne and her fellow public health nurses ‘follow’ the mothers and babies postpartum:“Part of our job is to liaise with the hospital with any new births, so we actually do a liaison function every day. We stop over and see the babies and do some discharge plan-ning and make sure they’re well supported as they go home. And part of that follow up, of course, is breast feeding support, and the general postpartum care that would be re-quired at home. Th e baby weights and so on—making sure that the newborn is adjusting to new life and with good weight gain, checking for jaundice, your typical newborn follow up. Same with mom—making sure she’s functioning well at home, and is feeling well. We troubleshoot ques-tions.  We also give a lot of family support to people who are having diffi  culty with parenting at home. We tend to be a referral service. We tend to know just about every service that’s available in town and who can access it and how it works, the hours of operation, whether there’s a cost to it or not. Generally we’ve either had personal contact with all these [service providers], or we’ve actually been part of their program development at some point in time.” VignettesMuch of the referral to services occurs during Baby or Well Child clinics, part of Anne’s typical day: “It’s well children that come in with their parents and they’re here for immunizations—that’s the purpose of their visit, as well as nutrition advice. We’re looking at injury preven-tion issues around car seats, tobacco cessation for parents, so it tends to be a sort of healthy lifestyle conversation you have with the parents. You look at the child development ... speech and language development, gross motor, fi ne motor, social development ... you immunize the child, discuss any concerns. Sometimes the concern isn’t about the child they bring in. It’s about an older sibling or a parent whose health has failed. Or they need advice on a totally diff erent subject. So you may be prepared for baby clinic, but in essence, the child’s immunized and that conversation happens, but your topic has moved on to a diff erent topic. So that’s a typical morning.” Anne and the other public health nurses in small com-munities play a key role in reproductive health education. Th ey work with schools on programs that deal with body image or maturational issues and the prevention of sexu-ally transmitted diseases:  “We run a weekly evening program open to anyone, but par-ticularly targeted to youth who are sexually active and need birth control. So they come in for education. As well, they see a physician, receive their prescription, which they can buy it right on site at a reduced cost. Plus we do drop-ins during the week. We dispense ECP, the emergency contra-ceptive pill, during the week, so we do a lot of pregnancy tests and counseling around that.” Th rough accessible and well-accessed services, Anne and her public health nursing colleagues are able to “trouble-shoot a lot of diff erent things” and in so doing, promote health and prevent illness in their communities. WHO  ARE  T H E  P R I MARY  H EA LTH  C ARE  R EG I S T ERED  NURSES  I N  B C ?CENTRE FOR HEALTH SERVICES AND POLICY RESEARCH 142. Providing Continuity of Care in an Episodic Environment: ER Primary Health Care NurseBeth has worked part time for the last decade in a ten-bed acute care hospital attached to a nursing home in a rural community. Typically, she assesses and treats many of the people who come to the emergency department for care. Beth describes what happens in her ER department on the weekend:“We will set up a clinic time and assess whether somebody needs to be seen right away or whether they can come back sort of as a group. We do a lot of telephone consultation as well. And sometimes that’s a big part of our nights. People phoning, not sure whether they should come in or whether it can wait until the morning.” Although a province-wide phone line service is available (BC Nurseline), many residents of small rural communi-ties prefer to talk to the nurses they know and trust at the local hospital.In small communities, the relationship that nurses in emergency departments have with community members enables a continuity of care, even in an episodic environ-ment, that assists in managing chronic conditions and preventing exacerbation. Beth discusses a very severe asthmatic who had received a fl u shot earlier in the day:“When he initially came in I wasn’t overly concerned be-cause he looked really good and his arm was just a bit red. He’s gotten to the point that when things start to happen, he comes in as early as he can now. He’s recognizing more of the urgency of [his condition].  