Nursing in Canada: An Overview Article developed by CRIN experts: Cheryl Uhlich, RN, BScN, MACT; Cathy Giblin, RN, BScN, MN; Suzanne L. Michaud, RN, BScN, MSc.// Russian in "Russian Nurses Association Tribune", Issue No 4/2006; No 1/2007 CHERYL UHLICH, RN, BScN, MACT Cheryl Uhlich is a Registered Nurse from Alberta with a Masters Degree in Communication Technology from the University of Alberta. Cheryl is the Academic Coordinator for the Canada- Russia Initiative in Nursing (CRIN) Project at Grant MacEwan College, Edmonton, Alberta, and was a member of the Canadian team in MacEwan s previous Health Education Link Project (HELP). MacEwan is Western Canada s largest college. uhlichc@macewan.ca CATHY GIBLIN, RN, BScN, MN Cathy Giblin is a Registered Nurse from Alberta with a Masters Degree in Organizational Dynamics. Cathy is the Manager of Regional Nursing Affairs with Capital Health, Edmonton, Alberta. Cathy represents Capital Health in partnership with Grant MacEwan College in the Canada-Russia Initiative in Nursing Project (CRIN). Capital Health is one of the largest integrated health regions in Canada and one of the country's top-rated health systems. cathygiblin@cha.ab.ca SUZANNE L. MICHAUD, RN, BScN, MSc Suzanne L. Michaud is a Registered Nurse from Quebec with a Bachelor s and Master s degrees in Nursing from the Université de Montréal. Suzanne is a Senior Nursing Consultant at the Canadian Nurses Association (CNA) in the International Policy and Development (IPD) department and acts as Project Coordinator for CRIN at CNA. IPD is responsible for bringing the voice of the Canadian nursing profession to international nursing, health and development policy. smichaud@cna-aiic.ca On the northern part of the North American continent, Canada is the second largest country in the world by land size following only Russia. However, relative to land size, Canada s population is small at 32.6 million people, of which 80% live in urban areas (Statistics Canada, 2001, 2006). The average life expectancy is approximately 80 years. Canada is divided into ten provinces and three territories, each with their own government bodies that come together under a federal constitutional monarchy with the Queen of England as our monarch. Canada s health care system is a publicly-funded, not-for-profit health care system delivery. It is governed by the Canada Health Act at the federal government level. All provinces and territories adhere to national care principles. The system is financed primarily through taxation in the form of provincial and federal, personal, and corporate income taxes. Some provinces supplement health care funding by using assets from sales taxes and other sources (such as donations and lottery proceeds) and two of Canada s provinces, Alberta and British Columbia, use health care premiums that are paid by the residents of the province. For many people this small payment is made for them by their employer. However, in accordance with the Canada Health Act, and with adherence by all provinces to national health care principles, prior payment of a health care premium is not a pre-condition for treatment. All residents of Canada have access to services. Page 1 of 10
Each province and territory within Canada has an obligation and responsibility to plan, finance, administer, and deliver health care within its area. Thus each province governs their hospitals and other health facilities, physician services, public health and prescription privileges. This obligation and responsibility requires competent management of health care funds; Canada spent 142 billion dollars on health care in 2005 with the greatest expenditure on hospitals followed by pharmacology (CIHI 2005). There are many people and professions involved in the health care of the Canadian patient. Characteristics of what constitutes a profession have been detailed by many authors. Carol Bradley, of NurseWeek Magazine (2000), and the Registered Nursing Association of British Colombia (2000), to name a few, detail how all criteria common to a profession are satisfied by the profession of nursing; it holds its practitioners accountable, possesses a specialized body of knowledge, emphasizes the competent application of knowledge, follows a code of ethics, has a tradition of the provision of service to the public, and engages in self-regulation. Bedside nurses work as self-governing professionals within a multidisciplinary team to coordinate the care plan of the patient, including the treatment plan initially set out by the physician. In addition to the physician and registered nurse, a team member may be a pharmacist, physio-therapist, dietician, occupational therapist, social worker or any other health care professional required to meet the patient and his family needs. In Canada, nurses are regulated through title control where registered nurses, RN and in some jurisdictions nurse is protected by legislation (CNA, 2002a). Only those registered with a nursing regulatory body may use these titles. Nursing is a profession with three primary categories of bedside nurse educated, regulated and employed in the country; the Registered Nurse (RN), the Licensed Practical Nurse (LPN) and the Registered Psychiatric Nurse (RPN). RN s comprise more then three-quarters of the regulated nursing workforce and the largest single group of health care providers in the country. There are also unregulated care providers