Canada and the United States are geographically large federal states with strong central (national) governments. These governments connect to partially self-governing provincial, state, and/or territorial governments that pose ongoing tensions in health systems. Like most countries, both are confronted with the need to contain spiraling costs while delivering better healthcare and promoting better population health. At the same time, they are challenged by global authorities, such as the United Nations, to deliver universal healthcare, primary healthcare, respond to development goals, and address the structural drivers of health inequities. Data from both countries affirms public trust in nurses, with the expectation that they will act in the public interest to improve care and population health. In this article, we focus on Canada. First, we briefly describe the history of health system development and reform, and then consider nursing policy and advocacy in the 21st century. Finally, we offer examples of nurse-led solutions from Canadian nurses and nursing associations to build, overhaul and improve health systems and influence health policy.
Key Words: Nurse, nursing, Canadian Nurses Association, health system, health policy, social determinants of health, indigenous, health equity, health inequities
“Nurses have knowledge and experience; they know what decision making is all about. If nurses mobilize – change could happen overnight… Nurses need to inform themselves. We have a responsibility to the human race to get involved. We do not have the right to be uninvolved.” Marion Dewar, CM; Former Mayor of Ottawa and former Public Health Nurse (as cited in Crowe, 2008, p 4). As we celebrate the Year of the Nurse and Midwife proclaimed by the World Health Organization ([WHO], 2019), Canada’s professional nurses and nursing organizations remain involved and continue as an essential contributor to the health of all Canadian citizens.
Canada and the United States (US) are geographically large federal states with strong central (national) governments. These governments are connected to partially self-governing provincial, state, and/or territorial governments. The countries have common roots in the United Kingdom (UK), share English as a common dominant language, have common, dominant religions (e.g., Roman Catholicism, Protestant Christians), and both feature ethnically and culturally diverse populations that are uneven in distribution across the geographies. The two countries are among the wealthiest and most privileged nations on earth, and they remain near or at the top of choices for intended migration globally. They also share complicated histories involving enslavement of African Peoples whose effects continue to unfold. Finally, both continue to be confronted by the devastating impacts of colonial histories on Indigenous Peoples—First Nations, Inuit, and Métis Peoples in the case of Canada, and Native Americans, Native Hawaiians, and Alaska Natives in the US.
Most countries face the need to contain health system costs while delivering better healthcare and promoting better population health...Most countries face the need to contain health system costs while delivering better healthcare and promoting better population health, following the Institute for Healthcare Improvement’s (IHI) now-ubiquitous triple aim (IHI, 2015). At the same time, global authorities such as the United Nations are pushing all nations to deliver universal healthcare, primary healthcare, respond to the Sustainable Development Goal, and address the structural drivers of health inequities (Commission of the Pan American Health Organization, 2019; United Nations Development Program, 2018; WHO, 2012). Canada and the US are no different, but they face the added challenge of negotiating the tensions that often exist in federations when funding, building, and operating complex social programs such as healthcare.
...the people of Canada accord nurses the highest respect and trust of any professionals in society Like Americans, the people of Canada accord nurses the highest respect and trust of any professionals in society (Insights West, 2017; Little, 2018). One poll revealed that they trust information coming from nursing organizations more than any other source (Ipsos, 2007). But the public expects more than talk or worry; they have significant concerns about healthcare, and they expect direct, informed, evidence-driven action by nurses, physicians, and others to transform health systems to make them more accessible, of higher quality, and more affordable.
Two important variables, geography and Indigenous status, also pose unique challenges for people, health-care administrators, and governments in Canada. One clear example of the differences between Canada and the US is seen in the design and funding of their health systems. These differ sharply by falling into the policy camps that Michael Decter (1994), a former provincial Deputy Minister of Health in Ontario Canada, coined as ability to pay (US) and ability to benefit (Canada). Two important variables, geography and Indigenous status, also pose unique challenges for people, health-care administrators, and governments in Canada. In this discussion, we will draw out examples of the ways Canadian nurses have responded to the public expectation they actively help to address these challenges, and to construct and strengthen Canada’s universal, publicly-funded health system. We begin with a brief history of health system development and reform in Canada to familiarize readers with baseline information.
History of Health System Development and Reform
While Indigenous Peoples developed and delivered traditional healing practices for millennia, modern North American health systems are rooted in the 17th century, in what is now the province of Québec. Jeanne Mance migrated from France and established the first documented lay nursing practice in North America. She established the Hotel-Dieu de Montréal hospital in 1642 (Daveluy, 2003), positioning the profession of nursing as a founding force in clinical healthcare and in policy and advocacy work. Florence Nightingale, from her base in London, England, later laid down a legacy of clinical and political advocacy nursing leadership that still shapes the historical nursing narrative globally. Her research, insights, and leadership led to an eventual overhaul of public health and hospitals on a global level, setting the course by the late 19th century for development of the health and hospital systems that dominate globally today.
