It is important to spend the time needed to determine the most appropriate professional background for your new FLS coordinator and this will largely depend on your local individual context. Nursing offers by far the best fit in terms of scope of practice. But should you hire an RN or an NP? This article aims to cover some of the important considerations.
NP as the FLS coordinator:
- An FLS with NP can ensure the model will be 3i FLS given the NP can prescribe the osteoporosis meds needed. In the Ganda meta-analysis, 3i FLS models had a bit of an edge over 2i models. Rate of treatment achieved by 3i models in that study was 46% for 3i FLSs vs. 41% for 2i FLSs (and contrast that with only 23% for 1i models and 8% for zero i models in that same meta-analysis).
- The FLS NP can work independently (but typically through a collaborative practice arrangement with one or more physicians). Regulations regarding collaborative practice arrangement differ between provinces.
- The initial set-up of the FLS will be easier and simpler, i.e. no need to develop a Care Directive to expand an FLS RN’s scope of practice. However, even hiring an FLS NP will not remove the absolute need for the design of the FLS to be done with close guidance from an FLS medical lead/physician.
- There are currently no NP FLS coordinators in Canada. Hence, it would be the exception rather than the norm.
- The salary expense will be significantly greater than that of an RN. It may perhaps be more difficult to ensure the FLS will secure sustainable longer term funding from government.
- Because all FLS coordinators work with pre-determined protocols, the new FLS NP may find that their scope of practice is very restrictive compared to what they have been trained to do and what their scope of practice might be in other positions (e.g. NP working in Primary Health Care). One rare FLS in Canada was previously using an FLS NP but it experienced a huge turnover in the position, with 3 new FLS NPs in less than 3 years. This FLS has since moved on to hire an FLS RN instead.
RN as the FLS coordinator:
- Salary expense will be less than that of an NP. This might facilitate sustainable longer term government funding.
- Many Canadian FLS RNs work with an expanded scope of practice (e.g. via a Care Directive). Because of this, most FLS RNs find their work rewarding rather than limiting. In Canada, there does not appear to be great turnover in the FLS RNs.
- There is a movement afoot in Canada towards RN prescribing. This is already established practice for FLS RNs in the province of Quebec. RN prescribing is currently being explored in other provinces (e.g. NS and Alberta). If this occurs, an FLS with a prescribing RN can easily be converted into a 3i model. This would likely prove to be the most cost-effective model of all.
- Most FLSs which hire an RN as their FLS coordinator will be 2i which are expected to have somewhat lesser results than a 3i FLS based on published studies. In Canada, based on the results of the national FLS audits, some 2i FLSs have actually seen results that are quite competitive with 3i FLSs. This is because OC’s Essential Elements of FLS ensure that any FLS model will be a bit more than just a basic 2i model, at least if they wish to be included in OC’s FLS Registry. Additionally, depending on FLS design, an FLS hiring an RN can sometimes be set up as a 3i model, but that requires the participation of one or more FLS physicians (e.g. in those FLSs, the FLS RNs do most of the work, but an FLS physician, usually a hospitalist, prescribes the osteoporosis medication). One FLS is currently exploring an option where the hospital’s pharmacist will be the prescriber of the osteoporosis medication for the patients enrolled in their FLS.
- To be as effective as possible, an FLS using an RN needs to work towards allowing the RN to have an expanded scope of practice (e.g. to allow the RN to order BMD tests). The regulatory hurdles for such an expanded scope of practice are best done in the early days of the FLS. Depending on the province, some of the necessary steps may include obtaining approval from the provincial College of Nursing, obtaining approval from local Medical Advisory Committee, etc. This type of work does require the support of a local physician, usually the FLS’s medical lead.
Are Registered Practical Nurses (RPN) or Licensed Practical Nurses (LPN) ever hired as FLS coordinators in Canada?
To date, RPNs as FLS coordinators are exclusively found in Ontario. It should be noted that the Ontario FLS model is somewhat different from those of other provinces. In Ontario’s FLS model, all high-risk fracture patients are automatically referred to an osteoporosis specialist, hence the latter is an integral and essential component of the FLS itself. This type of model is found exclusively in Ontario.
The lower salary cost of the RPN is attractive. On the other hand, this is offset by the higher cost generated by the involvement of the osteoporosis specialist for the majority of the FLS patients in that type of model.
One final word of caution: It is important that the job description should be drafted to best fit the needs of your new FLS, based on your FLS design, rather than making the job description fit a particular candidate you might have in mind for the position. Always ask yourself: if this particular candidate does not apply for this position, would it still be the best job description to fit our FLS’s needs?