The Registered Nurses Professional Development Centre (RN-PDC) in Nova Scotia would like to address the following quotation from this paper: "Historically, the roles and competencies of the FP-RN have not been clearly defined and, to date, there have been no formal training or education programs specific to family practice nursing in Canada." We understand that the authors' intent was to identify the fact that there were no formal courses within nursing degree programs that recognize family practice as a subspecialty. However, there is a post-licensure program.

RN-PDC was established in April 2003 as the result of a strategic assessment and repositioning of the former Post RN Specialty Education Program unit. RN-PDC is in the business of specialty certification for registered nurses in Nova Scotia and has recently taken a leading role in the development and implementation of interprofessional programs.

In 2007, Capital District Health Authority, in partnership with RN-PDC, initiated the Nursing in Your Family Practice Program, which in 2010 was renamed the Family Practice Nursing Program. This is a post-licensure program designed to facilitate the family practice nurse to work to full scope of practice. Included in this program is the five-day Foundation Week, a resource kit, 10 self-directed learning modules with clinical placements and integration support. The program is facilitated through the Registered Nurses Professional Development Centre. To date, this program has enrolled 72 family practice nurses from across Nova Scotia. For more information, interested parties may review the website www.cdha.nshealth.ca/default.aspx?page=RNPDC&category.Categories.1=894&centerContent.Id.0=62003, or contact us at RN-PDC.

Sincerely,
Tanya Magee, RN, BN
Corinne Hodder Malloy, RN, MS
Education Program Coordinators
Family Practice Nursing Program
Registered Nurses Professional Development Centre
1276 South Park Street, Bethune Bldg., Room 235
Halifax, NS B3H 2Y9

[Re: Our Healthcare "System" – What System?, by Lynn Nagle 23(4): 1–3]

In her timely editorial, Lynn Nagle (2010) questions whether the Canadian healthcare system is a system, given that it fails to meet the characteristics of a system – its various components do not function as a unit to meet its purpose. For example, with healthcare personnel not communicating with one another in a timely fashion or coordinating their care effectively, patient care has become fragmented and discontinuous. Patients are failing to receive the care they need. Nagle suggests ways to improve the system. One possibility is to have a navigator – a person to help people navigate their way through the system to secure the care they need. In recent discussions about the future practice of registered nurses (RNs), it has been suggested that RNs fulfill that role. But would that be a good use of RNs, or of any professional? Would it not make more sense to make the healthcare system more user-friendly and navigable on one's own? Why has the system been made so complicated that people need navigators and guidebooks explaining how it works?

During recent experiences with the healthcare system in Ontario, I found that so many agencies and personnel are now involved in the transfer of patients from hospital to community care, and then within community healthcare itself, that it is difficult for patients and families to determine who is responsible for what, and who (if anyone) is overseeing their care in the community. As well, it is difficult for them to make plans when the system will not tell them, until after hospital discharge and a home visit from a community care access centre (CCAC) case coordinator, exactly the kind of community care, and the number of hours of care, they will receive. Then, to complicate matters, if the care allowed by the coordinator falls short, patients and families discover that they have to seek, and pay out of pocket for, "extra" care. They further discover that the system emphasizes the importance of preventing caregiver fatigue and burnout, but does not provide adequate hours for respite care. Later, those with chronic conditions discover that their allowed care can be decreased at any time – a constant, real threat that adds to their anxiety.

In the current climate of cost containment, CCAC case coordinators have the difficult task of providing adequate care within ever-decreasing budgets. Supposedly, to ease that problem, personal support workers (PSWs) – unregulated or unlicensed workers with little, if any, formal preparation in healthcare – are increasingly being employed to give nursing care once provided only by RNs or licensed practical nurses (LPNs). The speed at which nurses, especially RNs, are disappearing and the speed at which PSWs are appearing, at the front line of community healthcare, is disquieting. While there is indeed a place for PSWs in healthcare, the system is endangering those it serves by using PSWs to give care that requires more knowledge and understanding than these workers acquire through their short programs (if they have attended any) or through short on-the-job training sessions. In community agencies, nurses supervise PSWs, but from a remote distance. Further, there is no supervision of PSWs with an independent practice (CNA 2005). The great danger of substituting PSWs for nurses (RNs and LPNs) has been clearly identified by Grinspun (2009), the executive director of the Registered Nurses Association of Ontario, but the practice continues.

Finally, I was chagrined by the extent to which community nursing care is being provided on a task-by-task basis: RNs and LPNs become involved in care only when a task arises requiring their expertise. Once the task is resolved, patients are discharged from the care of RNs or LPNs. Under this task-oriented model of care, no RN or LPN oversees or monitors the patient's needs and care. Also, patients and families tend not to distinguish healthcare providers in terms of their preparation. They do not know if the person caring for them is a PSW, an LPN or an RN (CNA 2005).

RN organizations are working hard to increase public awareness of the need for and value of RN care, but their message seems to be falling on deaf ears. Perhaps the reason is that most patients nowadays are receiving nursing care (especially in the community) only from a PSW but think they are being cared for by an RN. Not having experienced RN care, they do not know the difference that RN involvement would make in their care, and that their PSW is doing the work of an RN (e.g., overseeing and coordinating care). Like PSWs, families are doing the best they can but are putting themselves and others in jeopardy because they do not have the requisite knowledge, understanding or skill.

The present healthcare system is increasingly and unnecessarily adding to the already heavy burden of patients and families. In the process, it is making them ill, not better.

June F. Kikuchi, RN (Ret.), PhD
Professor Emeritus, Faculty of Nursing
University of Alberta
Edmonton, Alberta

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