Florence Nightingale... later laid down a legacy of clinical and political advocacy nursing leadership that still shapes the historical nursing narrative globally. The discovery of vaccines significantly reshaped the size and demographics of populations in Canada and the US beginning early in the last century. The premature death rate plummeted, particularly among children, in part driving the gain of 30 years average longevity among Canadians since 1900 (Government of Ontario, 2014). With many more people alive, demand for care, and indeed all other services in society, grew in parallel. The number of hospitals in Canada grew steadily over the 50 years between 1880 and 1930 (Government of Ontario, 1930), but the real explosion in hospital growth, and especially of large, tertiary, academic medical centers, began during and immediately following World War II. A Canadian Nurses Association (CNA) submission to the Royal Commission on Canada’s Economic Future in 1956 reported that the number of hospital beds had nearly doubled since 1932 (Elliott, Rutty, & Villeneuve, 2013).
The discovery of antibiotics during the 1940s alongside advances in surgical anesthesia meant that many wounded soldiers who previously would have died now survived their injuries and illnesses. With civilians at the time seeing the value of acute hospital care, the stage was set for curative treatment to emerge as the predominant way to seek health, a pattern that remains deeply entrenched across North America.
Nursing was transformed by the hospital movement, being recast as an institution-focused practice. Nurses at the time read the political tea leaves quite accurately: they saw where funding was allocated and new directions of health system growth. Until the Second World War, Canadian nursing was largely community- and home-based with a focus on public health, early child development, hygiene, education, and recovery from illness. Nursing was transformed by the hospital movement. Most nurses have never looked back. In 2017 for example, more than 70% of all regulated nurses in Canada worked in institutional acute and long-term care, and less than 14% were employed in home and community care (Canadian Institute for Health Information, 2018).
Geographic and Indigenous Determinants of Health
The interacting effect of a history of colonization, vast geography, and Indigenous status is evident in Canada, and nurses practice at the intersections of these and other factors that influence health. The distribution of Canada’s population of about 37 million (World Population Review, 2019) is highly skewed. Spread across six time zones, it is estimated that at least 86 per cent of Canadians live within 200 km (120 miles) of the Canada-US border running from Vancouver, British Columbia to St. Stephen, New Brunswick. Most of Canada’s population is concentrated in just four urban areas in Quebec, Ontario, Alberta, and British Columbia, creating stark population density disparities that lead to formidable governance and operational challenges.
The interacting effect of a history of colonization, vast geography, and Indigenous status is evident in Canada...Much of Canada is tough to access. Parts of the country are ice-bound year-round leaving many communities accessible only by planes, ocean-going ships, or winter ice roads. Other communities are connected by dirt roads that require several hours of driving to access. Delivering on the Medicare promise of equitable access to universal healthcare in the Canadian geographic context is a challenge. Health outcomes can vary widely depending on where one lives. Nurses often are the only healthcare providers in these demanding settings.
In a recent analysis for the Government of Canada, Subedi, Greenbery, and Roshanafshar (2019) found that people in rural settings “have worse health outcomes than their urban counterparts” (p. 3) and they cited earlier research by Sibley and Weiner (2011) showing that people living in rural communities have less access to services. Subedi et al. (2019) concluded that rural or remote geography may not drive poorer health, but “it may influence other socioeconomic, environmental and occupational health determinants” that do (p. 3). They asserted that this outcome may correlate with disproportionate mortality rates between people living in urban and rural settings (Subedi et al., 2019). Incidentally, Sibley and Weiner (2011) noted, perhaps paradoxically, that those living in the most urban areas may encounter the same access problems as those in the most remote areas.
Much of Canada is tough to access. Nurses often are the only healthcare providers in these challenging settings.In a 2012 report, the Conference Board of Canada rated Canada’s 13 provinces and territories on 11 population health indicators, concluding that British Columbia and Ontario came out on top, while Newfoundland and Labrador and the three Northern Territories placed last (Conference Board of Canada, 2012). It is not lost on nurses that the latter jurisdictions all have high proportions of Indigenous people and many Indigenous and non-Indigenous people who live with significant economic and geographic challenges. Recruiting and retaining providers, including nurses, is an ongoing challenge across Canada in rural and remote areas, where the proportion of nurses is significantly lower than the overall proportion of people living in these communities (MacLeod, Stewart & Kulig, 2018). In many Indigenous communities in Canada, nurses provide care primarily in community or primary healthcare settings. The more remote the setting, the more likely the care is to be led and delivered by teams of nurses (Conference Board of Canada, 2012).
According to the 2016 census, 1,673,785 people in Canada, nearly 5% of the total population, self-identified as Indigenous (i.e., First Nations, Inuit, or Métis) (Statistics Canada, 2017). The Indigenous population grew more than 400% above the rate of non-Indigenous people in Canada during the decade after 2006. Although Indigenous people are aging like the rest of the world, the average age of this population is a decade less that non-Indigenous people in Canada. There are more than 600 First Nations across Canada, with about 44% of the total population of nearly 1 million First Nation People living on reserves (Statistics Canada, 2017). Inuit Peoples (population 65,000) live in four regions of Canada’s Arctic, with nearly three quarters living in the Inuit Nunangat region of Nunavut. The majority of Métis Peoples (population 588,000) live in Ontario and the western provinces, with about two thirds living in urban neighborhoods.
