Introduction

Established in 1908, the Canadian Nurses Association (CNA) has evolved through and survived many times of triumph and tumult over the decades (CNA 2024a). But few times have found CNA in a tougher position than it is in today as we juggle the need to provide strong and effective advocacy, stewardship of the profession, a wide range of member services and a constant effort to attract voluntary members. Sustaining CNA as the national and global voice of professional nursing in Canada needs decisive support from the nurses of Canada. In this commentary, the current and past chief executive officers reflect on CNA's legacy of success and call on nurse leaders to rally support for an exciting and effective national professional association. 

The Beginning

In the early summer of 2023, more than 6,300 registrants from 145 countries took part in the biennial gathering of the world's nurses at the International Council of Nurses (ICN) Congress in Montreal (https://www.icn.ch/events/icn-congress-2023-montreal). The first in-person congress since before the COVID-19 pandemic, the Montreal meeting – co-hosted by CNA – brought nurses together to share knowledge, build relationships and celebrate nursing on a global scale. Nurses around the world have turned to Canada as a beacon of professional nursing excellence for over a century; this was the third time ICN met in Montreal (1929, 1969, 2023), along with the Vancouver Congress in 1997, again cementing the important link among nurses of Canada and the world (Elliott et al. 2013).

The connection to the larger world of professional nursing has deep roots in Canada that even pre-date CNA. Mary Agnes Snively, sometimes described as the “mother of nursing in Canada,” led the nursing department at the Toronto General Hospital for more than 25 years starting in 1884, and during that time, she had a tremendous impact on the education, regulation and professionalization of nursing in Canada and beyond (Elliott et al. 2013). Understanding the need for collective action, she worked closely with nurse leaders in the US and the UK, and with those colleagues, co-founded the ICN in 1899 (Elliott et al. 2013). She would serve as treasurer and later vice-president before going on to found what is now CNA (CNA 2024b), by pulling together existing provincial nursing and alumnae associations. The establishment of a national nursing association was a requirement for any country to become a member of ICN. Hence, CNA was born not only to unite Canadian nursing but also to link Canada formally with the world's nurses.

Advancing the Profession: A Proud Legacy

The spirit of action and stewardship of the nursing profession sparked by Snively has been embedded in the “DNA of CNA” for the past 116 years. For much of the 20th century, CNA was the only national nursing association of any type in Canada, leading the development of the overall profession with policy work and operational tools related to nursing education and curriculum, testing, clinical practice, management, working conditions and much more. The organization was forceful in the move of entry-to-practice nursing education from hospitals to community colleges and on to universities, and in the establishment of master's and eventually doctoral programs in nursing. It produced the first curriculum for nursing assistants and generated dozens of respected reports and briefs about the working and practice conditions of nurses. In all its work, CNA was busily advocating for patients, universal healthcare and better health for all, having an impact on disease treatment, public health policy and legislation such as the Canada Health Act (1985). None of these advances would have happened in the absence of a strong, credible, national, professional association.

As the century moved along, many of the functions of CNA were moved out into separate, free-standing organizations for nursing education, management, 40-plus nursing specialty and interest groups, research and union representation. All these sorts of changes began to narrow CNA's mission and scope of work. CNA has long been a force behind the regulation of nurses, and starting in 1970, CNA administered the Canadian Registered Nurse Examination (CRNE) written by all prospective registered nurses (Elliott et al. 2013), until regulators reached a decision to use a different exam starting in 2015. CNA was also the home of entry-to-practice examinations for licensed and registered practical nurses and nurse practitioners; it founded Canada's national nursing specialty certification program (CNA 2024c) and developed and maintained the profession's national code of ethics.

The peeling away of many of the previous stewardship functions of CNA, along with the CRNE revenue loss, were compounded by a dramatic shift in membership structures over the past decade. Provincial and territorial nursing organizations had held dual professional and regulatory functions for the past century, their nurses wrote CNA's examination to practice and registrants automatically became members of CNA with a fee transfer coming from each province/territory to support the national professional home of nursing. The decision that registered nurse regulators could not maintain their dual professional/regulatory function resulted in the dissolution of the long-standing link between the jurisdictions and CNA and the membership model that had supported CNA since its inception. That major shift was the last straw that rattled long-standing and reliable funding for the national body.

