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Written Submissions to the
National Expert Commission
A Call for Submissions through the Commission’s web pages invited written letters, stories,
research and examples of innovations, to inform the Commission’s report. The Commission received
nearly 60 submissions, ranging from brief e-mail messages to formal papers. These submissions came
from registered nurses, nurse practitioners, licensed practical nurses (registered practical nurses in
Ontario), nursing students, educators, members of the public and organizations.
Submissions are shared here in the language in which they were received, and were not edited by the
Commission. However, the submissions have been adjusted to remove personal identifying information.
Permission was obtained to publish the papers submitted by organizations.
For further information about any submission, please contact: [email protected]
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TABLE OF CONTENTS
INDIVIDUAL SUBMISSIONS .................................................................................................... 3
ORGANIZATIONAL SUBMISSIONS ......................................................................................... 30
The Academy of Canadian Executive Nurses (ACEN) Submission: ......................................................... 30
Registered Nurses’ Association of Ontario (RNAO) Submission: ............................................................ 41
Fourth Year BScN Students, Trent University Submission: ..................................................................... 56
Fédération Interprofessionelle de la Santé du Québec (FIQ) Submission .............................................. 64
English Translation: ............................................................................................................................. 70
Community Health Nurses of Canada (CHNC) Submission: .................................................................... 76
Canadian Hospice Palliative Care Nurses Group Submission: ................................................................ 84
Quality Palliative Care – Long Term Care Alliance (QPC-LTC Alliance) Submission: ............................... 87
Ordre des infirmières et infirmiers du Quebec (OIIQ) Submission: ...................................................... 100
English Translation ............................................................................................................................ 140
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INDIVIDUAL SUBMISSIONS
DATE
June 6, 2011
CONTENTS
Submission by a Nurse Practitioner:
I am a XXX of the CanWell Program, an exercise and education program for people with cancer in
Hamilton Ontario. The CanWell Program was the recipient of the Ontario Division Canadian Cancer
Society/Cancer Care Ontario Innovation Award in 2010. CanWell is innovative, in that it maximizes
the capacity of health care professionals (Physiotherapist, Nurse Practitioner), and exercise specialists
to provide interventions for cancer survivors in a community setting.
There is an ever increasing body of evidence regarding the significant benefits of cancer and exercise.
We believe programs such as CanWell, can help make our health care system sustainable by
improving the health of cancer survivors.
The CanWell Program is listed in the Canadian Partnership Against Cancer data base of leading,
innovative, and promising service delivery models.
http://www.cancerview.ca/idc/groups/public/documents/webcontent/hhr_repo_canwell.pdf
The CanWell Program is a partnership between Hamilton Health Sciences, McMaster University, and
the YMCA. This partnership has developed additional population specific programs, for example In
Motion, for people with bone and joint problems. I have copied XXX, General Manager of Community
Health Development YMCA. You may want to contact her to learn more about the innovative Live Well
programs offered by HHS, McMaster University and the YMCA.
If you are interested in learning more about the CanWell Program, please let me know...
www.canwellprogram.ca
Aug. 11, 2011
Submission:
XXX… I think you may find this article of interest re Mental Health First Aid:
http://www.medscape.com/viewarticle/725637
…. Perhaps the Mental Health Commission of Canada and its affiliated Mental Health First Aid
programming can find some collaborative common ground with this new Nursing Commission.
Aug. 30, 2011
Submission by a Registered Nurse:
Comments: As a nurse educator, I believe a national strategy to ensure the future recruitment and
education of nurse educators is a necessary part of the conversation for better care. To this end, there
must be fiscal and organizational support for those interested in education at the Doctoral Level in
Nursing Education. Better value is a product of "evidence" that only be demonstrated research on how
nursing does make a difference not only to quality of care, but also economically, fiscal responsibility
and life.
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Sept. 12, 2011
CONTENTS
Submission:
I hope that the Commission will consider inclusion of expanded roles for other health care
professionals in their review and deliberations. For example, the role of Community paramedics
(selected references attached) in preventing inappropriate transfers to the ER and the potential role
of community pharmacists in renewing chronic medications and providing medication reviews and
patient education. The latter was contained in a review for the Ontario MOHLTC by HPRAC and a
report released in Jan 2009 (available on the HPRAC web site). This work was done within a broader
review of non-MD prescribing.
Further to this, the current experiment in the UK of extending prescribing rights to general class RNs
who complete a post graduate educational program in pharmacology and prescribing, and are on an
approved list, has improved access to timely pharmaceutical care for persons who are home bound.
Such RNs have access to the full NHS formulary and since district nurses are seeing these individuals
in situ anyway, it avoids unnecessary transfers to a clinic or an ER (and then to a pharmacy) to get a
prescription renewal or medication to treat a minor, acute illness (such as URI or UTI, for example).
Some of these people require expensive transportation resources (such as an ambulance) and so this
saves $$ for the system.
Expanded roles for nursing are important but other members of the health care team are being under
utilized. I believe that waste of intellectual capital is one of the pressing problems for our health care
system. Many providers are educated to do more than other professionals, regulatory and
reimbursement structures, and/ or employers permit and support them to do. The waste of nursing
intellectual capital is particularly problematic as we have focused on advanced practice roles and not
on the unrealized potential of general class RNs. Even LPNs have seen expanded roles but not the
general class RN who could contribute much more in a supportive environment. Further, the public
requires education to make informed choices about providers. Often, they are ignorant about what
non-MD providers have to offer.
Sept. 22, 2011
I wish the Commission the very best in their work. It is vitally important. Thank you for the
opportunity to provide a comment.
Submission by a Registered Nurse:
Comments:
1. develop a comprehensive evidenced-based health care model that represents our health care
system... determining what should be in place to ensure that comprehensive, evidenced based care is
available to all Canadians within defined geographical areas. By having this model as a guideline,
communities will be able to identify gaps and duplication of services and know that the programs and
services they plan to implement will be consistent with CQI.
2. I believe that a Preventative Health Care Model would be ideal, since ALL health interventions are
PREVENTATIVE. It would be the ideal model since it could embrace all Practitioners and ideally suited
to the Nursing Profession since the very nature of their work puts nurses in a the position of being
Preventative Experts and would be complimentary rather than competitive with the medical
profession.
3. Communities agencies need to take responsibility for ensuring that their programs and services are
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evidence-based and these communities need a model of care they can rely on to ensure health-care
dollars are indeed going into improving and upgrading their services. Having such a model would
greatly facilitate collaboration between health care professionals and political discussion.
Sept. 27, 2011
Oct. 3, 2011
Oct. 6, 2011
4. This model should be available on-line for public and professional access, to inform and educate.
Many components of such a model already exist, but they need to be organized within a framework
which covers the life-span. As communities engage in organizing their services within this framework,
they will accurately identify gaps, and areas targeted for upgrading and improving services. The
evolving role of the Nursing Profession will find ample opportunity within this model to practise to
their full scope.
Submission by a Member of the public:
Comments: I would like to see more nurse practitioners working with Dr.'s to help patients manage
their health. We need to be more proactive to help people live healthier lives. This could be funded
through cost savings to health care and private insurers by monitoring the "whole" person rather than
the segments that we see today. People often don't take their meds and follow-up/coaching by nurses
(or perhaps a new position within healthcare) would help to uncover cost saving measures that also
improve upon the health of Canadians.
Submission by a Licensed Practical Nurse (Registered Practical Nurse in Ontario):
Comments: This is an article that makes you think “never thought of that!”
Submission:
I am an Operating Room Nurse at the XXX. Since 2006 management has been trying to implement
changes to the consent policy. To give some background, in 2006 the hospital realized that some
surgeons were lining up all of their consents and writing the procedure, signing their name and then
requiring the nurse on the unit to obtain the patients signature. This specific issue was not addressed.
Instead, the hospital decided that nurses should not be chasing after doctors for a completed consent.
As of now the policy states “all physicians are expected to produce satisfactory written evidence of
patient consent either through a signed consent form or through documentation in the patients chart
prior to conducting significant or invasive procedures at the hospital.”
Typically this evidence of consent can be found on Doctors Orders, or progress notes etc. and will state
that consent was obtained and for what procedure. This means the nurse is looking for this sentence
all through the chart instead of looking for one obvious form. The Booking Slip is typically used for
elective cases where the procedure is named and there is a tick box beside consent obtained.
On XXX date, there was a meeting with Operating Room nurses, the OR nurse educator, the OR nurse
manager and the Hospital Quality Risk Manager. It was stated by XXX that the hospital wants to have
the ownness of the consent on the doctors and not have the nurses “police the doctors” for a consent.
The doctor will still be required to obtain consent but it will not be required on the chart. The hospital
lawyer also supports this. The goal is to not have anything required to be written on the chart
regarding consent. The wording of the policy will be changed so that what will be followed will be the
“slate” also known as the OR typed up list. (Ward clerks, utilization etc. write this up leaving huge gaps
for error which happens). We will be the only hospital in Canada to follow this practice apparently.
We, the OR nurses are extremely concerned. We voiced all of our obvious concerns and presented our
ORNAC standards and were told that hospital policy over rides our standards and if there ever is any
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legal issue arising out of any of this the hospital will back us. We have been given no choice in this
matter and our concerns are ignored. The hospital appears to not grasp the concept of having a written
consent on the chart. We fear for our professional practice and for patient safety. Instead of having a
consent on the chart XXX stated the focus will be on patient advocacy and that OR nurses will be
required to ensure the patient understands what he/she is having done and will have to document
same. The concept that this is what the surgeon does when getting consent was lost. One OR nurse
brought up the fact that of course that is what we do as OR nurses, but also, when patients come to the
OR they can be nervous, confused and alone with no family. The fact that we will have to document
that the patient understands instead of having consent on the chart brings up so many more issues for
the OR nurse. Ultimately this will take up more OR time because if the patient is nervous or confused
the surgeon will have to explain the procedure to them again.
We as OR nurses feel we have no backing or support. We need advice where we stand legally. Your
help in this matter is greatly appreciated and desperately needed!
July 6, 2011
Submission by a professor at a university’s school of nursing:
I read the recent CNA newletter with Judith’s request to send items/research to the National Expert
Commission members. This article is “hot off the press:”
MACPHEE M. , SKELTON-GREEN J. , BOUTHILLETTE F. & SURYAPRAKASH N.
(2011) An empowerment framework for nursing leadership development:
supporting evidence. Journal of Advanced Nursing 00(0), 000–000.
It emphasizes the importance of empowering nurse leaders via leadership development-who in turn
empower their staff. I hope it will be a useful submission.
Oct. 14, 2011
Submission:
I believe to improve health care in Canada we need to move beyond the allopathic model we currently
have that puts the focus on health as interventions that happened downstream to a community based
model that has allopathic care as one component of our health care system. The amalgamated model of
healthcare would be built on relational ethics, social justice and allopathic care (when needed as one
component) and would look something like this:
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*QOL=quality of life
This model move the majority of care that people require out of hospitals and institutions to
communities and homes where people live. It would also but an emphasis on social justice and
working to eliminate inequities in health and social service.
I would like to call the commissions’ attention to two comprehensive national studies sponsored by
Health Canada on the cost effectiveness of home care:
Final Report of the National Evaluation of the Cost-Effectiveness of Home Care
http://www.coag.uvic.ca/resources/publications/reports/hollander_synthesis.pdf
Hollander, Marcus and Angela Tessaro. 2001. Evaluation of the Maintenance and Preventative Function
of Home Care. Victoria: Hollander Analytical
Services.http://www.hollanderanalytical.com/Hollander/Reports_files/preventivehomecarereport.pd
f/.
Oct. 25, 2011
Submission by a Registered Nurse:
Comments : Wow-one thing is Universal Public Healthcare-I require an Urgent MRI -I just got word
that that is booked for June 2012- this is unacceptable. ADs all over the city Of Calgary say come have
your MRI...Private...this is an important diagnostic....Public Healthcare!!.
Oct. 26, 2011
Submission by a Member of the public:
Comments: I am on the board of XXX. I encourage your Commission to investigate closely the educative
work done by the Canadian Health Coalition and by Canadian Doctors for Medicare. Additionally, the
Commission should watch a recently released film: http://www.healthcaremovie.net/ and speak
directly to Dr Michael Rachlis and other health-care policy analysts on how best to utilize resources
within our current publicly funded health care system..
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Oct. 26, 2011
CONTENTS
Submission by a Member of the public:
Comments: CHALENGES: Waiting lists for surgery and access to specialists; Lack of assisted and longterm care facilities with properly trained staff; Too few doctors & nurse practitioners. System needs to
become more responsive to public health needs. Governments need to ensure that all citizens have
ready access to medical treatment. Healthcare professionals and the public need to be involved in
developing policy. Nurse practitioners and mid-wives need to become more involved in providing
care. Consultation with healthcare policy analysts such as Dr. Michael Rachlis as well as Canadian
Doctors for Medicare. CHANGE: ELECTED Committee with the powers of the auditor-general and
budget to monitor the system to ensure that it is accountable and transparent about the use of health
resources. Committee should report publicly every 18 months..
Oct. 26, 2011
Submission by a Member of the public:
Comments : Communication and responding to public interest matters. I am launching a Workplace
Speaker Network that will create opportunity for all to have a voice, and improve health in workplace.
I sent a message to two government offices listed on Alberta Health web site. Healthy U office
responded 2-3 weeks after I sent a message that they wished me well but not interested. The other
health office contact info did not respond at all. My goal was to capture the voices of all involved in
health from business, employees, and government bodies to indentify needs and focus on common
health goals. Frustrating when all others bodies are excited to learn how to get more information and
government bodies do not show interest or reply. There is a disconnect in my opinion and leaves
public not happy with government representation.
Oct. 27, 2011
Submission by a Member of the public:
Comments :
1. Overuse of the emergency ward by individuals not requiring emergency treatment. Greater use of
primary care and increased numbers of family doctors to provide basic medical care would help
alleviate this situation.
2. Governments have made health care political, have increased expenditures by adding layers of nonmedical bureaucracy, and used elected officials (usually having minimal or no medical background as
Ministers of Health - ie: Liepert in Alberta).
3. When in the hospital, nurses have generally provided very good care. My one concern is that many
seem overloaded either with patients or bookwork).
4. This question overlaps with number 1 and 2. Unfortunately, our political system mandates elected
officials as Ministers, but this should not mean that the system needs to be as political as it is. In
addition, greater emphasis on individuals to promote their own wellbeing, such as concerns about
obesity..
Oct. 29, 2011
Submission by a Registered Nurse:
Comments: The most pressing health issue facing Canadians today is the endless and unstoppable
drain on resources caused by the excessive emphasis on expensive acute-care facilities and high
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technology interventions, to the exclusion of more broad-based interventions in primary, secondary &
tertiary prevention, such as management of chronic illnesses and conditions.
One solution would be to scrap, once and for all, the dysfunctional piecework compensation model for
physicians that is fee-for-service, and to introduce more multidisciplinary team-based approaches to
care.
Oct. 31, 2011
Submission by a Registered Nurse:
Comments:
1. Timely access to health services. Health services can include: surgery, access to specialists, long term
care beds
2. Focused strategies to maximize use of funding in order to increase capacity for health services and
to increase the funding to enable capacity.
3. Education on health promotion, preventative health, and chronic disease management.
Oct. 31, 2011
Nov. 2, 2011
4. Make lifestyle changes for increased fitness/exercise and better nutrition.
See Submission from the Academy of Canadian Executive Nurses (ACEN) below.
Submission by a Registered Nurse:
Comments: Improving the quality of life for long-term care (LTC) residents is of vital importance. The
LTC environment is often characterized by rigid schedules, high workloads, high staff turnover,
decreasing numbers of licensed nurses on staff, and large numbers of unregulated care providers with
limited education and training. Moreover, medical care is often provided by several physicians with
their offices located off-site, pharmacist visits can be intermittent, and few facilities have access to
advanced practice nurses.
Along with ensuring quality of life, quality of death is also important in LTC since estimates as high as
39% of residents will die in their LTC home by the year 2020 are predicted (Fisher, Ross & MacLean,
2000). A pain-free death has been recognized as a key element of 'a good death' since it can cause the
greatest suffering for individuals (Clark, 2002). Pain management for older adults in LTC, particularly
those with cognitive impairment, has been recognized as a national and international problem. This
brief will share a program of research aimed at improving palliative care, including pain management,
in LTC homes using a community capacity development approach. The work of CNA's National Expert
Commission to create policy recommendations is of great national importance and will impact on the
quality of life of all Canadians. We hope the commissioners' recommendations will help ensure those
people living and dying in LTC care homes have a good and pain-free death.
Nov. 3, 2011
Submission by Other Health Professional:
Comments : As a final year student nurse I am in the process of indoctrination into our health care
system and this has raised some troubling issues while I receive a world class education.
1. The most pressing health concerns that we current face are largely driven by a consumerist lifestyle
and a society that actively encourages behaviour that is detrimental to the individual and whole.
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2. Health care professionals seem largely ignored when it comes to decisions about social policy that
directly effect the health of the nation.
3. Genuine compassion in large care facilities is something that remains with health care recipients and
increases sense of control and betters patient outcomes. Yet it is indirectly discouraged due to
increasing time constraints and greater focus on technological solutions to medical problems. In my
opinion, health care professionals that provide a genuine person focused approach to healthcare are
one of the most satisfying and tranformative experiences for patients.
4. To improve the health of Canadians the onus of health care needs to be shifted from professionals
and government into the hands of Canadians. I would like to see legislation encouraging healthy
industry development and individual behaviour that would also be socially just.
My appreciation for providing a forum to listen to my concerns regarding our current health care
issues. Best of luck to the commission on developing and guiding future health care practice within our
nation!
Nov. 7, 2011
Submission by a clinical nurse specialist:
Hello XXX... Just a quick note to say how much I appreciated the opportunity to participate in CNA's
National Expert Commission on the future of our health system with you both in Vancouver on
Saturday, October 29th, 2011. There was some excellent dialogue.
When asked what one change I suggest to improve the health of Canadians I spoke about an aggressive
patient specific methodology to hasten and enhance postoperative recovery that I call Rapid Surgical
Recovery (RSR). The manner in which I have architected RSR and implemented in both cardiac and
general surgery is very goal directed and outcome driven.
The approach simplifies the complex and through humanizing, normalizing, preventative and
restorative strategies helps to rapidly return patients to their functional baseline. A natural byproduct
is a shorter hospital stay, fewer complications, fewer readmissions, and faster overall convalesces. A
win - win for both the patient and the health care system. RSR is supported by a conceptual framework
called the Reimer-Kent Postoperative Wellness Model.
The model shifts paradigms from illness-focused postoperative care the wellness-focused
postoperative care. Although this is extremely challenging work (changing practice and culture) it is
the right work. This approach with its nurse sensitive outcomes implemented on a larger scale would
have a tremendous effect on the thousands of Canadians that have surgery in this country every day.
RSR addresses the concomitant pressing health care issues of quality care, patient safety, and access.
RSR patients are ready to leave hospital in a timely and appropriate manner making room for patients
waiting for surgery. There is also the potential economic benefit as patients may be able to return to
the work force sooner through hastened convalesces. Although I developed this approach 16 years ago
it is very current and in keeping with a world-wide movement to optimize patient outcome by
reforming surgical care.
I have spoken broadly and widely on the topic nationally and internationally. CNA saw value in this
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work and invited me to speak on RSR at their 2010 biennium and they have referenced RSR in their
document Nurses on the Frontlines of Wait Times. Michael Rachlis in Prescription for Excellence How
Innovation is Saving Canada's Health Care System opens his chapter on A Canadian Agenda for
Excellence by citing this work. The accreditors for Accreditation Canada when assessing Fraser Health
in 2010 recommended that RSR be deemed a leading Canadian practice.
I have attached an article (starts on page 30) written in Fraser Health's News that I hope will give you
a greater sense of RSR and the impact it can have on patients and the health care system. [Article:
“Build it and they will come” In Fraser Health. (Fall 2008). In Focus.]
I hope you find the information helpful and I look to leaders such as yourselves to help move
important issues such as this forward...
Nov. 9, 2011
Submission by a Registered Nurse:
Comments: Are we still an iodine sufficient nation? If not, what impact might this have on our mental
health (depression/anxiety), energy (for exercising), metabolic rate (and obesity), immunity and
susceptibility to chronic illnesses?
Consider:
 Health conscious people are cutting back on sodium or switching to sea salt/gourmet salts (with
less or no iodine). The less health-conscious obtain a large portion of their diets from processed
and fast foods (high in non-iodized sodium).
 Many people haven't learned to eat fish/shellfish and don't eat enough fresh fruits and vegetables
to satisfy their iodine needs.
 our RDA is 1/100 that of the daily intake of the average Japanese citizen. They have lower rates of
lung and breast cancer and thyroid issues.
Nov. 9, 2011
Submission by a Registered Nurse:
Comments:
1. care of the geriatric population, chronic illness or chronic pain issues, aging demographics with
multiple co-morbidities, obesity, care of the dying, need increase in long term care beds (the elderly
often have difficulty caring for their elderly spouses/partners, better standards of care in long-term
care (especially with privately owned facilities).
2. further higher education for nurses in caring for the geriatric population and palliative care.
3. more focus on health promotion & disease prevention across the lifespan.
Nov. 14, 2011
4. increase number of long term care & assisted living beds, aid family caregivers (eg. financial, more
home services, housekeeping, etc), increase RN ratios versus LPNs or PCAs..
Submission by a Registered Nurse:
Comments: I would like to know how CNA believes nurses can be advocate for First Nation community
members living without proper running water, sanitation and housing. Renal patients have been
denied the option of peritoneal dialysis for these reasons and have had to move to an urban center to
receive in-centre haemodialysis. It seems like this important issue(water, sanitation and housing) has
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been tossed between the Provincial and Federal Government without consensus on who is responsible
for care. A health promotion perspective suggests that we work in collaboration with the community
and patient. Thoughts?.
Nov. 15, 2011
Submission by a Registered Nurse:
Comments: The Canadian Nurse Continence Advisor Association (CNCA) formed in November of 2000
and started as an emerging group with the CNA in February of 2001. The primary purpose of CNCA as
a professional organization is to represent Nurse Continence Advisors (NCAs) across Canada. As an
RN with specialized education, the NCA provides the knowledge, skills and abilities to effectively
manage and promote continence. All Canadians who experience urinary and/or fecal incontinence are
entitled to the services of an NCA, thereby accessing evidence-informed, person centered continence
care.
Continence clinics are innovative models of care delivery led by NCAs. There is limited access to
provincially funded continence clinics across the country. Through structured evaluation the existing
clinics have demonstrated clinical outcomes and economic benefits. NCAs led clinics decrease costs
related to incontinence for the individual as well as the health care system.
Nov. 16, 2011
CNCA is speaking out to the commission to advocate for Nurse Continence Advisor led continence
clinics. This is an important health strategy to support seniors to stay in their homes, reduce their
social isolation, and decrease the financial burden associated with urinary and/or fecal incontinence,
thereby embracing the specialized knowledge of NCAs and demonstrating better value. This will
benefit the health system by reducing or delaying admissions to long-term care facilities and
decreasing complications resulting in acute care admissions. The need to leverage our national
nursing expertise in continence also needs to be expanded beyond large urban and suburban areas to
smaller urban, rural and remote areas within each province..
Submission by Other Health Professional:
Comments: As a full time nurse practitioner I believe the most pressing health challenges facing
Canadians today is lack of access to medical care. One solution includes utilizing autonomous and
masters educated nurse practitioners in community based clinics to assess and treat patients who do
not need to go to emergency or wait up to 12-14 hours for assessment. NPs in Alberta practice to full
scope of practice enabling them to be comprehensive and holistic in their assessment and care. We
also educate, promote health and support clients at the end of life. One change to improve the health
care system would be to enable Nurse Practitioners to practice autonomously in publicly funded
clinics and community health centers. We collaborate with physicians and other health care providers!
We are a big part of the solution for Canadians needing urgent and ongoing health care. Thank you for
considering my comments. We are a big part of the answer - why isn’t anyone listening???
Nov. 18, 2011
Submission by a Registered Nurse:
Comments: I feel the most pressing issues are Seniors health and housing and ERtx/adm. I work with
Seniors daily and there are not enough LTC beds for their care. It will only get worse with our aging
population and we are not making any appropriate plans for the future. Stop putting more money into
homecare. There are not enough HCA's to care for clients at home and it is not cost effective. Build LTC
facilities and staff them with well trained people to give excellent care in a more cost effective way.
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These should not be private owned and operated. We pour millions into these facilities and end up
with poorly staffed and poorly cared for seniors. We think we're fooling people by changing names of
the housing and promoting them as able to care for LTC clients but people end up paying huge
amounts for care.EG-meds, wound care products, incontinent products, where in LTC facilities these
are covered..
Nov. 21, 2011
Submission by a Registered Nurse:
Comments: As president of the XXX, I can share that our professional nursing organization is trying to
engage HCW's in becoming aware of the impact HIV has on our patients, families and friends. Some of
the initiatives include: knowledge exchange via telehealth or face-to-face meetings allowing
communities to gain new knowledge and share experiences i.e. pilot project BC KEEN, linking expert
nurses in HIV / HCV with FNIH nurses or the Pacific to the Prairies project, linking virtually or face-toface with nurses from BC & SK. Utilizing the web to educate and support HCW by partnering with other
groups, i.e. the CATIE / CANAC web site shares information specific to HIV and HCV.
We have also partnered with CNA on developing a discussion paper about Harm Reduction and hope
to further that work. Advocacy is one of our underlying values as an organization and as professions
nurses. We are concerned that HIV is being used as an avenue to criminalize patients for nondisclosure of status as opposed to keeping this in the realm of public health. TB is not treated in this
manner. It is a PH matter and it dealt with under the PH Acts not the Criminal Code. We cannot provide
better health or care to Canadians if they do not know their status because they fear going to jail if they
test. How can the Canadian tax payer possibly see jailing someone with a chronic viral illness as better
value?
Nov. 23, 2011
Submission by a Registered Nurse:
Comments: Primary health care and access for all. Advance practice nurses (NPs) and family practice
nurses would greatly benefit larger population rather than physicians as access point. More
collaborative practice among all professionals. Nurses can be utilized much more effectively in
community settings - education, primary health, and in expanded roles. Integrated practice models
with all professions, less physician focus. Improved palliative care services in community rather than
having people die in hospital - better advanced care planning to avoid hospitalization if not