Recruiting and retaining providers, including nurses, is an ongoing challenge across Canada in rural and remote areas... The recent Truth and Reconciliation Commission of Canada (2015) shed light on the significant health and social disparities faced by Indigenous Peoples stemming from historical colonizing forces. If outcomes for people in Canada are worse for those living in rural settings, then access to care and population health outcomes are worse still for Indigenous people. In some areas, outcomes have improved, but the National Collaborating Centre for Indigenous Health (2013) noted that health outcomes for Indigenous People are poorer than their non-Indigenous counterparts in Canada and Indigenous People bear a higher burden of disease and disparities in health status. Indigenous Services Canada (2018), the federal department responsible for providing or funding direct healthcare for many First Nations and Inuit people, is striving to resolve significant disparities in areas such as life expectancy, infant mortality, diabetes, opioid-related deaths, and tuberculosis.
The Commissioners noted the need to increase the number and retention of Indigenous professionals working in the healthcare field (including nursing)... Canada is living through a period of deep reflection in the wake of the Truth and Reconciliation Commission of Canada (2015), which forced a harsh confrontation with history related to the treatment of Indigenous Peoples by settlers that has been cast as attempted cultural genocide. The Commission issued 94 calls to action in its 2015 report, including calls for nursing education to include “Aboriginal health issues, including the history and legacy of residential schools, the United Nations Declaration on the Rights of Indigenous Peoples, Treaties and Aboriginal rights, and Indigenous teachings and practices” (p. 3). The Commissioners recommended that nursing practice should encompass “skills-based training in intercultural competency, conflict resolution, human rights, and anti-racism” including Indigenous healing practices in the routine care of Indigenous Peoples (Truth and Reconciliation Commission of Canada, 2015, p. 3). The Commissioners noted the need to increase the number and retention of Indigenous professionals working in the healthcare field (including nursing) and to provide cultural competency training for all healthcare professionals.
Waves of Health System Reform in Canada
Discussions about paying for healthcare have paralleled the development of the Canadian health system from the beginning. Originally, care provided by nurses and physicians outside of charity settings was paid privately with cash or some aspect of a bartering system where care was traded for reciprocal service or goods. Early on, physicians operated sliding-scale payment models wherein wealthier patients were charged more to offset the lower fees (or no fees) paid by less affluent patients (Hall & Schneider, 2008).
Discussions about paying for healthcare have paralleled the development of the Canadian health system from the beginning... a belief that medically-necessary care should be accessible based on need, and not on the ability to pay, has been a prominent value in Canada...There have always been charitable services offered to vulnerable sectors of society by groups such as churches and community organizations. A mix of specialty and episodic services left much of the population paying for healthcare out-of-pocket, resulting in care delivered based on ability to pay, not based on need. However, from the beginning a belief that medically-necessary care should be accessible based on need, and not on the ability to pay, has been a prominent value in Canada and certainly within the CNA and the larger nursing profession.
Early in the last century, the CNA became an active voice advocating for care based on need, rather than ability to pay. CNA leaders met with the acting Prime Minister in 1935, for example, to present the organization’s position, Outline on Health Insurance and Nursing Services. (Elliott et al., 2013). Ultimately the federal government did strike a Royal Commission on Dominion-Provincial Relations that included a focus on health system structures and funding. The submission to the Commission by CNA “emphasized the need for a full national survey of all health services, and in recognition of the important role it believed that nurses played in the preventive aspects of health, the organization called for inclusion in the development, administration and regulation of any new health insurance plan” (Elliott et al., 2013, p. 59).
From the outset, the CNA landed firmly on the side of a publicly funded and administered, not-for-profit, universal health system. Many physicians, on the other hand, sided with the idea that payment should be a matter between doctors and their patients, and not the purview of governments. Saskatchewan physicians would eventually mount a strike in 1962 that attracted global attention to the movement by physicians to resist “collectively funded and administered healthcare” (Marchildon & Schrijvers, 2011, p. 204). However, in the face of overwhelming public support for universal Medicare, the strike failed, although physicians were successful in retaining a fee-for-service payment model still prominent today. The push for universal, comprehensive, publicly-funded healthcare goes on, but is only one issue shaping healthcare in Canada. For the purposes of this discussion, we frame three main waves of health system reform in Canada since the mid-20th century, as shown in Table 1.
Table 1. Timeline of Health System Reform in Canada: Focus, Activities, and Initiatives
Focus, Activities, and Initiatives
This era was a time of massive growth. The focus was on building facilities, health systems, a healthcare workforce, as well as the evolution of fees, funding, and payment mechanisms. A body of legislation developed across Canada over 40 years, beginning in the mid-1940s, led to broad social safety nets that included public pension plans; social welfare assistance; and universal, publicly funded coverage for all medically necessary care by physicians and in hospitals. Ultimately, with the Canada Health Act, 1984, principles and conditions for universal Medicare were laid down, including insured coverage for medically necessary services delivered by providers beyond physicians, and prohibiting extra billing by physicians. (Government of Canada, 2020).
