
                          THE CINDERELLA SYNDROME

                              By ANNE KERSHAW
                           Kingston Whig-Standard

     KINGSTON, Ont. - As the only health professional in the Inuit
     village of Tuktoyaktuk, one of Judith Friend's jobs was delivering
     babies.

     She delivered one of them in a tent in a summer fishing village on
     the tundra.

        See <29health> for a discussion of northern community care

     The peak of summer swelled the number of people under her care from
     300 or 400 to as many as 700. She was frequently called on to
     suture wounds suffered in accidents.

     Judith Friend is a nurse.

     And she's angry at a system that, for the most part, still refuses
     to accept an expanded, more responsible role for nurses.

        See <17health> for a discussion of rural doctors

     Her 16-year nursing career began in a remote B.C. Indian
     reservation, where she worked in pediatrics, obstetrics and the
     emergency ward.

     She has been head nurse in the operating room of a mission hospital
     in India, administering general anesthesia during reconstructive
     surgery on leprosy victims. She has also taught.

     Now 46, confident and self-assured, Friend is a nurse and former
     patient care co-ordinator at a 44-bed unit of St. Mary's of the
     Lake Hospital in Kingston.

     ``It was okay for me as a nurse midwife to work up north and
     deliver Eskimo babies,'' she says. ``But can I come down here and
     do it? No, I can't. And I wouldn't be allowed to do it up north if
     there was an abundance of doctors willing to go up there, away from
     the nice urban areas.

     ``I'm just a second-class citizen, in essence, as were the folks I
     was working with.''

     As the cost of health care mounts, Friend's criticism is becoming
     increasingly relevant. More questions are being asked about how
     efficiently Canada's 240,000 registered nurses are being deployed.

     Are we making the best use of their skills and expertise,
     especially at a time when this professional group is making
     significant wage gains?

     In a health care system where doctors have traditionally been akin
     to the gods, the part that has fallen to nurses is Cinderella.

     ``At one time of the day you're considered terribly competent,''
     says Dr. Alice Baumgart, head of the Canadian Nurses Association
     and former dean of nursing at Queen's University. ``At another time
     of the day you're considered an ignoramus.''

     That night-and-day treatment generally follows night-and-day lines.

     ``A nurse may be forbidden to do certain procedures in a hospital
     during the day,'' says Dr. Michael Rachlis, author of Second
     Opinion: What's Wrong with Canada's Health Care System:

     ``But at night, when there are no physicians around, they are
     allowed to do those things. And typically, nurses who work in the
     north on Indian reserves are allowed to do all sorts of things that
     they wouldn't be allowed to do if they were in the south.''

     The case for giving nurses more responsibility seems solid.

     Nurses currently spend as much as 30 per cent of their time
     performing non-nursing tasks, including clerical and cleaning jobs,
     that could be done by less qualified workers.

     In one such study, conducted by Dr. Walter Spitzer in the early
     1970s, patients in a family practice in Burlington, Ont., were
     randomly assigned to a doctor or a nurse practitioner for their
     care. The research detected no difference in the health recovery of
     patients or the degree of satisfaction they reported.

     Jonathan Lomas and Greg Stoddart, health policy analysts at
     McMaster University, have estimated that nurse practitioners could
     replace 20 to 32 per cent of Ontario's general-practice doctors,
     saving the system millions of dollars.

     Because of the emphasis of their training, nurses are particularly
     skilled in health promotion and prevention. But they are also well
     equipped to look at most minor illnesses - everything from colds to
     flu to venereal disease, says Dr. Rachlis.

     ``Not only can the nurse deliver the treatment services as well as
     doctors, but typically those visits for minor illness also require
     a lot of counselling and education and nurses are again better
     equipped than most physicians to provide those kinds of services.''

     The nurse practitioner first appeared on the Canadian scene in the
     late 1960s in response to a perceived shortage of doctors.

     About 250 nurses graduated from nurse practitioner programs before
     they were cancelled in 1983. Most worked in remote areas, including
     the North and Indian reservations, where doctors were reluctant to
     go.

     It was the increasing resentment of physicians, as nurses
     encroached on their turf, that helped push the movement to a
     standstill. Also, no one could decide how nurse practioners should
     be paid.

     Nurses weren't allowed to bill the system directly and they didn't
     like the idea of being paid by individual doctors, an arrangement
     that would only reinforce their status as physicians' assistants.

     Not all doctors are adverse to the idea of an expanded role for
     nurses.

     David Alexander, a Kingston pediatrician and family doctor, thinks
     attitudes are changing.

     ``I don't think the modern generation of doctors would present so
     much of an obstacle as the old generation did,'' he says. ``People
     are learning to work with one another.''

     Don Macgregor, president of the Alberta Hospital Association,
     agrees.

     ``There is within the professions themselves an acceptance that
     there is a need to put to rest once and for all some of the age old
     turf battles.''

     The influence of the growing number of women graduating from
     medical schools will only help, says Friend, who despite her
     criticism of the system is among those who finds doctors
     increasingly open to nurses as equal partners.

     ``I relate really well to women doctors,'' she says. ``There's a
     real basis of understanding there 99 per cent of the time.''

     As nurses struggle to free themselves from the straightjackets that
     have traditionally confined them, there are other encouraging
     signs.

     Some hospitals have adopted new policies to allow nurses to take a
     larger role in management decision-making.

     For example, nurses at Vancouver General Hospital have been handed
     responsibility for deciding when they can't accept any more
     patients and must close beds.

     But given the current surplus of doctors and the open-ended, fee-
     for-service mechanism by which they are paid, there is little
     financial incentive for governments to increase use of nurse
     practitioners, admits Dr. Rachlis.

     ``The government knows (nurse practitioners) might provide better
     services to some people but it's going to cost extra money because
     the government is already committed to paying for the doctors that
     are in practice.

     ``If you could substitute nursing services for doctors' services
     you could probably save money because nurses would be delivering
     many services not only better but cheaper,'' he says. ``But you
     can't lay off doctors.''