So I wasn’t too concerned. I knew we would probably be giving some intramuscular medications or some oral medications and that’s what we started to do. But then things got worse so we had to go the intravenous route.”Within half an hour, Beth had to access the patient’s por-tacath (a central venous line that is surgically implanted within the body. A membrane just below the skin gives access by a simple skin puncture to a line running straight into a main blood vessel).“I was able to do it very quickly and his is usually a very diffi  cult access. So he was able to get the medications that he needed fairly quickly before he got into a real crisis.”Beth noted the progression of the man’s allergic reaction by the sound of his coughing: “I was actually out of the room counting the drugs. And I could hear his coughing and said to the other nurse, we bet-ter go and check him.  Th e man’s family doctor had already started the Ventolin and then we got the other drugs going and the intravenous stuff  set up. I said, ‘What about put-ting the morphine in the nebulizer while I get this started’ and that’s what we did.  And that did help. And contrary to everything you hear about asthmatics, the only thing that works for his cough is to give him, usually, intravenous morphine. And when you don’t have an intravenous line we have found that we can put it in the nebulizer along with the Ventolin.”  Beth’s actions were based on a long history with the patient. Over the years, she had been involved in many transfers to the regional hospital with this patient and had discovered how to best accommodate his needs. “We discovered that his asthma would get worse in the back of the ambulance just because it was dry, I think. Usually we had a crisis by the time we got half an hour down the road. But if we ran continuous saline in his nebulizer then we didn’t run into problems.”Knowing the patient and the unique signs of how his asth-ma progresses, along with experience with his response to interventions, enabled Beth to work with the physician to provide timely, episodic care for a longstanding chronic condition, and prevent further complications. 15MARCH 20063. Ensuring Appropriate Access to Care: Home Care NurseCarrie, an RN in a home and community care program, provides services to adults between the ages of 19 and 75 with developmental disabilities, many of whom also have mental illnesses. Th e majority of her work consists of co-ordinating care to ensure early and appropriate interven-tion and support. Many of her clients live in small group homes, or are young people living at home with their parents. Although she sometimes works directly with clients, Carrie works mostly with caregivers, and liaises frequently with physiotherapists, social workers, public health nurses, family physicians, psychiatrists, govern-ment ministries, and public trustees. Carrie talks about working with Joy, a low functioning woman in her late 50s, aft er a lump was found in Joy’s breast: “Th e support worker found the lump, because I’ve taught all of the primary caregivers to do breast self-exams (BSE) once a month if the client cannot do it by themselves. In this case, Joy does the BSE but the caregiver goes behind her, because Joy wouldn’t know how to report something if she found it. Th ey found the lump together and had it diagnosed very quickly. Th ey called me right away.” Carrie met with the primary caregiver, the group home manager, the social worker and Joy to discuss the treat-ment options and potential outcomes that the doctor had outlined to the caregiver. Th ey discussed the best care op-tions for Joy, including the notion of avoiding sending her to a regional centre, which would be traumatic for Joy. Carrie and the caregivers explored approaches they