With access to doctors and hospital care well established across Canada by 1980, the second wave of health systems evolution was characterized by a growing focus on what those systems delivered (i.e., quality and safety, performance, cost control, and return on healthcare investments). Decision makers turned their focus to the broader framework of primary healthcare programs and services and the impacts of broad determinants beyond healthcare on population health outcomes. This era included a series of accords and agreements between federal and provincial and territorial governments intended to incentivize health system performance outcomes and cost efficiencies. The period was influenced by growing concerns about spiraling costs, and in a world with an exploding range of available services, attempts to determine what should constitute medically necessary care for coverage under the Medicare program.
The current wave of health systems transformation is focused on aligning health systems with changing societal and population needs, and de-institutionalizing programs and services to bring care closer the places people live, work, play, and pray. Debate about cost containment, or even opportunities for savings, remains prominent.
...CNA strongly advocated for system transformation to the full roster of primary healthcare services to balance the focus on acute care. In 1980, Justice Emmett Hall, who led the Royal Commission on Health Services in 1961 (Health Canada, 2004) that led to Canada’s Medicare legislation, was asked to undertake a review of the success and state of Medicare. Again, the voice of nurses was prominent and credible, leading Hall to state, “The whole submission of the Canadian Nurses Association demands close study by all governments, and I recommend that this is done in a serious way” (Elliott et al., 2013, p. 250). Throughout these decades, CNA strongly advocated for system transformation to the full roster of primary healthcare services to balance the focus on acute care. The association promoted roles that nurses could hold in wellness promotion and disease prevention and emphasized the impacts of a broad set of factors, or social determinants, on population health outcomes (Elliott et al., 2013). The CNA lobbied governments to consider nurses as credible, safe, points of entry into the formal healthcare system that would cost less than physicians while safe and satisfying to the public.
The Canada Health Act, 1984 (Government of Canada, 2020) cemented five principles of universal healthcare in Canada. This legislation and its principles have come to define Canada’s universal, publicly-funded, publicly-administered, not-for-profit health system, known commonly as Medicare. The program provides coverage for all medically necessary care delivered by physicians and other providers, and all care provided in hospitals. The battle for the Act was hard won. After an aggressive national advocacy effort, CNA was the only organization successful in seeing the legislation amended, in this case to extend public coverage to include a range of healthcare practitioners and not just physicians. As the CNA president, Dr. Helen Glass, said at the time, the role of CNA “was to protect the constitutionality of the act while at the same time [opening] the door to insured nursing services,” paving the way for the insured coverage of nursing and nurse practitioner services Canadians enjoy today (Elliott et al., 2013, p. 106). Public coverage for other aspects of care such as public health, primary healthcare, emergency transport, home care, dental care and hospice care, continues to vary widely across the provinces and territories. CNA continues its advocacy efforts in these critical areas.
Public coverage for other aspects of care such as public health, primary healthcare, emergency transport, home care, dental care and hospice care, continues to vary widely across the provinces and territories. In the wake of the landmark report by Canada’s then-Minister of Health, Marc Lalonde (1974) that re-examined factors influencing the health of Canadians, and the later Declaration of Alma-Ata (WHO, 1978), the second wave of health systems evolution in Canada was a time when attention began to turn to what actually determines health (Butler-Jones, 2008; Commission of the Pan American Health Organization, 2019; Falk-Rafael, 2005; Raphael, 2016) and the importance of prevention of illness and injury and the promotion of health and wellness (WHO, 1986). Much of that work in Canada has been led by nurses working with communities and interprofessional teams.
Much of that work in Canada has been led by nurses working with communities and interprofessional teams. Within individual jurisdictions, significant reform was also taking place, often focused on governance of health systems and the implementation of regional health authorities. In this transition, healthcare was to be developed in response to community health assessments, to reflect an inter-professional and integrated service delivery model and establish accountability to the communities served. The intent was to bring services closer to home; place governance within the community versus institutions and governments; integrate services across the continuum of care and use a formal community health assessment process to determine population needs, establish priorities, and measure progress.
Into the 21st Century: Nursing Policy and Advocacy
Nurses were active participants and contributors in all of these activities across Canada, sometimes in partnership with federal, provincial, and territorial governments, and at other times independent of them. Speaking at the CNA convention in 1998, the Honorable Allan Rock, federal Minister of Health, commented that the severe fiscal cutbacks of the mid-1990s had been born unfairly on the backs of nurses. It was at that same meeting that, responding to the lobbying of CNA, he announced the establishment of a federal Office of Nursing Policy to bring the voices and perspectives of nurses strategically into federal health policy development. Leading up to the 1999 federal election, CNA and its partners across the country applied significant pressure for a re-investment in nursing and healthcare that ultimately led to the establishment of the Nursing Strategy for Canada (Advisory Committee, 2000), the launch of a national occupational study of the nursing sector, and a 10-year, $25 million nursing research fund. The new Office of Nursing Policy was funded and opened in the spring of 1999.
