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NP Governance: More questions than answers?

By Daris Klemmer

Part 1

author Daris Klemmer in action

So here I am again the oldest NP taking on a slightly not exciting topic. However, I believe NP governance to be of great importance especially as more and more NP roles are created within our major health organization in Alberta-AHS/Covenant and the potential for a great number of NP positions within the primary care private world.

First of all, what is governance and why is it important to NPs?

Governance in healthcare refers to “a broad ethical and philosophical debate within society leading to values and cultures in an organization, and forms the basis for more specific management discussions on how to organize and steer…providers to achieve broader health systems objectives” (Chanturidze & Obermann, 2016).

How is this important to NPs specifically?

Well, there is this thing called “professional governance” that is a collective governance structure that gives professionals such as nurses a voice regarding issues that affect their practice (, 2021). Professional governance related to nurses appears a lot when searched on the internet. Hmmmm, you might be thinking “but we are not nurses anymore…I can’t operate the IV pumps or mix infusions! I don’t really know the electronic parental manual and truthfully don’t have the capacity to learn it all. I have been a NP for many years, this is new RN technology!” Truthfully, I have been learning all the skills needed for emergency NP care or emergency follow up care or NP as Most Responsible Provider in an IVT clinic-such as what antibiotic covers what bugs, what are the best drugs to use for procedural sedation for each unique patient that I am the caring for, learning how to do wrist reductions, heme-blocks, dental blocks, and medical care in general. This is no different than General Internal Medicine NPs, ICU/CCU NPs; their skill set is very different than that of RNs, other allied health providers and closely resembles a physician’s skill set. My reason for emphasizing this is that in AHS and Covenant NPs are governed/managed by RNs for the most part, or sometimes another allied professional such as a dietician, OT or PT or SW. In the private sector world, it is much the same, either an RN or other allied health professional or a physician.

My question for NPs to ponder is this: do you think that NPs should be governed/managed by RNs, physicians, or other allied health professionals?

Case in point: take my 15 year NP career in both Covenant and AHS. My first NP job/role was as the first fully licensed NP on the Primary Care Hospital Team at the Grey Nuns Hospital in Edmonton. I reported to the patient care manager of medicine whose motto was “I don’t care what you do as long as the physicians are happy.” Well funny thing is I know I made one of them happy as he is now my husband-lol but really???? My second role/job was in supportive living (SL) and I reported to the director of SL program – this was step up – she was a nurse but

for the first 12 months every time myself or my NP colleague met with her she asked us if we able to write prescriptions. My third role I was in facility living (FL) and I then reported to a PT; a very good manager but again at the management tables was unable to speak to what the NP role was and often would ask questions about scope of practice. My fourth role reported to a RN who point blank said that if she had a choice she would not have her child see an NP over a MD, seriously……??? My current manager is a RN/midwife and has the greatest understanding of the NP scope and role. I think it’s related to her knowledge of autonomous practice as a midwife and her willingness to support the NPs to be innovative and creative within a heavily physician-influenced organization. She still asks questions about scope of practice but with the trusting relationship that we built over the last 5 years she will often defer directly to me. In my current role, the leadership team has developed an informal triad relationship between myself the manager and the medical director.

Many NPs in AHS and private sector report jointly to physicians and RN managers at all different levels; PCM level, director level, or executive director level, with the PCN structure similar reporting structure is found. Interestingly that second only to salary, NP reporting structure is the next most common subject that NPs love to discuss. So, in anticipation of Part 2, here some things to think about: 1) If NPs reported to other NPs, what style would be best-the nursing style or the physician style-both very different-combination of the two? 2) How would the reporting structure look like within the organizational chart with AHS/Covenant? Private sector? 3) NP managers or NP leaders? 4) What skill set should the NP leaders have?