Health Committee on April 8th, 2014

[James Lunney, Conservative, Nanaimo—Alberni, BC]

Thanks for that. Again, we're talking about jurisdictional issues there, and which nurses are the right mix for which assignment and so on, and now we have nurse practitioners in there.

Dr. Mildon, you mentioned a federal-provincial-territorial table to try to address this.

Cynthia Baker, I think you were talking about a national framework for education.

Can I ask you both to expand on your vision for what these would look like and what outcomes you would anticipate coming out of these?

[Dr. Barbara Mildon]

The best example I can give you, as I alluded to in my presentation, is the Controlled Drugs and Substances Act, where we appreciate so much the work of Health Canada in working with nurses at CNA and with others to expand that provision so that nurse practitioners could prescribe narcotics, opioid-based narcotics, and drugs used in mental health, such as benzodiazepines.

However, that work stops short of brokering a collaboration across the country whereby those changes could be more immediately implemented into practice. What is happening as we speak is that approximately half the country has now reached the ability, under provincial or territorial legislation, to enact those provisions. The other half of the country is still working to do that.

So here the federal government did a great job, and we had what we needed, but it's very slow to be taken up. If there were such a table as a federal-provincial-territorial table that looked at harmonizing those at the point of brokering them, we believe there would be more immediate uptake.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

Are you talking, then, about an organization that might exist for a period of months or maybe a year to analyze this and try to sort out all of these things, or are you talking about creating some kind of permanent institution?

[Dr. Barbara Mildon]

I don't think that it even may need to be an institution. I think it may need to be just another step that's recognized as part of those kinds of processes.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

Thank you.

Ms. Baker, what about your national framework?

[Dr. Cynthia Baker]

Yes. I think I was influenced to some extent by the work that the physicians have done and are doing on their future of medical education in Canada project, their current work, which I believe they presented last week, in which they're looking at, I think, generalists, specialists, and specialization and linking that to human resources.

I see a real need for this in nursing, given what I've been discussing in terms of chronic illness, acute care, and the three categories of practical nurses, registered nurses, and nurse practitioners, a national look at harmonizing.... The outcome would be a harmonization of the education required to prepare practitioners in the future to meet the needs that we see linked to these changes that are coming down or growing in the next number of years. I don't know whether that is very clear. I'm using something of the processes that we have developed in involving all kinds of stakeholders, employers, regulatory bodies, and educators across the country to build this framework.

Then again, we did this with nurse practitioner education, and I think it has an influence. It has no clout legally, but it has influence nationally.

Would you agree?

[Josette Roussel, Senior Nurse Advisor, Professional Practice, Canadian Nurses Association]

Yes.

[Dr. Cynthia Baker]

In terms of harmonizing the preparation of new nurse practitioners, it's this type of exercise.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

Thank you for that.

In this study, of course, we're looking at how to best optimize health human resources. You have had some experience now, in the last number of years, for many years, obviously, of nurses working in northern remote communities. I'm wondering if you could help the committee understand the challenges nurses face in these settings, where there aren't the same resources that you have in the city. Where you have nurses in remote rural communities, what are the challenges they're facing in that area and what are the opportunities to improve those?

[Dr. Barbara Mildon]

Thank you for that question.

Ironically, I would suggest that if from a purely scope-of-practice perspective, nurses in remote and rural areas are most likely to be able to work to their full scope because of the shortage of resources. From a scope-of-practice perspective, they have full scope; they are often the only provider in an isolated setting, and they thrive on that kind of practice. It's when we come closer into urban settings that the scope of practice begins to get narrower and narrower.

Again, your focus is scope of practice. I don't think rural remote is an issue that way. I think the issue is why, when that nurse leaves the north setting or the rural remote setting and comes into an urban setting, he or she suddenly experiences these greater constraints. That speaks to the harmonization that my colleagues and I have spoken to this morning.

[The Chair, Conservative, Ben Lobb]

Thank you very much, Mr. Lunney.

For the next round, we'll have Ms. Fry, please.

[Hedy Fry, Liberal, Vancouver Centre, BC]

I want to thank all of you for bringing together something that is intriguing me.

I understand the provincial jurisdictions for regulation, etc., and for scope of practice.