such nursing assistants and other supportive personnel that work alongside and support the work of regulated nurses within the health care. The registered nurses have the knowledge, skills and judgment to coordinate the patient and his family overall care, whereas the Licensed Practical Nurse is usually more task oriented. Today the scope of practice of both roles is rapidly expanding. The Canadian Nurses Association and Jurisdictional Members The Canadian Nurses Association (CNA, 2006) is the national nurses association in Canada. It was founded in 1908 and today is a federation of 11 provincial and territorial registered nurses associations and colleges representing more than 126,000 registered nurses. CNA s vision is that registered nurses are leaders and partners working to advance health for all. CNA s mission as the national professional voice of registered nurses is to support them in their practice and advocating for healthy public policy and a quality publicly- funded, not for profit health system. In pursuit of the vision and mission, CNA (2006) has established the following goals: Page 2 of 10
1. CNA advances the discipline of nursing in the interest of the public. 2. CNA advocates for public policy that incorporates the principles of primary health care and respects the principles, conditions and spirit of the Canada Health Act. 3. CNA advances the regulation of Registered Nurses in the interest of the public. 4. CNA works in collaboration with nurses, other health-care providers, health system stakeholders and the public to achieve and sustain positive patient outcomes and quality practice environments. 5. CNA advances international health policy and development in Canada and abroad to support global health and equity. 6. CNA promotes awareness of the nursing profession so that the roles and expertise of Registered Nurses are understood, respected and optimized within the health system. CNA is the oldest national nurses association (NNA) in the world and is a member of the International Council of Nurses (ICN) which represents 129 NNAs in the world. This membership to ICN helps strengthen the global voice of nursing. Each province has its own registered nurses association and colleges that governs the activities of nurses within each jurisdiction. In Canada, nursing is a self-regulating profession meaning that the provincial/territorial governments delegate to the nursing profession, by statute, the power to regulate its peers (CNA, 2001). Through provincial and territorial legislation, nursing regulatory authorities are accountable for public protection by ensuring registered nurses are safe, competent and ethical practitioners. This privilege is granted by governments and can be taken away. Therefore, to maintain this privilege, nurses must maintain the trust of the public by engaging in self-regulation collectively as a professionals as well as individuals (CNA, 2001). For example, in the Province of Alberta, the College and Association of Registered Nurses of Alberta (CARNA, 2006) is the regulatory authority and professional association for all of the provinces RN s. CARNA was established in 1916 by an Act of the Alberta Legislature and has the history of a profession seeking to assert itself, to define and control its own body of knowledge and practice, and to win recognition, respect and just reward for its contributors. The Registered Nurse regulation of the Health Professions Act provided for self-governance enabling CARNA to set their own standards for practice, develop their educational programming, and establish the requirements for nurses to earn registration. Like the rest of the country, nurses in Alberta are self governing. There were several attempts throughout the years on behalf of the government to remove provisions from the nursing legislation, with the potential to weaken the profession and nurses were called to political action on many occasions to successfully keep the Act intact. The key components of Alberta regulation include mandatory registration with CARNA, protection of the use of the title nurse, a defined, but not exclusive, scope of practice, and clear practice statements that describe what nurses do. Other important components include mandatory compliance with continuing competence requirements. These requirements include achieving a minimum number of hours worked as a nurse each year, and participation in continuing education/professional development activities. CARNA collects annual fees from registered nurses to insure right to practice and for liability insurance coverage. These fees also support the Page 3 of 10