The federally funded Nursing Strategy for Canada (Advisory Committee, 2000) recommended establishment of a nurse-led Canadian Nursing Advisory Committee. That committee’s final report (2002) offered extensive recommendations to strengthen Canadian nursing. The federal government also funded the 2006 National Sector/Occupational Study of Nursing which looked at the state of the entire sector (Nursing Sector Study Corporation, 2006). These initiatives were undertaken to identify weaknesses and gaps in Canada’s nursing workforce as well as solutions caused in part by the significant federal budget cutbacks of the mid-1990s.
By the middle of the decade, there was significant energy around nursing in Canada, and the CNA took a lead and released its forward-looking report, Toward 2020, Visions for Nursing (Villeneuve & MacDonald, 2006). The report looked out to 2020, setting scenarios to move nursing and healthcare forward, many of which are playing out today, such as registered nurse prescribing. At the same time, under the leadership of the CNA and its provincial and territorial partners, the Canadian Nurse Practitioner Initiative (2006) received more than $9 million of federal funding to carry out the program of work that led to the education, regulation, and deployment of nurse practitioners across all 13 Canadian jurisdictions. There are now nearly 6,000 nurse practitioners regulated across Canada (Canadian Institute for Health Information, 2019).
With a goal to improve the care of Indigenous Peoples in Canada, the CNA and the Canadian Association of Schools of Nursing entered into a partnership with the Aboriginal Nurses Association of Canada (now the Canadian Indigenous Nurses Association). One outcome of this partnership was the 2009 report, Cultural Competence and Cultural Safety in First Nations, Inuit, and Métis Nursing Education (Aboriginal Nurses Association of Canada, Canadian Association of Schools of Nursing, & Canadian Nurses Association, 2009).
Perhaps no policy effort by Canadian nurses was more intensive or public than the National Expert Commission (2012), led by the CNA in 2011-2012. The goal was to position the association to contribute in meaningful ways to what was then anticipated would be a new Health Accord to succeed the 2004-2014 agreement. To up-end health systems in Canada, the Commission called for achievable, practical action in nine overarching areas:
- Achieve top-five status in five health and healthcare outcomes in five years,
- Put individuals, families, and communities first,
- Implement primary healthcare for all,
- Invest strategically in the factors that improve health,
- Pay attention to Canadians at risk of falling behind,
- Think health in all policies,
- Ensure quality and safety in healthcare,
- Prepare the providers,
- Use technology to its fullest.
These calls to action continue to ground the policy work of CNA and are prominent in its advocacy efforts.
Looking forward, there is a movement across the country to better align healthcare programs and services with actual population health needs. Looking forward, there is a movement across the country to better align healthcare programs and services with actual population health needs. In his analysis of Canadian healthcare, Simpson described hospitals as complicated, and named teaching hospitals as the most complicated of all, “the apex of Canadian healthcare” (Simpson, 2012, p. 22). While many aspects of hospital care are very good, they are expensive, tending to overwhelm provincial and territorial budgets while an estimated 75% of what determines population health lies outside the formal health system.
Hospitals and acute care can exert tremendous impact on individual health in terms of rescue and acute care (e.g., surviving a stroke or heart attack); how much they are able to influence population health is less clear. Goodfellow concluded that Canada is “culturally affixed to a delivery system that is overbuilt and under imagined for the age” calling for dramatic dehospitalization of healthcare (2013, p. 151). For the past century, physicians have been cast as the unquestioned leaders of care, and typically the only provider of diagnostic care, in all settings. This has led to spending in Canada of some 70% of all health system dollars on hospitals and other institutions, physicians, and drugs. While this distribution of spending might have been right during the era of Medicare development in Canada, it is proving a frustrating mismatch for the escalating needs of an aging and very diverse population; a high burden of non-communicable diseases; and growing health inequities in the 21st century.
Canada does not do well in areas such as patient safety and timeliness of care provision. It is concerning that, despite our high per capita spending on healthcare, successive annual updates of the American Commonwealth Fund studies have rated Canada second-to-last among its wealthy fellow Organisation for Economic Co-operation and Development (OECD) member countries in overall healthcare outcomes, ahead only of the US. Canada does not do well in areas such as patient safety and timeliness of care provision. The Canadian Patient Safety Institute has tracked alarming rates of adverse events across the Canadian health system and despite an unprecedented national focus on quality and safety over the past 20 years, Canada’s performance in the area of medical misadventure — adverse or never events — has declined (Conference Board of Canada, 2012).Population health demands and the services we seem willing to provide are increasingly conflicted.
Health systems in Canada are well structured to deliver emergency, acute and tertiary care aimed at rescue and cure in a country that will achieve super-aging status in 2025 (i.e., more than 20% of the population will be over age 65). At the same time, the public is asking for better access to health promotion services; preventive and primary care; affordable supports for healthy aging outside institutions; help to manage chronic conditions; and access to quality palliative and end-of-life care that is close to home. Population health demands and the services we seem willing to provide are increasingly conflicted. The result is frustration and pain points across the health system and costs higher than need be, if we could align systems for the realities of 2020 (Health Council of Canada, 2013). Nurses must be involved because meeting the bulk of all of these health needs falls within the scope and practice realm of Canada’s nurses today.