might use to help Joy—“a wonderful lady, with a sense of humor” but who gets angry easily and has a hard time coping with change—to understand and cope with the treatment process. “We’re going to use her sense of humor aft er this happens. She’ll wake up, she’ll see the dressing there and she’ll realize something’s missing. And then her caregiver will just tell her, ‘Oh, it’s gone’. And no doubt she will deal very well with that piece of it. Because she thinks when things are gone “they’re gone, they don’t come back”, she knows that. So the fi nality of it, she probably won’t mind…She’s still go-ing to have one left , so for her that’ll be important…” Carrie and Joy’s caregivers talked about her usual reac-tions to pain, how to assess post-operative pain accu-rately through monitoring her physical movements, and what approaches might work to help Joy. They planned for the potential of Joy coming home with a drain that she would likely try to remove, discussed what support she might need during chemotherapy, and determined what additional staffing might be needed to cope with Joy after the operation. After the care group examined possible treatment options, Carrie presents her findings to the public trustee: “I try to help them, the public trustees, get to know the person as a person. So when they’re making the decisions for Joy, the reason we’re choosing this one route is because this one she will get through and be okay with.” As the coordinator and facilitator of Joy’s health care, Car-rie helps the care staff , who:“don’t know anything about the breast cancer piece of it, the surgery, the outcomes aft er. By alleviating their stress they can support her better. As the person that liaises with the public trustee, I can give him the information I’ve collected from the caregivers, the doctor and from knowing Joy, on what might work best for her, and then we’ll discuss that further. So I think by having that piece, when the choice is made for Joy, it’s made not just on looking at a chart. It’s made [by] collecting a lot of information and knowing her as a person and helping the trustee, who is making the actual decision, make the right one for her. And I think unless somebody’s there to speak for Joy and to put that informa-tion forward, there may not be the right decision made.” The nurse works with those responsible for care when clients with multiple health concerns can’t enact their own care. This helps to build a coordinated understand-ing of treatment options and ramifications, and how to best support the client in accessing and obtaining appropriate care. WHO  ARE  T H E  P R I MARY  H EA LTH  C ARE  R EG I S T ERED  NURSES  I N  B C ?CENTRE FOR HEALTH SERVICES AND POLICY RESEARCH 16Across BC in 2000, there were 27,570 practicing RNs, which equates to 679 RNs per 100,000 population or 147 people per RN. Among this provincial workforce, 3,179 or 12 per cent were PHC-R RNs, which equates to 78 per 100,000 population or 1,277 people per RN. Another 590 were deemed to be potentially practicing in the PHC sec-tor. In combination, these two groups total 3,770 provid-ers or 93 RNs per 100,000 population. We found no association between PHC-R RN supply and British Columbians’ health status in 2000. Communities with lower levels of health did not have more PHC-R RNs and communities with higher levels of health did not have fewer PHC-R RNs. Nor did we fi nd a strong association between population health status and the combined sup-ply of PHC-R RN and PHC physicians. Our team has pre-viously documented disparities in geographic distribution of PHC physicians,7 but at that time we also documented equity in utilization of PHC services.5 In combination, these results suggest that people move across jurisdiction-al boundaries to obtain the PHC services they need. Th e extent of this mobility has been estimated in a previous CHSPR report. Interestingly, when counts of PHC-R RNs and PHC phy-sicians were combined, the extent of variability in supply among the workforce is attenuated. Where there are fewer PHC physicians in BC there are more PHC-R RNs, and vice versa. We documented 3,179 RNs and 4,152 physi-cians7 providing PHC-R services in BC during the study period—RNs