Since the release of the report of the Canadian Nurses Association's National Expert Commission on the future of healthcare (National Expert Commission 2012), I have been struck by the slow response of the system and the health professions to the recommendations contained in the report. As a Director of one of the country's largest nursing schools with a full range of undergraduate and graduate programming, I feel accountable for keeping the dialogue going about the role of professional nursing in health system transformation.

With some 300,000 active registrants, registered nurses represent the largest single health profession in Canada — and we are one of the few professions whose practice spans the sectors of primary care, public health, long-term and complex continuing care, home and community care and acute care. As an educator, I know that we must prepare the nurses of the future who can practice in all of those settings, but the reality is that the vast majority of new graduates will find their first employment in the acute-care sector. Institutional care is the dominant model of health service delivery in Canada, and it is entrenched despite tacit knowledge that this is not a sustainable model in the long term. Of all of the health professions, nursing has the most to gain and the least to lose by shifting care out of institutions to the community, but we are a very meek and quiet voice in the wilderness. We must ask why a profession numbering 300,000 of the most experienced and best educated nurses in history is having so little impact on system transformation.

We have a burning platform backed up by ample evidence. Healthcare costs are currently being artificially held at a 2% increase per annum, and they comprise almost half of many jurisdictional budgets. There is pent-up demand that is estimated to drive costs to 4%–5% per annum increases in the very near future. Healthcare could negatively impact budgets for other government branches that actually have a much larger impact on population health, such as public health, economic development, education, justice and so on. Some evidence suggests that less than 20% of what makes a population healthy can be explained by access to traditional models of healthcare services.

Canada's aging population is not the boogeyman we once thought, because we know that the highest users of the healthcare system are persons of middle age who have chronic co-morbid conditions, including mental health diagnoses, and poor social support (Browne et al. 2012). We know that poverty is the biggest predictor of poor health, and no amount of high-tech, institutional care can fix a lifetime of deprivation. Most of the money we spend on an individual's healthcare will be in the last two weeks of life and largely will be futile – merely prolonging the dying process at a very high cost. Nurses have options for the healthcare system that are community based, low-tech, patient/client-centred and efficient and effective. But at this point in time, the nursing voice is often absent from the system transformation discourse.


Healthcare in Canada

Canada is a federal nation and in accordance with our Constitution, healthcare is largely a provincial responsibility. As a result, Canada's healthcare system is really a mix of the healthcare systems in our ten provinces and three territories, with the federal government also delivering direct services to some Indigenous Peoples, federal prisoners, members of the Armed Forces and veterans.

Canadians spend more than $200 billion on healthcare annually — the world's sixth most expensive system per capita. Funding comes from a mix of public and private sources, with about 70% falling on the public, government side and covering medically-necessary physician, hospital and some post-hospital home care services. Most dental care is privately funded, although surgical dental care in a hospital is a public, insured service. Within the public bundle, roughly 70% is spent on hospitals and other institutions, physicians and drugs.

To rein in constantly climbing costs and improve quality and effectiveness of care, Canada has been on a journey of healthcare transformation for 15 years — with a constant push to re-orient the system to focus more strongly on primary care, chronic disease prevention and management, support for healthy aging and providing compassionate end-of-life care for all Canadians.

 

In this special issue, we have the opportunity to hear from some innovative thinkers about the role of leadership in unleashing the potential of nurses to impact health services delivery. A selection of papers presented at the Dalhousie University Think Tank on the Future of Undergraduate Nursing Education in Canada (MacMillan 2013) and the Wicked Leadership for Wicked Times colloquium held at Dalhousie University to mark the 65th anniversary of the School of Nursing are included in this special issue. To paraphrase American humourist Finley Dunne, if the role of nurses is to comfort the afflicted, then our goal as leaders in this special issue of CJNL is to afflict the comfortable. Questions posed by audience participants during the dialogue following panel presentations at the Wicked Leadership colloquium also are included in this issue; participants were thoughtful and the panelists provocative.