We have noted that Indigenous status and geography are two social determinants of health (SDOH) that often co-exist in the same populations. Nurses often are the prominent, or even the only, health professionals in some settings. Creating the right conditions that lead to better health and better care for Indigenous Peoples would help to ensure better health and care for all people in Canada. Culturally safe care for Indigenous women in a remote First Nation, for example, would be good care for a Muslim girl in a downtown Halifax emergency room. Implementing strategies to bring care closer to people who live in small, rural towns in the Northwest Territories or Inuit communities in Nunavut can also be deployed in dense urban settings where there are hard-to-reach populations, including people with problematic substance use and/or those who may be homeless.
Creating the right conditions that lead to better health and better care for Indigenous Peoples would help to ensure better health and care for all people in Canada. Feasible solutions requiring nursing leadership to alleviate population health and healthcare challenges driven by the interlinked variables of Indigenous and geographic status include: 1) ensuring cultural safety across health systems for all people, 2) bringing care closer to the where people live, work, learn, pray, and play, and 3) re-imagining ways that health human resources are deployed and optimized. We discuss these solutions from a nursing leadership perspective.
Solution 1: Deliver Culturally Safe Care to All People
Because nurses deliver more care in more places than any other providers in Canada, there is an urgent need for leaders in the nursing profession in Canada to move the dial to respond to the Truth and Reconciliation Commission of Canada (2015) calls for action. Organizations such as CNA that have a national reach are not only well placed to take on a leadership role in this work but, as the national professional voice of Canadian nursing, have a duty to do so.
The CNA Board and staff take this responsibility seriously and have acted to support system transformation in several areas. After more than two centuries of colonial oppression, there is understandable skepticism, and sometimes outright anger and fear, expressed by some Indigenous people regarding colonized structures such as professional associations. Some of this fear stems from the reality that nurses have been complicit in some activities that have caused harm for Indigenous people (e.g., residential schools and Indian hospitals).
In the spirit of honoring the notion of nothing about us without us, CNA has committed to hear, ask, consult, and collaborate with Indigenous nurses by working closely with the Canadian Indigenous Nurses Association. Initiatives have included work on common position statements, media work, and shared appearances in parliamentary committees and other policy settings, all while recognizing that the burden of the reconciliation journey lies largely with settlers.
...leaders understand the obligation to identify and then de-colonize structures and policies that marginalize or otherwise exclude Indigenous people and their ways of knowing and of working together. CNA is in the process of reviewing its entire governance and membership structures, as well as its future branding. In doing so, leaders understand the obligation to identify and then de-colonize structures and policies that marginalize or otherwise exclude Indigenous people and their ways of knowing and of working together. These changes will create safe spaces for Indigenous people to participate. The entire CNA staff took part in the KAIROS Blanket Exercise (2019), a participatory history lesson developed with Indigenous people to support knowledge, truth, understanding, respect, and reconciliation between Indigenous and non-Indigenous people.
An Indigenous public member has been appointed to the Board of Directors to bring Indigenous knowledge and perspectives to the Board’s deliberations and behaviors. Her leadership is shaping positive changes in the ways the Board works. We open and close our Board meetings in a large circle, joining hands and committing to working together as relatives in good ways. As our Elder and Indigenous board member always says, “We may still fight after we hold hands and pray together; it’s just harder.”
Beginning in 2018, responding to requests by Indigenous colleagues, CNA dismantled a traditional physical structure for its annual meetings, moving away from large stages with the Board of Directors seated above and facing down to the audience in favor of a simpler circular format that attempts to place participants on equal footing around concentric circles. This structure has been extremely successful and will continue going forward.
In April 2020, as part of the Year of the Nurse and Midwife (WHO, 2019) celebrations, CNA will launch an Indigenous Leaders Series designed to help the organization and nursing more broadly to engage meaningfully in the reconciliation journey. Honoring the four seasons and four directions important to Indigenous people, CNA will host one Indigenous leader each season beginning with Spring 2020, inviting four leaders over the year, representing First Nations, Metis, Inuit and international Indigenous communities to work with us. Each leader will be invited to undertake activities with our Board and staff to help us understand and de-colonize our structures, and to take on one public activity that informs and encourages the reconciliation journey more broadly.
CNA partnered with the Canadian Association of Schools of Nursing (CASN) in its Truth and Reconciliation Committee (Truth and Reconciliation Commission of Canada, 2015) led by the Canadian Indigenous Nurses Association and created to respond to the Commission’s direct call for changes in nursing education. CNA is working with other nursing groups to develop clear positions to condemn racist actions, such as forced sterilization of Indigenous women, and to determine the correct response to the roles nurses may play in those procedures.
...as part of the Year of the Nurse and Midwife celebrations, CNA will launch an Indigenous Leaders Series... Finally, in this area, CNA is working with Indigenous Services Canada, the federal department delivering healthcare services to some Indigenous people (particularly in remote settings), the Canadian Indigenous Nurses Association, and other partners to deliver three pillars of work within the Nursing Now Canada campaign, part of the global campaign to raise the profile and influence of nurses in 2020. One of the three pillars of work focuses on responding to the call for action in the area of cultural competency, safety, and humility in nursing, with the intention to elevate nursing in Canada across these crucial areas of the reconciliation journey.
Solution 2: Bring Care Closer to Where People Live, Work, Learn, Pray, and Play
In its policy and election platforms, CNA has for some time called for structural changes that could help move care away from buildings and beds to have a much stronger home and community focus. We discuss two of these below.
Leverage technology. In the 2019 federal election campaign, CNA called on candidates to support infrastructure changes, such as broadband access. This access is needed to scale care options (e.g., telehealth) that can help people receive meaningful, safe, and satisfying care in their homes or close to them, thus avoiding costly and inconvenient travel in much of rural and remote Canada. At the time of this writing, the budget of the newly-elected government has yet to be announced.
Establish mobile clinics. Despite its significant geographical challenges in terms of distance, Canada still relies on patients moving great distances at high costs to receive care, typically in urban centers. In many rural parts of Canada, there may be only one daily flight in and out of a community; a trip for a simple diagnostic test or primary care visit may involve missing two days of work and include an overnight hotel stay, and time alone for people who may not have skills to help them manage life alone in a large city.
...Canada still relies on patients moving great distances at high costs to receive care, typically in urban centers. All surgical and birthing cases, including major dental surgery, require travel away from remote communities to a hospital setting. Canada, and other countries facing similar challenges, might take a lesson from Australia and some African nations where teams are flown in on planes capable of serving as mobile operating rooms to treat multiple patients (who do not require in-patient treatment) within a short period of time. The province of Alberta has initiated at least one mobile service using buses where communities have road access, but the notion of bringing care to people versus the reverse model really has not caught on, despite its obvious benefits to patients and systems. Again, in its federal policy and election campaign work, CNA has advocated for governments to invest in digital infrastructure to enable a wider range of mobile solutions.
In a model testing mobile nursing care at the Western Division of the Toronto Hospital, the team has reduced unnecessary visits to the Emergency Department by seniors by sending nurses out to make house calls. The test was so successful in achieving positive impacts on patient care, reduced unnecessary transfers, improved nursing practice, and lower costs that it has now been funded permanently (McNally, 2012). Stand-alone nurse-led clinics in the UK have lifted a significant burden from emergency departments and other walk-in clinics, freeing them to treat the people who really do need the care of a physician.
...the notion of bringing care to people versus the reverse model really has not caught on, despite its obvious benefits to patients and systems. A new model of care is not needed in Canada; what we are missing is a dramatic scaling of models that we already know work well; are clinically effective; safe; satisfying to people and communities; and affordable. CNA has developed Canada’s national framework on registered nurse prescribing (2015) and has worked with partners across the country to roll out this additional skill set in select clinical areas in several provinces and territories.
Solution 3: Deploy the Right Providers with a Scope of Practice Optimized for Challenging Settings
Nothing about system transformation can happen without the right people involved and no group is more important than nurses. According to the Canadian Institute for Health Information (2019), nearly half (48%) of healthcare providers in Canada are regulated nurses. The three regulated nursing categories in Canada numbered 431,769 nurses in 2018 as follows: 301,146 registered nurses, including 5,697 nurse practitioners (all registered nurses): 122,600 licensed practical nurses (titled registered practical nurses in the province of Ontario); and 6,023 registered psychiatric nurses. Problematic for people in rural and remote parts of Canada's provinces, where 17% of the population lives, is that just 10% of registered nurses work in those settings (Canadian Institute for Health Information, 2016).
Aspects of Canada’s 2003 federal/provincial/territorial health accord were informed and shaped by nurses in the federal Office of Nursing Policy, in particular elements related to health human resources and the need for expansion of inter-professional education to support collaborative inter-professional practice. Leaders within the Office had appeared before the Commission on the Future of Health Care in Canada (2002) to speak about nursing and health human resources, and their messages were heard. Commissioner Roy Romanow, a former Canadian premier, noted at the time that nurses are in particularly short supply and doctors are poorly distributed outside major urban centers, while suggesting that “the solution is not merely a question of increasing the number of care providers produced in Canada to reverse the decline of the 1990s” (Canadian Health Services Research Foundation, nd, p. 1). Romanow asserted that “new money should go to changing the way the health care system works, not just paying more people or topping up salaries” and he called for allocating funds to “establish a new type of care, where the mix of the health care providers we already have is better integrated (Canadian Health Services Research Foundation, nd, p. 1). Professionals, from doctors to physiotherapists, nurses, and pharmacists, would work together in a new way that allows different professionals to use the full scope of their skills and training, which does not consistently happen now (Canadian Health Services Research Foundation, nd).
CNA believes strongly that while providers must be well educated and regulated to deliver them, no one owns competencies. For far too long, we have fallen into a trap of assuming that one provider should deliver any one aspect of care (e.g., differential diagnosis) and of more concern, that only that provider can ever deliver the service. Partly as a result of that inertia, we have seen tensions between physicians and registered nurses, and between registered nurses and licensed practical nurses. This pattern continues in pharmacy, rehabilitation sciences, dentistry and so on, all while the public is clamoring for access to services that many different providers could deliver quite safely.