represented 43 per cent of the combined PHC workforce in BC at a time that predates policy ob-jectives to enhance the interdisciplinary mix of providers delivering PHC.Th e unique contribution of these analyses is that we have identifi ed and described the supply of RNs working in the PHC sector, in order to identify those most likely to deliver PHC as the majority of their work. It is important to acknowledge, however, that population-based admin-Discussionistrative data sources have not yet been suffi  ciently devel-oped to substantiate the degree to which all PHC-R RNs deliver all of the core functions of PHC—fi rst contact care and services considered to be responsive, comprehensive, continuous and coordinated. In so far as health care deci-sion-makers fi nd the analyses presented in this chapter to be useful for policy and planning purposes, we now have data algorithms to measure and monitor the supply and distribution of PHC-R RNs in BC.Indeed, the vignettes presented reveal that RNs working in PHC-R roles are involved, to a large degree, in the core functions of PHC. Th ey provide fi rst-contact care such as baby visits and youth clinics. Th ey provide services that are responsive and coordinated for patients with complex health needs. Even RNs working in emergency depart-ments, especially in rural communities, provide continuity of care for some patients. Th ese vignettes suggest that RNs are part of a PHC network that patients depend upon in order to meet their health needs, whether they are acute, episodic, or related to health promotion and prevention. It is possible that identifying PHC-R RNs using registra-tion data undercounts the number of PHC-R RNs, since RNs employed in the acute care sector likely provide primary prevention and some PHC services. Th e extent to which RNs working in the acute care sector provide a comprehensive array of PHC services warrants future investigation. Additionally, 832 RNs whose work status was self-reported as ‘casual’ were excluded from this analysis. However, including the casual status RNs would have accounted for only three per cent of the total count of PHC-R RNs.Th e validity of the analyses presented here could be as-sessed by the addition of two items to the CRNBC registra-tion form. First, RNs could report the extent to which they provide PHC services. Second, those working casual hours could accurately report the number of hours per week worked. Th ese new data elements could be used in future  17MARCH 2006years to describe this population of RNs, and could also be used to test the concurrent validity of the data defi ni-tion used here. Should our data defi nition hold high levels of concurrent validity, it would enable temporal analyses across periods of time prior to the introduction of the self-report item on the CRNBC registration form.     Th e geographic-based analyses rely on the complete-ness and accuracy of data regarding each RN’s primary employer location. Th e data sources used to create this report include a number of addresses for each RN. Th e challenge was to select the geographic location in which each provider delivers most services, knowing that some RNs work at more than one location. Th ese locations may or may not be in the same HSDA or health authority. Th is report relied on newly created methods to assign RNs to jurisdictions based on self-report data regarding work-place location. While this report focuses on counting the number of PHC-R RNs in a historic period, current policy and plan-ning activities related to PHC require more up-to-date information. Our intent in using 2000 data was to com-bine data regarding RNs and physicians. Data from 2000 represents the most recent period for which Alternative Payments Program data is available at CHSPR to identify the population of PHC physicians.  Th ere is still much to learn about the health of British Columbians and the many facets of their PHC system, and much work to be done to improve the administra-tive data infrastructure in BC to inform PHC planning and evaluation. CHSPR is committed to this agenda and looks forward to developing a comprehensive picture of the attributes and qualities of the PHC system in BC as we progress through our research program.WHO  ARE  T H E  P R I MARY  H EA LTH  C ARE  R EG I S T ERED  NURSES  I N  B C ?CENTRE FOR HEALTH SERVICES AND POLICY RESEARCH 181. Government of Canada. 