In Part 1 of this column (Villeneuve and Mildon 2013), we highlighted the background, activities and final report of the National Expert Commission (NEC), and the plan for transformation outlined in its nine-point Nursing Call to Action (NEC 2012). The titling of the report was deliberate, reflecting the commissioners' intentions to call all of nursing to action, and at the same time, to support nurses calling others to join in. The commissioners were clear in their resolve that the need for significant, transformative action is urgent if we are to preserve and strengthen the public, not-for-profit, medicare system Canadians value so much.

In all this, the Canadian Nurses Association, which established and funded the NEC, is a key player – arguably the key player. But it does not have a mandate to speak for all sectors of nursing, nor can it bear alone the burden of bending the curve on system transformation without the involvement of many other groups across nursing and beyond. It must be remembered that the NEC was quite deliberately struck as an independent body working at arm's length from CNA; its report, while tabled with the CNA Board, is both to and from nursing more broadly. And CNA is not just the team in Ottawa – the association represents nearly 150,000 Canadian nurses. "Making it happen" has implications for all of us.

In this column, we turn to the responses to the NEC by CNA and other nursing leaders and organizations. We will gauge progress and identify next steps in advancing the action plan of this important milestone – Canada's first national healthcare commission, executed and funded by the country's registered nurses.

Immediate Public Response to the Call to Action

The NEC's report was tabled with the CNA Board and then released to nurses and the public at the CNA Annual Meeting in Vancouver in June 2012. In the wake of a comprehensive media strategy, the report was covered in print, radio and television media for several days across the country – perhaps the most visible being the appearance that week of NEC co-chair Marlene Smadu and member Thomas d'Aquino on Power and Politics with Evan Solomon (who had himself spoken at the CNA convention).

Certainly, there was wider spread of awareness of the report through the participation of CNA convention speakers such as the commissioners themselves, as well as Margaret Trudeau, Arlene Dickinson, Dave Matthews and national-level journalists Andrew Coyne, Chantal Hébert and Jeffrey Simpson, all of whom were briefed on the report and the work of CNA. A constant feed of Twitter messages was provided during the CNA meeting and subsequent convention, which also featured NEC content woven through the entire event.

There was no official comment from government officials or from health professionals outside nursing. Beyond healthcare, the report was featured on the websites of some of the groups consulted, including the Canadian Association of Retired People. The report was linked on the websites of some CNA jurisdictional and associate/affiliate members, as well as in the American Journal of Nursing. The Canadian Federation of Nurses Unions and some of its jurisdictional members immediately issued supportive press releases and put links to the NEC on their websites, as did several schools of nursing.

CNA Responds

Given the breadth of consultation with governments, the public and professionals across the country during 2011 and 2012, and the strong health system focus of the report, the muted response to the NEC by some groups seemed out of step with the energetic responses of participants in the consultations across Canada and with the responses of audiences when the NEC's work is presented. Whether that reflects uncertainty, disagreement with tone or content, or perhaps even transformation fatigue is unclear. Certainly, the report is already being discussed and studied in undergraduate and graduate nursing programs across the country.

With the understanding that "someone has to go first," CNA took a risk in funding and launching the NEC. In turn, the commissioners generated a transformative plan focused on "better health, better care and better value," with an eye to the best use of nurses and nursing in the outcomes equation. Commentators such as Jeffrey Simpson, national affairs columnist with The Globe And Mail, found strength in that approach, with Simpson observing that the report was "realistic in the proposals it advanced" without being self-serving.¹ All nurses and nursing groups had the chance to participate in the NEC consultation process, and many did so. The responses of individual nurses and nurse leaders when they listen to presentations about the NEC's report have been supportive and encouraging. After receiving and digesting the report, CNA established a small internal working group to pull together a formal response, with a plan to involve nurses, the public, governments, corporate Canada and other health professionals across the country. Project charters have been developed, or are in development, to respond to the NEC in the following ways:

1. Champion the "Top 5 in 5"

An invitational consensus conference was held June 5, 2013, to identify five priority health status and system performance indicators that are clear and measurable, with an emphasis on those that are nurse-sensitive.

