A Time for Renewal and Redirection

In response to the unseasonable warmth of an early spring, new growth is blossoming all around us. Unlike any spring in recent times, a new energy also envelops us as we emerge from the hype and fervour of a very successful Olympics. Across the country, Canadians found themselves replete with national pride and a seemingly new-found patriotism. I loved the entire experience, but it left me wishing that there was a comparable event for nursing, an opportunity to showcase our excellence to the country and to experience that nationalistic sense of our unity as a profession. Although our profession has many celebratory events recognizing nurses and their contributions to the health of Canadians countrywide, I wonder how many, and how often, other Canadians take note and celebrate the centrality of nurses to health services delivery in this country? No question that displays of excellence happen every day in every care setting. We know that without nurses, the health system would be bereft of many of the qualities we value as citizens and as care providers. But I wonder – would there be a public outcry if nurses ceased to be the primary caregivers in a majority of care settings, replaced by less educated, less knowledgeable, less skilled, non-professional workers?

With the advent of another spring comes another budget year and, of course, never-ending demands for new ways of delivering healthcare. In recent months, many nurse leaders have lamented the difficult budgetary decisions they are facing, akin to those of the 1990s, if not worse. The damage resulting from decisions taken then took a decade from which to recover: the dilution of professional nursing, an exodus of nurses by the thousands, a decrease in nursing school enrolments and an overall erosion of the quality of care. Are the discussions and decisions of 2010 a déjà vu? Let's hope not. Nurse leaders are talking about their concerns that the staffing changes being made are unquestionably weakening the patient safety net. The litany of evidence demonstrating the correlations between staff mix, nurse–patient ratios, environmental complexity and clinical outcomes seems to have taken a back seat to the demands of budgetary constraints yet again. Nurse executives describe a certain "pressure to be silent" about the implications of staffing adjustments, but why? This is a rhetorical question, of course, as I have experienced this "knowing–doing" gap at first hand. And what I realize more now than ever before is that while there are powerful messages in the large body of extant evidence, it takes great courage to use it to deflect potentially harmful staffing decisions.

On another level, as part of recent deliberations, some jurisdictions have seen fit to eliminate the most senior nursing positions. Over the past decade, federal and provincial chief nursing officers (CNOs) have been very instrumental in securing nursing's position and voice within governments and, more importantly, in influencing the formulation of health policy. Forthcoming issues of CJNL will chronicle some of these accomplishments and highlight the importance of sustaining these roles. We need to ask ourselves why such positions are being eliminated; whether we have influenced different decisions and, if so, how; and how we might ensure that these roles are an imperative for every health ministry on a go-forward basis.

With the unrelenting debate about the ever-rising costs of healthcare, I also wonder if the Canadian public fully realizes the extent to which the system could be taking greater advantage of nursing expertise. Do people realize that nurses' practice capabilities are largely underutilized and could be further extended to complement and supplement the work of other health professionals, particularly in the delivery of primary and pre-emptive care? Not to mention that these services can be delivered by nurses at a lower cost compared to other professionals. This message was poignantly conveyed in a recent column by André Picard (2010). He calls for the system to embrace nurse practitioners (NPs) not only for their capacity to shore up primary and acute care, but also to deliver care that doesn't require a physician. Refreshingly and accurately, he stresses that NPs are not "mini-doctors" but "maxi-nurses." He states bluntly that after four decades of proven value, NPs continue to be constrained in their practice by "vested interests that don't want to surrender their power" and the prevailing paternalism in jurisdictional legislation. While I find myself buoyed by such journalistic support, this rallying cry should be led by our own profession. In provinces like Ontario, the Ministry of Health has committed to establish NP-led clinics as part of the "Family Healthcare for All" strategy, yet none of the 11 clinics announced since February 2009 has been funded, leaving thousands of citizens still without a primary care provider. Suffice it to say that such clinics and an expanded scope of practice for all nurses could well serve the needs of Canadians in rural and urban settings across the country.

Facing budgetary challenges, the emergence of new roles such as physician assistants and the disappearance of other roles such as clinical nurse specialists and senior nursing executives, we need to remain diligent to retain the pivotal role of nurses in Canada's healthcare system. Paternalism is alive and well, and warrants that we embrace a professional nationalism akin to that engendered by the Olympic spirit. Recent news of the unrest within some of our jurisdictional regulatory bodies, and the possible unravelling of our nursing unity, are cause for concern. Without one voice, one message and a unified profession, we will be the losers. "Our strength is our unity of purpose. To that high concept there can be no end save victory" – Franklin D. Roosevelt.

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