“Nursing education has been a key factor in the quality of health care throughout Canada’s history, and the quality of education for nurses has been a major focus for the CASN throughout its considerably shorter history. The progress in educational standards has clearly been substantial since Dr. Mack first established his training school in 1875. History suggests, however, that this progress is always tenuous and subject to erosion or subversion by external forces. The overriding goal set by the Association’s founding members for nurse educators to join together and present a strong voice in support of quality in nursing education continues to be as relevant in today’s complex environment as it was in 1942.”
This was the conclusion in a most interesting history of nursing education entitled “Ties that Bind”, published by the Canadian Association of Schools of Nursing, 2012.
And, so, it has been since the early days of the Grey Nuns and the Sisters of St. Joseph in their early work centuries ago in Quebec which preceded Dr. Mack’s first School of Nursing in St. Catherine’s, Ontario in 1874. Then other nursing schools opened in major cities, including Halifax, NS, shortly thereafter.
In those days the medical and nursing professions worked together in changing the face of health care and introducing formalized and much-improved training for nurses and physicians. The Flexner Report published in 1910 set the tone for what we now know as strong, university-based education for physicians and nurses. Up to that point, for both professions, education was really based on the apprenticeship system with hospitals relying on both medical and nursing students to provide essential care for patients.
How many students should be admitted to the university Nursing Programs in NB each year?
With the Nursing Profession holding, deservedly, such high prestige in the public, one tries to respond to that question with much care and caution. It can be said, for instance, that it is anticipated that 200 nurses will leave the workforce each year and therefore we should admit a bit over 200 students to allow for attrition. That may be a mathematical calculation based on positions articulated annually by the nurses’ union and/or the nurses’ association.
True enough, there seems always to be a shortage of nurses, or, at least, a difficulty in filling shifts frequently. Small wonder. Nursing is a tough job and many of the shifts that are tough to fill are night shifts, weekend shifts or stat holiday shifts, the days and times that people normally want or need to be with their families. Shift work is a huge problem in the nursing profession; some like nights, some like days, most don’t like weekends. For some, the 12-hour shift has been a great step for enabling a full workweek to be compacted into much less than 5 work days.
The dream of most with whom I have worked is to get to a “day job”, except for those who have a liking for “permanent nights” or rotating shifts. The need for predictability is perfectly understandable for good people who strongly desire good work-life-family-friends balance.
But nursing is more than RN’s and more than B.N’s. By definition, Nursing describes a continuum of activity ranging from very basic personal hygiene and oral care to managing dressings and fractures to carefully administering life-saving and complex medications to managing the patient in ICU on technology that is highly complex and challenging. Florence Nightingale, known as the original founder of the profession, said that nursing is the “the act of using the environment of the patient to assist him in his recovery.” Much has changed since that day, but the basic concept of assisting a patient in recovery still holds. One major difference today would be the emphasis on the role that nurses play in that which is not recovery but maintenance such as living with one of the many chronic diseases that are so prevalent and for which there are many therapies available. Other differences include the extent to which some nurses become involved in supervision, direction, evaluation, clinical trials, research, and much more.
In Florence’s day health care was pretty simple. There are books filled with hundreds of interventions, surgical procedures, transplantation technology, reproductive technology, thousands of drugs that were not even dreamed of in those days. All of this enormous technological growth, and we are by no means near the end of that yet, has created a whole new world for nursing care. Reconstructive orthopaedics, neurosurgery, clot-busting drugs, dialysis are only a few of the broad categories of interventions that have created the need for nurses to perform at a very high level both in pre-and post-intervention.
The technological revolution has turned the care of patients upside down. In the major hospitals, nurses in certain units are required to become very adept at using highly computerized and digitized equipment used in saving and maintaining lives. They also must become very knowledgeable of complex combinations of medications with great attention given to the impacts and side-effects of many therapies not even on the radar screen 30 years ago.
In the Emergency Departments, nurses are called upon to “triage”, or sort, patients depending on perceived severity of symptoms and seriousness. Professional nurses are called upon to make judgement decisions, often under conditions of serious distress.
Life in the 1960’s and earlier:
Years ago, in times when care was much less complex, care in hospitals was overseen and directed by highly talented RNs who gave direction to nursing orderlies, Nursing Assistants, Ward Aides, porters and more. Those were the 1960’s and before. As knowledge and research advanced, there were various trends in the organization and structure of nursing ranging from team nursing to total patient care. For years, the concepts and approaches to organization of the nursing staff moved back and forth between trends. The Director of Nursing was a very powerful position, setting the standard for performance and discipline. Hospitals were often administered by physicians or senior nurses.