needed/wanted.
Nov. 28, 2011
Submission by a Registered Nurse:
Comments: I have been privileged to work in a nurse led clinic for 17 years. The Comox Valley Nursing
Centre began as a demonstration project, highlighting nurses working to the full scope of their
practice, in partnership with the community. Chronic illnesses and in particular chronic pain were the
primary needs.
Patients and colleagues have taught us much:
1.Poverty undermines a person's ability to pursue health. We must address the intersection between
socioeconomic factors and illness. Cross ministerial planning is key to supporting those families most
at risk.
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2.Partnership with patients is critical to the pursuit of health. Partnership means listening to what the
patient's goals are, not assuming we know based on a common diagnosis or standard care plan.
Partnership means supporting patients to gain knowledge, recognize their own strengths. Partnership
helps them navigate a complex health care system through nursing advocacy.
3.Ope referral policies to ambulatory community based programs (i.e. low barrier access to nursing)
means patients are not waiting for doctor's orders to access nursing.
4.Nurse led clinics with access to interdisciplinary teams are effective for chronic disease management.
The Sudbury Nurse Practitioner Clinic is another example of innovation through nursing leadership.
Existing approaches to health care funding or delivery models that insist on MD leadership or provide
funding only through physician or large corporate entities limit cost effective innovation. We need to
take what we learn from successful projects and "grow it" -- continue funding beyond the innovation
stage.
Finally, what do we need from nurses, other health professionals, governments and the public to
address the challenges? We need compassion, basic respect for humanity and a civil society that seeks
to support all of its citizens.
Nov. 29, 2011
Submission:
What can nurses do to have the greatest impact on the health outcomes of all Canadians?
I believe that nurses today can work the health the health care system to support and deliver
“upstream thinking healthcare”. I think that now more than ever health care needs to be focused
around preventing illness and providing patients with the support, education and tools they need to
maintain their own health for as long as possible. Budgets can not be taken away from outpatient
clinics and redirected to inpatient care if we expect to be able to sustain an adequate level of health
care for patients. If we can help patients care for themselves in the home or manage and minimize a
disease before a patient requires hospitalization then we will be saving the health care system millions
of dollars, as well as providing patients with the autonomy and support necessary to remain hospital
free. This will benefit the patient as in hospital they are more likely to pick up hospital acquired
infections, may lose money from days not worked and are segregated from family and friends who may
otherwise be able to play an active role in their life while they are at home.
I think it is imperative that nurses continue to educate patients about how to take care of themselves.
Early screening programs such as breast and prostate self exams, coaching on healthy eating, simple
smoking cessation interventions and education on the undeniable facts about the devastating effects of
smoking on ones health are necessary for patients or clients to make informed decisions about their
health.
When patients are discharged from hospital it is also important for nurses to educate patients about
WHY they were in hospital, HOW they were treated, WHAT medications they have been started on
(their dose, how they work and why they are taking them), WHO they can contact if they need further
assistance after discharge, and what they can do to take care of themselves and prevent further
complications of their health in the future. Too often patients are admitted to hospital and treated
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without really ever understanding what got them there in the first place and what they can do to
prevent this in the future. Patients need to be held accountable for their own health and the only way
they can do this is by having us use our vast medical knowledge and background to educate patients
about their health and how to maintain it.
It is inevitable that in the future, as the baby-boomers age, there is going to be a tremendous strain on
the health care system. More patients than ever are going to require advanced care and beds in an
already stressed health care system. By providing patients with knowledge and tools to try to prevent
or at the very least delay illness we will be taking the fist steps to ensure a future for not only our
patients the health care system itself.
Nov. 29, 2011
Submission by a university nursing class:
Comments: Modern health challenges facing Canadians are complex and interrelated.
Incomplete application of the principles of Primary Health Care (PHC) results in deficient resource
allocation to health promotion and illness/injury prevention compared to tertiary care. As chronic and
mental illness rise, inefficiencies of services and poor communication create avoidable gaps between
hospital and community-based care. Preventable complication and increased demand for service erode
health care budgets, Canada Health Act principles and the values espoused in the Ottawa Charter for
Health Promotion. Inequity in society grows.
Governments and health care providers cannot continue to redo the same; status quo is unacceptable.
Better health and value require principled leadership, willingness to partner within and across all
sectors to share power and expertise in decision-making; and most importantly authentic attention to
the voice of the 'people' who are experts in the impact of policy on their daily lives.
The next Health Accord must expand the Health Act to comprise the full PHC continuum, including
home and pharma care; with full implementation of Ottawa Charter values and strategies. Flexible
Healthy Public Policy to protect health equity for all Canadians is essential. Truly innovative health
system change must first originate from the perspective of 'community' and the people; include
partnered decision-making to allocate resources for long term benefits; then expand to tertiary care. In
tandem, nurses must conduct research to create the evidence that links population health outcomes to
practice, health systems and policy.
Nov. 30, 2011
Submission:
The most pressing health challenges facing Canadians today is the shift towards caring for patients in
the home and away from care in the hospital. Patients are being seen, treated, and discharged quicker
than ever, leading to the “quicker and sicker” mantra among nurses and other healthcare
professionals. Patients are often discharged home feeling ignored and unprepared due to the
continued emphasis on bed management and utilization as the focus shifts away from the acute-care
setting.
While this shift in itself is not necessarily problematic, it is worrisome that there does not seem to be
an increased lack of funding or resources that are being put into efficient, appropriate, and sustainable
nursing and healthcare services. Community homecare nurses are overworked and severely underpaid
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and if the shift to homecare continues this must change if we hope to continue to provide holistic and
complete care for patients in their homes.
Nurses have a huge impact on the health of Canadians in a supportive and teaching role. In the
community the nurse is often the sole contact patients have with the healthcare system and receive all
their care, knowledge, and information from the nurse. Because of the shift towards increased care at
home, nursing is situated in a prime position to grow and develop as a profession. As a whole
community, nurses need to stand up and continue to take on an advocacy role, like the acute-care RN
in hospitals. We must advocate for Canadians as a whole, better supports in the community, better
resources, and better consistency and quality of care. We also must stand up for our profession as a
whole, and ensure that nurses working in every area of the healthcare system are respected and
valued for the contributions that they provide.
Nov. 30, 2011
Submission by a Registered Nurse:
Shared Responsibility, Shared Power
There needs to be a shift in the health model that our government currently employs because too
much formal and informal power has been given to the physicians group. I make this bold statement
not with the intent of insulting my physician colleagues, but to draw attention to a health care system
that is mandated and controlled by a small group of professionals.
While the Ontario government has worked to increase the scope and practice of the nurse practitioner
though recent legislation and the creation of NPLCs across the province, in the tertiary care centers
health care decisions continue to be mandated by physicians and physician administrative directors.
The hiring of a NP can be delayed or even stopped by the medical directors in our hospitals. When
making decisions to hire NPs, funding is limited and departments must consider cutting physician
fellowships to create funds. These actions only increase the tensions between the nurse-physician
relations.
Looking back at history, it was the nurses who ran the hospital and the physicians would come and
visit the patients. Over the span of about 100 years, nursing has lost this power and are now subject to
budget cuts and underemployment in some parts of the country.
I believe that the health of Canadians would be best served by increasing the support and formal
power of nursing through political presence, public appearance, research and appropriate wage
increases.
As many studies have demonstrated the efficacy of nurse practitioners, more funding opportunities
need to be created to allow for the hiring of NPs in tertiary care centers. Our country needs to
recognize that NPs have specialist knowledge just like our physician colleagues; Therefore, it is time to
engage these nurse specialists in the health of Canadians.
Finally, on a personal note, as I near graduation from an acute care nurse practitioner program this
coming spring, I find myself looking to the United States for employment and further educational
opportunities. This choice is not based on financial gain but professional interest. As I look for job
opportunities in Canada, I have come to realize that there are no pediatric intensive care nurse
practitioners in Canada at this time. I will need to go to the USA for training; however this does not
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guarantee me a job upon returning to Canada. On the other side of the boarder, there are multiple job
openings with competitive salaries that will allow me to practice to the full scope of my practice. While
I have put plans in motion to practice in Canada, the final decision will come down to two things:
the medical director’s interest in creating a nurse practitioner position and hospital finding.
Dec. 2, 2011
Submission:
1. What are the most pressing health challenges facing Canadians today?I believe that there is a lack
of attention paid to examining the socio-political and historical positioning of particular groups, such
as the Aboriginal and homeless population, resulting in discourses that unwittingly support further
disadvantage, oppression and marginalization.
2. What do we need from nurses, other health professionals, and the public to address the current
challenges? Public access to knowledge about the nature of domination and inequities leads people to
accept more responsibility for changing their practices. Nursing and other health care professionals
must view critical analyses of these issues as central aspects of education, research, theory and
practice.
3. What can nurses do to have the greatest impact on the health outcomes of all Canadians? Nurses
can critically engage within the wider context of politically charged health care relations - including
health policy and policymaking. I believe there is a need for critical engagement with nursing
knowledge that is focused on the historical context and ongoing processes of issues that contribute to
health disparities that exist with our present day heath care system.
Dec. 5, 2011
4. If you could make one change to improve the health of Canadians, what would it be? I would bring
awareness to present health disparities that exist amongst us. For example, Attawapiskat is Aboriginal
Reservation stricken by poverty, one of many, that is presently making News Headlines. I think this
one of many opportunities for government organizations such as the CNA to bring attention to public
health issues. Poverty, on of the main determinates of health affecting the overall health of many
populations. Nurses must take advantage of certain situations and expose the gaps and barriers in
healthcare services. They need to assist in creating a health care environment in which poverty,
oppression and social malaise become priority issues.
Submission:
I believe that Canada needs to increase funding for Home and Community Care (HCC) and
create a national policy. HCC is not equitable across Canada even though the call for expansion of HCC
and equality started in the 1990’s (Brackley & Penning 2009). Despite critiques, HCC remains
inequitable, for example, some provinces have instituted a cost sharing with clients while other
provinces and all territories cover all costs (Collier 2011). I would be interested to know if provinces
with cost sharing show evidence of a decrease of stays in hospital for patients waiting for long term
care. From personal experience, I know that we often have multiple patients waiting for long term care
when they could be supported at home if we had adequate supports to give them.
HCC of British Columbia has recently been given a revised policy manual developed by the
Ministry of Health Services of British Columbia. Upon review, the policy provides needed high level
strategic goals by defining the priorities and objectives (Nadler, Behan & Nadler 2006, p.134). The
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programs and services included in Home and Community care, the rationale behind them and the way
that they should be delivered to the public are clearly defined. A vision statement and principles are
also included (Ministry of Health Services of British Columbia 2011, pp. 1-2). In my opinion, this
document is appropriate foundational work to support HCC throughout the province of British
Columbia. However, financial constraints hinder the operationalization of the policy. Realistically
services are established via assessment of budget versus assessment of need.
This reality is unfortunate as HCC has the potential to keep seniors in their homes, increasing
quality of life and decreasing cost to the health care system (Meiner 2010; Hollander & Chappell 2002,
p. iii; McGrail et. 2008, pp. 20-23; Makarenko 2007; Tsasis 2009, p. 136; Rantz et al. 2011, p. 37). Home
support is a valuable component of HCC and often makes the difference between being able to manage
at home and being admitted to a long term care facility. Indeed, there is evidence that people with this
type of help remain at home longer, stay healthier and cost the health care system less, however, in
British Columbia, this service is provided on a cost sharing basis which often puts a financial strain on
senior citizens to the point that they make the health trade off to go without the services that they need
(Meiner 2010; Hollander & Chappell 2002, p. iii; McGrail et. 2008, pp. 20-23; Makarenko 2007; Tsasis
2009, p. 136; Rantz et al. 2011, p. 37). As well, this service is often so inconsistent that patients cannot
rely on it. It is known that without support, clients end up in long term care or in hospital waiting for
long term care (Hollander & Chappell 2002, pp. iii). Hospitalization costs the healthcare system more
money than supporting them in home (McGrail 2008, p. 23). It also costs the clients as they lose their
sense of independence and often their health (Meiner 2010).
In conclusion, I am pleased to see CNA taking the challenge of policy development, however I’m
concerned that despite excellent policy that the reality will not change if the budgets are not there to
support them.
References
Brackley, ME & Penning, MJ 2009, ‘Home-care utilization within the year of death: trends, predictors
and changes in access equity during a period of health policy reform in British Columbia, Canada’,
Health and Social Care in the Community, vol. 17, no. 3, pp. 283-294.
Collier, R 2011, ‘National home care standards urged’, CMAJ- 8-FEB-2011; 183(2): 176-7, viewed 10
august 2011 MEDLINE <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3033922/>.
Hollander, M & Chappell, N 2002, ‘Synthesis report: Final report of the National evaluation of the costeffectiveness of home care’ viewed 09 August 2011 at < http://www.homecarestudy.com/reports/fulltext/synthesis.pdf>.
Makarenko 2007, ‘Romanow commission on the future of health care: findings and recommendations’,
Maple Leaf Web, Viewed 24 August 2011 <http://www.mapleleafweb.com/features/romanowcommission-future-health-care-findings-and-recommendations>.
McGrail, KM, Broemeling, A, McGregor, MJ, Salomons, K, Ronald, LA & McKendry R 2008, ‘Home health
services in British Columbia: A portrait of users and trends over time’, UBC Centre for Health Services
and Policy Research, viewed 19 August 2011,
<http://www.chspr.ubc.ca/files/publications/2008/chspr08-15.pdf>.
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Meiner, SE 2010 Gerontologic Nursing, 4th edn, Mosby Elsevier, Missouri, viewed 5 August 2011,
Mosby’s Nursing Consult.
Ministry of Health Services of British Columbia 2011, Home and Community Care Policy Manual,
Ministry of Health, Victoria, BC. <http://www.health.gov.bc.ca/hcc/pdf/overview.pdf>.
Nadler, D, Behan, BA &Nadler, MB 2006, Building better boards: a blueprint for effective governance,
Jossey-Bass, San Francisco, CA.
Rantz, MJ, Phillips, L, Aud, M, Popejoy, L, Marek, KD, Hicks, LL, Zaniletti, I, & Miller, SJ 2011, ‘Evaluation
of aging in place model with home care services and registered nurse care coordination in senior
housing, Nursing Outlook, vol. 59, no. 1, pp. 37-46.
Tsasis, P 2009, 'Chronic disease management and the home-care alternative in Ontario, Canada', Health
Services Management Research, 22, 3, pp. 136-139, CINAHL with Full Text, EBSCOhost, viewed 17
August 2011.
Dec. 6, 2011
Submission by a Registered Nurse:
Comments:
1. Lack of general health knowledge and follow up care/understanding of disease/illness. No routine
follow up from GP's no encouragement of self care.
2. Better chronic disease management in the community, better discharge from hospital information &
care for pts & their families & government regulations on food products.
3. Increased patient teaching.
4. More community based health care resulting in improved continuation of care, increased long term
care facilities with better staffing resulting in less returns to ER departments with same complaint.
Better use of equipment.
eg. ambulance services use one type of IV tubing, hospitals use another - waste of money.
Better use of resourses.
eg. VON's travelling hundreds of kilometres to see patients. System should return to locally managed
sites. Pts could then have a self referral system, GPs could also refer more easily in this scenario.
Dec. 7, 2011
Dec. 7, 2011
See Submission from the Fédération interprofessionnelle de la santé du Québec below.
Submission by a Member of the public:
Comments : Among the most pressing health challenges today is the lack of capacity in the system, and
in the mental health system especially. Without long term beds and more efficient administration,
demand will continue to outweigh availability and get worse. Professionals can help by working
efficiently and helping to streamline procedures, maintaining continuing education, and providing
input on policy. However, if I could make only one change to improve health, it would be to fund more
acute care beds and long term community care beds to reduce unacceptable wait times.
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Submission by a Registered Nurse:
Comments : Answers for the 4 questions...
1. there seems to be a lack of real caring and compassion in many hospitals and Continuing Care
Centres nowadays (perhaps R/T lack of good leadership and increasingly poor morale in the
workplace with so many merges and re-orgs.); a lack of true listening (perhaps a hangover from the
professional knows best? - a shift back to one's comfort zone when one is on shaky ground); and a lack
of truly working together as a team (perhaps R/T ongoing stove-piping and turf protection due to job
insecurity) to create better outcomes for all Canadians...i.e., entering data on the computer seems to
have replaced the evening care and the relaxing back rub.
2. remember: the patient, and his or her family, are/were supposed to be first and foremost - however,
often all the talk about patient centered care is all talk and nothing more.
3. speak up and be articulate about the issues; and come with solutions - lots of solutions...do NOT get
bogged down on the problems - there will always be problems.
4. truly, all of the determinants of health need to be implemented, but b/c we live in a cold country for
almost 8 months of the year - we need to get our governments to regulate all utilities so the price of
water/gas/electricity does not interfere in acquiring healthy nutritious foods &/or the required
medications.
Dec. 9, 2011
(English translation below)
1- Nous avons absolument besoin de FINANCEMENT POUR les IA et les IP afin que celles-ci puissent
implanter des solutions novatrices en soins de santé. Je suis IP. Avec les fonds que le Ontario Stroke
Strategy nous a fait parvenir, j'ai pu développer une clinique basée sur un modèle où le patient de
l'urgence reçoit son congé rapidement afin de venir me voir rapidement le lendemain pour une
évaluation urgente en neurologie en clinique externe. Cette clinique a permis aux patients d'avoir
accès MÊME à des SOINS SPECIALISÉS puisque nous n'avions nos neurologues qu'une fois par semaine
dans notre petite région rurale. Les résultats ont été une diminution de plus grand que 50% des
réadmissions et de visites subséquentes à l'urgence. Voici un exemple où en investissant dans la
profession infirmière, les gouvernements pourraient sauver beaucoup d'argent et, de ce fait même,
améliorer la qualité des soins administrées. Étonnamment, je suis IP en soins primaires et je travaille
maintenant en soins spécialisés. Il faut donc avoir des financements pour aider les IP à prendre de
telles initiatives et à avoir l'opportunités pour aller chercher de la formation qui n'est pas dans le cours
de base de l'IP. Mon sujet de thèse explorera ce thème de soins spécialisés et IP en soins primaires.
2- Il y a 4 ans, je fus estomaquée de voir que le gouvernement donnait des argents aux hôpitaux
ontariens pour l'implantation du rôle de PHYSICIAN ASSISTANT tandis qu'il n'y avait PAS cette
initiative pour les IA ou les IP en soins primaires ou aiguës au sein des cliniques externes. Pourquoi
reléguer encore les infirmières aux oubliettes et laisser plus de place à une autre profession quand
celle qui existe déjà n'est pas utilisée à son plein potentiel?
3- De plus, ces argents donnés par subvention en santé par le gouvernement devraient être contrôlés
PAR les infirmières et non pas par des administrateurs gouvernementaux. Laissons du POUVOIR
ADMINISTRATIF et de GESTION de SUBVENTIONS AUX INFIRMIERES!!!
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4- Par ailleurs, comme IP, j'ai des idées de projets novateurs, mais je ne sais pas À QUI M'ADRESSER
pour obtenir des fonds. J'ai l'idée d'effectuer des soins de santé PRIMAIRES à DOMICILE. Le fardeau
des maladies chroniques doit être pris à la source. Souvent, ce sont les personnes âgées qui se
retrouvent hospitalisées puisqu'ils ne voulaient pas et ne pouvaient pas se déplacer pour des rendezvous médicaux. Revenir au concept que c'est le professionnel de santé qui est en santé et, donc, que
c'est lui qui devrait se déplacer et non pas le client. L'IP pourrait avoir un secteur désigné par des
limites géographiques efficaces. Elle va distribuer sa carte d'affaire aux gens de la communauté et se
fait connaître parmi les organismes communautaires. Elle est reliée avec un centre de santé. Elle utilise
l'INFORMATIQUE pour le soin et pour distribuer l'informatique aux patients tel que des outils de
gestion automatisés pour l'autosoin du patient.
5- FAISONS des SOINS DE SANTÉ PRIMAIRES et non SEULEMENT des SOINS PRIMAIRES. Nous parlons
de soins de santé primaires, mais ce n'est pas ce que nous faisons, nous faisons de la santé primaire
uniquement en plaçant des pansements sur les gens au lieu de travailler aussi en amont, aux causes
des causes! Les centres de santé n'ont pas réalisé leur vrai mandat, ils n'accomplissent pas leur mission
globale. Ceci est sûrement dû à un manque de compréhension réelle de la définition des soins de santé
primaires vs les soins primaires.
6- N'oublions pas l'innovation en INFORMATIQUE en soins infirmiers. Si nous aurions une institution
qui aurait le privilège de créer des outils avec des informaticiens, la population canadienne pourrait en
bénéficier! Pensons à des outils de GESTION AUTOMATISÉS en AUTOSOIN. Ce concept d'autosoin étant
une pierre angulaire à la gestion des maladies chroniques.
7- Où plaçons-nous les principes des soins de santé primaires (OMS, 1978) lors de l'élaboration de
nouveaux programmes et de nouvelles stratégies en santé? Nous oublions souvent d'inclure
MONSIEURS ET MADAME TOUT LE MONDE dès que nous avons des discussions. Ils sont souvent
concertés trop tard dans notre processus de développement de programme. Serait-ce pour cela que
notre système ne fonctionne pas, nous n'allons pas rejoindre monsieurs et madame qui, lui, UTILISÉ le
système. Ici, je ne parle pas des gens éduqués que nous prenons pour siéger dans nos conseils
d'administration, mais du citoyen qui en arrache. Pensez à utiliser la méthode de recherche d'action
participative pour aller rejoindre le plus d'utilisateurs, je veux dire les VRAIS UTILISATEURS, même si
ceci peut générer plus de temps et de ressources au début, je crois que les programmes instaurés
auront ainsi plus de valeur pour la communauté et ces programmes se soutiendront dans le temps.
8- En parlant d'ACCESSIBILITÉ aux soins, réalisons que l'accessibilité n'est PAS SEULEMENT
GÉOGRAPHIQUE! Revenons à la définition de l'OMS (1978): accessibilité fonctionnelle, géographique,
culturelle, financière, etc. Comment faire pour savoir si nous ne demandons pas directement aux
patients qui a peine à utiliser les services, qui deviennent de plus en plus complexes. Nos programmes
doivent refléter toutes ses composantes d'accessibilité.
9- Arrêtons de développer des programmes sur des études épidémiologiques! Sommes-nous demeurés
dans les années 40? Pour garantir de bons programmes en soins de santé primaires, obtenons une
VRAIE ÉVALUATION COMMUNAUTAIRE selon les règles de l'art. Les infirmières sont les
professionnelles là-dedans, laissons-leur la place.
10- Finançons des IP CHERCHEUSES dans toutes les provinces! Sinon, cette nouvelle carrière se fera
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imposer des structures dont nous aurons à nous débarrasser dans quelques années, comme ce qui est
survenue à la profession infirmière, qui a presque été sous la tutelle de la profession
médicale...totalement aberrant!
11- PUBLIONS nos innovations infirmières, non seulement dans des revues scientifiques, mais dans
des journaux PUBLICS et dans les médias, très bien vulgarisées pour monsieur et madame tout le
monde. La participation et la connaissance du public aidera grandement la profession infirmière à
acquérir de la crédibilité et d'effectuer son avancement!
Je vous remercie grandement de considérer ma rétroaction,
1- We definitely need FUNDING FOR RNs and NPs so they can implement innovative health care
solutions. I am an NP. With the funds sent to us by the Ontario Stroke Strategy, I was able to develop a
clinic based on a model whereby patients in the emergency room are discharged quickly so they can
come and see me as soon as possible the following day for an urgent neurological assessment in the
outpatients clinic. This clinic EVEN provided patients with SPECIALIZED CARE because our
neurologists only visited us once a week in our small rural area. This resulted in a reduction of over 50
percent in readmissions and subsequent visits to the emergency room. This is an example in which, by
investing in the nursing profession, governments could save a lot of money and, consequently, improve
the quality of the care delivered. Surprisingly, I am a primary care NP and I now work in specialty care.
There should be funding to help NPs take such initiatives and have the opportunity to go and take
training not included the basic NP course. My thesis topic will explore this theme of specialty care and
primary care NPs.
2- Four years ago, I was flabbergasted to see the government giving money to hospitals in Ontario to
introduce the PHYSICIAN ASSISTANT role, although there was NO such initiative for RNs or NPs in
primary or acute care in outpatient clinics. Why confine nurses to the sidelines and make more room
for another profession when the profession that already exists is not being used to its full potential?
3- Moreover, this money given as a health grant by the government should be controlled BY nurses, not
by government administrators. Let’s leave ADMINISTRATIVE POWER and MANAGEMENT of GRANTS
TO NURSES!
4- As an NP, I have ideas for innovative projects, but I do not know WHO TO APPROACH for funding. I
have an idea for delivering PRIMARY health care at HOME. The burden of chronic illnesses must be
dealt with at the source. Often, elderly people are hospitalized because they did not want to or could
not travel to medical appointments. Let’s revert to the concept that it is the health care professional
who is healthy and thus must travel, not the client. The NP could be assigned a sector with suitable
geographical boundaries. She would hand out her business card to people in the community and make
herself known to community organizations. She would be associated with a health care centre and use
COMPUTER TECHNOLOGY to deliver care and provide patients with tools such as automated
management of patient self-care.
5- LET’S PRACTISE PRIMARY HEALTH CARE, not JUST PRIMARY CARE. We talk about primary health
care but this is not what we do, we practise first line care by putting solely band-aids on people instead
of also working upstream, on the causes of the causes! Health care centres have failed to achieve their
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real purpose: they are not fulfilling their overall mission. This is undoubtedly due to a lack of
understanding of the definition of primary health care compared with primary care (first line).
6- Let us not forget the innovation in COMPUTER TECHNOLOGY in nursing. If we were to have an
institution that had the privilege of creating tools with computer specialists, the Canadian public might
benefit! Just think of AUTOMATED MANAGEMENT tools for SELF-CARE. This concept of self-care is the
cornerstone of managing chronic illnesses.
7- What role do we assign to the principles of primary health care (WHO, 1978) during development of
new programs and new health strategies? We often forget to include the AVERAGE PERSON OFF THE
STREET when we hold discussions. The average person is often consulted too late in our program
development process. Could this be why our system is not working? We do not involve the people
USING the system. I am not talking here about educated people whom we ask to sit on our board of
directors but regular citizens who have to cope with the system. Think about using the participatory
action research method to involve as many users as possible—and I mean the ACTUAL USERS. And
even if this results in more time and resources at the outset, I believe that the programs implemented
will have more value for the community and will be sustainable over time.
8- When we talk about ACCESSIBILITY of care, we must understand that accessibility is NOT JUST A
MATTER OF GEOGRAPHY. Let us go back to the WHO’s definition (1978): functional accessibility,
geographic, cultural, financial, etc. How do we determine this if we do not directly ask patients who
have difficulty using services, which are becoming increasingly complex? Our programs must reflect all
aspects of accessibility.
9- Let’s stop developing programs based on epidemiological studies! Are we still in the 1940s? To
guarantee sound primary health care programs, we must obtain a GENUINE COMMUNITY
ASSESSMENT based on accepted practices. Nurses are professionals in this; let them do their job.
10- Fund NP RESEARCHERS in all provinces! If not, this new career will have structures imposed on it
that we will have to get rid of in a few years, just like what happened to the nursing profession, which
was virtually under the control of the physicians—totally absurd!
11- PUBLISH our nursing innovations, not only in scientific journals but also in WELL KNOWN journals
and the media, greatly simplified for the average person off the street. The general public’s
participation and knowledge will greatly help the nursing profession acquire credibility and make
progress! Thank you very much for considering my feedback.
Dec. 9, 2011
(English translation below)
Autre professionnel de la santé:
Comments : Je suis une étudiante infirmière praticienne en soins de première ligne. Dans le cadre d'un
de nos cours où nous nous sommes intéressés à la valeur ajoutée du rôle de l'infirmière praticienne,
nous avons abordé la prise en charge de l'ostéoporose. L'IPS est bien placée via ses suivis et l'examen
médical périodique pour promouvoir la santé et prévenir l'ostéoporose tout au long du continuum de
vie. De plus, cette maladie est sous dépistée et sous diangnostiquée auprès de la clientèle âgée. Cette
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constatation nous a permis de penser à la possibilité de créer des cliniques d'ostéoporoses en