activities of the provincial association and a small amount (about 3%) of this money is transferred to CNA as membership fees to the National nursing association. Legislation in Alberta has authorized CARNA to be self regulating. This mandate is achieved through a variety of regulatory activities such as establishing registration and licensing processes, setting monitoring and enforcing Canadian standards in ethics, education and practice. These standards are based on the values of the profession. Regulatory authorities also clarify the scope of RN practice, and establish entry-level competencies and professional conduct review processes to deal with complaints/concerns about nursing practice. Furthermore, they approve or recognize nursing education programs leading to initial entry to the profession and set, monitor and enforce quality assurance and continuing competence requirements. In addition to these important functions, CARNA is charged with administration of the national RN examination within Alberta. The Canadian Registered Nurse Examination Following completion of an approved nursing diploma or degree program the competence of the entry-level nurse is measured, in part, by the Canadian Registered Nurse Examination (CRNE) develop by CNA in collaboration with nursing experts across the country. The purpose of this exam is to protect the public by ensuring that those who are licensed possess sufficient knowledge and skill to perform important professional activities safely and effectively. The exam is administered by the provincial or territorial regulatory authority. The questions on this challenging examination are designed and tested by senior nurses across the country and following successful completion, the nurse is awarded the designation of Registered Nurse (RN), a title which is well known, respected and trusted by the Canadian public. The exam focuses on the competencies related to safe and effective practice that can be measured in a multiple-choice and short-answer questions format. Of course, there are certain entry-to-practice competencies that are more effectively measured by performance tests. Performance is evaluated within the nursing student s formal education and forms part of the criteria for graduating. Following the initial completion of the diploma or degree the RN may return to University at any time to further education in nursing. Masters and Doctoral levels of study in nursing are available at universities in most provinces in Canada for nurses that wish to continue their formal education. However, even nurses with master and doctorate degrees in nursing must successfully complete the RN examination to practice. Registration is renewed annually and the individual nurse engaged in self-regulation maintains registration and/licensure requirements, adheres to the code of ethics and standards of practice. The nurses practices within her/his level of competence and maintains competence to practice. Page 4 of 10
For example, in Alberta, registration is maintained through a minimum of 1125 hours of nursing practice completed within the preceding five years. The nurse must also complete an annual competency profile which is a workbook of activities and goals prepared for submission to CARNA. The nurse reviews the completed profile with a colleague or supervisor and together they examine the continued learning needs the nurse has identified. It is the nurse s responsibility to ensure that these learning needs have been met as they will be reported in the registration renewal in the following year. Knowledge-Based Practice in Provision of Service to the Public RN practice comprises different and interrelated areas of activity including direct practice, education, administration, research and policy. The central focus of RN practice is direct patient care. RNs in designated education, administration, research and policy positions provide support for RNs providing direct care to clients. Nursing Practice Standards apply at all times to all nurses regardless of the role in which they practice. Nursing standards provide guidelines to assist nurses in decision-making and support nurses by outlining practice expectations of the profession. They also inform the public and others about what they can expect from practicing nurses; and are used as a legal reference for reasonable and prudent practice. The registered nurse is personally responsible and accountable at all times for ensuring that his or her nursing practice and conduct meet the standards of the professional and legislative requirements. The nurse follows current legislation, standards, and policies relevant to the profession or the nurse s own practice setting, and questions policies and procedures inconsistent with therapeutic patient outcomes, best practices, and safety standards. The RN continually strives to acquire knowledge and skills to provide competent, evidence-based nursing practice, while practicing only within their own level of competence. The RN sets justifiable priorities and his or her documentation is timely, accurately reports the nurses data collection, interpretation, planning, implementation, and evaluation of the nursing care provided. The nurse supports, facilitates, or participates in research that is relevant to nursing. The registered nurse provides service in collaboration with the patient and family members, and with other health care professional using communication and team building skills to enhance patient and family care. New roles and practice settings for RNs are being created and will continue to be created in the future to respond to the health needs of Canadians and to address gaps in health service delivery. Ethical Practice and Professional Values A unified nursing community focused on promoting patient safety and excellence in nursing practice in the interest of protecting the public is central to the mandate of a professional Page 5 of 10