As you all know, in the health accord, which is no longer there, there was a piece that talked about an HHR plan, a plan for looking at the whole issue of harmonizing and at scope of practice to ensure that, no matter where you lived in Canada, if you were an RN or a licensed physician or any other health care provider, you would be able to work anywhere in Canada where you were needed. This made a lot of sense because we knew that would happen.

That's not happening. That didn't happen. That was cut off at the knees some time in 2007. So, I think we need to talk about how we get back on track for this, because it's essential. That's my first question.

I also wonder if you can tell me why so many nurses, RNs and LPNs, who are working in the system have only contract work. They cannot get a full contract in which they are working and getting all the necessary benefits, and they keep working on a contract basis, which seems to me to be a ridiculous use of educated people. That's the second question I want to ask.

The third question is about nurse specialists. Given that we're looking at home community care models, how do you see the mix of nurse practitioners, LPNs, RNs, and people working in the acute care system unfolding?

Those are three questions: how the mix, including specialists, is unfolding; how we get into an HHR pan-Canadian strategy now that it's no longer there; and why nurse employment is on a contractual basis only, which I think is a crying shame.

[The Chair, Conservative, Ben Lobb]

Who would you like to direct those questions towards, Ms. Fry?

[Hedy Fry, Liberal, Vancouver Centre, BC]

Barbara can take the first one on the HHR strategy.

[Dr. Barbara Mildon]

I'm happy to start, and I invite Anne and others to join in. I'll be very quick.

With regard to staff mix, CNA does have an evidence-based staff mix review tool which it has published. I have personally used that in my practice, most recently in the past year when we were looking at our patient population.

I work in a mental health tertiary hospital where our patient criteria or patient characteristics changed, so we applied this evidence-based process to look at whether we had the right staff mix. In one of our units, we found that we had poor nurse satisfaction. The nurses were not satisfied with their roles, because they were doing a fair bit of non-nurse work, work that could be done by others. We had a patient population that had become extraordinarily complex over the years, and that really directed us then to add registered nurses to that mix.

In the same hospital at the same time, we took a second unit, went through the same process, and found that in fact we needed more licensed practical nurses, or RPNs as they are called in Ontario, for the same reasons. There is an imperative today to use the evidence-based tools to look at our staff mix, always with a focus on patient needs. Staff mix, I believe, is a constantly dynamic function.

The HHR strategy pieces basically speak to nurse employment. Nurse employment is a complex combination of several factors. Number one, again, is needs of patients. Do we have a consistent number of patients in a setting? Do we have an ebb and flow of patients coming and going? How many do we need at what point? When we look at health system funding, that's always an issue.

Another factor is nurses' choices themselves. Some nurses do actually choose to be contract or to not take full-time jobs because doing so gives them greater flexibility in planning their lives.

It's a combination of those three complex factors.

I would leave it at that.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Does anyone else want to answer some of that?

[Anne Coghlan]

I'd be happy to respond to your first question, Dr. Fry.

In terms of mobility and the ability of nurses to move across the country, I would say we've made great strides in that work. Regulators have been working for many years to harmonize the requirements, and the agreement on internal trade put further mechanisms in place.

There are now mechanisms for nurses who are regulated in one jurisdiction to very quickly become regulated in another jurisdiction. The added piece to that is what I mentioned earlier in terms of the creation of the national nursing assessment service, so that once internationally educated nurses have been registered or regulated in an individual jurisdiction, they then will be recognized for mobility across Canada.

While you may be disappointed with some of the outcomes of the health accord, the work that regulators have been engaged in across Canada has gone a long way to support labour mobility.

[Hedy Fry, Liberal, Vancouver Centre, BC]

I am told by many nurses I meet that choice alone is not their reason for contractual work and that many of them cannot get full-time work. They even work overtime on contract work, but I think that their concern is that they don't get the benefits because they're not full-time permanent workers in the health care system.

Paul is nodding his head. Did you want to say something about that?

[Paul Fisher]

Yes, for the practical nursing profession in many provinces, 90% of new graduates are probably only getting casual employment.