collaboration avec divers professionnels de la santé, au même titre que les cliniques de diabète et de
MPOC. Nous croyons que l'IPSPL aurait un rôle majeur à jouer dans la prise en charge de cette maladie
qui pourrait améliorer la santé et l'autonomie fonctionnelle chez nos personnes âgées. .
Submission from other health professional:
Comments: I am a student primary care nurse practitioner. As part of one of our courses in which we
looked at the added value of the nurse practitioner role, we addressed the management of
osteoporosis. The specialty nurse practitioner is well placed, as a provider of follow-up care and
periodical medical examinations, to promote health and prevent osteoporosis throughout the every
stage of life. Moreover, this disease is not well screened and is under diagnosed among elderly clients.
This observation has led us to think about the possibility of creating osteoporosis clinics in
cooperation with various health professionals, along the same lines as diabetes clinics and COPD
clinics. We believe that primary care nurse practitioners would have a major role to play in managing
this disease that could improve the health and functional independence of the elderly.
Dec. 10, 2011
Submission by a Registered Nurse:
Comments: Wait times for psychiatric services in the community. I live in Moncton, NB, and I am
enrolled in a Master of Psychiatric Nurses Program. A problem with having strong unified mental
health services is the split in how mental health nurses are trained and recognized in Canada. Could
the glue that brings us together, at the advanced level, be the Masters program? I have not been
involved with any of the politics, and don't understand the problem per se, but I know that a unified
body would help. Masters prepared psychiatric nurses (APPN's) could fill some gaps in services where
wait times for psychiatrists are unacceptable. .
Dec. 11, 2011
Submission by a Registered Psychiatric Nurse:
Comments :
I am currently enrolled in the Master of psychiatric nursing program at Brandon University. Recent
dialogue within our group discussion and forum posts focussed on identifying the needs of the
population and current health care barriers. In addition to intervention, out discussions often focused
on our nursing counterparts and their advancements in the areas of health promotion and public
education, As advance practice psychiatric nurses of tomorrow, our collective goals is to make
ourselves more visible to our nursing colleagues, our other health care colleagues and the community
at large. Our aim is to conduct needs assessments throughout communities identified as high risk so
that we can determine what role the advance practice psychiatric nurses could have in alleviating
some of the burden. I am confident that the APPN could compliment and not threaten the already
established APN's such as the CNS' and NPs. We recognize that most who face mental health problems,
first president to GPs and are often left to wait far too long for a referral to psychiatry, when it is
required. Our vision is to rectify this and what better way to do this, than to come together and
collectively look at how we can achieve better outcomes for our public, specifically, those with mental
health challenges. Thank you for the opportunity to share.
24
DATE
Dec. 12, 2011
CONTENTS
Submission by a Registered Nurse:
Comments : Better care and value:
Do NOT allow the American nursing exam to be written by Canadian nurses instead of the Canadian
exam. We are Canadian with particular needs of our own and these will not be addressed by a blanket
exam based on the American system. Do not jeopardize the Canadian nurses by allowing this to
happen! This only benefits the American people and makes it easier for Canadian trained nurses to
work in the U.S.A.
Dec. 13, 2011
Submission by a Registered Nurse:
Comments: It is necessary to improve road access to northern Manitoba communities; this would
enable their communities to obtain healthy foods at affordable rates (milk, cheese, etc. rather than
coke and chips). Ultimately, this investment will save healthcare dollars by decreasing the prevalence
of chronic disease.
Comments: In the Woman & Child Program (Obstetrics, patients deliver 24 hours/day. Baseline
staffing needs are usually the same on night shift as well. Currently, the baseline staffing for nights is 1
less RN than on days and evenings. More money needs to be applied to increase staffing (volume
funding).
Dec. 13, 2011
Submission by a Registered Nurse:
Comments : On behalf of VON Canada
Without proper supports in place, increasing frailty can make day-to-day activities difficult. The
Seniors Managing Independent Living Easily (SMILE) program enables frail and elderly seniors to
receive help with the activities of daily living and make their own decisions about care. Seniors can
choose the services they need, when they will need them, and who will provide them. SMILE can also
provide help with planning and managing care. With the right supports in place, maintaining
independence and staying at home is possible.
SMILE offers support with activities of daily living such as: meals, housekeeping, shopping, laundry,
errands, transportation to and from health care appointments, seasonal outdoor chores and grounds
keeping. Admission is based on specific eligibility criteria. The senior must require assistance with
their activities of daily living and be at risk of increasing frailty.
SMILE has proven very successful in helping seniors remain independent at home. A study of the
clients admitted between December 2008 and April 2009 who were on Long Term Care wait list on
admission showed that 68% of them were still at home or deceased and only 22 % went to LTC. 80%
of clients admitted to SMILE had no Instrumental Activity of Daily Living (IADL) services in place prior
to admission. This indicates that SMILE supports frail clients who were not previously identified
within the health/social community care system for IADL support. This speaks to the achievement of
raising awareness of all services available to seniors, one of the goals of the SMILE program.
Comments : SMART (Seniors Maintaining Active Roles Together)®, a functional fitness program, was
developed by VON Canada as a result of seeing which activities provided the best outcomes-the biggest
difference in physical and mental health as a result of a fitness regimen that considers the limited
25
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CONTENTS
capabilities brought on by the process of aging.
The mandate of SMART is to promote healthy aging across Canada by developing and implementing
innovative, progressive physical activity interventions that engage older adults who are not currently
participating. The high-quality fitness programming delivered by specially-trained volunteers
encourages independence and improves quality-of-life. The program is delivered once per week in
group settings in the community, or can be provided to individuals in their home. The exercises are
well-received by all participants that have a demonstrated interest in 'active living'.
Participants take part in physical exercises which progress to give greater strength and well-being,
diminishing or eliminating the effects of frailties (such as falls) or after-effects of illness or injury.
Independence and quality-of-life are improved, lowering the chances of further decline in health.
A 2008 evaluation of the SMART program showed at least 62% of participants reported achieving or
surpassing the goals set at the onset of the exercise plan, and 31% reported that they were able to
maintain their ability level, even when it was expected to decline. A full 100% of participants reported
improved functioning. Three-quarters of participants regarded the program as part of their overall
health care plan-not as a purely recreational program.
Comments : To help individuals dealing with more prevalent chronic diseases, VON Canada piloted a
project that combines self-management strategies with the use of technology in the home. Clients in
the "Stay@Home with VON" 12-week program receive an initial assessment, followed by information
on their condition and education on the practical skills needed to manage the daily challenges of living
with a chronic condition. Participants gain confidence and are motivated to better manage their own
health. Self-management strategies and tele-monitoring lead to properly managed chronic conditions
resulting in fewer emergency room visits and hospital admissions, thus reducing overall health care
system costs.
Regulated professionals visit their home to do a full assessment that looks at clients' health and levels
of understanding about the condition being treated. Then a care plan and a customized management
program is developed that includes daily tele-home monitoring, disease-specific education and peer
support. The client is provided information about their disease and the chosen treatment plan.
Motivational interviewing helps clients set goals and develop problem-solving skills.
Daily monitoring of client blood parameters is facilitated through tele-home monitors. Each day the
client completes the necessary vitals and answer a few questions. Client data is collected and stored
centrally for review and action.
The program has shown promising results. From the clinical perspective, the majority of the clients
admitted to the program demonstrated improved or maintained confidence in their ability to selfmanage their condition, resulting in a decline in emergency room visits or hospital admissions.
Comments : On behalf of VON Canada
The Home-at-Last (HAL) program was developed to be part of a patient's continued care once they are
ready to return home from the hospital or emergency room. Working with a hospital or health
authority and a community support service provider, the HAL program helps medically fragile seniors
or those with disabilities return home safely and comfortably, reducing the risk of a return hospital
26
DATE
CONTENTS
visit. HAL is not for everyone - the HAL program was designed to meet the needs of persons who are
self-managing with some supports-and is not meant for those with complex medical needs.
At discharge, a HAL Attendant picks up the patient and transports them home, stopping for errands,
and settling them in at home with medication management and a meal. The HAL Attendant remains
until safety and comfort are assured, or until family or a caregiver arrives. The HAL Care Coordinator
follows up and determines whether additional health care or community supports are necessary to
assist with daily living.
This program has proven to help patients return home more quickly and prevent re-admission, thus
diminishing pressures on the health care system. The cost per patient for HAL varies according to the
individual plan developed, ranging from $400 to $550 per client if a follow-up visit is required.
Costly hospital admissions can be avoided when appropriate levels of care are available. Patient flow is
improved and better health outcomes are achieved. HAL provides preventative care to keep people
home and out of hospitals.
Comments : Adult Day Programs are gaining in popularity across Canada because clients and their
caregivers both need care. The client is cared for in an environment that is safe, comfortable,
stimulating and friendly, while his or her caregiver is able to enjoy some much needed "self" time.
VON Canada's Adult Day Programs are designed for people with physical and/ or memory challenges,
or for seniors in need of companionship. They reduce social isolation, delay institutionalization and
provide respite for family caregivers.
A variety of stimulating individual and group activities are offered. By staying active and involved,
deterioration is slowed, quality of life is maintained (or even improved in some cases), and the client
experiences optimum levels of intellectual, physical and social functioning. Adult Day Programs
provide clients the opportunity to use their abilities and skills to help maintain the optimum level of
intellectual, physical and social functioning. Adults greatly benefit from the social stimulation and the
dynamic participation in a variety of activities
Caregivers receive a much-needed rest while assured that their loved one is comfortable and safe.
When the caregiver is rested, there are lower levels of stress and less chance of caregiver breakdown.
Highly-skilled caring professional staff and volunteers provide personalized care within a positive and
safe group setting. Activities include exercises, games, musical entertainment, crafts, celebrations of
special events, and discussions. Health maintenance activities may also be provided such as hygiene,
medication monitoring, grooming, hairdressing, and nutrition monitoring.
Comments : Primary Health Care Nurse Practitioners (NPs) are Registered Nurses with advanced
education and skills to provide a broad range of health care services from a holistic nursing
perspective. NPs diagnose and order tests, prescribe medications, and manage diseases, disorders, and
conditions within a professionally regulated scope of practice. NPs work in close collaboration with
other health care professionals and service providers.
VON Canada is proud to be the largest community-based employer of primary health care Nurse
Practitioners (NPs). Through NP-Led Clinics in medically under-serviced areas, our NPs provide
27
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CONTENTS
comprehensive health care to thousands of clients, with a focus on preventing illness and disease and
supporting good health and lifestyle choices, along with the management and treatment of both shortterm and long-term illness. Using a client centred approach, VON NPs collaborate on the best care and
service for an individual so that positive health and social outcomes can be achieved.
VON supports its NPs through a Professional Practice Centre which provides evidence-based clinical
support, advanced practice nursing guidance, education, networking, and collaboration among NPs,
and can help address advocacy needs at both the community and profession-based levels. The Centre
provides VON the ability to recruit and retain health providers while delivering excellence in care and
service. This, along with the role of VON's National Director of NPs, ensures adherence to regulatory
and legislative requirements while supporting full scope of practice.
Dec. 13, 2011
Submission by a Registered Nurse:
Comments: I believe the lack of national goals for health is a deterrent to the negotiation of the new
Health Accord. The most pressing challenges are access to clean potable water and safe sewage
treatment for all Canadians.
The other challenge is the re-organization of the physician and dental pay for service system to a
combination of capitation payment (salaries) and fee for service. Coverage for home care services,
preventive dental care, and medications should be part of medicare insurance.
The principles of the Canada Health Act need to be affirmed and implemented. Portability of benefits
across provinces, for example, is not consistent.
Nurses need to speak up to reduce the invisibility of their role. If every community had one or more
nurses from different practice settings named as a media contact then our perspective would be
profiled and people would understand more about the complex and broad role of nursing in Canada.
Nurse organizations must continue to work together to lobby government and negotiate broad
agreements with other disciplines.
My one change to improve the health of Canadians would be to reduce the income disparity between
the lowest income citizens and the high paid CEOs.
Dec. 14, 2011
Submission by a Registered Nurse:
Comments: I object Canadian new RNs to be examined by US standards.
Are we so illiterate that we can not develop our own exams? Why pay the USA for this exam?
Will this mean the US will honour our RNs as as being able to practice in the USA?
Please stop this exam procedure!! We are CANADIAN and value our healthcare system
Dec. 14, 2011
Dec. 15, 2011
Dec. 15, 2011
Dec. 16, 2011
See submission from the Registered Nurses’ Association of Ontario (RNAO) below.
See submission from 4th year Trent University BScN students below
See submission from the Quality Palliative Care – Long Term Care Alliance (QPC-LTC Alliance) below
See submission from the Community Health Nurses of Canada (CHNC) below
28
DATE
Dec. 16, 2011
CONTENTS
(English translation below)
infirmière autorisée:
Comments: Question 3
Sensibiliser les intervenants de santé sur la promotion de la santé et prévention des maladies afin
qu'ils deviennent eux-même des modèles de santé. Les supporter dans leur projet de vie (la santé) en
leur offrant l'accès dans leur milieu de travail à des programmes de mieux-être similaires à ceux
développer pour les communautés (programme de gestion des maladies chroniques, programme pour
diminuer le stress, approches atlernatives, programmes de santé mentale... Les intervenants de santé
ciblés pourront partager ces encadrements à leur membre de famille (réaliser deux objectifs à la fois).
Également, encourager les intervenants à initier des projets de santé interdisciplinaires dans leur
communauté respectif et de les partager via leur association ou certains organismes qui prônent le
mieux-être tel que le MACS.
Submission by a Registered Nurse:
Comments: Question 3
Raise awareness among health workers about health promotion and disease prevention so that they
themselves become models of health. Support them in their life management (health) by providing
them with access in their workplace to wellness programs similar to those developed for communities
(chronic disease management program, stress reduction program, alternative approaches, mental
health programs, etc.). The health workers targeted would be able to share this advice with their
family members (killing two birds with one stone). In addition, encourage health workers to initiate
interdisciplinary health projects in their respective communities and to share them through their
associations or specific organizations that advocate wellness, such as MACS [Acadian movement for
healthy communities].
Jan. 6, 2011
Submission by a Registered Nurse:
On Dec 5th I had the opportunity to attend the CMA meeting on transforming health care. I attended as
a XXX. I am also a registered nurse and was delighted to see the collaboration between CMA and CNA
in developing the joint principles. However, during the discussions some participants expressed
concern that the background documents to the joint principles and several of the statements are bit
too reflective of the medical model. Judith Shamian also mentioned this following the discussion. I
note that the CNA expert commission highlights the broader determinants of health in a way that
doesn't come through as clearly in the CMA/CNA joint principles. This note is to express my concern
and to support the notion of looking at revisions to the joint principles that will include the critical
importance of a social- environmental approach to health.
Jan. 25, 2012
Mar. 13, 2012
See submission from the Canadian Hospice Palliative Care Nurses Group below
See submission from l'Ordre des infirmières et infirmiers du Québec(OIIQ) below
Cont’d...
29
ORGANIZATIONAL SUBMISSIONS
The Academy of Canadian Executive Nurses (ACEN) Submission:
By the Academy of Canadian Executive Nurses
 XXX
 XXX
Leadership for Health System Transformation: What’s needed in Canada?
Brief for the Canadian Nurses Association’s National Expert Commission on
The Health of our Nation, the Future of our Health System
Overview ...................................................................................................................................... 29
Who is ACEN? ............................................................................................................................ 31
Canadian Values and the Leadership Imperative ................................................................... 31
Leadership Challenges in Health System Transformation ..................................................... 32
Approach ..................................................................................................................................... 32
Recommendation 1: Balance national vision and strategy with local flexibility ................... 33
Recommendation 2: Develop avant-garde executive leadership competencies..................... 33
Recommendation 3: Tap into expertise to develop executive leadership capacity and
accelerate change...... .................................................................................................................. 34
Recommendation 4: Foster executive leadership continuity and succession planning ........ 34
Call to Action ............................................................................................................................... 35
References .................................................................................................................................... 36
Appendix A – Competencies for Health Service Executives ................................................... 39
Prepared October 27, 2011 by XXX.
30
Overview
The purpose of this brief is to recommend what is needed for health executives and senior leaders to
effectively lead health system transformation in Canada. To develop a truly integrated client-centric
health system, health leaders are called upon to work across boundaries related to organizations,
professions, sectors, geography, and jurisdictions.
We offer the following recommendations to strengthen the role of executive leadership in transforming
the Canadian health system:
1. Balance national vision and strategy with local flexibility
2. Develop avant-garde executive leadership competencies
3. Tap into expertise to develop executive leadership capacity and accelerate change
4. Foster executive leadership continuity and succession planning
Note: In this brief, the terms ‘executive’ and ‘health leader’ both refer to executive and senior
management leadership roles in healthcare.
Who is ACEN?
The Academy of Canadian Executive Nurses represents the voice of nursing leadership in Canada.
Founded over thirty years ago, ACEN is now a network of nurses in executive and leadership positions in
healthcare, education, research, government, and health and/or nursing association chief executive
officers. ACEN provides a forum for nurse executives to deal with unique challenges and a network to
influence federal policies on several health-related subjects in the interest of better healthcare for
Canadians.
ACEN would be pleased to collaborate with the Commission and other key stakeholders to support and
implement emerging recommendations in our organizations and regions and at the national level.
Canadian Values and the Leadership Imperative
Canada’s healthcare system is fundamental to Canadian culture and identity. Canadians strongly support
the Canada Health Act principles of administration, comprehensiveness, universality, portability, and
accessibility and are concerned about the long-term sustainability and accountability of our healthcare
system.9
Tommy Douglas, the father of Medicare, envisioned an acute care system solidly underpinned by a
comprehensive primary and public health system to optimize the health status of Canadians. 22 A
preventive approach to population health was essential to minimizing acute care demands and ensuring a
sustainable health system. As Michael Rachlis points out, although we have committed to funding acute
care systems extensively, we have yet to achieve the second stage of Medicare. 30 Integration of health
services across the continuum of care is urgently needed given the dramatic increases in life expectancy
and chronic disease prevalence during the past 50 years. The second stage of Medicare must build a
system that is population health focused, equitable, client-centred, effective, accessible, and safe.30 To
achieve this, the health system must be efficient, accountable, and appropriately resourced and be based
on non-profit delivery.30
What’s needed from health leaders to achieve this transformation of the Canadian health system?
Visionary and servant leadership, ethical decision-making, and the adoption of innovation grounded in the
principles of the Canada Health Act are all necessary to uphold these core Canadian values. 7,24 This brief
31
extends the discussion by recommending strategies to strengthen the contributions of health leaders to
Canadian health system transformation.
Leadership Challenges in Health System Transformation
Despite decades of restructuring, the Canadian healthcare ‘system’ remains a patchwork of health
services. Health leaders face many challenges to develop a truly integrated client-centric health system. In
recent years, Regional Health Authorities and Local Integrated Health Networks have required health
leaders to work across organizational, sectorial, and geographic boundaries to align local needs with
broader system priorities. Health leaders are also contending with flattened structures and leadership
shortages within organizations, as well as fluctuations in labour and financial markets.5,19 These trends are
complicated by increasing pressure to demonstrate improved quality and outcomes relative to population
health needs, in a transparent, accountable, and cost-effective manner.19
In coming years, key challenges that will continue to drive health system transformation include:
 the need for integrated delivery of health services across the continuum20 to manage a growing
population of clients with chronic conditions5 – as well as the complex legal, financial,
regulatory, and leadership issues that accompany such a reorganization of services
 advances in technology such as pharmacogenetics and bioinformatics, which will not only alter
the costs and methods of medical treatment, but also the power dynamics of the healthcare
industry5
 a shrinking government tax base coupled with an aging baby boomer population and anticipated
healthcare provider shortages which will oblige health leaders to provide more healthcare service
with fewer resources.34
While organizations have made great strides in re-organizing services and building cultures to support
patient-centred care, now is the time for health leaders to harness their collective efforts to develop a
truly integrated client-centric health system for Canadians and to achieve the second stage of Medicare.
Approach
Information for this brief was synthesized from a variety of sources, including a literature search on the
professional competence of executive health leaders. Commentaries by opinion leaders and lessons
learned about health system transformation from the Veteran’s Health Administration (VHA) in the US,
the National Health Service (NHS) in the UK, the Jönköping County Council in Sweden, and from
Canada were also included. Synthesis of information from all sources was guided by the following
questions:
1. What is the leadership imperative to transform Canada’s health system?
2. What leadership lessons can be learned from other jurisdictions?
3. What competencies and characteristics are needed in future leaders to enable transformative
change in Canada’s health system?
32
Recommendation 1: Balance national vision and strategy with local flexibility
Although mainly delivered through organizations and networks, health services for populations are
positioned within a broader health ‘system’.10 The planning, design, and funding of health systems are
influenced by the limits and opportunities afforded by broader political, economic, social, and
technological contexts.12 The interplay between the local level, where services are delivered, and the
system level, where overall strategy is determined, is key to health system transformation.
First, a singular, compelling vision and a performance orientation were pivotal to focusing efforts and
effecting large scale health system change. A clear and consistent vision and the metrics to monitor
progress and accountability toward the vision were central to transformations in the VHA, NHS, and
Sweden.3,14,31
Second, local flexibility in adaptation of performance measures and in change implementation supported
health system transformation. Tailoring performance measures to the clinical populations served enabled
health leaders in the VHA and in Sweden to drive changes that were meaningful to care providers and
clients.3,4,31 In the NHS, a recent shift from compliance with quality standards to commitment to quality
improvement is allowing health leaders flexibility and creativity in leading local change.6,8
An overarching national vision and strategy for Canadian health system transformation will enable health
leaders to rally around shared goals. Local flexibility in aligning priorities and performance measures
within an overall Canadian strategy will enable health leaders to meet local needs and to improve quality.
Recommendation 2: Develop avant-garde executive leadership competencies
A review and synthesis of recent literature on professional competence1,11,13,16-18,24-29,32,33,36 revealed high
consistency with the Canadian College of Health Leaders’ executive competencies which include:
leadership; communication; life-long learning, consumer and community responsiveness and public
relations; political awareness in the health environment; conceptual skills; results-oriented management;
resources management; and compliance with standards, ethics and laws (see Appendix A).7
The following are new emerging competencies identified from the literature:
 Global awareness and interoperability16,28 is the ability to dialogue externally and internally with
other leaders and to proactively identify and synthesize healthcare and health profession issues (e.g.,
pandemics, migration of health human resources) across diverse cultures and markets. This
competency facilitates the planning and alignment of national, regional and local healthcare initiatives
across professional, organizational, sectorial, and jurisdictional boundaries.
 Public policy acumen22,24,31,35 is the ability to assess the broader policy context, to position healthcare
on the policy agenda, and to engage and gain the commitment of policy makers and influential
stakeholders in adopting change. This competency enables health leaders to secure the political will
that is necessary to address the broad determinants of health and the systemic nature of healthcare
issues.
 Rapid response capacity13,16 is the ability to use short-term, highly responsive strategy formulation
and implementation skills. This competency aids health leaders in adapting proactively to a rapidly
changing healthcare industry characterized by fragmentation and turbulence.
33
 State-of-the-art communication and information technology savvy16,37 refers to the ability to apply
work design processes to virtual communication modalities and to harness emerging information
technologies (e.g., biometrics, information systems, electronic records). This competency facilitates
the portability and integration of relationships and operational processes.
 Innovation13,24,29 is a state-of-being that draws on all executive competencies to strategically redesign
health services to achieve an integrated health system in a manner that is both responsive to the
changing context and consistent with core values.
These emerging leadership competencies are crucial to transforming increasingly integrated, virtual, and
high-tech health systems in globalized, policy-driven, and rapidly changing contexts.
Recommendation 3: Tap into expertise to develop executive leadership capacity and
accelerate change
Many health systems attributed success in the transformation process to investing in the on-going training
of executive and medical leaders. A key lesson is that organizational learning and cultural change were
expedited by tapping into centralized expertise outside the organization.21
For example the VHA, NHS, and Sweden purposefully trained health leaders in change implementation
through the Institute for Health Improvement in the US, with some systems subsequently developing
internal capacity to spread these improvement methods.3,21,23,31 Both the NHS and Sweden invested in
leadership councils to foster leadership capacity, as well as mentoring relationships with either leading
healthcare corporations or experts from abroad.2,3,23
Investing in centralized or national initiatives, such as the Canadian Health Leadership Network
(CHLNet), to increase local training and to create mentoring partnerships between organizations are
potential approaches to tapping into external expertise that will accelerate health system change in
Canada.
Recommendation 4: Foster executive leadership continuity and succession planning
Health leader tenure, stability, and succession planning enable transformative change and improve health
system performance. In Canada, the supply of executive and management roles will soon suffer deep
losses due to the baby boomer retirement demographic and will be very difficult to replace due to the
advanced educational and experience requirements associated with health leader roles.15
Allowing administrators to build long and successful careers within an organization enhanced
transformation efforts in the VHA, NHS and Sweden.3,4,21 Succession planning through extensive training
and leadership development at all levels was essential to ensuring on-going system transformation.3,4
Developing clinician leaders was critical to success in the NHS,2 and similar calls have been heard in
Canada.8,10,34 By virtue of their professional expertise, clinician executives are well positioned to unravel
the complexity of point-of-care issues, incorporate the broad determinants of health, balance financial and
clinical outcomes, and to foster collaborative interdisciplinary cultures.10,31,34
Monitoring the production, supply, and deployment of qualified health leaders as part of an overall health
human resources strategy will inform system level planning for health leadership sustainability. A
deliberate strategy to cultivate a critical mass of clinician executives across all disciplines will strengthen
the interface between management and clinical domains and facilitate local and system level
transformation.
34
Call to Action
For these recommendations to be put in action, ACEN provides the following considerations to the
Commission:






Articulation of a compelling, national vision for system level change grounded in the principles
of the Canada Health Act is essential to achieve an integrated client-centric health system for
Canadians.
A strong, overarching federal strategy balanced with jurisdictional flexibility will enable health
leaders to meet the population health needs of Canadians in local contexts.
Investing in the development of avant-garde executive competencies will enhance leadership
capacity for rapid health system innovation.
Tapping into expertise to develop leadership and quality improvement capacity and mentoring
partnerships will accelerate health system change.
Growing a critical mass of clinician executives will enhance local and system change.
Fostering executive continuity and planning for succession will ensure the sustainability of health
leadership in Canada.
Healthcare remains integral to our Canadian identity. To achieve the second stage of Medicare, that is, the
fully comprehensive and preventive Medicare system originally envisioned by Tommy Douglas, we must
consider who will lead system innovation and redesign. Urgent action is required to ensure a vanguard of
visionary and influential health leaders who will enable the successful transformation of our Canadian
health system.
35
References
1.
Arnold, L., Drenkard, K., Ela, S., Goedken, J., Hamilton, C., Harris, C., Holecek, N., & White, M.
(2006). Strategic positioning for nursing excellence in health systems: Insights from chief nursing
executives. Nursing Administration Quarterly, 30(1), 11-20.
2.
Baker, G.R., MacIntosh-Murray, A., Porcellato, C., Dionne, L., Stelmacovich, K., & Born, K.
(2008). Birmingham East and North Primary Care Trust and Heart of England Foundation Trust.
High performing healthcare systems: Delivering quality by design (pp. 27-64). Toronto, Ontario:
Longwoods Publishing.
3.
Baker, G.R., MacIntosh-Murray, A., Porcellato, C., Dionne, L., Stelmacovich, K., & Born, K.
(2008). Jönköping County Council. High performing healthcare systems: Delivering quality by
design (pp. 121-144). Toronto, Ontario: Longwoods Publishing.
4.
Baker, G.R., MacIntosh-Murray, A., Porcellato, C., Dionne, L., Stelmacovich, K., & Born, K.
(2008). Veterans Affairs New England Healthcare System (Veterans Integrated Service Network
1). High performing healthcare systems: Delivering quality by design (pp. 71-114). Toronto,
Ontario: Longwoods Publishing.
5.
Baker, R. (2001). Healthcare managers in the complex world of healthcare. Frontiers of Health
Services Management, 18(2), 23-32.
6.
Blackler, Frank. (2006). Chief executives and the modernization of the English National Health
Service. Leadership, 2(5), 5-30.
7.
Canadian College of Health Service Executives. (2005). Competencies for today’s health service
executive. Retrieved from
http://www.cchse.org/assets/certification/2005%20Competencies%20for%20Certified%20Health%
20Executives.pdf
8.
Canadian Health Services Research Foundation. (2011). CEO forum 2011: Report of the fifth
annual CEO forum. Author, Ottawa.
9.
Commission of the Future of Health Care in Canada. (2002, November). Building on values: The
future of health care in Canada - Final report. Ottawa, Ontario, Canada. Commissioner: R. J.
Romanow.
10.
Denis, J., Davies, H.T.O., Ferlie, E., & Fitzgerald, L. (2011). Assessing initiatives to transform
healthcare systems: Lessons for the Canadian healthcare system. Ottawa, Ontario: Canadian
Health Services Research Foundation.
11.
Englebright, J., &Perlin, J. (2008). The chief nurse executive role in large healthcare systems.
Nursing Administration Quarterly, 32(3), 188-194.
12.
Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources.
(2005). A framework for collaborative pan-Canadian health human resources planning. Ottawa,
Ontario: Author.
13.
Hartman, S.J., & Crow, S.M. (2002). Executive development in healthcare during times of
turbulence: Top management perceptions and recommendations. Journal of Management in
Medicine, 16(4-5), 359-370.
14.
Fooks, C., & Decter, M. (2005). Commentary: The transformation experience of the Veterans
Health Administration and its relevance to Canada. HealthcarePapers, 5(4), 60-64.
36
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Hewitt, A. (2006). Health leaders and managers in Canada: The human resource dilemma.
Ottawa, Ontario: Canadian College of Health Service Executives.
16.
Huston, C. (2008). Preparing nurse leaders for 2020. Journal of Nursing Management, 16, 905-911.
17.
Kirk, H. (2009). Factors identified by nurse executive directors as important to their success.
Journal of Nursing Management, 17(8), 956-964.
18.
Kirk, H. (2008). Nurse executive director effectiveness: A systematic review of the literature.
Nursing Management, 16(3), 374-381.
19.
Leatt, P., & Porter, J. (2003). Where are the healthcare leaders? The need for in leadership
development. HealthcarePapers, 4(1), 14-31.
20.
Leatt, P., Pink, G.H., & Guerriere, M. (2000). Towards a Canadian model of integrated healthcare.
HealthcarePapers, 1(2), 13-35.
21.
Levine, D. (2008). Commentary: Veterans Affairs New England Healthcare System (VISN 1).
High performing healthcare systems: Delivering quality by design (pp. 115-120). Toronto, Ontario:
Longwoods Publishing.
22.
Margoshes, D. (1999). Tommy Douglas: Building the new society. Lantzville, British Colombia:
The Quest Library.
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Martin, M. (2008). Commentary: Birmingham East and North Primary Care Trust and Heart of
England Foundation Trust. High performing healthcare systems: Delivering quality by design (pp.
65-70). Toronto, Ontario: Longwoods Publishing.
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Canada. Seminars for Nurse Managers, 5(2), 97-105.
25.
Meadows, A.B., Finstuen, K., & Hudak, R.P. (2003). Pharmacy executives: Leadership issues and
associated skills, knowledge, and abilities in the U.S. Department of Defense. Journal of the
American Pharmacists Association, 43(3), 412-418.
26.
Meadows, A.B., Maine, L.L., Keyes, E.K., Pearson, K., & Finstuen, K. (2005). Pharmacy executive
leadership issues and associated skills, knowledge, and abilities. Journal of the American
Pharmacists Association, 45(1), 55-62.
27.
Misener, T.R., Alexander, J.W., Blaha, A.J., Clarke, P.N., Cover, C.M., Felton, G.M., Fuller, S.G.,
Herman, J., Rodes, M.M., & Sharp H.F. National Delphi study to determine competencies for
nursing leadership in public health. Image Journal of Nursing Scholarship, 29(1), 47-51.
28.
Palarca, C., Johnson, S., Mangelsdorff, A.D., & Finstuen, K. (2008). Building from within:
identifying leadership competencies for future navy nurse executives. Nursing Administration
Quarterly, 32(3), 216-225.
29.
Porter-O’Grady, T., & Malloch, K. (2009). Leaders of innovation: Transforming post-industrial
healthcare. Journal of Nursing Administration, 39(6), 245-248.
30.
Rachlis, M. (2007). Completing the vision: Achieving the second stage of Medicare. In G.
Marchildon, & B. Campbell (Eds.), Medicare: Facts, myths, problems, promise. Toronto, Ontario:
James Lorimer & Co. Retrieved from
http://www.policyalternatives.ca/publications/reports/medicare
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Rachlis, M. (2004). Prescription for excellence: How innovation is saving Canada’s healthcare
system. Retrieved from
http://www.michaelrachlis.com/pubs/Prescription%20for%20Excellence%20pb%200412.pdf
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32.
Stefl, M.E. (2008). Common competencies for all healthcare managers: The Healthcare Leadership
Alliance model. Journal of Healthcare Management, 53(6), 360-373.
33.
Sentell, J.W., & Finstuen, K. (1998). Executive skills 21: A forecast of leadership skills and
associated competencies required by naval hospital administrators into the 21st century. Military
Medicine, 163(1), 3-8.
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Shamian, J. (2010). Clinician executives: A new breed of leader. Canadian Journal of Nursing
Leadership, 23(4), 22-27.
35.
Shamian, J., Skelton-Green, J., & Villeneuve, M. (2002). Policy is the lever for effecting change.
In Realities of Canadian Nursing (pp. 83-104). Canada: Lippincott, Williams & Wilkins.
36.
Sutto, N.B., Knoell, M.D., Zucker, K., Finstuen, K., & Mangelsdorf, A.D. (2008). Executive
competencies of nurses in the Veterans Health Administration. Military Medicine, 173(1), 47-53.
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Wertenberger, S., Chapman, K.M., & Wright-Brown, S. (2011). The Department of Veterans
Health Administration Office of Nursing Service, “Transforming nursing in a national healthcare
system: An example of transformation in action”. Nursing Administration Quarterly, 35(3), 260269.
38
Appendix A – Competencies for Health Service Executives
Canadian College of Health Leaders7
These are the nine competencies that are seen as essential for leaders of health service organizations (click
here to download the detailed competencies):
1. Leadership
Defining a vision and guiding individuals and groups while maintaining group cohesiveness,
motivation, commitment and effectiveness
 vision
 team capabilities
 flexibility
 personal Management
 commitment
2. Communication
Communicating information effectively and understanding the essence and subtle meanings of what
is said.
 verbal communication
 listening
 written communication
3. Life-long Learning
Continually learning and promoting the value of learning for self and others



self-directed learning
teaching/mentoring/facilitating
emotional intelligence
4. Consumer and Community Responsiveness; Public Relations
Responding to consumer and community needs; actively partnering with and promoting positive
relations with the community and consumer groups
 public relations


responsiveness
partnerships
5. Political Awareness in the Health Environment
Sensitivity to political issues and the health environment and their impact; furthering health services
through active involvement
 political awareness and sensitivity
 health services environment
 determinants of health
6. Conceptual Skills
Identifying and analyzing situations and problems to find viable solutions, and approaching tasks and
problems in a way that considers total systems and strategies.
 analysis and synthesis
 problem solving
 systems thinking
 emotional intelligence
7. Results-oriented Management
39
Establishing courses of action for self and others to achieve results.
 planning
 implementation
 monitoring/evaluating
8. Resources Management
Managing human, capital, financial, and information resources so that organizational objectives are
achieved.
 human resources/intellectual capital
 financial resources
 capital/material assets
 information
9. Compliance with Standards, Ethics and Laws
Promoting compliance with accreditation standards and ethical and legal requirements
 accreditation standards
 ethical practices
 legislation
40
Registered Nurses’ Association of Ontario (RNAO) Submission:
Submission to the Canadian Nurses Association National Expert Commission on Transforming
the Health-Care System
RNAO Recommendations to the CNA National Expert Commission on Transforming the
Health-Care System

Address income inequality as a key determinant of mental and physical health, linked to lower
life expectancy, greater exposure to environmental damage such as climate change and toxics,
decreased educational performance, increased violence and decreased social mobility.

Strengthen Canada’s publicly-funded, not-for-profit health care system and reject efforts to
commercialize or privatize health care delivery.

Oppose the negotiation of comprehensive trade agreements that seek to undermine the ability of
governments to regulate or implement programs in the public interest such as publicly-funded,
not-for-profit health care.

Support examples of successful innovations that are proven to produce better outcomes and value
within the publicly-funded, not-for-profit system, such as the 80/20 program for late-career
nurses, Registered Nurse First Assists and advance practice nurses, targeting 70 per cent full-time
nurses in all sectors, new nurse graduate guarantee initiatives, long-term care best practice
coordinators and all RNs and NPs working to full scope.

Fully utilize nurse practitioners and RNs in primary care, community care, long-term care and
acute care, including funding for innovations such as NP-led clinics as pioneered in Ontario, and
other inter-professional primary care models.
Guarantee all Canadians timely access to team-based primary care, within a strong primary
health care system.


Ensure nursing leadership in primary care sets the agenda on quality and accountability in
primary care service provision, research, administration and governance.
41

Increase investment in home care services, including homemaking and professional services, to
support persons with chronic conditions and/or older persons so that they continue to remain
active and vibrant members of our community.

Provide incentives for collaboration of all community health care partners, including mental
health and chronic disease management, in addition to home care services.

Reject competitive bidding as a method of allocating funding for home care.

Expand the publicly-funded, not-for-profit health care system to include a comprehensive
national home care and pharmacare strategy, and a strategy for mental health and addictions.
42
The Registered Nurses’ Association of Ontario (RNAO) is the professional organization representing
registered nurses in Ontario. It is the strong, credible voice leading the nursing profession to
influence and promote healthy public policy. We welcome the opportunity to contribute to the CNA
National Expert Commission’s vitally important and timely consultation with Canadians on
transforming and strengthening our treasured publicly-funded, not-for-profit health care system.
A. Improving Health by Acting on the Social and Environmental Determinants of Health
According to the World Health Organization’s Commission on Social Determinants of Health,
“social justice is a matter of life and death. It affects the way people live, their consequent chance of
illness, and their risk of premature death.”1 The “new progressive”2 global Occupy Movement has put
the spotlight on growing economic inequalities that underpin vast power differentials that erode
democratic processes so necessary for individual and collective health. Income inequality in Canada
has increased over the last 20 years3 and the increase in income inequality has been greater in Canada
than in the United States since the mid-1990s.4 The richest one per cent in Canada are taking more of
the gains from economic growth than ever before in recorded history.5 Understanding these trends is
crucial as the evidence grows that the costs of inequality include worse mental and physical health,
lower life expectancy, decreased educational performance, increased violence, and decreased social
mobility.6
As health inequities are unfair, unacceptable, and largely avoidable, they are a shared responsibility
that requires engagement of all sectors of government and all segments of society.7 The voice of
nursing must be aligned with the wisdom of social movements and public interest civil society
organizations who are demanding “governments fulfill their obligations to act to guarantee social
rights and state protection.”8 In particular, it is critical to address the clout of financial capital in the
global economy by initiating and enforcing international tax mechanisms to control global
speculation and eliminate tax havens.9 Global trade agreements and regulations need to be
refashioned to ensure equity-based social protection systems, including protecting publicly financed
and publicly provided not-for-profit health systems.10
The Chief Medical Officer of Health of Ontario has called for the application of a “health lens to
every program and policy” so that the health impacts and benefits of various decisions may be
known.11 12 The Chief Public Health Office of Canada has emphasized the need to approach
“problems from all sides with coordinated, multi-pronged, intersectoral action.”13 In addition to
monitoring progress and holding governments accountable for action on the social determinants of
health, it is also vital that health impact assessments be used “to document the ways in which
unregulated and unaccountable transnational corporations and financial institutions constitute barriers
to Health for All.”14
The Registered Nurses’ Association of Ontario’s Creating Vibrant Communities: RNAO’s
Challenge to Ontario’s Political Parties is grounded in the values of human rights in its pursuit of
transformative change that seeks to improve health, the health care system, and access to nursing
services.15 One of the key principles articulated in that document is fairness and respect for our first
peoples: “vibrant communities mean respect for the right of our first peoples to self-determination
and equitable access to resources, jobs, health care, clean water, good schools and safe housing.” 16
Canada’s nurses must find meaningful ways to support First Nations, Métis, and Inuit communities
that continue to struggle with living conditions that are harmful to health and human dignity. 17 18
43
Evidence of the connection between the environment and health is well established. The World
Health Organization estimates that environmental factors account for 24 per cent of the world’s
burden of disease and 23 per cent of all deaths.19 Environment is estimated to play a larger part in
some conditions, such as asthma (44 per cent).20 Climate change itself affects human health, by
contributing to extreme weather events, killer heat waves, poor air quality, and vector-, rodent-, foodand water -borne diseases. By fighting global warming, we are not merely protecting the
environment – we are protecting the health of Ontarians. Creating vibrant communities means
building healthier environments through cleaner air and water; creating good green jobs on a base of
equity and environmental sustainability; getting serious about climate change; and reducing toxic
substances and other pollutants in the environment, in our workplaces, in our consumer products, and
in our food and water.
As the principle of environmental justice reminds us, the costs of environmental damage and climate
change are disproportionately borne by lower income people.21 This is particularly true at the global
level with climate change; it is the most vulnerable people in developing countries that are at greatest
risk of inequity. These are the people who did the least to cause global warming. Human-generated
greenhouse gases that further global warming are likely to exacerbate droughts in sub-Saharan Africa
and threaten a “catastrophic reversal in human development.”22 When confronting the social and
environmental determinants of health in Ontario, we must consider the impact on our most
vulnerable populations, particularly Aboriginal people. Social justice, clean air and clean water all
must be recognized as human rights and the starting point if we are to be serious in improving
individual, community and population health.
B. Publicly Funded and Not-For-Profit Health-Care Delivery are Non-Negotiable
There is widespread support among Canadians for our publicly funded, not-for-profit health care
system, with recent polling showing that 94 per cent of Canadians support public, not private forprofit, solutions. This is up about ten per cent from a similar poll one year ago, indicating growing
support as governments engage in re-negotiating the 2004 Health Accord.23 Any doubts that publiclyfunded not-for-profit health care provides better care and better value are quickly allayed by a look
south of the border.
Commercialization of health care in the United States has not served its population well. There were
49.9 million Americans (16.3 per cent of the U.S. population) without any health insurance in 201024
while the U.S. was still the outlier nation in terms of health expenditures among OECD countries.
Total health spending accounted for 17.4 per cent of GDP in the United States in 2009 compared
with the average of 9.5 per cent in OECD countries and 11.4 per cent for Canada.25 In terms of total
health spending per capita, the United States with $7,960 USD (adjusted for purchasing power
parity) spent more than twice the OECD average of $3,223 USD in 2009.26 Total health spending in
Canada accounted for 11.4 per cent of GDP in 2009, with spending of $4,363 USD per capita.27 The
OECD estimated that Canada’s health share of GDP had dropped to 11.3 per cent in 2010.28
44
Robert Evans provides strong evidence that market approaches to health care reform have a
“redistributive agenda” that is both more costly for health care systems as a whole and privileges
those who are healthy and wealthy.29 “Any shift from public to private financing, by whatever means,
will necessarily transfer costs from those with higher to those with lower incomes, and from the
healthy to the ill.”30 Private insurance31 32 and medical savings accounts33 34 are two examples of nonpublic financing common in the United States that would increase inequities in health outcomes and
in access and quality of health care while costing more.
It is critical that nurses remain attentive to these power dynamics as well as to language that signals
support for privatized, for-profit entrepreneurial health care. For example, persistent calls for forprofit financing and delivery of certain health services are often cloaked as “innovation” and “patient
choice”. Flirting with for-profit health care must be rejected, in the strongest possible terms based as
thorough review of the evidence shows that for-profit delivery produces worse patient outcomes, and
is more expensive than not-for-profit delivery.
A review of four decades of experience with privatization in the United States with a combination of
public funding and private health care management and delivery found that “for-profit health
institutions provide inferior care at inflated prices.”35 Private contracting in the U.S. Medicare
program for seniors through the Medicare health maintenance organization (HMO) contracting
program is a cautionary tale in that it evolved into a multi-billion dollar subsidy for HMOs who often
cherry-pick the healthiest clients while refusing those most acutely and expensively ill. 36 The
experience of public-private competition in the United States is that for-profit “firms carve out the
profitable niches, leaving a financially depleted public sector responsible for the unprofitable patients
and services.”37
Considerable evidence is available on quality of care differences between for-profit and not-for-profit
delivery across sectors. Studies show that the quality of care in for-profit institutions is lower.38 39 40 41
42
|The most conclusive evidence comes from systematic reviews and meta-analyses of peer-reviewed
literature on for-profit versus not-for-profit health care, which found higher patient mortality rates in
for-profit as compared to not-for-profit centres.43 44 45 One compelling example is that patients
attending for-profit dialysis had eight per cent higher death rates than those who received care at nonprofit facilities. This translates into an estimated 2,000 premature deaths each year in the United
States linked to for-profit dialysis.46 Furthermore, worse health outcomes have also come with higher
costs: a systematic review and meta-analysis of peer-reviewed literature concluded that for-profit
hospitals charged a statistically significant 19 per cent more than not-for-profit hospitals.47
Canadian evidence from the long-term care sector has found that staffing levels were higher in notfor-profit facilities than in for-profit facilities,48 and health outcomes were better in not-for-profit
facilities.49 50 Differences in staffing were likely to result in the observed differences in health
outcomes.51 A review of North American nursing home studies between 1990 and 2002 similarly
concluded that for-profit homes appeared to deliver poorer quality care in a number of process and
outcome areas.52 A systematic review and meta-analysis published in 2009 confirmed that the
evidence suggests that, on average, not-for-profit nursing homes deliver higher quality care than forprofit nursing homes.53 This meta-analysis estimated that pressure ulcers in 600 of 7,000 residents
with pressure ulcers in Canada and 7,000 of 80,000 residents with pressure ulcers in the United
States are attributable to for-profit ownership.54
The research evidence is clear – Canadians will benefit most from strengthening the public financing
and not-for-profit delivery of health services. This is precisely why the RNAO joins many other civil
45
society groups in opposing comprehensive trade agreements that are inevitably negotiated behind
closed doors and seek to undermine the ability of governments to regulate or implement programs in
the public interest such as health care.
The above does not mean that systemic changes and innovations are not necessary and achievable,
but these are best accomplished through strengthening our health care system. Michael Rachlis has
identified many success stories in the public, not-for-profit system in improving clinical services,
reducing wait times and decreasing costs.55 56 57
C. Innovation in the Not-for-Profit System: Innovative Models of Care Delivery, Quality and
Technology
Given the changing health care needs of Canadians, as well as the growing complexity and fractured
nature of our current health care system, innovative solutions are called for, within the context of notfor-profit delivery.
According to a September, 2011 World Health Organization report, 89 per cent of all deaths in
Canada result from non-communicable diseases (ie. diabetes, respiratory diseases, cancers, and
cardiovascular diseases).58 Continuing to fund and manage health care services primarily structured
to treat communicable diseases and acute episodes of illness rather than preventing and treating
chronic and non-communicable diseases will perpetuate ineffective, inefficient and costly care.
While the need to increase public funding of health care services that would assist in the care of
chronic diseases (ie. home care, pharmacare, and diagnostic equipment including MRIs), remains,
new and innovative service delivery options for already insured services do not require additional
spending.59 Restructuring to achieve high quality care will in fact strengthen our treasured health care
system, in part by improving access and controlling costs.60 We must spend better and and smarter,
instead of focusing on cost reduction.”61
Scaling up Validates Innovative Models of Care Delivery
Working together in high-functioning inter-professional teams reorients the system to focus on the
person receiving care.62Current examples of successful innovations that produce better outcomes and
value that should be replicated nationally include: 1) Nurse Practitioner-led clinics,63 64 2) Registered
Nurse First Assistants,65 3) the 80/20 principle for innovative professional development,66 4) targeting
70 per cent full-time nurses in all sectors; 5) new nurse graduate guarantee initiatives 67 6) LTC Best
Practice Coordinators68 7) defining and integrating APN role and responsibilities69 and 8) all RNs and
NPs working to full scope.
For example, RNAO has long campaigned for 70 per cent full-time employment for all nurses.70 Fulltime RNs increased from a low of 50 per cent in 1998 to 67.9 per cent in 2011 (68.2 per cent if nurse
practitioners are included). 71 This dramatic progress has resulted in better retention, better quality of
patient care, and more people wanting to enter the profession. Moreover, employing full-time instead
of casual agency nurses ensures the continuity of care, continuity of caregiver and workforce stability
that is associated with lower mortality rates and improved patient behaviours. 72 73 74
46
Full Utilization of RNs and NPs
In August, 2011, landmark legislation was proclaimed that enables Ontario’s NPs to maximize their
potential within the acute care system. Legislation and complementary regulations in the Public
Hospitals Act support NPs to autonomously treat and discharge hospital inpatients. As of July 1,
2012, NPs will also be authorized to admit patients into hospital.
Other groundbreaking enhancement to NPs, RNs and RPNs scope of practice in Ontario includes:





Nurse practitioners can autonomously prescribe medications appropriate to patient care, rather
than from a pre-determined list
A restrictive list of laboratory tests that NPs are authorized to prescribe has been removed
NPs are authorized to set and cast fractures of bones and dislocations of joints.
NPs are enabled to dispense, compound and sell medications in certain situations
RNs and RPNs will be able to receive patient care orders from NPs
Enabling NPs to provide these services not only improves hospital quality measures, patient safety,
cost-effectiveness and patient flow, it also nurtures an equitable, collaborative professional paradigm
that motes excellent value within the not-for-profit system.
In November, 2011, the RNAO announced the creation of a task force to recommend ways to
maximize utilization of primary care/family practice nurses. There are currently 4,285 family
practice nurses in Ontario, of whom 2,873 are RNs and 1,412 are registered practical nurses. To
bring about transformational change in Ontario’s primary care system, the doors must be opened to
utilize all health care professionals to their maximum scope of practice. For example, family practice
nurses are ideally positioned to coordinate care at home, conduct “house calls”, and assume a
navigating role. By leveraging their central role, family practice/ nurses can help build a primary
health care system that promotes health equity and addresses root causes of health disparities,
including addressing the social and environmental determinants of health. Since 2002, some primary
care RNs in the UK have been functioning in an expanded role as independent nurse prescribers.
Increasing access to needed medications and maximizing the skills of all health professionals are two
reasons the British government championed this expanded role. Independent nurse prescribers are
“first level” registered nurses who have completed a specialized certification training course. They
are responsible and accountable for patient assessments and clinical management, including
prescribing. In some jurisdictions, the nurse prescriber must work in partnership with a mentor for a
specified period of time before working autonomously in the role. Independent nurse prescribers do
not work from a formulary list of permitted medications but rather are authorized to prescribe any
medication appropriate for patient care within their competence, knowledge and skill. In an
evaluation published in 2010, nurse prescribing was found to be safe and clinically appropriate and
widely accepted by patients.75
47
Technology Serves to Improve Quality of Care
Information technologies that improve the efficiency of administration, documentation and reporting
may free up time and resources that can be used to enhance service delivery. 76 Assistive technology
can improve workforce capacity and client independence. 77 Both serve to reduce costs (goods,
services and time), while improving quality of care. New strides in point of care information
technology should focus on coordinating care while reducing the proportion of time nurses spend on
documentation. Assistive technology, such as hand-washing reminders, and weightless transfer
devices, should reduce morbidity in nurses who are disproportionately prone to illness and injury. 78
Nurse fatigue may also be minimized by technological enhancements to workplaces that incorporate
best practice design principles to optimize lighting, reduce noise and interruptions, improve lines of
sight, and reduce walking distances.
Better Care and Better Value in Primary Care
At its best, primary care is a person-oriented entry point to the health care system which fits within
the bounds of a strong primary health system. It may encompass health promotion, primary and
secondary disease prevention and health maintenance and restoration across the life span.79 80 81 82 In
Canada, however, primary care is often framed by disease-oriented models of care and dominated by
family physicians.83 84 Federal policy in the form of the Canada Health Act constructs and reinforces
this system by guaranteeing funding for family physicians, but no other health or community
services, outside of the hospital setting.
Canadians need equitable and timely access to primary care services that will seamlessly address
physical, mental and social health needs. This includes access to a variety of health care providers,
community supports, and treatments and medications. Such a system ideally builds from teams of
nurses and other health care providers collaborating with individuals and communities to provide
safe, timely, relevant, accessible and efficient services.85 86 87 As of 2012, Ontario will have 26
functioning NP-led clinics across the province, joining Community Health Centres and other interprofessional models in providing access to high quality primary care for thousands of people.
Thousands of Canadian Registered Nurses and Registered Practical Nurses play varied and critical
roles as system navigators, health promoters, clinicians, advocates, collaborators and educators in
primary care.88 In some places, the primary care nursing role has the potential to be strengthened
significantly through leadership and increased recognition of the immense opportunities this nursing
role provides for the health care system as a whole. As partnerships between primary care and public
health increase, RNs are particularly well equipped, with a client-centered, population health
perspective to show the way as leaders, researchers, administrators and front line providers in
primary care across the province.
48
Home care – It’s Time!
High quality home care keeps our communities vibrant by allowing people with acute and chronic health
conditions to remain independent, active and involved. The home has become a principal site for efficient
health care delivery across Ontario and Canada. Home care provides critical support services, from posthospitalization follow-up to homemaking and personal care.89
However, as people are being discharged from acute care settings “quicker and sicker”, access to care that
was until recently provided in hospitals and assured under the Canada Health Act is being eroded.90 A
Canadian home care strategy is critical. It must balance individual and family self-reliance with guarantees
for the provision of core health care services including access to registered nurses. Advances in treatments
and technology, limited resources, decreased length of hospital stay, increased day surgery treatment and
changes in expectation have significantly increased the care requirements of today’s community client. 91 92
Direct and indirect health care costs, such as wound care supplies and lost wages secondary to caregiving
responsibilities are being passed from the public sector to individual patients and families. 93 Wages for
professionals and formal (paid) caregivers in the home care sector remain low when compared with the
hospital setting but nonetheless we are seeing increasing volumes and complexity of nursing care provided
in the home.94 Home care policy must take into account the importance of nursing workforce stability for
continuity of care and patient safety, in addition to adequate funding all the services required to keep
people well in their homes.
Use of competitive bidding in the home care sector is antithetical to client-centred care as it inevitably leads
to contracts awarded on the basis of price rather than quality. Ontario is the only province relying
exclusively on competitive bidding, and home care is the only health sector in Ontario where direct care is
contracted out. It is not a model that should be replicated in other jurisdictions. As Ontario’s Auditor
General has noted in several reports, the suggested benefits of a competitive model have never been
realized while many unintended consequences have left Ontario with an ailing and debilitated home care
sector.95 96Within a competitive bidding system, for-profit agencies have edged out not-for-profit
organizations who have historically offered higher wages, more stable working conditions, superior quality
of care and more transparent accountability structures.97 98
National Pharmacare Program
As with home care, increasing and improving access to health care, equity and sustainability requires an
expansion of the publicly-funded, not-for-profit system to cover the cost of pharmaceuticals. In 2009,
spending on drugs accounted for 16.4 per cent ($30 billion) of health expenditures in Canada. 99 The share
of health care spending on drugs has nearly doubled over the last 30 years and now makes up the second
largest proportion of health care spending, after hospital care.100 With drugs being a major driver of health
care costs, priority should be given to a standardized, national, publicly funded and publicly controlled
pharmacare program covering essential drugs. Since 1997,101 calls for a pan-Canadian pharmacare program
have accelerated, including high-profile recommendations such as those arising out of the Romanow
Commission.102 103 104 Such a program would provide equal access to prescription drugs across the country
and keep the rising cost of prescription drugs in check.
49
Access to Mental Health and Addiction Services
Tackling mental health and addictions issues is vital for the health of individuals, families, and
communities. It is estimated that at least 60 per cent of individuals diagnosed with a mental illness also
have addictions. Mental health and addictions account for nearly 12 per cent of the overall burden of
disease, yet a province such as Ontario consistently spends only five per cent of the provincial health
budget on mental health and addictions.
In its report Every Door is the Right Door,105 the Ontario government points out that in total, including lost
productivity, law enforcement, and disability claims, drug costs, and employee assistance claims, mental
health and addictions cost Ontario at least $39 billion per year. Every dollar spent on mental health and
addictions saves $7 in health costs and $30 in lost productivity and social costs.
A mental health strategy must be developed that is delivered at the individual’s preferred location, with
special consideration for: members of Aboriginal communities; older adults tackling new and ongoing
mental health and addictions challenges; people from racialized communities; new Canadians; people with
disabilities; discharged members of the Canadian Forces, especially those who were in combat roles;
children and youth requiring increased and enhanced mental health and addictions services; and, inmates in
correctional facilities and rehabilitated ex-convicts.
People facing mental health and addictions challenges must receive respectful, equitable, appropriate, and
seamless client-centered access to health and social services. Stigma in perceptions, attitudes, and actions
needs to be addressed.
D. What do we need from nurses, other health professionals, governments and the public to address
the challenges that we’re facing?
As the CNA National Expert Commission heard in a Toronto focus group106, economic anxiety is
increasing while public awareness of economic inequality and health inequities remains low, despite the
“Occupy” movement beginning to shine a light on the growing gap separating the top one per cent and the
vast majority of Canadians. Nurses were reminded by focus group participants of the tremendous support
and credibility they have as a profession, and the potential influence that over 266,000 registered nurses can
have as a force for change.107 To meet the most pressing health challenges that Canada faces, it is critical
that Canada’s nurses work together with civil society groups, health professionals that share the same
commitment to equity, and the public, especially those who have been marginalized, to transform
government and other societal structures in order to build a more just society. The Final Report of the
Commission on Social Determinants of Health,108 the Rio Political Declaration on Social Determinants of
Health,109 and the Rio Declaration by Public Interest Civil Society Organizations and Social Movements110
provides a strong framework for action to decrease health inequities.
Conclusion
The RNAO appreciates the opportunity to have input into the important and historic work of the CNA’s
National Expert Commission.
50
References
__________________________________________
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Ibid.
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51
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44
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45
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Devereaux, P. Schünemann, H, et al. (2002). 2449-2457.
47
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52
48
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49
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51
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52
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62
Ibid.
63
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71
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54
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108
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from http://www.phmovement.org/
55
Fourth Year BScN Students, Trent University Submission:
XXX
Fourth Year BScN Students
Trent University
Peterborough, Ontario
Contact: XXX
December 15, 2011
Dear National Expert Commission members,
As fourth year nursing students at Trent University in Peterborough Ontario, it is with great
interest and excitement that we submit this briefing to the National Expert Commission on health system
improvement, entitled The Health of Our Nation — The Future of Our Health System. We support the
Canadian Nurses Association’s work to move primary health care forward and to influence the successor
to the 2004-2014 federal/provincial/territorial health accord and the future of health care for all
Canadians. Based on our extensive review of the literature, one of the most pressing challenges, from our
perspective, is the incidence of mental health issues and specifically youth suicide in many First Nations
communities across Canada. We are suggesting a National Youth Suicide Toolkit be created to address
this issue. While we are not actually creating the toolkit, we will be providing what we believe to be the
most relevant strategies for said toolkit. We will also briefly address how the social determinants of health
are having a profound effect on these young people.
We believe this is an issue that fits into the Commission’s objectives listed as part of your call for
submissions. For Better Health; in communities as small and tight knit as many First Nations
communities are, the tragedy of a child’s suicide affects the emotional and mental well being of the whole
community. By addressing the issue of suicide among these young people we are not just improving their
health, but the health of the community as a whole. Regarding Better Care; Remote Aboriginal
communities are not traditional care settings. Location, resources, and cultural health belief systems are
all things that need to be taken into account when providing care in these regions. We believe our toolkit
will not only address these issues but also the priority of Better Value, as we promote the use of
community capacity, something that could ease the funding concerns faced by many First Nations
Communities.
In Canada, people of Aboriginal communities generally have a lower life expectancy rate, lower
degree of health as well as an increased level of suicide Factors such as a history of discrimination,
colonization and loss of land place aboriginal people at a significantly higher risk of mental health issues,
such as suicide, depression and substance abuse. Aboriginal youth are at particular risk for suicide, with
current rates of suicide six times higher than that of the non-reserve population. The high risk of suicide
among Aboriginal youth is also closely linked to the social determinants of health; and as we will touch
on, the living conditions on many Aboriginal communities are often quite extreme. This significantly
impacts the mental and physical well being of those living with unclean water, poor shelter and often
fighting to live as close to a healthy lifestyle as they can. Poverty is the main issue on many Aboriginal
reserves and the social determinants of health (SDOH) have had a very significant impact on the lives of
the youth in these remote Aboriginal communities. Reflecting on an extensive amount of research, listed
56
on the reference page, we have decided to provide a snapshot of some of the facts related to the SDOH
that we found;
Income and Social Status
 The unemployment rate is at an alarmingly high rate with an average salary of only $8,500
 The isolated nature of reserves is related to these locations being closed off to employment with
very few jobs available and limited employment on reserves means no economic sustainability
 The youth on reserves are affected with high numbers of teen suicide, and many youth feel a
sense of hopelessness and lack of motivation because of the whirlwind of problems on these
Aboriginal reserves.
Education and Literacy
 The United Nations human development index found that Aboriginal communities in Canada
were ranked 63rd in the world related to longevity, educational achievement and adult literacy
 It is estimated that 50% of Aboriginal youth will drop out, or be pushed out, of high schools;
resulting in diminished literacy and employment, as well as increased poverty in future
generations
 Retention in schools is another issue for Aboriginal youth with reasons for low retention rates
being poverty; racism; lack of parental involvement; unstable home life; and the damaging effects
of residential schools on Aboriginal peoples, cultures, and languages
Employment
 The average unemployment rate among reserves is 19.1% almost triple that of the Canadian
average, but has been reported as being as high as 70% on some reserves.
 Many Aboriginal people are unable to find employment due to discrimination and low levels of
education
Physical Environments
 It is estimated that about one in four (22 per cent) reserve dwellings had more than one person per
room, compared to one per cent in the rest of Canada
 On some reserves houses lack plumbing, electricity, heating, and sewage, which are things most
Canadians would probably consider basic necessities.
 In a survey of the unhealthiest communities in Canada, 65 out of 100 were Aboriginal
communities
 On reserve in a remote community the cost of one container of infant formula is $58, a box of
diapers is $35, and a box of laundry detergent is $25. These are costs that place the community
members at risk for inadequate nutrition, poor hygiene practices, and poverty
Health Services
 The number of health care services in Aboriginal communities is limited because few healthcare
providers are willing to live in these sometimes isolated communities
 Reasons for such a high rate of turnover of nursing staff include lack of preparedness, change of
culture, distance from other medical professionals
Culture
 New generations of Aboriginal youth are unable to learn important cultural values from their
parents, because of the trauma residential schools caused when all forms of their Aboriginal
culture were removed.
57