association such as CNA. CAN is committed to advancing the discipline of nursing and the regulation of Registered Nurses in the interest of the public. To this end, every collective agreement for nurses in Canada contains an article that directs every hospital, public health facility, and long term care facility, to have a professional responsibility committee. This committee is comprised of equal representation from employees and their managers and the committee mandate is to examine and make recommendations regarding the concerns of employees relative to patient care, including issues around staffing. There exists in Alberta an additional mandate that every concern or complaint formally voiced by a patient be addressed individually. This has resulted in the creation of nursing positions dedicated solely to responding to concerns formally voiced by patients and their families. In further realization of the CNA s vision, mission and goals, in 2002 the association published a booklet detailing the Code of Ethics for the registered nurse that acts as a guide for decision-making concerning ethical matters, serves as a means for self-evaluation and reflection regarding ethical nursing practice and provides a basis for peer-review initiatives (CAN, 2006). The code was written to educate nurses about their ethical responsibilities and values that are held by the RN, but it also informs members of the public and other health care professionals about the code of ethics and morals that nurses commit to when providing health care TABLE 1 Primary Values Central to Ethical Nursing Practice Safe, competent and ethical care Health and well-being for all Individual autonomy and Choice Dignity and respectful treatment of all people Safeguarding of information and the individuals right to confidentiality Equity, fairness and justice in receiving a share of health services Accountability for nursing practice and maintenance of nursing standards Quality Practice Environments to ensure safety, support and respect for all Source: Canadian Nurses Association, Code of Ethics for Registered Nurses (2002b) services. The Code of Ethics for Registered Nurses is governed by eight primary values and provides examples of ethical behavior that demonstrates each of the values in practice (see table 1). The code of ethics is thought at school and is integrated into the employers policies and performance management process. Together, the Code of Ethics and standards provide the basis for nursing practice in Canada. The provincial/territorial regulatory authorities establish, monitor and enforce standards of professional practice and conduct. Standards are necessary to demonstrate to the public, government and other stakeholders that a profession is dedicated to maintaining public trust and upholding the criteria of its professional practice. Educational Requirements The prospective nursing student graduates from high school following completion of 12 grades that include course work in the sciences, mathematics and English. The demand for placement within a nursing program is greater than the capacity and some applicants are not immediately enrolled in the program of their choice. Today at Grant MacEwan College there are five applicants for every one available space in the four-year baccalaureate program. Page 6 of 10
Canadian nursing programs are designed to allow a student completing one level of nursing education to move into the next level seamlessly maintaining continuity throughout the nurses education. This is accomplished through a uniform curriculum that is shared by all and the same for all students. Therefore, a nurse studying at one institution may transfer to another to continue education without penalty or repetition of course work. While most practicing RN s today hold a three year diploma from an accredited nursing college (see table 2), the generally accepted level of education for entry to the profession and the level that has been established by the majority of provinces and territories in Canada as the entry-to-practice requirement is a baccalaureate degree in nursing. In Alberta, CARNA regulation will require the entry level nurse to have earned a four year University degree in Nursing by 2010. There are several rationales for this movement; the most dominant being the tremendous increase in TABLE 2 Educational Level of Nurses in Canada, 2005 Diploma (3 years) 166,004 66% Bachelor (4 years) 79,306 31% Master Degree in Nursing (6 years)/doctorate in Nursing (6 6,348 3% years +) Not Stated 17 Total number of nurses in Canada 251,675 Source: Canadian Institute for Health Information knowledge available to the nursing student today. Changes in illness patterns and their increasing complexity, health care delivery mechanisms, and technological advances have contributed to the expanding body of knowledge shared with the nursing student. Additional reasons for baccalaureate preparation for all include the emphasis on humanizing health care, the development of research based nursing practice, and increasingly complex ethical concerns facing the nurse today. Following the four-year university degree, RNs can choose to pursue advanced education at the master s, doctoral and post-doctoral levels. Although the Canadian government subsidizes tuition fees, the student will still be responsible for fees between 8 10,000 dollars for a four year degree program in Nursing. Registered nurses may also choose to get a specialty certification in one or more of the 17 specialty programs developed by CNA. This voluntary program gives national scope to the principle of continued competence encouraged by provincial/territorial quality assurance programs. It s a tangible distinction, confirming knowledge and skill levels in a specialty (CNA, 2006). This program indicates that the certified nurse is qualified, competent and current in the nursing specialty The Nurse in Alberta In the Province of Alberta there is approximately one RN for every 135 persons and the average age of nurses is 43.3 years. Nurses are the oldest and most experienced are in the mental health areas, the operating room, geriatric and clinic or ambulatory settings. In the coming years there will be an exodus from the profession as greater numbers of nurses retire. In the mean time, Page 7 of 10