2003 First Ministers’ Accord on Health Care Renewal. Ottawa: Health Canada; 2003.2. Health Canada. First Ministers’ Meeting on the Future of Health Care: A 10-year Plan to Strengthen Health Care. Health Canada. Available at: http://www.hc-sc.gc.ca/eng-lish/hca2003/fmm/index.html. Accessed Nov, 2004.3. Watson D, Wong S. Canadian Policy Context: Interdis-ciplinary Collaboration in Primary Health Care. Ottawa, ON: Enhancing Interdisciplinary Collaboration in Pri-mary Health Care Initiative; Feb 2005.4. Marriott A, Mable J. Sharing the Learning: Th e Health Transition Fund. Synthesis Series: Primary Health Care. Ottawa, ON: Government of Canada; 2002.5. Watson D, Krueger H, Mooney D, Black C. Planning for Renewal:  Mapping Primary Health Care in British Colum-bia. Vancouver, BC: Centre for Health Services and Policy Research; Jan 2005.6. Watson D, Broemeling A, Reid R, Black C. A Results-Based Logic Model for Primary Health Care: Laying an Evidence-Based Foundation to Guide Performance Mea-surement, Monitoring, and Evaluation. Vancouver, BC: Centre for Health Services and Policy Research; 2004.7. Watson D, Rahim-Jamal S, Bogdanovic B, Mooney D, Reid R. Who are the Primary Health Care Physicians in British Columbia. Vancouver, BC: Centre for Health Services and Policy Research; in press.8. Canadian Institute for Health Information. Supply and Distribution of Registered Nurses in Canada, 2000. Ottawa, ON: CIHI; 2000.9. Health Human Resources Unit. Rollcall Update 00: A Status Report of Selected Health Personnel in the Province of British Columbia. Vancouver, BC: Centre for Health Services and Policy Research; 2001.10. Birch S, Eyles J. Needs-based planning of health care: a critical appraisal of the literature. Hamilton, ON: Centre for Health Economics and Policy Analysis; 1991. 91-5.11. McGrail K, Schaub P, Black C. Th e British Colum-bia Health Atlas, 2nd Edition. Vancouver, BC: Centre for Health Services and Policy Research; 2004. CHSPR 2004:12.12. Shi L, Macinko J, Starfi eld B, Politzer R, Xu J. Primary care, race, and mortality in the US. Social Science and Medicine. 2005;61:65-75.13. MacLeod M, Kulig J, Stewart N, Pitblado R. Nursing practice in rural and remote Canada. Ottawa, ON: Cana-dian Health Services Research Foundation; Sept 2004.14. MacLeod M, Kulig J, Stewart N, Pitblado R, Knock M. Th e nature of nursing practice in rural and remote Canada. Canadian Nurse. 2004;100(6):27-31.15. DuPlessis V, Beshiri R, Bollman R. Defi nitions of rural. Ottawa, ON: Statistics Canada; 2001. 21-006-XIE.16. Canadian Institute for Health Information. Under-standing Emergency Department Wait Times: Who is Using Emergency Departments and How Long are They Waiting? Ottawa, Ont: Canadian Institute for Health Information; 2005.17. Canadian Nurses Association. Legislation, regulation & education of the nurse practitioner in Canada. Canadian Nurses Association. April. Available at: www.cna-aiic.ca. Accessed Sept 10, 2004.ReferencesWHO  ARE  T H E  P R I MARY  H EA LTH  C ARE  R EG I S T ERED  NURSES  I N  B C ?CENTRE FOR HEALTH SERVICES AND POLICY RESEARCH 20Appendix I: Data Quality and Modifi cations Data Element Number CompletePer Cent CompleteREGNUM 33,070 100%DATE_FILE      16,364 49%CITY 33,070 100%PROV       32,546 98%COUNTRY 33,099 100%POSTAL       32,571 98%TITLE               2 0%SEX       33,099 100%PBAS_STAT   29,264 88%BIRTHDATE 33,099 100%DATE_CONVERTED 33,099  100%AGE       33,099 100%BUS_ADDR              1 0%BUS_PHONE 9,002 27%BUS_FAX           37 0%INIT_TYPE 33,099 100%INIT_DATE      33,099 100%SCHL_TYPE      33,099 100%GRAD_DATE  33,097 100%SCH_NUR 33,099 100%AFFIL_PROV 2,276 7%AFFIL_LPN 1,887 6%AFFIL_RPN 975 3%AFFIL_MW 1,106 3%POSTBAS_ED 33,099 100%POSTOTH_ED 33,099 100%COMPETENCY 30,180 91%PBAS_ED300 18 0%MEM_TYPE 33,099 100%STATUS           111 0%STATUSDATE 645 2%ED_PROG 7,349 22%MAIL_CODE 33,096 100%CHAPTER 33,099 100%ELECT_DIST 33,099 100%Data Element Number CompletePer Cent CompleteVOTING  1,322 4%LAST_NUR 3,445 10%LAST_REG 3,528 11%COMMENTS 8,577 26%MEM_HIST 33,099 100%HRS_HIST 33,099 100%JURISCODES 