We constantly hear from those graduates that significant factors include: one, the health authorities not receiving funding for the number of full-time equivalent positions to allow them to make a position permanent or, say, temporary, for one or two years; and two, the high amount of sick time. If a person is a permanent full-time employee, then that's an added benefit with a cost that the employer has to absorb; whereas for practical nurses, depending on what union they're in, if they work as a casual employee, they might not get those same sick benefits, so it's not as big a financial burden for the employer.

[The Chair, Conservative, Ben Lobb]

The next round is for seven minutes. Ms. Adams.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

I'd like to thank all of you for joining us here today, and I'd especially like to reach out and compliment the tens of thousands of nurses you represent. Whether they're nurses who are coming out through VON to tend to elderly parents in our homes, or the wonderful nurses who show nothing but exceptional compassion in a palliative care unit, your members really do make the difference day in and day out for Canadians across the country, so thank you. We very much value the service that is provided by your members.

The challenge that we face is that primarily a scope of practice is something that is set by the different provinces and territories. What we're hoping to do here as a committee is to offer some best practices guidance to the provinces on how we might be able to ameliorate health care through innovation.

For instance, recently, I was fortunate enough to provide a very large amount of money, about $6.5 million, to McMaster University for a collaborative care research project. This project has community volunteers going out into the community, working with individuals who are at risk of developing illness, and so on. The community members then come back in and report to nurses and physicians. This was funded through the Canadian Institutes of Health Research. Through the limited levers available to the federal government, we're trying to provide demonstration opportunities for best practices. We have every confidence that the $6.5 million should come forward and benefit not only the GTA area but also offer some type of guidance across the country.

Are you aware of any other projects like that? Perhaps you could speak to what the best practices might be that you are aware of, where we can go out and leverage the wonderful abilities of our nurses across the country.

[Dr. Barbara Mildon]

I'm happy to speak to that, and thank you for the funding. I know it will make a difference.

Yes, I think what you're speaking to are innovative HHR practices. You're really at the heart of what needs to evolve as we go forward.

In the case you've described, this is breaking down barriers between sectors, between, for example, a hospital and its walls, the community, which is permeable, and even long-term care settings. We still need to work further on breaking down those barriers.

We are seeing the emergence of some programs, such as those that I'll refer to as family health trusts, where the family health trust is a combination of physicians and other allied health groups, including registered nurses and allied health professionals. They can go out into the community to take care of their rostered patients. This is also a best practice in utilization. It allows registered nurses, for example, to not only get to know the family in the family health trust, because it is essentially an access to care, but it also allows them to go into the homes and meet the needs there.

We can give you more information on those projects, from CNA's perspective, but they are beginning to emerge.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

The other role that I know you're all experts in and that the federal government holds is obviously to offer nursing services and health care services in remote and northern communities. We do struggle to ensure that we are able to provide as much nursing care as possible. It is difficult to recruit into the north, though. You're quite right that nurses in the north are able to actually practise to their full scope of practice. We're hoping, though, to continue to remove barriers so that we can continue to provide top-notch health care to our northern communities.

Could you perhaps speak to any suggestions you might have, for instance, giving drug samples, or anything else that nurses in northern communities are not able to provide right now, but you think they're fully qualified or ought to be quickly qualified to do?

[Dr. Barbara Mildon]

Again, I will speak to nurse practitioners in particular, with the recommendations we made to remove some of the restrictions from their signing various federal forms and so forth, and being able to give samples of drugs. That they can prescribe the drug, but they can't actually give a sample of the drug is quite ironic. This would enable them to help patients on the spot. Usually these are drugs such as blood pressure medication to reduce blood pressure that's too high and dangerously high, etc. Removing those barriers would really make a difference.

The other thing, in terms of supports specifically to our nurses who work in the north, is that notion of skills training. Concerning the national type of education programs that are available—of course I need to mention CNA's own various certification programs—we need to ensure that those nurses are confident in their skills and have the resources that they need to call on when they are faced with some of the very complex situations that they cope with.

Those would be my thoughts there.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

Thank you.

Is there anybody else who wants to comment on what else we ought to be doing to assist nurses in northern communities? I'm simply focusing on that because that actually is a core responsibility for our ministry, the Ministry of Health, and for the federal government.

Dr. Baker.