Karima Velji, former president and chair of the board of directors of the Canadian Nurses Association (2014–2016), recently addressed the newly inducted fellows of the Canadian Academy of Nursing, sharing her observations on the current state of the Canadian healthcare system and the critical role nurses can play in supporting patients and building the system of tomorrow.

Introduction

Thank you and congratulations to the third class of fellows, the new inductees to this wonderful academy. I feel very proud to stand in your great company. I cannot believe that we are 800 members strong. It is just a wonderful growth of membership over a short period of time.

I have spent a lot of time thinking about the topic on which I want to speak to you today. I thought I would spend some time today, sharing some of my views and observations on the experiences of Canadians as they interact with the healthcare system and the dilemmas that they face. Then, I will juxtapose this with the current state of nursing in Canada and end with a call for action and a possible role for us as members of this academy.

Nursing in Canada is in a developing position, where it has the highest in numbers among healthcare professionals in Canada. Nurses comprise the most educated workforce in its history and are high holders of the public trust. Nurses are often the first point of contact for people who need healthcare. They interact across all the sectors of healthcare from community care to different organizational settings as well. Nurses are the providers who touch healthcare around the clock on a 24/7 basis.

Lifelong Commitment to Equity

Let me go back a bit to help you understand where I come from. I was the oldest of three daughters. My dad died an untimely death in Tanzania at 34. My mother was 33 years old when he died. She raised her three young daughters on her own and never remarried. As a child, my observations of our interactions with the healthcare system back home were very eye opening. Every interaction with the healthcare system started with a visit to the business office, where you had to pay a fee for service in order for anyone to lay eyes on you or for you to get the care that was needed. As I mentioned, my dad's death was untimely. That really weighed on me from a very young age. Frankly, my dad died because the right standard of care was not available in that country, at that time. He had kidney failure, and there were no dialysis or transplant services. Even if they were available, we could not have afforded it, so he would have died regardless.

I became devoted to the idea of a publicly funded health system. I decided that I was going to advocate for this for the rest of my life – the idea that healthcare must be equitable and accessible to everyone. People should not have to pay to get the basic care they need. I am a big believer in public-funded healthcare.

My family came to Canada as immigrants because of two simple reasons: good healthcare and good education. Our thinking was that these would give us a standing and opportunities in life. I was surprised to see, as I went into nursing, graduated and started to work, that the state of our healthcare system was not what it should be. Although I am proud of Canada and all its accomplishments in healthcare, one in 10 to 15 of us do not have access to a primary care practitioner. Stable primary care practice is the most basic, foundational aspect of care in a healthcare system. Canada also has an aging demographic, which is begging for investments in community-based solutions.

How does an average person access the care they need in our country? It is not easy. There are barriers to accessing healthcare that are rooted in systemic racism and inequities. We have seen the wait times in mental health and addictions services. We would not tolerate that kind of wait time for any other condition. Yet, mental healthcare is just one example of the difficulties people are experiencing in accessing care.

Leveraging the Health Human Resource Challenges

The COVID-19 pandemic has laid bare Canada's workforce issues. Ontario is leveraging the health human resource challenges to bring to attention and enable action on some long-standing matters. For example, the chief nurse position has been reinstated at the federal level, and my own position has been elevated to a senior leadership level at the ministry of health in Ontario.

We have also made progress in enabling internationally educated nurses to enter practice far more quickly now than in the past. In Ontario, the minister of health has directed the College of Physicians and Surgeons of Ontario and the College of Nurses of Ontario to expedite the registration of internationally trained practitioners to ensure timely care to Ontarians (Government of Ontario 2022b).

In Ontario, as in other provinces and territories, we have also started to move in the right direction by creating more seats in education and by continuing to expand and optimize the scopes of practice of healthcare professionals. We are fast forwarding bridging programs in nursing and putting in resources to support supervised practice to onboard new nurses faster into the system. We have implemented several programs to enable people to learn and stay in practice, particularly in underserved communities. We are also providing nursing students with employment opportunities while they are students; many have bridged into full-time vacancies. Ontario has also implemented long-awaited reforms. For example, in the long-term care sector, we are moving in the direction of implementing an average of about four hours of direct care per resident per day guarantee while we build more long-term care capacity (Government of Ontario 2022c). We are also funding the integration of nurse practitioners in long-term care homes (Government of Ontario 2022a). No doubt, we have learned from the issues during the pandemic and have moved to action.

Strategies are under way that will address some of the gaps, but we know that there is more work to be done. We will not recruit and retain our way out of the challenges we face; this presents an opportunity to reimagine healthcare and reimagine nursing.

Seize the Opportunity

There is a historical number of vacancies and absenteeism in nursing, and this scarcity of nurses and health human resources needs to be treated as the dire urgency that it is. There is a body of literature and guidance (e.g., Magnet organizations [Brennan 2019]) that, if implemented in a standardized way across the system, could elevate workplace environments to be able to recruit and retain nurses. Anecdotally, I can tell you that although the whole system is experiencing health human resource challenges, there are organizations that are implementing Magnet strategies of shared governance, flexible scheduling, career ladders and so on, that have a much more stable health human resource experience.

We have to ensure that models of care serve population needs and help respond to our concurrent health human resource challenges. Are nurses occupying the right places for the right care providers in the system? Have nurses been placed in the service of vulnerable populations, such as people with mental health illness and addictions, to address the issues of access and inequity? Have nurses been positioned in upstream roles to prevent inappropriate hospitalizations? Is the healthcare system poised to face the shifting aging demographic to serve our elders with the best solutions in the community? Preserving the status quo where the highest educated and experienced nurses are aligned to acuity rather than complexity puts us in a vulnerable place where we become observers and commentators rather than architects of the models of care that need nursing leadership and involvement.

I get very passionate about this because from where I sit, I see how other healthcare professions are evolving to be architects of community-based solutions that will improve access. Nurses' roles need to be strengthened in primary care and home-based care to address the gaps that the pandemic has brought to the forefront. We have to work across sectors to deliver care in an integrated way to those we serve. We also need to unleash the full potential of nurses to ensure the health of the population.

Call for Action

We need to find a path forward and work together to ensure that Ontarians, and all Canadians, receive safe, high-quality healthcare as the health system continues to respond to and recover from the COVID-19 pandemic.

We have an incredible opportunity in Canada right now. But we need to raise our heads from the day-to-day dilemmas that are occupying our minds and start reimagining the healthcare system of tomorrow, and the role of the nurse in that system.

There is wisdom throughout Canada and each of its provinces and territories. Let us find and harness this wisdom to build a healthcare system that meets patient care needs and the needs of the workforce. All nurses, in all settings, have a real opportunity to step up and shape the future of healthcare and nursing and to help position nurses as architects and leaders of our healthcare system.

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