For generations, RNs were trained in hospital-based nurses’ training programs and the graduates were ever so proud of “their alma mater”. Training was a three-year program directed by the hospital. Usually, the School of Nursing would be directed by a nurse-leader and the programs had a high degree of discipline in matters ranging from behavior with patients to interactions with other health professionals, to details of charting and recording, administering drugs, and, of course, the requirement for perfectly starched white uniforms. The programs were intense as was the discipline, and violations of the discipline were typically met with fairly harsh response.
If the hospital determined that there was an impending shortage of nurses, the next incoming class might be expanded by a few seats because the key goal was to train sufficient nurses to keep the hospital operating efficiently and then some. This was in the days when, aside from the university nursing programs, the majority of Canada’s service needs were satisfied by hospital-based schools of nursing. Academic analysts refer to it as “apprenticeship style” training.
In 1965, the American Nurses Association issued a position paper calling for the creation of two levels of Nursing Practice, one with the baccalaureate degree as the basic qualification and a technical level of nursing practice that would require a two-year Associate’s degree. In that same year, the National Commission on Nursing Practice and Nursing Education was created for the purpose of studying the approach to nursing education in the United States.
The Hall Commission Report of 1964 was perhaps the most famous reference for health care in Canada in modern times and it made recommendations on the key elements of the health system. It was the most important and most-quoted reference in Canada in modern times for health care services. In particular, it recommended a major re-structuring of nursing education in Canada. Specifically, it said “in light of our knowledge of and established practice in the education of all other professions, the apprenticeship-type system by which the majority of nurses are now solely trained clearly requires re-examination”.
The Hall Commission recommended a degree program and a “bedside nurse” program, one to be 4-year Baccalaureate and the other a two-year program. Approximately 25% were to be educated at the 4-year level while 75% at the two-year level. Since that time there have been initiatives with two-year, two plus one, then, in NB, strictly 4-year B.N. Meanwhile, the LPN program has grown from apprenticeship/learn-on-the-job to a one-year program then a two-year program complete with provincial regulation and education in established Community Colleges.
In the ensuing decades the approach to the introduction of university schools of nursing grew incrementally across the country with graduates working in a variety of environments, not the least of which was hospital-based schools of nursing.
One of the keys to the success of the hospital-based training programs was that the working relationship between the School of Nursing and the Nursing Service Department, as well as the Administration and Hospital Board, tended to be very close. Indeed, often one would find a board level Nursing Education Committee that would support the Director and faculty, ensuring proper financing and policy support.
As the pressure to increase university-based programs grew, one of the themes of the Flexner Report was heard vociferously across the country. Terms such as “free labor” were used to describe the “over-emphasis on labor and shortage of emphasis on academic achievement.” That language was very persuasive to policy-makers and it is not language without substance. This theme was repeated 60 years later in the Canadian Hall Commission Report. On the other hand, graduates of the hospital-based programs will tell you “it was hard work…. but we sure learned how to look after sick people and we knew that the patient was top priority for us.” In those days, it was also not uncommon to see nurses, at the desks, working for up to an hour after their shift concluded to ensure the patients charts were complete and accurate.
The relationships between training program, administration, governance leaders were typically collegial relationships which are critical in any environment for academic excellence. Typically, local physicians were actively involved in nurse education as well, either simply as moral support or as lecturers in various clinical topics.
Then later in the 1970’s and 1980’s, the push intensified for the training to be transferred to the universities and along with that was the push for the baccalaureate degree as the basic qualification for nurses. This was a long journey from 1905 when the first overtures in Canada were made to the University of Toronto to become involved in nursing education.
In 1982, the prestigious Canadian Nurses Association board passed a motion to the effect that the baccalaureate degree be adopted as required for entry to practice nursing by the year 2000. This generated much debate across the country and caused much uncertainty amongst employer organizations, employees, and more. One major concern in the debates was the prospect of having to invest countless millions of dollars in radically expanding university Nursing Programs in order to meet the service need when hospital schools were phased out.
In New Brunswick, collaborations were limited as the diploma schools of nursing were closed in 1989 and incorporated into the two universities in the province.
In the DECRH, the concept of the all-RN staffing formula was created and implemented. This meant that nursing orderlies, aides and LPNs were eliminated from the staffing formula, leaving the routines of care to be done by highly trained and educated RNs. In 1995, the McKenna government made the decision that the university degree would be, henceforth, the basic qualification for entry to practice nursing. This, together with the “all RN staffing formula”, where it was implemented, led to a level of staffing challenge and distress amongst others who had been functioning in the care continuum.
