What Do We Need to Do Now?
Over the past few months, in a world closed to face-to-face service delivery and social interaction, we have adapted and, for the most part, realized the importance of being apart to keep us all safe. In the face of the pandemic, we saw emergency department (ED) visits and hospitalizations for all but the most urgent injuries and illnesses drop dramatically. The number of people who failed to seek timely treatment because of fear of exposure to the contagion will never be known. But this also raises the question of how the thousands of non-emergent cases seeking care in Canada's EDs in pre-pandemic times have managed over these past months. Has anyone realized that once and for all, policy needs to mandate changes to ensure appropriate ED utilization?
Months of service reductions, delayed elective procedures, routine screenings and clinic and physician office closures will undoubtedly result in untoward outcomes for many. However, Canadians across this country will reap the benefits of a silver lining from this crisis. It is striking to me that after more than two decades of efforts to advance virtual care delivery, in the blink of an eye, the uptake is widespread, being federally and jurisdictionally supported. Virtual care will likely expand and endure for the long term, providing convenience and cost savings. Obstacles of the past, including physician resistance and the absence of specific billing codes, are dissipating. The benefits of telehealth, telemedicine, telehomecare and associated techniques for the delivery of virtual care are being rapidly realized. Accelerating virtual care negates the need for "in-person" assessments, consultations, follow-up care and therapy. Virtual care improves timeliness, reduces travel time and costs and extends access to specialist services, particularly for those in rural and remote communities – not to mention avoiding the need for long waits in congested waiting rooms with potentially infectious individuals.
There is nothing like a crisis to realize the benefits of new models of care. How will our nurse leaders respond to the possibilities for new models of virtual nursing?
Similarly, the closure of educational institutions has challenged schools of nursing to become creative in the provision of classroom and clinical teaching. The adoption and use of online learning platforms and clinical simulation have been accelerated across the country and will also likely be sustained for the long term. Today's students are seeking contemporary approaches to teaching and learning that leverage available tools and technologies. Nurse educators have been significantly challenged to meet the ongoing needs of their students; for many, the use of new pedagogical approaches has been optional until now. How will our nurse leaders in education design and drive the adoption and use of virtual and simulated learning models in the months ahead?
In this issue, our contributors provide perspectives on designing and implementing new models of care delivery, nurse practitioner (NP) practice and support for registered nurse (RN) prescribing.
Specifically, Jeffs et al. (2020) outline the design of a collaborative academic practice model intended to elevate the quality of interprofessional care. Informed by current evidence, engagement of stakeholders as co-designers and alignment with corporate strategic plans, their approach and resulting model will likely have relevance to other organizations. MacPhee et al. (2020) describe their efforts to redesign care delivery within three healthcare organizations transitioning from total nursing care to team-based nursing care. They share several resources and examples that may also be of value to others engaged in the redesign of care delivery. Another organization's journey to implement a model to "support the integration of nurses in their workplace, improve their mobility between clinical areas, enhance their collaboration with other healthcare professionals and empower them professionally" is described by Debs-Ivall et al. (2020). The authors describe their planning, implementation and evaluation of this model in this case illustration. Each of these papers provides key learnings worth considering in the face of rethinking a model of care.
NP practice continues to evolve in conjunction with models of care in Canada, particularly concerning the provision of primary care. Focused on NP practice in northern British Columbia, Bourque et al. (2020) describe a pathway through a NP model that has been implemented, supported and sustained. Contributing to the transformation of primary healthcare in this region, this work has informed new roles, structures and operational processes and improved NP recruitment and retention across the region. Although initiatives such as this are underway, Rayner et al. (2020) focus on the lack of standardized data available to understand NP activities at the system level. They describe a pilot project in Ontario, the Nurse Practitioner Access Reporting (NPAR) system, which involves NPs recording and submitting standardized codes. Overall, they found that the NPAR data did not adequately describe the scope or breadth of activities of NPs practising in primary healthcare. Clearly, better data are needed to demonstrate the invaluable contributions being made by our NP colleagues.
Finally, in conjunction with the need for better data, not just for NP practice but for all of nursing practice, new models of care will need to consider emerging changes to the scope of nursing practice. As a case in point, the emergence of RN prescribing is about to be a game changer in many clinical settings. Moody et al. (2020) share their findings from an environmental scan designed to understand education processes for RN prescribing nationally and internationally. As Canadian nurse leaders develop RN prescribing regulation and education, these findings highlight important aspects to be considered.
Although all of these initiatives are to be applauded for their contributions, the overwhelming questions that remain in the face of a post-pandemic world are: what elements of existing care delivery models will need to change now and how? How do we address the requisite isolation of those sick and dying in our healthcare institutions? Is there anything we can do to ensure that no one has to die alone? As we anticipate the development of a vaccine for COVID-19, societal norms are being significantly modified and will likely remain so for a very long time, if not forever.
Let us consider the implications for care delivery into the future. What have we learned as healthcare leaders? What needs to be different, and what can we do better as the dust settles on this crisis? I would be remiss in not mentioning overwhelmingly tragic outbreaks and an inordinately high number of deaths in our country's long-term care facilities – likely a focus for another issue of CJNL. The heart-wrenching failure to protect our treasured and most vulnerable citizens should incite all of us to do better – we must do better the next time. As a citizen, as a nurse, as a leader, what will you do?
To all of our colleagues, nurses, personal support workers and other health professionals, as well as all support personnel working throughout this crisis, you are our heroes. Thank you for your commitment and courage. From all of us at CJNL, our sincere gratitude.
Lynn M. Nagle, PhD, RN, FAAN
University of Toronto
University of New Brunswick
Bourque, H., K. Gunn and M. MacLeod. 2020. A Pathway for Implementing the Nurse Practitioner Workforce in a Rural and Remote Health Region. Nursing Leadership 33(2): 44–53. doi:10.12927/cjnl.2020.26238.
Debs-Ivall, S., E. Kerr and G. Lemire-Rodger. 2020. The Development and Implementation of a Model of Nursing Clinical Practice: A Journey. Nursing Leadership 33(2): 38–43. doi:10.12927/cjnl.2020.26239.
Jeffs, L., J. Merkley, N. Amaral, L. Ginty, K. Ronald, L. Yang et al. 2020. Co-Designing a Collaborative Academic Professional Practice Model for an Integrated Health System: Sinai Health's Journey. Nursing Leadership 33(2): 7–20. doi:10.12927/cjnl.2020.26241.
MacPhee, M., B. Fitzgerald, F. Havaei, B. Budz, D. Waller, C. Li et al. 2020. Nursing Care Delivery Redesign: Using the Right Data to Make the Right Decisions. Nursing Leadership 33(2): 21–37. doi:10.12927/cjnl.2020.26240.
Moody, E., R. Martin-Misener, J. Carrier, M. MacDonald, K. MacMillan and S. Axe. 2020. The Educational Terrain of Preparing Registered Nurses to Prescribe: An Environmental Scan. Nursing Leadership 33(2): 54–66. doi:10.12927/cjnl.2020.26237.
Rayner, J., F. Donald, R. Martin-Misener, R. Glazier and A. Kopp. 2020. Nurse Practitioner Activities in Ontario Family Health Teams: Comparing Three Different Data Sources. Nursing Leadership 33(2): 67–79. doi:10.12927/cjnl.2020.26236.
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