The New Age Of Nursing: It’s not just changing diapers

November 1, 2006 by Natalie Salat

ILLUSTRATION: BERNADETTE LAU

ILLUSTRATION: BERNADETTE LAU

Jodie Boltuc may be putting it bluntly, but it’s only because she is passionate about her intended career: nursing. “You’ve got everything from bedside care and community nursing to research,” says the fourth-year student at Ryerson University’s school of nursing in Toronto. “Before, if you entered nursing you would never have thought of getting your PhD. Now, you can teach or be the CEO of a hospital.”

Boltuc, an active member of the Canadian Nursing Students Association, is not the only one who would like to clear up some common misconceptions–like the idea that nurses are there to simply hold the patient’s hand and do as the doctor says.

With a worsening shortage of health care staff across Canada, nursing students, organizations and schools are becoming more vocal about what the profession has to offer, and more politically active. “We’re doing lots of recruiting,” says Marlene Smadu, president of the Canadian Nurses Association, which represents more than 125,000 nurses. “We’re recruiting aboriginal populations and minorities and males–targeting groups we haven’t targeted before. But even with that, we won’t likely bring our numbers up to where they have been.

The baby boomers are leaving, and we haven’t created the same number of people to replace them.” However, she says, given that nurses represent the largest workforce in health care, “By our sheer numbers, we can change the way health care is delivered.”

She offers a few examples, like advocating for the use of electronic health records to prevent patients from repeatedly being asked their medical histories by hospital staff. Or changing the way health care professionals communicate and work together, so that gaps or overlaps in patient care are avoided. “For too long, we haven’t done that well,” says the registered nurse of nearly 30 years. “We shouldn’t be duplicating work.”

As it stands, Canada’s 315,000 nurses have a lot on their plate. They keep hospitals running round the clock, get many community health programs off the ground, teach other nurses, and are often the only source of health care in the country’s farthest-flung communities. They assess patients’ conditions, administer medications, perform intubations, create care plans, co-ordinate health services, and break both good and bad news to loved ones. They work in all areas of health care–from maternity and pediatrics to oncology and palliative care. “Nurses are better educated and have a lot more responsibilities nowadays,” says Joan Davis, a clinical professor at the University of Ottawa who has nursed for 40 years.

Davis is still passionate about nursing. This summer, while volunteering at the Canadian Museum of Civilization’s special nursing exhibit in Ottawa, Davis enthusiastically shows visitors how the profession has evolved in Canada, from the founding of North America’s first hospital in Quebec by three French nuns in 1639, to the intrepid adventures of the Grey Nuns and the Victorian Order of Nurses in the Wild West and Far North during the 19th century, to the vital contributions of Canadian nurses during the major conflicts of the last century.

Today’s crop is facing different challenges, she notes. “Right now, the patients who are in hospital are much sicker. There is an aging population, so naturally there are going to be a lot more people having medical problems. Nurses are overworked and probably overwhelmed with the workload.” They also have to deal with occupational hazards such as exposure to contagious diseases and violence in the workplace. As Davis observes, “In the emergency department, you never know who’s going to come through those doors, and in what condition.”

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Canada has three main nursing professions: registered nurses (RNs), of whom there are 247,000 practising across the country, registered psychiatric nurses (RPNs), of whom there are 5,000, and licensed practical nurses (LPNs), of whom there are 63,000. (In Ontario, LPNs are called registered practical nurses.)

All three professions are self-regulating. This means that provincial and territorial governments have delegated, by law, the power to nurses to set standards of practice for themselves and ensure that these standards are met.

The standards for each group are set by professional associations in each province or territory, and are based on a code of ethics. The associations also serve as the licensing bodies. They determine the educational requirements for prospective nurses and administer the certification exams. In the case of RNs, for instance, all jurisdictions except Quebec administer the Canadian Registered Nurse Examination.

Higher levels of education and responsibility are what set registered nurses and registered psychiatric nurses apart from licensed practical nurses. Most provinces and territories (apart from Quebec) now require, or will soon require, that RNs and RPNs coming into the system have at least a four-year bachelor’s degree in nursing from a recognized university.

Licensed practical nurses, formerly known as nursing assistants, must have a community college diploma. Whereas LPNs work with clients whose outcomes are stable and predictable, the other two nursing groups are qualified to care for patients who have unpredictable outcomes, says nurse Leigh Chapman, an education consultant for the College of Nurses of Ontario.

The bachelor of nursing degree has a strong emphasis on science, and covers everything from nursing across the lifespan, to physical and health assessments, to legal and ethical issues, to communication with other health care professionals. Clinical placements in settings such as hospitals and long-term care facilities make up about 40 per cent of the program.

Those aiming to become registered psychiatric nurses focus their studies on mental health. Besides learning to perform standard nursing functions, students gain the skills and knowledge needed to provide counselling, draw up treatment plans and participate in crisis interventions.

Canadian nurses are becoming progressively more educated. According to the CNA, 8,076 students graduated from university “entry-to-practice” nursing programs in 2004, representing a 76 per cent increase since 1999. In the 2004-05 school year, the number of students enrolled in baccalaureate nursing programs throughout 120 schools was just under 28,000, while some 3,500 were enrolled in graduate degree programs.

Education is essential, says Smadu. The CNA president, who is a professor at the University of Saskatchewan in Regina, explains, “The practice of nursing has changed so fundamentally in the last 25 years. (It has become) a high-tech, high-touch profession. The public expects the high touch (part), but you can’t really function without being very knowledgeable about health and medical technology.”

Higher levels of education have also changed the dynamics within health care. “A doctor couldn’t walk into a role and know how to nurse,” observes Dr. Sally Thorne, a professor and director of the University of British Columbia’s School of Nursing, the first school in the British Empire to offer a degree program in nursing–in 1919. “There are distinct things going on. Very happily, we’ve moved past doctor-nurse games and power dynamics, to a really strong commitment on the part of educators and clinical settings to make sure communication is effective from the beginning.”

Boltuc got to see that during her 16-week placement at the critical care trauma centre at the London Health Sciences Centre in Ontario. “I noticed the cohesion (of the health care team). It’s not what you would picture in the past, where a nurse only spoke when spoken to. The nurse would suggest things to the physician, and the physician would readily take the suggestion.”

Linda Silas, the president of the Canadian Federation of Nurses Unions, agrees things are better, if not perfect. “In today’s health care system…there’s a lot more teamwork, especially with the younger doctors. They’re coming into the system and saying, I don’t want to work 70, 80, 90 hours a week.”

There is one area, however, where the CFNU president sees “turf protection” on the part of doctors–the use of nurse practitioners or NPs. NPs are registered nurses with advanced education that enables them to fulfil some of the duties of family doctors. Although there has been a gradual acceptance of nurse practitioners in collaborative medical practices, “we still have only 830 or 840 in this country,” she says. “That doesn’t make sense.”

Silas asserts that nurse practitioners could relieve some of the pressure on family doctors, and make the health care system more efficient. “Why waste the time of a doctor when what you need is preventive medicine–a Pap test, a blood test?”

Dr. Ruth Collins-Nakai, past president of the Canadian Medical Association, responds, “Nurse practitioners have always existed up North, (in places) where there is insufficient work for an MD. (Those) who work in a combined practice with other physicians are valuable members of the team.” However, she says, more work needs to be done to establish what the scope of practice of nurse practitioners should be, especially if they are going to work independently. “There need to be liability and training considerations.”

Kathleen Matthews, a nurse practitioner at the Great Slave Community Health Clinic in the Northwest Territories, has nothing but positive things to say about her experience. “Some people didn’t really understand what the role was (initially), and there was some education required. But once that took place, I’ve been very well supported by the physicians I work with. Basically, I can see people with common illnesses and stable chronic illnesses. When someone becomes unstable or I’m unsure of the diagnosis, I’m expected to refer.”

Aside from the nurse practitioner debate, Collins-Nakai says official relations between the CMA and the CNA are better than they have been. For one thing, they are united by a desire to tackle the worsening shortage of health care professionals. “It’s a big problem,” she comments. “So we’ve gone together with nurses and other health care groups to say, you’ve got to have pan-Canadian planning. We still have ministers of health acting like little dictators in each province, who want to control their own fiefdom rather than have pan-Canadian planning.”

Drastic cuts in government health care spending during the 1990s resulted in layoffs, pay rollbacks and heavier workloads, driving many health care professionals away, or down to the United States. The greying of the baby boomers is not only set to ramp up demand for health services but also to deplete nurses’ ranks. As of 2004, more than one-third of Canada’s 247,000 practising registered nurses were over 50.

The Canadian Nurses Association anticipates that by 2011 the health care system will be short 78,000 nurses. “We (already) have a severe shortage,” observes Silas. “Nurses are doing more overtime than ever–18 million hours in this country a year. That’s equal to 10,000 full-time jobs. Of course there’s a ripple effect. Nurses are burning out.”

That’s not good for their health or their patients’. Numerous Canadian and international studies point out that a lack of nursing staff results in “adverse occurrences” such as medication errors, bedsores, post-operative infections and longer stays in the hospital. And, points out Collins-Nakai, “if you’ve got a shortage of critical care nurses, you have to close intensive care unit beds, and that backs up critical surgeries. If you have a shortage of operating room nurses, that cuts back the number of surgeries you can put through.”

Even well-off provinces such as Alberta are not immune. Last July, the Calgary Health Region had to temporarily close four out of 18 ICU beds at the city’s largest hospital because there weren’t enough nurses available.

Those at the front line themselves feel that quality of care has been compromised by the shortage of staff, as they have indicated in focus groups conducted by nurses’ unions and health researchers.

Nonetheless, Collins-Nakai says Canadian nurses are highly regarded for their skills, knowledge and caring. “One of our biggest problems is that the Americans like them so much they spend a lot of time recruiting them.”

There has been some progress on this side of the border to address the health human resources crunch and stem the southward tide. With prodding from advocacy groups, the public and the media–not to mention the telling health care reports in 2002 by the Romanow Commission and Senator Michael Kirby–provincial and territorial governments have begun taking some positive steps.

Wages are certainly better than they used to be. Silas observes that nurses’ pay was “awful” in the 1990s, but caught up by 20 to 24 per cent in the early 2000s, and especially benefited the nurses who work weekends and shifts. Two-thirds of nurses work in hospitals, so 12-hour shifts are common.

Rates of pay vary widely across the country, depending on economic conditions and the type of nursing. Registered nurses and registered psychiatric nurses tend to earn the same wages, given their similar levels of responsibility. Senior general duty nurses in B.C., Ontario and Alberta earn between $33 and $37 per hour, whereas at the lower end in Quebec, Newfoundland and P.E.I., they earn around $27 to $28 an hour. Licensed practical nurses earn between $15 and $25, with the best rates being paid in Manitoba.

Smadu says remuneration and benefits such as vacation time are “getting there” thanks to the collaboration of unions and governments. However, she maintains, “when you think of the complexity, the intensity and the life-and-death nature of the work, the nursing profession as a whole has still not caught up with many professions in society.”

Besides improving wages, other government initiatives include the establishment of nursing retention funds to the tune of hundreds of millions of dollars, which provide money for full-time nursing positions (which only half of nurses have), the admission of more international nurses to Canada, and the addition of more student seats at universities.

That’s a start, says Sally Thorne. “We have to become more self-sufficient. In many parts of Canada–B.C. is certainly an example–we’ve only been educating about half the health care professionals we need, assuming they’ll come west from somewhere else.”

Thorne acknowledges that all the provinces are keen on increasing the number of medicine and nursing seats in the Canadian system. “The problem is finding adequate faculty and clinical placements,” she points out. “You can’t just train nurses in the classroom. The things nursing students are doing are significantly serious that, if they’re not done well and appropriately, could cause harm. There does have to be appropriate supervision and support for students in a clinical setting.”

Major Lee-Ann Quinn, for one, is doing her bit to bolster the nursing profession. The Yukon-based nurse practitioner, who has done tours in Rwanda and Bosnia, is in the middle of finishing a graduate nursing degree. Her aim is to teach up-and-coming nurses at the university level.

With the many years of education she has behind her, Quinn observes, “I could be doing brain surgery. But I would never give up the profession of nursing, and it’s because of what we do from day to day at the patient’s bedside that is so phenomenal. We don’t just look at somebody with a sore arm or sore eye….We look at the whole individual.”

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