Educator or Producer of Workers?
A serious point of stress in the system has been around the interface of the philosophy of: “Are we a primarily an academic institution or are we the focal point for training a specific quota of trained people for the marketplace?” Reading through the history of the evolution of nurse education, it is clear that creating graduates ready for the workplace has been a point of debate amongst university administrators throughout the transition from Hospital based programs to university programs.
Health Care, however, is different from other professions educated in universities. Unlike lawyers, engineers, and computer scientists, nurses do not typically exit from university and have endless job opportunities throughout the marketplace. It is true that historically there have been some nurses who have successfully sought and maintained private duty nursing arrangements, but those typically yield unpredictable incomes and benefits and are more limiting in professional activity. Typically, the first entry position is at a hospital where they make an enormous contribution and get great experience that then strengthens their experience base, making it easier to move to some more coveted position in supervision, Operating Room, Primary Care Setting, research and more.
Impact of Demise of Hospital-Based Schools of Nursing:
With this transfer and demise of the hospital-based schools of nursing, the responsibility for student numbers and curriculum now moved from the service side of health care to acadaemia. Previously for the majority of nurses trained in the country, curriculum was decided locally albeit with standards promulgated by the nursing association. This has set up an entirely different set of health care political dynamics.
In the transfer of these programs from hospitals, the relationships between teachers and clinical supervisors changed. With the replacement of the hospital-based program with the university program, now it became more challenging to collaborate, to plan together, to align staffing needs with student intake decisions and more. So, hospitals, long term care facilities, and other employers have had to work with the universities to forge and maintain those collegial relationships. In those areas in which major health employer organizations and university program leaders work at such collegial relationships with intentionality, the results are profound.
The Dean of a Nationally-recognized university nursing program recently referred to their hospital/university relationship as “hand in glove” to describe the relationship between the hospitals and the faculty of nursing. She then went on to outline how students are supervised in clinical settings by experienced and qualified nurse role models. She also explained how committees in the university have membership from service personnel and many other elements of interaction.
This same Dean told me that their school is experiencing unprecedented demand for admission; this year a 65% increase in application rate. Their program was oversubscribed last year as well and when I asked her why, two reasons:
Accreditation of Canadian Schools of Nursing: in 1986 the Canadian Association of University Schools of Nursing implemented a much-planned and discussed program of Accreditation for nursing faculties across the country. This has led to standardization of curriculum and approaches to teaching in Canadian university schools of nursing.
Planning for all the health care resources needed to sustain the system now and into the future, Nursing staffing has all become a huge challenge for government and public policy. It would be terrific if there were one focal point with which government could speak in order to make determinations about investments in health care program education. And in New Brunswick, a small province, the issue is exacerbated by the long-standing convention of “everyone knows everyone and everything is political”! Part of the culture of New Brunswick has been, to its detriment, that if the interests of any group are not satisfied completely, they seem to have free and easy access to elected officials and the media who seem to engage in “us vs. the government”. In health care and long-term care, government is always characterized as intransigent, not progressive, and worse.
A public policy challenge for government in New Brunswick is in deciphering messages received from a variety of key messengers on the topic. We have nurse education programs at University of Moncton with campuses in Moncton, Shippegan, and Edmunston; UNB Fredericton with also a campus in Moncton and Toronto; then a UNBSJ with campus in Saint John. Then there is the entry of private colleges who wish to introduce a nursing program along with the Nurses Association that represents the regulatory and professional advancement roles for nurses, followed by the Nurses Union which has been a strong and active participant in nursing issues.
But health care human resource decisions are too important for mixed messages and somehow from all this, government needs a clear focal point for decision-making. There is evidence, quality, best practices, efficiency, affordability and, above all, excellence to be equally considered in decision-making. New Brunswick is just small enough that it could very well be a living lab or a model of service excellence for the country. But it cannot ever get there without the various elements of the system adopting a collaborative set of relationships and culture.
Then enter the roles of PSWs, LPNs along with RNs. Some of the original thinkers in planning nurse education conceived of a continuum and if health care services are to be high quality and sustainable, that principle needs to be squarely on the table for strategic decision-making.