nursing colleges and universities are attempting to keep up with the demand for nursing education by potential students. Thirty-seven percent of Alberta Nurses work full time with 42% employed part time and 14% on a casual basis. Greater numbers of part-time positions allow nurses to remain in their profession for longer, to have greater flexibility while raising children or to continue their education. Nurses take on many roles including that of caregiver, manager, health promoter, teachers and counselor. They provide direct patient care, screen for health and illness, and conduct research. Male nurses bring an important perspective to nursing care and are greatly appreciated in the profession by both their colleagues and their patients. Although there is a trend towards more male applicants for nursing student positions, 95% of nurses are female. The RN in Alberta seeks employment in an area of their greatest interest. In addition to bedside nursing or primary care activities within an acute care facility or clinic, the nurse may work within the community, in a public health setting, in primary care or provide services in the patient s home. As a community nurse, the RN works as an administrator responsible for developing policies such as safety while working alone in the community, and managing resources including nurses, supplies and physical resources to optimize patient care. These responsibilities encompass scheduling, setting staff to patient ratios and evaluating the outcomes of these decisions. The community RN functions autonomously in the assessment of patients and, using the nursing process, plans and coordinates the care of his or her patients while responding to urgent patient calls as they happen. The public health care nurse may work within a variety of clinics addressing the specific needs of their community. This may include working with the elderly or with newborns and their families providing ongoing growth and development assessments and immunization as per an established schedule. The nurses may be within a sexually transmitted disease or birth control centre or in a tuberculosis clinic where the nurse provides assessment, education, and recommendations for treatment as necessary. Wherever Canadian RN s applies their skill, they do so with reliance on their unique body of knowledge that constitutes nursing as a true self-determining and self-governing profession independent of others, focused on health promotion, teaching, comfort, coping and promoting independence while also delivering the necessary medical treatments that will alleviate immediate symptoms. Unlike Medicine that focuses on one aspect of the patient s condition, disease and cure, nurses are trained to consider the physical, psychological, social, cultural and spiritual condition of the patient though any stage of the patient's life. The nurse is a welleducated, autonomous, accountable authority on patient and family care charged with the responsibility of caring and advocating for the health care of their patients and the public. Page 8 of 10
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References: Bradley, C. (Ed). Nurse Week Magazine, October 9, 2000. Accessed November 27, 2006. http://www.nurseweek.com/ednote/00/100900.html Canada Institute for Health Information (CIHI). Accessed November 12, 2006. http://secure.cihi.ca/cihiweb/disppage.jsp?cw_page=statistics_results_topic_nurses_e&cw_topic=health% 20Human%20Resources&cw_subtopic=Nurses Canada Institute for Health Information, Workforce trends of regulated nurses in Canada, 2005. Accessed November 27, 2006. Canadian Nurses Association. Accessed November 27, 2006. http://www.cna-nurses.ca/cna/ Canadian Nurses Association. (2002a). Advanced nursing practice: A national framework [Revised]. Ottawa: Author. Canadian Nurses Association. (2002b). Code of Ethics for Registered Nurses. Ottawa: Author. Canadian Nurses Association. (2001). Self-regulation: Safeguarding the privilege. Nursing Now, 10. February. Ottawa: Author (http://www.cna-nurses.ca/cna/documents/pdf/publications/selfregulationfeb2001_e.pdf) College and Association of Registered Nurses of Alberta (CARNA). Accessed November 27, 2006. http://www.nurses.ab.ca/default.htm Nursing Practice Standards and Continuing Competence. Accessed November 15, 2006. http://www.nurses.ab.ca/contcomp/standards-and-cc.html Registered Nurses Association of British Columbia. (2000). Competencies required of a new grad. Accessed November 27, 2006. http://www.crnbc.ca/downloads/499.pdf Statistics Canada (2001). Population urban and rural, by province and territory. Accessed 24 November 2006. http://www40.statcan.ca/l01/cst01/demo62a.htm Statistics Canada (2004). Health Care Expenditures. Accessed November 27, 2006. http://www40.statcan.ca/l01/cst01/health13.htm Page 10 of 10