In November 2008, during their Annual General Meeting, ACEN members initiated an open discussion of current changes in the healthcare system with a view towards clarifying what is happening across the country and the impacts of change on nursing leadership roles. Using a "cross-country check-up" approach, members shared their jurisdictions' experiences with six issues:

• Restructuring of healthcare governance and professional regulatory approaches;
• Changes to organizational care delivery systems and the scopes of practice of nurses and other disciplines;
• The aging of the nursing leadership and the lack of concerted succession planning;
• Funding challenges and cost-containment initiatives in light of increasing service demands;
• The focus on patient safety and quality of work life; and
• The need to invest in information technology.

Following the AGM, ACEN received funding from Health Canada's Office of Nursing Policy to extend the "cross-country check-up" discussion by seeking input from nursing leaders who did not attend the November meeting. This extended review was conducted by the Janet Davies Group and yielded a comprehensive pan-Canadian snapshot of the impact of changes on senior nursing leaders and their roles.

The Snapshot

Health system reform: Restructuring of governance

Health system governance reform and redesign is ongoing in virtually every jurisdiction, with regionalized governance being the primary approach. In this model, multiple facilities and services (usually in geographic proximity) are amalgamated and governed under a single appointed board. These changes are being effected primarily to reduce costs related to duplication of administrative structures and to create economies of scale. In some jurisdictions, such as Ontario, this approach has only recently been initiated and to date, changes have been relatively modest. In other provinces, reforms have been underway for several years and have been sweeping, as evidenced by the collapsing of all health governance structures into a single "super authority."

In many cases, these changes have also led to a reduction in senior nursing leadership positions. This outcome has implications for both the profession of nursing and its ability to influence decision-making at the senior and executive levels in healthcare, as well as on the sustainability and the representativeness of ACEN.

Policy governance of the system continues to change as well; over half the respondents identified turnover of health ministers and/or deputy health ministers in 2008. At the same time, over half the respondents reported the introduction in 2008 of new legislation affecting the health system. These changes also affect ACEN members and their ability to build strong working relationships with
decision-makers and to influence policy decisions.

Regulatory reform: Professional regulation

Changes to professional regulation are also occurring, again at different levels and speeds across the country. Much of this change has been driven by two major concerns: (1) growing shortages in nursing and other professions and the need to remove existing legislative and regulatory barriers to allow better utilization of human resources, including those educated in other jurisdictions and countries, and (2) an increasing demand for professional accountability and more robust regulatory oversight in the interests of patient safety. Many regulatory colleges have introduced new entry-to-practice competencies in the last 12 months and are contemplating or implementing more stringent continuing competency requirements.

As well, initiatives are underway to establish interprovincial reciprocity in credentialing (e.g., between British Columbia and Alberta). In response to such initiatives and the perceived delays in licensing of foreign-educated nurses and other professionals, ACEN members reasoned that because some of the stepping stones to licensure - such as articulation of competencies and licensure examination - are already developed nationally, the efficacy of national licensure would soon be a topic of discussion. ACEN members acknowledged that before this can happen, the challenges involved in moving to a single licensing approach would need to be addressed - for example, reaching agreement over standardizing educational preparation and other requirements for licensure, and the importance of continuing registration processes at the provincial/territorial level.

Although the implications regarding regulation of health professions relate primarily to workforce planning, ACEN members would be very concerned if the pressure to standardize nursing education for all categories of nurses led to an agreement to roll back educational preparation for both registered and practical nurses to the lowest existing level.

Care delivery and models of care

ACEN members described the need for interprofessional collaboration in the delivery of care in what is expected to be an exponential increase in service demands as the "baby boomer" generation reaches old age. They talked about the need to enhance primary healthcare, including promoting and supporting self-care across all populations. Members also believe that social and environmental issues require attention if we are to achieve "health for all." They are very aware of the links between social determinants, such as homelessness and mental illness, and strongly support strategies that will address social determinants and reduce the burden of illness among all populations. Because of their awareness of the potential impact of these demands on service delivery, senior nursing leaders must be involved in planning and implementing strategies to meet these challenges.

Work redesign

ACEN members reported that changes in the mix of staff and an increased dependence on support workers (particularly in long-term care) are rapidly becoming the norm. Staff-mix alternations are occurring as a result of changes to the educational preparation and scope-of-practice legislation of nurses and other providers that have occurred in most jurisdictions over the past several years and are designed to make the best use of all providers' full skill sets. (The "trickle-down" effect is also now driving a demand for increased education and regulation of support workers not currently regulated.) However, opportunities to change the mix of staff required to provide care are also viewed by decision-makers and operational leaders as a strategy to address fiscal and service demand pressures. While such a strategy may be appropriate in most situations, ACEN members caution that care must be taken to ensure that changes to service delivery models and substitution between categories of staff do not compromise patient safety.

Demographics of the nursing population

Members acknowledged short- and medium-term challenges in maintaining PhD-prepared nurses in the domain of education but support this level of preparation for nurse educators, particularly those also engaged in knowledge generation through research. However, to meet the need for educators in the short and medium term, and to create a strong, continuing link between the education and service sectors, they strongly encourage and support strategies to allow creative use of cross-appointments between academic and service settings to support the educational development of new nurses.