9,452 29%JURISTYPE 9,223 28%JURISDATES 25,482 77%JURISNUMBS 9,163 28%EXTERNAL 2,914 9%CONSENT 31,857 96%CERT_TYPE 28,236 85%CERT_YR 4,544 14%DEGREE_YR 2,772 8%REFRSH_YR 1,814 5%QUALCRS_YR 986 3%COMITEE_DT 1,199 4%BOARD_MEET 1,088 3%PERMIT_EFF 2,652 8%PERMIT_ISS 2,651 8%PERMIT_EXP 2,652 8%LAST_CHG 33,099 100%ROLLCALL STAT 33,099 100%EMPLCOUNT 28,109 85%EMPLCODE1 28,109 85%EMPLNAME1 28,086 85%EMPLCITY1 26,815 81%EMPLPROV1 26,862 81%REG_CAS1      28,109 85%FULLPART1      28,109 85%PLACE1 28,109 85%POSN1 28,109 85%FIELD1 28,109 85%STARTDATE1 28,089 85%      Th is appendix illustrates the characteristics of the original data and what changes were made in order to conduct analyses. Th e original data fi le comprised the following:RN counts: Registration Database (2000), RNABC (now CRNBC).  21MARCH 2006Field IssueBirth date Several birth dates had a year and month and ‘00’ for the day — in order to enable Microsoft Excel to compute ages, all ‘00’ days were changed to ‘01’.Title Deleted as there were only two entries, each of which was a number.Business Address Deleted as there was only one entry, which was a name.Business Fax Deleted as there were only 37 entries, many of which were ‘0000000’.Comments Deleted as only 26% complete, with many nonsensical entries such as ‘PAYDED’. Most of the other entries simply stated at which site the IP was active. Data Element Number CompletePer Cent CompleteHOURS1 9,480 29%EMPLCODE2        7,402 22%EMPLNAME2   7,395 22%EMPLCITY2 6,842 21%EMPLPROV2 6,814 21%REG_CAS2   7,378 22%FULLPART2 7,097 21%PLACE2         7,401 22%POSN2 7,298 22%FIELD2 7,307 22%STARTDATE2 7,334 22%HOURS2 3,525 11%EMPLCODE3 1,973 6%EMPLNAME3 1,973 6%EMPLCITY3 1,805 5%EMPLPROV3 1,798 5%REG_CAS3 1,964 6%FULLPART3 1,839 6%Aft er some preliminary inspection, the following changes were made:Th e probable causes of the above issues are:1) Birth date–these people supplied only their birth year and month, but not the day2) Title–these were data entry errors, as no one supplies a title because the 2000 registration form does not ask for title in any way (check boxes, specifi c space, other)3) Business address–these were data entry errors, as no one supplies a business address because the 2000 registra-tion form asks only for the name of the place of work4) Business fax–these were data entry errors, as no one supplies a business fax number5) Comments–internal CRNBC codes that are not of interest to outside partiesWHO  ARE  T H E  P R I MARY  H EA LTH  C ARE  R EG I S T ERED  NURSES  I N  B C ?CENTRE FOR HEALTH SERVICES AND POLICY RESEARCH 22Appendix II: Detailed Methods and Analysis—The Five-Step PHC-R RN Eligibility ProcessTh is appendix describes, in detail, the data analyses used in this project. Th e goal was to determine the number of RNs providing PHC services. Because no explicit code exists in the CRNBC database to distinguish this group, some assumptions were made. Th ese are represented by the PHC columns in the tables that follow.BC RNs by Work PlaceFirst, we examined RN’s ‘places of work’ as described in the following table. Th e ‘1’ designation in the PHC column indicates a place that was deemed to be PHC.Place CodeDescription PHC PHC TotalPHC % Number %03 Extended Care 1,310 5%05 LTC/Nursing Home 2,422 9%06 Home Care Agency 1 556 556 2%07 Community Health Agency/Health Centre 1 2,533 2,533 9%08 Business/Industry/Occupational Health 1 215 215 1%09 Physician’s Offi ce/Family Practice Unit 1 484 484 2%10 Educational Institution 674 2%11 Self-Employed/Private Practice 1 312 312 1%22 Rehabilitation/Convalescent Centre 209 1%25 Private Nursing Agency/Private Duty 1 101 101 0%26 Association/Government 505 2%27 Nursing Stations/Outpost/Nurse Clinic 1 91 91 0%31 Hospital (gen., mat, peds, psych) 0.16 1,131 17,626 63%32 Mental Health Centre 1 370 370 1%99 Other 700 2%Total 5,793 17% 28,108 Most RNs in BC work in hospitals. Th e second and third most common workplaces are community health agen-cies and nursing homes respectively. Considering place of work only, about 17 per cent of BC RNs would be catego-rized as providing PHC.   RN counts: Registration Database (2000), RNABC (now CRNBC).  