Transformation and Restructuring

With so many changes underway and on the horizon, CNA moved to restructure the organization so it would be fit for purpose for the 21st century, including the establishment of a new governance and membership structure to reflect the new reality of having no provincial or territorial organizations as members. The organization consulted with nurses across Canada in 2019 and 2020 about their expectations of CNA, membership structures and the value that CNA could bring to their practice. Nurses said they wanted to be able to participate and influence important decisions, they wanted better lines of communication and they wanted a more robust mechanism for election of the board that did not look like a rubber-stamped process. CNA responded with a new individual membership where any nurse in any regulated category could join CNA directly in a voluntary model with full voting privileges, along with the ability to run for an officer or board seat. CNA also included membership options for nursing students and retired nurses.

While direct, individual membership in CNA has many advantages, it came at the expense of the historic connections with the provincial and territorial organizations, as well as the national specialty associations. In the past, nurses automatically became members of CNA by renewing their licence to practise each year as the CNA membership was bundled; this is no longer the case creating confusion among many nurses who still believe they are members of CNA, when they are not. Canada's anti-spam legislation (https://ised-isde.canada.ca/site/canada-anti-spam-legislation/en) created an additional barrier to easily connect with the nurses of Canada, making it a tough task for CNA to speak directly with nurses about the value and importance of membership in their national association.

At a time of so much distress across our health systems and the nursing workforce, the presence of a strong national professional nursing association is more critical than ever. Certainly, the voices of organizations such as the Canadian Association of Schools of Nursing (https://www.casn.ca/) and the Canadian Federation of Nurses Unions (CFNU) (https://nursesunions.ca/) are important pillars in the advocacy and lobbying of nursing at the national/federal level. However, CNA is the only association charged with speaking for all nurses in all regulated categories, all practice settings and domains of practice and in all provinces and territories – and is still Canada's link to the ICN. CNA speaks for the profession at large, and is its overarching steward, but that professional voice has been destabilized by the many changes that have confronted CNA over the past decade.

Despite many threats in the environment, CNA has been active and effective in its lobbying efforts related to wide interests, including medical assistance in dying; senior care; access to care (primary care, palliative care, mental health); cannabis education; the COVID-19 response; health human resources; antimicrobial resistance; and funded research related to racism and discrimination in nursing and strengths-based nursing and healthcare leadership. In fact, despite the many challenges, CNA was so effective that it was named three times since 2018 in the Hill Times’ list of the top 100 lobbyists in Ottawa (Paez 2018).

Nurses have told us that they want a strong professional nursing voice speaking for them both locally and nationally. Currently, there are provincial nursing associations in British Columbia, Alberta, Manitoba, Ontario and Quebec, along with groups attempting to build associations in Saskatchewan and the Atlantic provinces. There is no formal connection among these organizations, at times, creating an obstacle to unity on important policy matters and resulting in duplication of service offerings and member benefits that create competition for members. While the provincial associations and CNA have and continue to collaborate, this new reality has resulted in a risk of the loss of the national professional nursing voice. And since nature abhors a vacuum, we can be sure that others will step in to speak for nursing – with physicians historically claiming that space. CNA has a solid relationship with the Canadian Medical Association, and we work very well together, so this comment is not a slam to physicians; rather, it is a cautionary note that in the absence of a national professional nursing association, historic patterns may re-emerge. The same can be said of the CFNU, where the organization is large and leads tremendous work but represents only unionized nurses. Moreover, with its core work being the “strong national voice for unionized nurses in Canada,” CFNU is, of course, not charged with advancing the larger profession (CFNU 2024).

A Call for Collaboration and Support

A strong collaboration among provincial associations, the national specialty associations and CNA is vital, and given the voluntary membership model, we must also consider sustainability, particularly in smaller jurisdictions. To respond to the desire for a strong national and local voice, CNA has initiated the development of a chapter model to allow an option for a local presence in provinces and territories not on a scale large enough to support the presence of an ongoing professional association. To survive, professional nursing associations must work together and seek new approaches to fund operations that are not solely dependent on membership or that create innovative, alternate mechanisms of reaching potential nurse members, for example, through employers.

At this time of sands constantly shifting beneath our feet, transformation of health systems needs informed input from nurses; there has never been a time when powerful nursing advocacy was more essential. In the interests of sustaining and building a vibrant nursing profession and ensuring access to the best possible care for people in Canada, we must pull together and support a strong national professional nursing voice.

Correspondence may be directed to Tim Guest by e-mail at tguest@cna-aiic.ca.

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