ACEN members also report the actual or threatened loss of executive and senior nursing leadership positions as system redesign continues, with the resulting loss of executive nurses at decision-making tables. They are also concerned about younger nurses' seeming lack of interest in nursing administration as a career path. A significant proportion of current ACEN members and other nursing leaders are within five to 10 years of retirement. ACEN members report that there is now considerable activity and support for the professional development of emerging nurse leaders in most jurisdictions, but they note that the perceived lack of job security in the face of ongoing administrative restructuring, plus the daunting workloads and role expectations attached to leadership positions, make these positions less attractive career options for young nurses.

Funding challenges and fiscal reform

Ongoing fiscal challenges in the current economic downturn were reported by all leaders. Coupled with increasing service demand and expectations of the public regarding access to both technology and care, most governments are actively seeking ways to reduce costs. Along with regionalization, downsizing and changing of staff mixes, many ACEN members report involvement in operational reviews targeted at finding and eliminating unnecessary or redundant services and processes through work redesign. Technology is viewed as both a key cost driver and potential solution by both ACEN members and those working with them at the senior executive levels.

Patient safety and quality of work life

Members talked about increased attention to patient safety and occupational health issues as a central focus at the organizational and provincial health policy levels. Patient safety has become a predominant driver as a result of increased public and political attention to safe care and the emergence of organizations designed to address patient safety issues, including the Canadian Patient Safety Institute.

The focus on occupational health and safety and quality of work life is reported to be related to two issues: (1) the retention of nurses and other providers in the face of growing shortages, and (2) a response to the SARS experience and the urgent need for the system to prepare to manage pandemics. Additionally, the link between healthy staff and positive patient outcomes is increasingly reported in the research literature and being championed by such initiatives as the Quality Work Life, Quality Health Care Collaborative (QWQHC). As a result, assessments of staff health are being included in accreditation processes, and strategies to support the development of healthy workplaces are appearing in contract agreements.

Research

With the development of economic action plans to stem the impacts of economic recession, increased public attention has focused on investment in research. Despite this, funding for the Nursing Research Fund is threatened, and the renewal of its one-time grant of $25 million is uncertain. ACEN members are very concerned about the impact of this lost funding on the generation of nursing knowledge, particularly at a time when such research is critical in supporting innovation.

Impacts of issues and changes on ACEN and its members

Nursing leaders in Canada paint a picture of a health system in flux, and many current trends will have a substantial impact on both ACEN and its members. The ongoing restructuring of health governance and the care delivery systems is having a major impact on senior nursing leadership roles in some parts of the county. In some cases, the roles are being deleted, while in others the scope of these roles is being expanded to incorporate very broad portfolios that will very likely lead to a dilution of their focus on nursing issues. ACEN can support nursing leaders in these changes by providing a network for necessary information and resources, as well as a forum for the identification and consideration of the effects of change. Similarly, ACEN can support members who participate in policy forums and discussions with decision-makers regarding system change, both locally and nationally.

There is also a need for an organization such as ACEN to articulate the perspectives of nursing and nursing leaders at national decision-making tables and in collaborative initiatives. Although healthcare is a provincial responsibility, many activities and collaborative endeavours that have an impact on healthcare and nursing practice are organized at a national level, including accreditation processes through Accreditation Canada, standards and initiatives related to patient safety through the Canadian Patient Safety Institute, health research funding under the Canadian Institutes of Health Research, leadership development initiatives through the Health Care Leaders Network, nursing education under the Canadian Association of Schools of Nursing and the quality work life through the Quality Work Life, Quality Health Care Collaborative. ACEN is currently involved in initiatives to bring a senior nursing leadership perspective to all these organizations.

Developing strategies to ensure the sustainability of ACEN and its ability to provide this support is a priority. Discussions at the November meeting included the identification of strategies and tactics that ACEN could use to support nursing leaders and nurses through current changes in the health system, including exploring the viability of electronic communication strategies and social networking, such as YouTube and Facebook, as mechanisms for sharing and mentoring. Leaders positioned these tools as supports for a community of practice. A scan of change management literature confirms that consultative communication is one of the five principles of managing change. The literature proposes tapping into collective experience and knowledge as a strategy for assessing and creating timely and effective responses to opportunities.

Conclusions

ACEN's cross-country review offers clear evidence that at every level of the health system, from government policy through organizational design, nursing leaders continue to live in "interesting times." Nursing leaders will continue to be involved in and affected by ongoing changes intended to make the system sustainable. Because of this, senior nursing leaders in Canada, now more than ever, need the support, information and advocacy that ACEN can provide. As leadership consultant Dr. Carol Kinsey Goman noted, there is real benefit to be obtained from networking with peers and colleagues to optimize change:

The more access agents have to one another, the more possibilities arise for creating innovative solutions to challenges faced by the whole system - and (as a direct consequence) the more prepared the system is to anticipate and react to change. ... What really distinguishes high performers from the rest of the pack is their ability to maintain and leverage large, diversified networks that are rich in experience and span all organizational boundaries.

The findings from ACEN's report will be used by the Executive Committee to formulate plans for the organization and its future. These will be reported in future issues of CJNL. In the meanwhile, we believe that the findings will also be of interest and use to readers of the Journal.

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