We launch this focused issue with Tom Keighely's call at the Dalhousie Think Tank to discuss and debate an initial framework that could guide a modification of nursing education to future-proof our graduates. Tom is an experienced lobbyist at regional, national and international levels affiliated with King's College London, the University of Sheffield and the University of Toronto.

Dr. Sara Kagan, the Lucy Walker Honorary Term Professor of Gerontological Nursing and Director of the Undergraduate Nursing Honors Program, University of Pennsylvania, points to the need to ground the education of nurses in a deep understanding of the fundamentals of care, presenting a synthesis of present dilemmas in nursing and nursing education, highlights from the fundamentals of care literature and suggesting implications for nursing education.

Maureen McTeer, noted Canadian author, lawyer and legal scholar, who co-chaired the CNA National Expert Commission, reviews the process, major findings and recommendations from the Commission and challenges us again to act forcefully in overhauling undergraduate nursing education.

Dr. Jeff Cohn, President of the Washington-based Plexus Institute, describes the difference between outdated models of industrial leadership and physical production that dominate institutional healthcare and which serve to manage and control innovation in place of providing critical space for much needed innovation. His paper outlines how complexity theory applied to leadership can create opportunities for positive deviance and ground up solutions to complex problems.

Current President of the International Council of Nurses, Dr. Judith Shamian describes her observation that each sector of the system and each profession is functioning in a "bubble" or sphere of influence, and spoke about the need for these bubbles to link and connect for a coherent response to the challenges facing health system delivery and the nursing profession.

Steven Lewis, Saskatchewan-based academic and health policy analyst, points out that nurses are as much agents of where the system is today – stuck – and are just as accountable for leading change as any other stakeholder group. He reminds us of the potential power in our numbers and in public reputation and credibility.

Finally, we also include in this issue, the insightful reflections on nursing and education provided to the Dalhousie Think Tank from two of our preeminent international nurse leaders and scholars. Dr. Alison Kitson is Professor of Nursing and Head of the School of Nursing at the University of Adelaide, Co-Director of the Centre for Evidence Based Practice South Australia and an Associate Fellow of Green Templeton College, University of Oxford in the U.K. Dr. Anne Marie Rafferty is Professor of Nursing Policy and former Dean of the Florence Nightingale School of Nursing at King's College London. She was the 2013–2014 Frances Bloomberg Distinguished International Visiting Professor at the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto.

The papers in this focused issue lay out a case for change and offer new insights into ways we are failing to take advantage of the rare opportunities that present themselves when systems are truly taxed to do more with fewer resources. What the Canadian health system looks like in the next decade and what the role of nurses will be in that system is largely up to nurses and to the nursing profession to influence and impact. We will not be doing that within our own little bubble or from a stance of passive victimization – waiting to be invited to the table. The stakes are high for nursing, for the vulnerable people that we serve and for the cherished publicly funded Canadian healthcare system. It is time to move from mere advocacy to action and to impact.

Kathleen MacMillan, RN, PhD
Director, School of Nursing
Dalhousie University
Halifax, NS

About the Author

Kathleen MacMillan, RN, PhD, Director, School of Nursing, Dalhousie University, Halifax, NS

References

Browne, G., S. Birch and L. Thabane. 2012. Better Care: An Analysis of Nursing and Health Care System Outcomes. Ottawa, ON: Canadian Health Services Research Foundation & Canadian Nurses Association.

MacMillan, K., ed. 2013. Proceedings of a Think Tank on the Future of Undergraduate Nursing Education in Canada. Halifax: Dalhousie University School of Nursing. Retrieved December 2014. <http://www.dal.ca/faculty/healthprofessions/nursing/faculty-and-staff/think_tank.html>.

National Expert Commission. 2012. A Nursing Call to Action: The Health of our Nation, the Future of our Health System. Ottawa, ON: Canadian Nurses Association. Retrieved December 2014. <http://cna-aiic.ca/en/on-the-issues/national-expert-commission>.