One of the features of nursing in New Brunswick, and it probably has an impact on recruitment of students at a level not necessarily recognized, is the negative culture in the public square that typifies healthcare in New Brunswick. The messaging in the local press and social media in recent months and years has not been terribly positive, leaving many in the public believing that “government has created a problem and government needs to fix it”:
The positive messages should and must focus on:
Those who have recruited and employed such personnel in health and long-term care in New Brunswick have invariably found them to be good workers with solid work-ethic and standards. In coming to New Brunswick they need to become engaged in a clear pathway that, subject to their abilities to either challenge or pass exams along the way, will help them to reach their goal of registration. In this way we add to the ability of the province to maintain essential staff coverage in hospitals, clinics and long-term care.
One nurse leader in New Brunswick signs off her e-mail messages with the following: “people may forget what you said but they never will forget how you made them feel.” It appears that some, or many, foreign graduates do not feel welcomed or assisted along a pathway to recognition. One remarked that for 10 years all she has felt were obstacles. That can change and needs to change if we are to become the welcoming province that we say we are. That is not to suggest that all foreign graduates will make it to the RN designation but they need to experience a welcoming process that guides them to their maximum level of competence.
This needs to be an exercise based on clear evidence and fact. Health systems in various African countries, European and Scandinavian countries, as well as Oriental countries are well developed and, in some measures, out-perform Canada when measured by OECD statistics.
One of the critical principles of excellent health care service is: “The lowest cost qualified option is always the best option.” It may be interesting for a post-op bed bath to be given by a well-educated university graduate nurse but the same bed bath with the same results can be equally well done by an aide or LPN, assuming both have had the appropriate training and orientation. Law offices have title searches and many other routine functions performed by legal assistants and para-legal staff. Similarly with engineering in which engineering technologists do an enormous amount of very important work, allowing the engineer to focus on assessment, evaluation, planning, designing. The same principle applies to virtually every vocation and profession and must be rigorously applied in health and long-term care. When you educate and train people to do work at a certain level then they find that half the work they are required to do could/should be performed by others with good but less training, you end up with a frustrated workforce! You don’t train 747 pilots to fly two-seater Cubs!
Therefore, it is essential for rational planning of health and long-term care services human resources to be based on the principle of the continuum of service and care. Much “nursing care” can be and is provided by Personal Support Workers as well as family care-givers; much higher-level clinical activity can be an is provided by LPNs; the work of the RN educated at the baccalaureate level needs to be focused on that which was the focus of education; that of the Nurse Practitioner, as well, needs to focus on what he or she devoted two years post BN for and on it goes.
At the same time, BN graduates must be encouraged to continue in academic and research pursuits. There will be an increasing growth in demand for nurses with advanced education in Geriatrics, Primary Health Care, Health and Wellness. Also, the need for Nurse Practitioners will grow as Primary Health Care becomes rationalized.
New Brunswick can and must be a centre of excellence. This province is just small enough to be that “living lab” that has been the dream of many. That can happen when all involved stop pointing fingers at someone else and reflect on the simple question: How do we develop common ground amongst all the players? How do we celebrate the common ground to move forward while finding the right place and the right manner in which to resolve those matters that we are not entirely united on? We owe it to ourselves to do that. It is reminiscent of the question I posed to a group of employees in a health organization in which I had, three months earlier, become CEO: “do we really want to spend the rest of our working lives working like this? Or can we agree to work together to find a better way?” They did not want to work “the old way” and we together built a new culture for the workplace that centred on Excellence!
The employer organizations need to weigh in heavily on this topic. Not only must they be very proactive in forecasting the types and styles of nursing-related positions needed but they must make workplace culture a priority. There have been organizations, even in New Brunswick, that have greatly reduced their recruitment issues by making positive workplace culture a priority. This honestly needs to involve the employers along with medical staff, the professional associations, and the university and community college educational facilities.
Jim Sinegal, founder of Costco, in commenting on how Costco employees are treated and managed, remarked: “Culture is not the most important thing; it is the only thing.”
The players have to stop looking to the Premier or a Cabinet Minister to resolve issues or respond to their expressed positions. And the front page of the newspapers is not the place to have these discussions or disagreements.
Public Policy Issues for Resolution:
These are complex issues and highly politically-charged, as is most of health care! But if we all mean what we say about our desire for high standards, best interests of the patient, quality health and long-term care, then all those with interest in this complex agenda need to be challenged to lay aside conventional positions and thinking and first come to a table to at least try to support progressive strategies that will take New Brunswick from constant bickering over these matters to the active pursuit of excellence:
April 19, 2021
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Ken McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada.