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Dear Dr. Pringle,
I was quite amused reading this editorial, and for several reasons. The case of Chaoulli v. Quebec is an interesting one. It is an issue that many Ontarians will face at some point when seeking medical care. It is also an issue some of us nurses face as we seek our own healthcare, because we are an aging population. On the one hand, we need hip replacements; on the other, we must wait an extraordinary amount of time to get one. Then we have the workplace complaining that we are off sick and are needed back in the workforce ASAP. This is one issue that caught my curiosity.

The other was your comment about nursing being slow to respond to issues on a publicly funded, single-payer system, and that we were slow to respond on the waiting lists dilemma. I see nursing front and centre on its position. Through RNAO, I believe the message is loud and clear. RNAO's officers, executive director and many of us members are in the media all the time - including on the Chaoulli case and wait times.

I, myself, make sure I take every opportunity to make my voice heard. I do not assume the "silent" position, and I encourage my colleagues to stand firm in their beliefs and convictions.

Your editorial was quick to condemn the "lack" of voice from nursing. Was your voice resonant?

Saverina Sanchez, RN, BScN
Richmond Hill, ON
saverinasanchez@msn.com

Dear Dr. Pringle,
I read your recent editorial by Dorothy Pringle on waiting lists with some interest, but am still a little confused as to her objective in publishing the piece. Rather than offering some direction or constructive proposals for addressing a very complex issue, based on the rather off-hand example of the innovation of the nurse anaesthetist, she provides a scattered analysis of options for the nursing profession that addresses satisfactorily neither the waiting list issue nor the post-Chaoulli future of medicare in Canada.

Moreover, by focusing on the particulars of the role and the presence or absence of "organized nursing" in the media at a given point in time - always a selective strategy - she feeds into a vision of leadership as equivalent to the number of media hits generated, rather than recognizing that policy is more likely to be advanced through the collaborative and multidisciplinary process that has characterized nursing as a profession since my mother and grandmother practised.

Sincerely,
Janet Maher
Toronto, ON
janet.maher@sympatico.ca

Dear Dr. Pringle,
I must say that, as an Ontario nurse, I feel that nursing has been a strong advocate on the issue of waiting lists in general. Sure, there are the medical and diagnostic procedure waiting lists, but RNAO has certainly been vocal on these issues. Of even more interest to myself, though, has been nursing's increasingly loud voice on waiting lists for housing, for food banks, for additional social assistance benefits - all factors that, in the long run, have an even bigger impact on Canadians' health and on the reduction of healthcare cuts.

Cathy Crowe, Street Nurse
Toronto, ON

Dear Dr. Pringle,
In the October 2005 editorial in the Journal of Nursing Leadership, Dr. Pringle asked the question, "Have we [nurses] nothing to say" about wait times, and suggested that the Canadian Nurses Association (CNA) has not offered helpful solutions that might address the issue. In fact, the CNA believes that wait times for health services are an important issue for Canadians and thus for nursing - and has for several years undertaken a roster of activities designed to address that very problem. Specifically in regard to primary care services, CNA sees two approaches to improving access: the implementation of the role of Nurse Practitioner and enhancing collaboration with other professions. The Association's Web site features evidence related to both approaches.

In addition, the Web site includes a July 2004 paper produced by the Canadian Nurses Association and Canadian Medical Association entitled "Taming of the Queue". The paper synthesizes the national and inter-national research on the accessibility of health services. Pertinent to the points raised in the editorial, "Taming of the Queue" offers ideas of how, and where, nursing can play a role.

Using the above-referenced evidence, the CNA successfully lobbied governments to focus collective governmental action to improve access to health services. The 2004 intergovernmental Ten-Year Plan to Strengthen Healthcare reflects those efforts of the CNA

In February 2005, CNA hosted a meeting of representatives from seven nursing specialty organizations to identify a framework for decision-making about waits. As a result, CNA is working with government and other stakeholders to broaden the understanding of the care pathways - rather than an intervention - related to conditions and diseases. Certainly, access to nursing care is vital throughout the care pathway. CNA recognizes the important link between the availability of human resources and wait times. Over the last five years, CNA has significantly augmented the knowledge in the country about the health workforce. It has led and participated in research and analysis of nursing demographics, creation of economic and cost-effectiveness tools, identification of indicators to measure access to the health system, as well as planning and scenario modeling for human resource projections. The documents and recommendations related to these initiatives are available through the CNA Web site.

We hope any misunderstanding about the work of the Canadian Nurses Association has been corrected. At the CNA we remain strongly committed to working with our members and partners, including governments, to improve timely access to high-quality nursing care and other health services needed by Canadians.

Yours truly,
Lucille Auffrey, RN, MN
Executive Director, Canadian Nurses Association

RNAO: Speaking Out for Health, Speaking Out for Nursing

"It is an opportunity for those of us here at Queen's Park to thank the RNAO for the superb leadership you have shown, and continue to show, in representing this province's registered nurses. Joan, Doris and the board and staff of RNAO, you are a passionate and valued voice on health policy."
- George Smitherman, Minister of Health and Long-Term Care (January 28, 2005)

The Registered Nurses' Association of Ontario (RNAO) welcomes any critical analysis of the profession's contribution to the challenges facing healthcare today; indeed, we encourage thorough and thoughtful evaluation of the efforts and efficacy of nursing in influencing and improving the health of individuals and the system. Such reflection can help highlight emerging gaps that require filling, new issues that need action or new directions that should be taken.

We do expect, however, that any analysis of nursing's role in influencing health policy or public debate be based on the facts and flow from an adequate review of relevant information. Unfortunately, the editorial in the last issue of the Canadian Journal of Nursing Leadership fails to meet this basic expectation. So it is with great disappointment that we write to correct the inaccuracies in Editor-in-Chief Dr. Dorothy Pringle's ill-informed commentary, "Waiting Lists? What Waiting Lists? Not Nursing's Problem."

The editorial takes nursing to task for not weighing in early or often or with any effect on the issue of waiting lists for healthcare services or on the implications of the Supreme Court ruling (Chaoulli v. Quebec) striking down the ban on private health insurance for medically necessary services. The editorial, which states that the media did not ask nurses to respond to the ruling, also claims that nursing has been largely silent or slight in proposing solutions to wait lists and wait times. The editorial concludes with this sweeping comment: "Nursing as a discipline in Canada does not assert itself as a knowledgeable and opinionated policy source."

These assertions could not be farther from the facts, and do a disservice to the profession and to the readership of the Canadian Journal of Nursing Leadership. So, to set the record straight, we'll address the errors point by point.

On the issue of responding to the Supreme Court ruling, the author declares: "Nursing as a discipline was silent: silent both about the decision and about its implications for the current health system, and silent on the issue of waiting lists." Wrong. Only hours after the Supreme Court ruling (issued June 9, and not June 12, as the editorial erroneously states), RNAO produced a news release on the decision. Distributed across the country, the news release decried the decision as "deeply disturbing." Acknowledging that all Canadians want better and quicker access to healthcare services, RNAO president Joan Lesmond said the answer was not to introduce two-tiered healthcare, but rather "to strengthen public, not-for-profit healthcare and to improve access to health services for all Canadians." RNAO offered the following advice: "We must focus on healthy reforms such as improved primary healthcare, expanded home care, and strategic investments to reduce wait times and increase the number of healthcare providers." The Canadian Nurses Association also issued a news release the same day, noting that "registered nurses believe that promoting privately owned health services will lead to a deterioration of public health service delivery in Canada."

The editorial also stated that "No nurse was asked by the media for an opinion on the implications of the decision. This is surprising and unacceptable." Wrong again. RNAO's reaction to the ruling rang out repeatedly on national, provincial and regional airwaves - on CBC Newsworld, CTV NewsNet and French CBC television, on English and French radio stations in Ottawa, Toronto, Thunder Bay, Sudbury - and was heavily referenced in national and regional newspapers. Indeed, RNAO was among the first healthcare organizations in the country to be invited to react publicly to the ruling.

Some of your readership may have watched the 10-minute panel discussion on CTV NewsNet's Countdown with Mike Duffy the evening of June 9 with RNAO's executive director Doris Grinspun, Senator Michael Kirby, Canadian Medical Association president Dr. Albert Schumacher and Prof. Martha Jackman, the lawyer who represented the Canadian Health Coalition in the case. And the morning after the ruling, nurses and others may have read comments from RNAO's president in the Toronto Star, the Kitchener-Waterloo Record and the Windsor Star, or learned of RNAO's reading of the ruling in the National Post and the Ottawa Citizen. And RNAO's president also devoted her column in the May/June issue of Registered Nurse Journal to an anticipation of the challenges that the Chaoulli case could present to the sustainability of the healthcare system.

Indeed, RNAO didn't wait for the Chaoulli decision to make the point that the introduction of a parallel private healthcare system would exacerbate nurse and doctor shortages and result in reduced access to health services and longer wait lists and wait times. At every opportunity - whether at royal commissions, first ministers' conferences, program reviews, standing committees, protests, backroom strategy meetings or media conferences - RNAO has been present, advising governments and leading advocacy efforts, using evidence, argument and research to secure the resources, conditions and policy and practice changes that nurses - and the public we serve - need to reduce wait times and sustain a strong, single-tier, not-for-profit healthcare system.

The editorial suggests that the nursing profession has contributed little in the way of concrete solutions to the wait list problem and provided no analysis of how nurses in specialized roles could help curb wait lists. And yet, RNAO has presented targeted recommendations on wait times and access in many documents, including our response to the Romanow and Kirby commissions. As recently as August 11, RNAO again outlined the multi-pronged approach that must be taken to tackle wait times. In a letter published in the Toronto Star, RNAO's president wrote: "Money alone won't eliminate wait lists. That will take more healthcare providers, working more collaboratively, with a better focus on disease prevention and health promotion. It will take the implementation of a successful wait list strategy that addresses what is a reasonable wait and what waits imperil the health of patients. And yes, it will take time for our system to catch up." That same day, RNAO's executive director was quoted in an Osprey News feature on wait times that ran across the province. "When you look here at wait times, two things affect wait times," Grinspun said. "One, we don't have the necessary number of surgeon specialists on certain floors, anaesthesiologists being one of them. The second is, we don't have the right number of nurses in places like ICUs and other units," she said. "Well, both of them are totally solvable." Furthermore, RNAO has presented evidence-based proposals for all of the roles - and more - suggested in the editorial, and done so directly to Health Minister George Smitherman and other public officials.

RNAO has been consistently and intimately involved in providing solutions for wait times in all sectors. Ontario's professional association is also leading critical initiatives to improve access and reduce wait times, including the formation of the Elder Health/Elder Care coalition that was appointed to advise both the health minister and the minister responsible for seniors. RNAO was the only provincial/ territorial jurisdiction invited to be present at the First Ministers' Health Summit in Ottawa, where the Wait Times Strategy was developed last year. We listened, advised and responded to the premier, his health minister and officials from other governments. RNAO was also present, on-site and throughout the media, at this weekend's (October 22 and 23) ministers of health meeting, at which wait times and other important matters were discussed. While CJNL Editor-in-Chief Dr. Dorothy Pringle says that, as nurses, "we have to earn our place at the table," we say: "We're already there, and working hard with governments and others to implement the changes nurses have identified and advocated for so many years."

None of this is to suggest that nurses or RNAO should be smug or complacent about the challenges that the Chaoulli ruling presents. Neither should we underestimate the will and work it will take to ensure that all Canadians, regardless of income or geography, have reasonable access to healthcare services wherever they need them. We agree that we need more quantitative research and analysis about nursing and wait times. What we don't need more of, however, are unsubstantiated commentaries that suggest nursing is silent on public policy issues - including wait times. Ill-prepared criticisms are destructive, even more so when they come from the editor of an important nursing journal.

Joan Lesmond, RN, BScN, MSN
President, Registered Nurses' Association of Ontario

Doris Grinspun, RN, MSN
Executive Director, Registered Nurses' Association of Ontario

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