2. Enhancing RN scope of practice

An invitational, pan-Canadian roundtable was held during National Nursing Week 2013 to convene key nurse leaders and organizations to lay the groundwork for a plan leading to the education, regulation, deployment and clinical practice of RNs able to diagnose illnesses and injuries, and prescribe medications at the generalist level by 2020.

3. National health promotion partnership

This initiative is intended to engage public-based organizations, including YMCA Canada, in influencing positive change for the "Top 5 in 5" through pilot projects bridging nurses and the public.

4. Health in all policies

Work is already underway to study and recommend a health impact assessment process that includes a health impact screening tool to be used at all government levels. This tool will be previewed and implemented during the CNA Board's day on Parliament Hill, Fall 2013.

5. A quality/safety agenda

An action plan for leadership by CNA and the Canadian Federation of Nurses Unions (CFNU) linking both organizations' work is being developed. A meeting of CNA and CFNU with Accreditation Canada and the Canadian Patient Safety Institute was held in March, and an action plan has been endorsed by the CNA and CFNU boards of directors.

6. National Nursing Education Task Force

Plans are in development to launch a National Nursing Education Task Force charged with developing the plan for nursing education reform under the initial leadership of CNA and the Canadian Association of Schools of Nursing.

7. Maximize technology for better care

Work is underway to identify common technology barriers that nurses face in clinical settings and determine how those barriers will be removed so that nurses have appropriate access to the tools they need. Information and communication technology leaders have been consulted, and innovative partnerships involving the private technology sector are being considered.

Still in the development stages are projects in four further areas:

• Nursing Best Practices for Aboriginal Health
• Research to Action for Seniors
• Development of a CNA Centre for Health Policy
• Calling Nurses to Action – a pan-Canadian competition to encourage and reward nurses for their involvement in system transformation

If the NEC's nine-point action plan was daunting in its implications, so too is the challenge of mustering nurses, nursing organizations, other health professions, governments and the public to come together in alliances to move things forward in coordinated ways. CNA hopes, as did the commissioners, that the "Top 5 in 5" initiative will serve as a rallying point and rallying cry for all groups, and will be a logical point of articulation for all the other work.

While the follow-up work on the NEC has begun to unfold, CNA has of course been busily pursuing its existing policy agenda – not the least of which has been its pivotal work as a partner with the Canadian Medical Association in the work of the Council of the Federation in such areas as scope of practice and innovation. The CNA Board met with members of Parliament and senators during their annual time on the Hill in November 2012, when the NEC's work, of course, was prominent. And to spread public awareness of the NEC, CNA purchased special "advertorial" space in The Globe And Mail in December 2012 to share broad messaging about population health and the views of nurses on system transformation.

In her role as CNA president, Dr. Mildon reported on the response to the NEC during the CNA's Annual Meeting in Ottawa on June 19, 2013. Regular updates will be published in Canadian Nurse, and of course the whole plan of action on the NEC will feature prominently at the biennial convention in Winnipeg in June 2014.

A Concluding Challenge

So, the difficult first step, a successful health system commission, was well done, and the work to respond to it has started. But the really hard work still lies ahead. Talk is one thing; transformative action is another!

On behalf of its members – and by extension, on behalf of all nurses – CNA has undertaken a significant body of work to advance the health of Canadians. Strategies to engage nurses more broadly will be essential to the success of this agenda. The CNA team has significant reach and capacity, but can't be expected to lead or execute all this alone. At Dalhousie University, Dr. Kathleen MacMillan showed that a relatively small fiscal investment could go a long way towards helping to build an agenda and move it along.

We invite all of you – especially the members of the Academy of Canadian Executive Nurses, whose members oversee so much care across Canada – to imagine how you can connect with CNA, offer your talents and expertise, and help to move the project charters into vibrant actions that start to shift the curve!

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