For far too long we have fallen into a trap of assuming that one provider should deliver any one aspect of care... Tools like the Service-Based Planning Framework, evolving under the leadership of Tomblin-Murphy and her colleagues (2013), can simplify the task of thinking about health human resources as they relate to population health needs. In this model, population health needs are identified as are the competencies of providers affiliated with that population (e.g., a hospital unit, a city, a region). Tipping traditional health human resources planning somewhat on its head, or essentially delivering the services any group of providers decide fit for any population (and leaving many gaps in care), this model asks what services and are needed and who might provide them. Looking at the competency gap, or the space between needs and available competencies, it becomes clear in most cases that several different providers might be able to quite safely deliver the required care.
Nurses could contribute more effectively to system and population health outcomes by mobilizing to the licensed scope of practice they are already regulated to deliver. There are many influences and barriers to optimal scope of practice between what a nurse is regulated to do, what she or he feels competent to do, and what is allowed or expected in any given practice setting. In Canada, we have developed the best-educated generation of nurses in our history by requiring the baccalaureate degree to enter registered nursing practice in all jurisdictions other than Quebec, and master’s preparation as the requirement for advanced nursing practice. More stringent educational requirements may be in vain if hundreds of thousands of highly educated nurses are deployed to do exactly as they did in the 1980s other than the use of more advanced technology.
What is missing is a real commitment and scaling of proven models of excellent care. It is our view that nurses can and should be educated, regulated, and deployed to deliver a broader scope of practice that is better aligned with the needs of people in Canada in 2020. The efficacy of nurse prescribing in the UK, and the highly successful outcomes of nurse practitioner care in Canada (Roots & MacDonald, 2014) and the US have made plain that these providers are perfectly capable of delivering care in the place of traditional physician-led models. The public is pleased with care from these nurses, and the taxpayer is, too (Browne, Birch, & Thebane, 2012). What is missing is a real commitment and scaling of proven models of excellent care.
Achieving large-scale change is not easy despite ample evidence for changes that would support the system to function more effectively. There is broad agreement that if we were to start over and design health systems from the ground up in today’s context, they would not look as they do today. Despite years of health accords and other strategies to drive change (including buying it) in Canada, a long line of governments at the federal, provincial, and territorial levels have been unable to drive these major system wide changes. Canadian analysts Tholl, Bujold, and Grimes labelled the problem, Medicare malaise (2013).
The public continues to turn to nurses for leadership. Nurses may be tired, but we do not have Medicare malaise. The public continues to turn to nurses for leadership. Strengthening nursing leadership and advocating for policy leadership through appointments of government chief nursing officers are key pillars of the Nursing Now Canada campaign 2020 (Nursing Now Canada, 2020). We know we will not achieve the system-level change required, especially changes to resolve the impacts of social determinants of health such as geography and Indigenous status, by tweaking the same models of care that have been in place for the past century.
Pushback against change continues. Some forces would be happy to see more private care. Our history indicates reluctance or inability on the parts of elected leaders to risk too much upset. The hard work will continue to fall to professional nursing associations working with partners, including physicians. In 2020, the Year of the Nurse and Midwife, and beyond, the members of CNA will continue to mobilize our collective voice to support elected officials and governments who have the authority to fund and drive change, informed by evidence and experience, to create tipping points toward real transformation.
Michael Villeneuve, MSc, RN, FAAN
After four decades of progressive experience across all domains of nursing practice, Michael Villeneuve was appointed Chief Executive Officer of the Canadian Nurses Association (CNA) in May 2017. Over the previous 17 years, he held executive, leadership and consulting roles with Canada’s federal Office of Nursing Policy, the OECD in Paris, the Academy of Canadian Executive Nurses, and CNA’s National Expert Commission conducted to recommend solutions to transform Canadian health systems. One of three authors of the Canadian Nurses Association’s centennial history book (2013), Michael also is author of Public Policy and Canadian Nursing: Lessons from the Field (2017), the first Canadian text focused on nursing and public policy. Recognizing his contributions to health policy advocacy, he was named in 2018 as one of the Top 100 Lobbyists in Canada’s capital, Ottawa and he was inducted into the American Academy of Nursing in 2019.
Claire Betker, PhD, MN, RN, CCHN(C)
Claire Betker is President of the Canadian Nurses Association and is the Scientific Director of the National Collaborating Centre for Determinants of Health (NCCDH). The NCCDH, hosted by St. Francis Xavier University in Antigonish Nova Scotia, is one of six centres funded by the Public Health Agency of Canada. Through innovative knowledge synthesis, translation, and mobilization the NCCDH facilitates increased capacity for evidence-informed policy and practice decision making with a focus on health equity and the social determinants of health. Dr. Betker previously has served as the acting Executive Director of the Population and Public Health Branch with Manitoba Health, Seniors and Active Living. Her career has included leadership roles in rural public health and home health, primary healthcare, a regional health authority and the Public Health Agency of Canada. Dr. Betker is a past President of the Community Health Nurses of Canada and her PhD work focused on the capacity for public health leadership to advance health equity.
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