23MARCH 2006BC RNs by Area of Responsibility at WorkTh e next important piece of information considered is area of responsibility, described in the following table. Th e ‘1’ designation in the PHC column indicates a responsibility that was deemed to be PHC.Responsibility CodesDescription PHC PHC TotalPHC % Number %1 Rehabilitation 1 349 349 1%2 Oncology 376 1%3 Operating Room 1,220 4%4 Post-Anaesthetic Recovery Room 513 2%5 Emergency Care 1 1,322 1,322 5%7 Ambulatory Care 403 1%8 Community Health 1 1,843 1,843 7%9 Home Care 1 882 882 3%10 Critical Care (ICU, CCU) 2,030 7%11 Medical/Surgical 5,880 21%13 Maternal/Newborn 1,731 6%14 Psychiatric/Mental Health 1 1,489 1,489 5%15 Paediatrics 787 3%16 Geriatrics/LTC 4,001 14%17 Occupational Health 1 184 184 1%18 Several Clinical Areas 1,014 4%19 Other Direct Care 1,441 5%21 Nursing Services Admin. 603 2%22 Nursing Education Admin. 54 0%23 Other Admin. 437 2%31 Teaching – students 555 2%32 Teaching – Employees 243 1%33 Other Education 61 0%34 Teaching – Patients/Clients 255 1%41 Nursing Research Only 36 0%42 Other Research 146 1%99 Other 253 1%Total 6,063 22% 28,108 Most RNs in BC perform medical or surgical services. Th e next largest group provides geriatric services, while the third and fourth largest provide critical care and community ser-vices respectively. According to this variable only, about 22 per cent of BC RNs would be considered PHC-R RNs.RN counts: Registration Database (2000), RNABC (now CRNBC). Appendix III: Sensitivity Analysis—Criteria for PHC-R RNsDefi nition of Primary Health Care Related Registered Nurses in BC in 2000Th is project determines the PHC-R cohort of RNs in BC in 2000. Because RNs are typically salaried (rather than paid through fee-for-service), no specifi c billing information exists to easily identify PHC-R RNs. Th e starting point for this project is self-reported registration data from the CRNBC. Neither the annual RN license renewal registra-tion form nor the existing electronic dataset uses catego-ries, codes, or fi elds that allow a straightforward method to establish which RNs are PHC-R RNs. Th us, in collabora-tion with CRNBC, a defi nition was created based on the information available. A list of all available fi elds can be found in Appendix I. Th e main steps are depicted in the fi gure below and described in more detail.Total RNs registered in BC in 2000N=33,099Practicing RNsN=27,570Practicing RNs with PHC-R placeN=5,793Practicing RNs with PHC-R place and area of responsibilityN=4,249Practicing RNs with PHC-R place,area of responsibility and positionN=4,011Final cohort: practicing RNs with PHC-R place, area of responsibility and position, and eligible work statusN=3,179Non-PHC-R place of workN=21,777Non-PHC-R areaof responsibilityN=1,544Non-PHC-R positionN=238Ineligible work statusN=832Non-practicing, not in BC, or missing employer infoN=5,529lesslesslesslesslessStep One – RNs Practicing in BC in 2000Initially, a combination of the variables—place of work (e.g. hospital, long term care facility, etc.) and area of responsibility (e.g. rehabilitation, mental health)—was used. However, several issues arose. A major diffi  culty was identifying the cohort of RNs on which to base the analy-sis. Th ough the total number of RNs in the dataset was 33,099, it included non-practicing RNs, those with missing employer information, and those who were out-of-prov-ince. Once these groups were excluded, 27,570 practicing RNs in BC formed our base cohort.Step Two – Place of Work ExclusionTh e next step was to look at a combination of place, area of responsibility, and position codes of both primary and secondary employers (7,142 or 26% of this population of RNs have secondary employers) for each of the 27,570 RNs in our cohort. Th e primary place of work reported by this group of RNs is described by the Place Distribution graph.Th e RNs deemed to be PHC-R (in green) represent initial thoughts about what kinds of workplaces were consid-ered to be PHC-R. However, when layered with the other characteristics, there were instances when RNs from non-PHC-R places were included in the PHC-R RN group and vice-versa. Third Step – Area of Responsibility ExclusionTh e next level of stratifi cation was done by area of respon-sibility, or the kinds of services being provided by each RN in every place of work listed. Th is perspective yielded the results illustrated in the following graph (when only considering the primary employer).Most RNs in BC in 2000 were providing medical/surgical services (22%), and 14 per cent were providing geriatric/LTC services. Th e green bars depict PHC-R services—community health, mental health and emergency care services.CENTRE FOR HEALTH SERVICES AND POLICY RESEARCH 24WHO  ARE  T H E  P R I MARY  H EA LTH  C ARE  R EG I S T ERED  NURSES  I N  B C ?RN counts: Registration Database (2000), RNABC (now CRNBC).  