By Damien Contandriopoulos, UVic School of Nursing
Anyone who has been paying attention to health care developments in BC will have noticed that we are in the midst of a well-orchestrated campaign from the Canadian Association of Physician Assistants asking BC to legalize the Physician Assistant (PA) roles in BC. If successful, BC would be the fifth Canadian province to allow PAs to practice (after Manitoba, Ontario, New Brunswick and Alberta). This is an important matter, one that raises issues of professional autonomy, medical dominance and the very nature of health care provision. But the silence of nursing organizations is (once again) quite deafening.
Both NP and PA roles appeared in the 60s during the first contemporary episode of a perceived physician shortage. In both cases, the rationale was to create roles for specially trained non-physician professionals in order to alleviate accessibility and efficiency issues.
NPs were the nursing response, providing nurses with more comprehensive training and an extended scope of practice so that they could treat a broad range of primary-care and specialized health issues. Unsurprisingly, this idea didn’t exactly enthuse the medical establishment. For a while, nurses have had a stubborn tendency to defend such ideas as disciplinary autonomy and a distinct conception of care, which suggested that allowing nurses a wider scope of practice could lead to them appropriating some of the turf historically controlled by physicians. And, well… as history eventually showed, NPs did exactly that.
The PA role appeared at the same time, and for the same reasons as NPs, but – as the name suggests – the choice made here was that the profession would locate itself firmly within a subordinated position to medicine. This positioning is not surprising as the role of PA was, from the outset, designed from within the American Medical Association. The same applies in Canada where such bodies as the CMA and Doctors of BC have been supporting PAs for many years.
Don’t get me wrong here, I’m absolutely certain that most PAs are great individuals, skilled professionals and dedicated persons. There also is evidence that PAs provide safe, high-quality care. This isn’t the issue. The three issues worth discussing in the context of the current campaign to get PAs in BC are related to system disruption, the definition of professional boundaries, and the inadequacy of the policy presence from nursing bodies.
As their origin and history show, despite being born in response to the same challenge, NPs and PAs have evolved into very different professions. On the one hand, NPs are steadily disrupting the status quo by prompting a redefinition of professional roles and the very nature of care. On the other hand, as a profession, PAs assume a subordinate position and even seem to accept being described as “physician extenders” (which sounds more like a prosthetic than a professional denomination).
It is important to understand that professional boundaries – the socially accepted definition of who legitimately does what in care delivery – aren’t a purely legislative matter. They are the product of an ever-evolving dynamic equilibrium reflecting what happens in the workplace, in the media and in the legislation. The very nature of care is affected by those boundaries. For example, the more primary care is conceived as a physician-only affair, the higher the likelihood that the conception of “care” in primary care will be squarely limited to medical care. On the other hand, reframing primary care as a joint endeavour of multi-professional teams is the best avenue to broaden the definition to include a community focus where social and mental well-being have a place, and where primary determinants of health are addressed.
In that light, the current push to have PAs in BC is essentially an effort to maintain the status quo in primary care. Registered nurses and NPs already have the training, competence and legislative autonomy to fulfill the roles that PAs are currently being touted for. So why would BC need PAs? The answer is that PAs are unlikely to stir up any disruption. We’ll have a bit more of the same, for a marginally cheaper price. Great, isn’t it? Save for the little detail that what we actually want and need is precisely not more of the same.
Which all brings me to my last point: nothing discussed above will be new or surprising for anybody in the field. One could then have expected nursing bodies (yes BCNPA, NNPBC, CNA, BCNU, I’m talking to you) to be weighing in on the issue and explaining why legislating in favour of PAs in BC isn’t such a great idea after all. However, we have only heard static and silence. Once again, it appears that the “strong voice of nursing” they have been bending our ears with is stuck with the mute button on.
PS. Oddly enough, UVic’s website advertises for PA training in Manitoba