Better Health, Better Care: The Role of Nurses in Chronic Disease Management, by Patricia Foster RN

By Patricia Foster, RN

I have been privileged to work in a nurse led clinic for 17 years. The Comox Valley Nursing Centre began as a demonstration project, highlighting nurses working to the full scope of their practice, in partnership with the community.  Chronic illnesses and in particular chronic pain were the primary needs.

Patients and colleagues have taught us much:

  1. Poverty undermines a person's ability to pursue health.  We must address the intersection between socioeconomic factors and illness. Cross ministerial planning is key to supporting those families most at risk.
  2. Partnership with patients is critical to the pursuit of health. Partnership means listening to what the patient's goals are, not assuming we know based on a common diagnosis or standard care plan.  Partnership means supporting patients to gain knowledge, recognize their own strengths.  Partnership helps them navigate a complex health care system through nursing advocacy.
  3. Open referral policies to ambulatory community based programs (i.e. low barrier access to nursing) means patients are not waiting for doctor's orders to access nursing.
  4. Nurse led clinics with access to interdisciplinary teams are effective for chronic disease management. Existing approaches to health care funding or delivery models that insist on MD leadership or provide funding only through physician or large corporate entities limit cost effective innovation.  We need to take what we learn from successful projects and “grow it” -- continue funding beyond the innovation stage.

Finally, what do we need from nurses, other health professionals, governments and the public to address the challenges?  We need compassion, basic respect for humanity and a civil society that seeks to support all of its citizens.


Patricia Foster is a dynamic, passionate and articulate nurse with 37 years of experience in a variety of roles and settings: nurse practitioner in First Nations communities; continuing care case manager; clinical nurse specialist in geriatric rehab and private practice (continence speciality); educator; staff nurse and manager in primary health care setting.

Since 1998 Patricia has been the Manager of the Comox Valley Nursing Centre/North Island Regional Eating Disorder Program. She is a consultant for Community Living BC and a committee member for the Provincial Ethics Network, BC Ministry of Health.

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Heather Mass

I would like to thank Pat for her comments. I too was privileged to be part of the Centre in it's early days when it was an RNABC demonstration project. From its very beginning it flourished and has continued to be a great success. The people of the Comox Valley are fortunate indeed to have had the opportunity to be part of the development of, and to receive stellar care from, a very innovative service staffed by an amazing group of nurses!!

What Pat (modestly) did not say was that this project has also already had a significant impact on the nursing profession and the health care system in BC. From a policy perspective, learning from this project led to other RNABC initiatives that also showcased nursing's role in primary care, such as the RN 1st Call project. Among other things, they provided RNABC (and later CRNBC) with evidence needed to successfully argue for an enhanced scope of practice for RNs in BC in the health professions scope of practice review process.

It is important to note that at the time these projects were initiated the "association" arm of RNABC was a respected participant in health and social policy forums. Unfortunately, with the reformation of RNABC into CRNBC, and it's restricted mandate of professional regulation, the opportunity to mount such projects, and to influence health and social policy decisions at the Government level was lost. Thankfully, ARNBC has emerged to address this gap and bring the knowledge of wise nurses like Pat and her colleagues in the Nursing Centre - and the thousands other nurses who great have ideas about how similarly innovative health care services could be delivered across BC - into the policy decision-making processes once again.

Much discussion about the shape and purposes of this new Association will occur in the coming months, but in the end I hope and trust that all nurses in BC will agree to support ARNBC to pick up this important work. Perhaps we will even see other such innovative nurse led projects, jointly sponsored and supported by government and other nursing organizations, begin to emerge and inform health policy in BC once again.

Mary Adlersberg

I too remember a time when RNABC was at the forefront of some truly incredible and innovative nursing initiatives and am excited that we seem to be entering a new phase in our professional history when those voices for nursing health policy can be raised in the public domain once again. I honour Pat Foster for all that she has done for her community and for nursing. And as she has indicated, this kind of work becomes possible within a community of practice that shares a commitment to the role of nursing knowledge and expertise in finding ways to do things better – something Pat has persistently and consistently demonstrated over those 17 years. I believe that the success of this nurse led clinic is an exemplar for what nursing can and should be contributing to the health care of British Columbians with chronic conditions.

While I celebrate the benefit that has come to the Comox Valley as a result of this clinic, I feel sincere regret that we have not yet found the political and policy voice to expand this model of care delivery to a wider range of communities. The evidence from evaluation of that clinic project has remained solid over time, and we know that it has been highly effective. It seems a pity therefore that other populations in BC whose members are similarly affected by chronic disease and inequity do not yet have access to this kind of resource. I understand the political nature of such matters, and recognize that the absence of a particular kind of policy voice in the province over the past 5 years has meant that there is no one strongly advocating for this kind of approach to primary care reform. While the voices of some other disciplines have had a strong impact in how reform has been enacted, nursing has not found a place at those policy tables. So I am highly optimistic that this new Association will once again create a strong argument for nurse led clinics as a logical adjunct to a comprehensive set of community based health care services, and that initiatives driven by nurses will once again have a chance to see the light of day.

Jennifer Graylands

I am a RN working for a gastroenterologist in New Westminster - I work as an "IBD nurse" (a role that has become commonplace in the US and to some extent in eastern Canada, but is relatively new in BC) and care for all of his patients with Crohn's and Colitis. These are chronic diseases that often start in childhood and continue throughout the patients life and affects more people in Canada than multiple sclerosis or HIV and is almost as many as epilepsy and Type 1 diabetes (ccfc.ca - http://www.ccfc.ca/site/c.ajIRK4NLLhJ0E/b.6431205/k.884D/The_Burden_of_IBD_in_Canada.htm). Despite this fact Crohn's and Colitis is not recognized by the health authorities or the BC government as needing the same funding and nursing support as chronic conditions like diabetes.
There are currently four of us in the lower mainland, and we are struggling to obtain professional recognition and funding for our positions. With the exception of the IBD nurse at BC Children's Hospital all of our positions are funded through grants from pharma and research funding. We work every day counseling patients on their disease and medications, doing lab reqs and refilling prescriptions, tracking labs, filling out disability forms, insurance forms and pharmacare applications... among any other things! We would love to work with some of the nurses involved with ARNBC who seem like they could be mentors for us - to help our role in the care of these patients be recognized. We believe we not only provide the patients with valuable support - both medical and psychological - but that we also save the health system money by recognizing complications or worsening disease earlier and preventing the need for expensive hospitalizations and/or surgeries.

I am excited to make contact with a group that can help guide me through this process - it is my first foray into political activism as a nurse, and I may need help not sticking my foot in my mouth!