25MARCH 2006������������������������������������������������������������������������������������������������������������������������������ ������������������������������������������������������������������������������������������������������������������������������������������� �� ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� ������������������������������������������������������������������������������������������������������������������������ ��� ��� ��� ������ ���������������������������������������������������� ������ ��������Place Distribution of Registered Nurses (RNs) Practicing in BC in 2000Area of Responsibility Distribution of Registered Nurses (RNs) Practicing in BC in 2000RN counts: Registration Database (2000), RNABC (now CRNBC). RN counts: Registration Database (2000), RNABC (now CRNBC). Fourth Step – Position ExclusionTh e next criterion considered in formulating a defi nition of PHC-R RNs was position. All possibilities are listed in the table below, with the bolded green items representing the positions we considered to be PHC-R.Most RNs (80%) are staff  nurses, so this criterion does not exclude many individuals, though it was important to ensure the RNs in the fi nal cohort provide PHC-R services directly to patients.  Position Description04 Clinical Nurse Specialist08    Instructor/Professor/EducatorInstructor/Professor/Educator09   Consultant11 Staff Nurse/Home12 Offi ce/Occupational/Industrial Nurse 13   Researcher14 Manager/Assistant Manager/Supervisor15   Director/Assistant/Associate16 Chief Nursing/Executive Offi cer88 Other99 OtherFifth Step – Work Status ExclusionTh e fi nal criterion was work status. Consideration was given to whether an RN reported working full time, part time or casually, and for which employer(s). If an RN worked only for PHC-R employers, and at least part-time for one of them, then that RN was classifi ed as PHC-R. Or, if an RN reported working on a casual basis for a primary employer that was not considered PHC-R by the four criteria and then reported working full time or part time for a secondary employer that was considered PHC-R, we considered that person a possible PHC-R RN. Our criteria excluded casual work status since the ‘number of hours’ fi eld is rarely fi lled in and is considered unreliable.WHO  ARE  T H E  P R I MARY  H EA LTH  C ARE  R EG I S T ERED  NURSES  I N  B C ?CENTRE FOR HEALTH SERVICES AND POLICY RESEARCH 26RN counts: Registration Database (2000), RNABC (now CRNBC).  27MARCH 2006Appendix IV: Distribution of Possible PHC-R RNs����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� ���������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� �� �� ������ �� �����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������Possible Primary Health Care-Related (PHC-R) Registered Nurses (RNs) by Place of Work, Position, and Area of Responsibility RN counts: Registration Database (2000), RNABC (now CRNBC). Appendix V: Age Distribution of PHC-R RNs and Population������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������CENTRE FOR HEALTH SERVICES AND POLICY RESEARCH 28WHO  ARE  T H E  P R I MARY  H EA LTH  C ARE  R EG I S T ERED  NURSES  I N  B C ?Primary Health Care-Related (PHC-R) Registered Nurses (RNs) and Total Population, by Health AuthorityRN counts: Registration Database (2000), RNABC (now CRNBC). Population counts: PEOPLE 28 (2000), BC Stats.���������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 29MARCH 2006RN counts: Registration Database (2000), RNABC (now CRNBC). Population counts: PEOPLE 28 (2000), BC Stats.

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.52383.1-0048320/manifest

Comment

Related Items