Helping Aboriginal people especially the younger generation of the community to relearn the
language and traditional aspects of their culture could facilitate the healing process
Funding
 In 2010, First Nations received less than half of the funding the average Canadian citizen ($8,750
per capita compared to $18,724 per capita) to support local programs and services
 Approximately 40% of reserves are currently without a mental health policy, 30% of which have
no program to carry out mental health awareness or care.
The facts presented above are highlights of some of the issues plaguing the youth in some remote
Aboriginal reserves. When reading some of these statistics, it becomes easier to see why some youth feel
a sense of hopelessness and abandonment, and why some choose such a tragic way out.
As a group of nursing students, we have developed this submission of our suggestions for
Aboriginal youth suicide prevention, intervention and postvention. A national toolkit that focuses on
mental health promotion has the potential for offering a culturally sensitive and safe approach to healing;
that we hope could be integrated into multiple Aboriginal communities. Some of our suggestions for
integration into a toolkit include learning from elders to integrate their teachings into helping youth in
crisis, giving the prevention tools to community members to teach to other members to use and helping
create a cultural continuity for the youth to be proud of them and to have role models to look up to. Our
vision of what we feel this toolkit should include is for the policies and programs to reflect diversity,
interest and vision, promote a relationship of respect, good faith and partnership with First Nations,
bringing communities together to make decisions together, and to bypass the inter-jurisdictional problems
of Aboriginal communities.
Two main foci that we think are integral, and need to be highlighted, are capacity building and
cultural continuity, as we think that they are two of the most useful tools in tackling this issue. Many
healthcare planners, providers and administrators continue to rely solely on the use of urban-western
focused approaches which can sometime clash with the holistic health and cultural practices in many
Aboriginal communities.
Community capacity is an approach that focuses on what resources and strengths a community
has, rather than what it lacks. It assumes that there are strong relationships among individuals, families,
groups, and organizations within the community and that attention must be given to the web of
connections affecting all persons, organizations, groups and communities involved. An approach like this
could be vital in isolated communities that do not have the mental health resources it may need. The
resources can be a person (community elder), a structure (healing center), or a business (provides jobs).
Any resources that help support and build community strength is a valuable resource. The Helping Skills
program in Newfoundland was developed to address mental health issues in a small remote community
with limited resources. The project taught people to recognize signs of distress, listening skills, and
emotional support, to provide to those who couldn’t access the mental health services they needed. This
project renewed a sense of trust in the community and many expressed that although formal mental health
programs are important they are not the only, nor necessarily the most important support that help people
with mental illness to lead fulfilling lives in the community.
58
Community
Renewal
Strategies
Cultural Enhancement
Traditional healing practices
Community Development
Interagency communication
and co-ordination
Revive First Nations culture, help youth bridge Aboriginal and nonAboriginal culture, support youth self-esteem.
 Use traditional teachings, practices and spirituality to overcome trauma
and transition.
 Enhance existing community strengths to help the community respond
effectively to social, economic and health needs.
 Assess how effectively community agencies work together to deliver
services
Please see Appendix A for ways in which we think cultural continuity and community capacity
can be integrated into a toolkit.
It has been argued that, if they are to thrive, both Aboriginal young persons and whole cultural
communities must somehow succeed in developing a sense of continuity, or persistent identity, in a
rapidly changing world. Cultural continuity is the extent at which cultural markers, such as language, and
other cultural practices are being continued and practice in various Aboriginal communities across
Canada. Promoting cultural continuity has been shown in numerous studies to reduce the risk of youth
suicide in communities that are actively trying to maintain their cultural practices. One study examined
language as a form of cultural continuity found that those bands with high language use had six times less
youth suicides than those that did not use their language. Another study looked at the impact that Elder
involvement and influence had on youth suicide rates. Many children raised in the shadow of residential
schools have not known a healthy upbringing, but instead have been faced with abuse, violence, and an
overwhelming lack of hope. Elders in a British Columbia community helped revive traditional healing,
dances, ceremonies, and spiritual rituals and saw alcohol consumption in the community drop from 95%
to 5%.
Programs that focus on utilizing the entire community and practicing cultural continuity can help
marginalized individuals, such a youth with suicidal ideation or past attempts, become better integrated
into the community, and can help to shift previous negative beliefs regarding suicide throughout the
community. We can no ignore the travesty of Aboriginal youth suicide that is plaguing reserves across
Canada. Though there are some reserves where this not a problem at all, on the reserves where it is
occurring, like the remote community of Pikangikum in northern Ontario, it is happening at alarming
rates, with multiple attempts, and multiple waves. Just this summer alone, Pikangikum lost six youths in a
three month period to suicide.
By not taking action we are ignoring the problem and this group believes that inaction is no
longer acceptable. It is obvious through facts and the news that we as Canadians are failing an entire
generation of young people. The loss of potential through one suicide is immeasurable, but if we do not
try and help we will lose the potential of an entire generation. We hope that you consider our submission
to the National Expert Commission, this is an issue we are all passionate about, and as future nurses, we
hope that we are able to bring about change through our actions.
Sincerely,
XXX
Fourth Year BScN Students
Trent University
Peterborough, Ontario
Contact: XXX
59
Appendix A
Community
Education
Strategies
Peer helping Programs
Youth leadership Programs
Community gatekeeper
training
Public communication and
reporting guidelines
Means restriction
Train youth to help other youth.
Create opportunities for youth to develop skills such as leadership,
involvement and decision-making.
Improve ability to recognize and manage crises for people in regular
contact with youth, through education and skill-building.
 Educate the public and media on responsible suicide reporting to lower
negative effects and prevent cluster suicides.
 Reduce youth access to most common forms of completing suicide
such as guns, poisons, inhalants, medications.
School Strategies
School gatekeeper Training
School policy
School climate
Cultural arts program as a
powerful tool for healing.
Improve ability to recognize and manage crises in school personnel
through education and skill-building.
Write guidelines for the effective handling of crisis situations within the
school.
Organize the educational setting to enhance the well-being of staff and
students.
 Storytelling, dancing, drumming, singing, painting, dramatic arts, etc.
Youth/ Family
Efforts
Self-esteem building
Life skills training
Suicide awareness education
Family support
Support groups for
youth
Develop programs to create positive self-esteem in youth which may
decrease suicidal behavior.
Offer programs to teach youth social skills needed to support positive
social, emotional and academic development.
Talk directly to youth and community about suicide to provide
necessary knowledge and skills for risk assessment and intervention.
Support positive parenting.
Bring together vulnerable youth to deal with concerns and practice life
skills.
Adapted From: National Aboriginal Health Organization (2005). Assessment and Planning Toolkit for Suicide
Prevention in First Nations Communities.
60
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63
Fédération Interprofessionelle de la Santé du Québec (FIQ)
Submission:
MÉMOIRE
DÉPOSÉ À
LA COMMISSION NATIONALE
D’EXPERTS DE L’AIIC
Le 7 décembre 2011
Consultation de l'Association des infirmières
et infirmiers du Canada
64
La Fédération interprofessionnelle de la santé du Québec – FIQ salue l’initiative de l’Association
des infirmières et infirmiers du Canada (AIIC) de procéder à une consultation, par le biais d’une
commission nationale d’experts, en vue d’élaborer des recommandations visant à transformer le
réseau de la santé pour qu’il réponde mieux aux besoins de la population. Pour la FIQ, cette
initiative s’inscrit parfaitement dans les suites de son dernier congrès, tenu en juin 2011, lors
duquel ses membres ont décidé d’oser, d’agir et d’influencer afin, entre autres, de provoquer des
changements et de proposer des solutions aux problématiques vécues dans le réseau de la santé.
De fait, les infirmières, les infirmières auxiliaires, les inhalothérapeutes et les perfusionnistes du
Québec veulent jouer un rôle d’initiatrices du changement. En ce sens, les membres de la FIQ se
mobiliseront dans l’objectif d’élaborer de nouveaux modèles visant à répondre aux besoins de la
population et des professionnelles en soins1.
Pour la Fédération, l’une des principales problématiques du réseau de la santé se situe dans la
mauvaise gestion des maladies chroniques, due principalement au manque d’intégration des
services offerts aux personnes qui en souffrent. Actuellement, les maladies chroniques sont l’une
des principales responsables du temps d’attente pour accéder aux services de première ligne,
notamment à l’urgence. Ainsi, 50 % des soins de courte durée sont requis par 5 % des
patient-e-s, dont la majorité souffre de diverses maladies chroniques2. De plus, les services qui
leur sont offerts ne répondent pas de façon optimale à leurs besoins.
La FIQ est d’avis que, pour assurer une bonne gestion des maladies chroniques, il est nécessaire
de fournir des soins et des services intégrés à la population. Au Québec, c’était d’ailleurs
l’objectif ultime du projet de loi 25, la Loi sur les agences de développement de réseaux locaux
de services de santé et de services sociaux3, qui « vise, par la mise en place d’une organisation de
services de santé et de services sociaux intégrés, à rapprocher les services de la population et à
faciliter le cheminement de toute personne dans le réseau 4 ». Par la suite, chacune des agences
avait pour mission « de mettre en place, sur son territoire, une organisation de services
intégrés5 ».
Lors de la présentation de ce projet de loi, le ministre Couillard mentionnait que l’objectif
poursuivi était de corriger la situation suivante :
« […] l'engorgement fréquent dans les urgences témoigne de la fragmentation et du manque d'intégration de nos
services de première ligne. Chaque crise des urgences agit comme une indication, bref comme un révélateur de notre
difficulté à bien satisfaire les besoins de la population, notamment des personnes atteintes de maladies chroniques ou
1
Fédération interprofessionnelle de la santé du Québec, Oser, agir, influencer, le changement passe par nous, 9e
congrès, 6 au 10 juin 2011, [En ligne]. [www.fiqsante.qc.ca/congres2011/documents/A11-C-I-D6_thematique.pdf ].
2
Commissaire à la santé et au bien-être du Québec, Le défi des maladies chroniques au Québec : prévenir,
organiser, outiller et soutenir, Communiqué, 13 mai 2010.
3
Première session, 37e législature, 2003, chapitre 21.
4
Note explicative, projet de loi 25.
5
Ibid.
65
en perte d'autonomie, des personnes affectées par des maladies respiratoires ou cardiaques ou des personnes
souffrant de troubles mentaux, soit les plus vulnérables d'entre nous6. »
Force est de constater que la situation décrite lors de la présentation du projet de loi est encore
d’actualité. La difficile gestion des maladies chroniques indique clairement que la réforme mise
de l’avant pour assurer une meilleure intégration des services n’est pas implantée adéquatement.
Dès le départ, la FIQ s’était prononcée contre la mise en place des réseaux locaux au Québec,
mais elle s’était tout de même dite en faveur de l’intégration des services, sous réserve de
certaines conditions. Elle dénonçait alors la tendance hospitalocentriste difficilement justifiable,
entre autres en raison du fait que les experts prédisaient que, dans l’avenir, 70 % des soins de
santé se donneraient hors des murs de l’hôpital7. Déjà à l’époque, la Fédération prônait
l’implication des professionnel-le-s de la santé dans l’intégration des services, notamment celle
des infirmières qui jouent un rôle capital dans la promotion, le maintien et le recouvrement de la
santé des patient-e-s et qui représentent 25 % de l’effectif du réseau8. Malgré sa pertinence, cette
recommandation n’est toujours pas suivie par le gouvernement. Pour la FIQ, il va de soi que les
infirmières doivent jouer un rôle plus grand dans l’intégration des services et que, pour ce faire,
elles doivent pouvoir s’éloigner de plus en plus de l’hôpital.
À cet égard, l’évaluation de l’implantation des réseaux locaux de services, effectuée par le
ministère de la Santé et des Services sociaux (MSSS) en mai 2010, est très révélatrice. En ce qui
concerne la fusion d’établissements, le rapport mentionne que :
« Il apparaît que l’approche par programme ainsi que le projet clinique sont
davantage porteurs de changements quant à l’intégration des services. D’ailleurs,
tout au long du processus d’évaluation, des interrogations ont été soulevées quant
à la nécessité de fusionner les établissements pour optimiser la mise en réseau9. »
Cette évaluation révèle aussi que, malgré certaines avancées dans le suivi des usager-ère-s,
comme le suivi systématique pour les personnes présentant des maladies chroniques, « peu de
changements sont observés globalement dans la disponibilité et l’utilisation des services offerts
par les [centres de santé et de services sociaux] CSSS10. » La FIQ constate que certaines
conditions qu’elle jugeait essentielles à une intégration des services, soit l’implication des
professionnel-le-s de la santé, le partage d’informations et le soutien au changement, notamment
6
Assemblée nationale du Québec, Journal des débats de l’Assemblée nationale, 37e législature, 1re session, le mardi
9 décembre 2003, vol. 38, no 38.
7
Fédération des infirmières et infirmiers du Québec, Pour l’avenir des services publics … des projets de loi :
inutiles, incomplets et dangereux, décembre 2003, p. 21.
8
Ibid., p. 27.
9
Ministère de la Santé et des Services sociaux, Évaluation de l’implantation des réseaux locaux de services de santé
et de services sociaux, Évaluation Santé et Services sociaux, mai 2010, p. 89.
10
Ibid., p. 85.
66
par des formations au travail multidisciplinaires11, n’ont pas été mises de l’avant et ressortent
comme des lacunes dans l’évaluation des réseaux12.
Actuellement, au Québec, il n’existe pas de stratégie optimale pour la gestion des maladies
chroniques13. Certains projets ont vu le jour, mais ils n’ont pas obtenu l’effet escompté par
manque de concertation. De fait, le réseau de la santé demeure davantage orienté vers les
maladies aigües et n’est pas suffisamment axé sur la prévention des maladies chroniques, alors
qu’il est nécessaire que les soins soient prodigués de façon intégrée et continue14.
Le Québec aurait avantage à miser encore plus sur l’apport des infirmières et des autres
professionnel-le-s de la santé dans l’intégration des services à la population, particulièrement
pour les personnes souffrant de maladies chroniques. Ces professionnel-le-s pourraient
également jouer un rôle primordial dans la promotion et la prévention : des éléments essentiels à
la saine prise en charge des malades chroniques. En ce sens, la FIQ partage l’avis de l’AIIC
selon lequel que les infirmières doivent appuyer :
« L’élaboration d’une approche intégrée à la prévention des maladies chroniques
qui se penche sur les facteurs de risques importants les plus courants et qui intègre
les programmes des secteurs de soins primaires, secondaires et tertiaires en
matière de prévention et de promotion de la santé et les programmes connexes
d’autres disciplines15. »
La FIQ trouve importantes les recherches effectuées par l’AIIC qui démontrent que les
investissements dans les soins infirmiers ont des incidences directes sur le cout des soins de
santé, notamment par la réduction du nombre de jours d’hospitalisation et de visites aux
urgences. Les effets sont également significatifs sur le plan de la qualité des soins compte tenu
de la réduction des délais d’attente, des meilleurs suivis offerts et de la diminution du nombre
d’hospitalisations16.
Il existe un certain nombre de projets qui ont remporté du succès grâce à la contribution des
infirmières à l’intégration des services. Par exemple, dans le cadre du programme Défi Santé, le
CSSS des Sommets a décidé d’assurer une meilleure intégration des services auprès des plus
grand-e-s consommateur-trice-s de soins afin qu’ils-elles ne se retrouvent pas systématiquement
11
Fédération des infirmières et infirmiers du Québec, op. cit., note 7, p. 20.
12
Ministère de la Santé et des Services sociaux, op. cit., note 9, p. 85, 93.
13
Ibid., p. 81.
14
Commissaire à la santé et au bien-être du Québec, Rapport d’appréciation de la performance du système de santé
et de services sociaux 2010, État de situation portant sur les maladies chroniques et la réponse du système de santé
et de services sociaux, p. 76.
15
Association des infirmières et infirmiers du Canada, Les maladies chroniques et les soins infirmiers, Résumé des
enjeux, Document d’information de l’AIIC, octobre 2005, p. 6.
16
Association des infirmières et infirmiers du Canada, Les infirmières et infirmiers aux premières lignes des temps
d’attente – pour aller de l’avant, mars 2011.
67
aux urgences. Ce projet s’inspire du Chronic Care Model, développé par l’Organisation
mondiale de la santé (OMS), qui implique que le-la patient-e soit au cœur des décisions le-la
concernant et qui nécessite l’implication d’une infirmière gestionnaire de cas ou d’une infirmière
de proximité17. Pour un investissement de 100 000 $ par année, le projet a permis d’abaisser de
72 % les visites de cette clientèle à l’urgence et de 90 % le nombre de jours d’hospitalisation18.
Un projet similaire a été mis en place par l’Agence de la santé et des services sociaux de la
Capitale-Nationale, soit le programme Alliance de prise en charge des grands utilisateurs de
services. Dans le cadre de ce projet, des infirmières gestionnaires de cas ont pris en charge
1 500 patient-e-s qui effectuaient, au total, 21 000 visites aux urgences par année19. Fait
étonnant, 95 % de ces patient-e-s avaient un médecin de famille20, ce qui démontre que
l’implication unique de celui-ci n’est pas suffisante et qu’une intégration des services est
nécessaire.
Des projets ont également vu le jour dans des services de 2e ou de 3e ligne, où des infirmières
agissent à titre de pivot au sein d’équipes multidisciplinaires en oncologie. Elles y jouent un rôle
capital, tant au regard de l’information donnée au-à la patient-e sur sa maladie et son traitement
que du point de vue de la continuité des actes entre professionnel-le-s de la santé. Cette
coordination a pour effet de diminuer le stress que la personne atteinte du cancer vit à toutes les
étapes de sa maladie21.
Certains des projets développés s’appliquent spécifiquement aux personnes âgées et peuvent
servir de modèles en matière d’intégration des services. Par exemple, le Programme de recherche
sur l’intégration des services pour le maintien à domicile (PRISMA) a donné des résultats
intéressants, soit une réduction de 7 % de la perte d’autonomie, un degré de satisfaction plus
grand, une meilleure autonomisation, une utilisation plus efficace des services en CLSC et une
stabilisation du nombre d’hospitalisations22.
Quant au projet SIPA, il vise également les personnes âgées et propose un :
« Système de soins intégrés ayant des assises communautaires offrant des soins de
santé et des services sociaux de première et de deuxième ligne, y compris des
17
Centre de santé et de services sociaux des Sommets, Les défis de la chronicité : le suivi clinique intégré et
intensifié des clientèles cibles, France Laframboise, DQSS et Jean Mireault, coordonnateur médical au projet Défi,
24 avril 2008.
18
Ariane Lacoursière, « Désengorgement des urgences : mode d’emploi », La Presse, 3 octobre 2011.
19
Pour plus d’information voir : Agence de la santé et des services sociaux de la Capitale-Nationale, Programme
Alliance www.rrsss03.gouv.qc.ca/SP-programmeAlliance.html.
20
Ariane Lacoursière, op. cit., note 18.
21
Charles Meunier, « L’alliée du patient travaillant en équipe multidisciplinaire, les infirmières pivots en oncologie
assument un rôle essentiel », Perspective infirmière, novembre/décembre 2008, p. 27.
22
Réjean Hébert et Michel Raîche, « Résultats de l’étude d’impact PRISMA-Estrie, Méthodologie, implantation et
efficacité », www.prismaquebec.ca/documents/CIFGG/Hebert_et_al-1.pdf
68
soins de courte et de longue durée offerts dans la communauté et en
établissement23. »
Ce projet a aussi connu un beau succès de par les impacts qu’il a eus sur la diminution des
hospitalisations et du recours à l’urgence. Pour ce qui est des dépenses, elles sont demeurées
équilibrées grâce à un transfert des couts en institution vers des couts liés aux ressources en
communauté, entre autres les soins à domicile24.
Dans chacun des projets mentionnés, une constante demeure : l’impact est plus grand sur les
déterminants de la santé si l’attention est portée sur le-la patient-e ainsi que sur les aspects
préventif, communautaire et populationnel. Des soins à domicile intégrés et continus sont
recommandés, mais ceux-ci doivent être financés adéquatement et l’infirmière doit reprendre son
rôle de proximité auprès de le-la patient-e.
En effet, l’infirmière a vu son rapport au-à la patient-e changer avec l’évolution des
connaissances et le développement du réseau de la santé; son lieu de travail est ainsi devenu
davantage institutionnel. Bien entendu, cette réalité a permis le développement de nouvelles
compétences chez les infirmières afin qu’elles soient mieux outillées pour offrir les soins et les
services dans les établissements. Par contre, au quotidien, elles jouent beaucoup moins leur rôle
social et professionnel qui comprend l’éducation à la santé des communautés, la prévention de
certains problèmes de santé et l’identification des besoins d’accès à des services de santé,
particulièrement auprès de certaines clientèles vulnérables. Les nouveaux moyens de
communication ne peuvent remplacer la relation de proximité infirmière-citoyen-ne-s. Le retour
de l’infirmière dans la communauté est essentiel, notamment pour permettre une meilleure
gestion des maladies chroniques.
La Fédération croit donc qu’il est opportun de développer des nouveaux modèles de prestation
des soins et, en ce sens, de solliciter l’appui des gouvernements. Les barrières à une réelle
intégration des services doivent être abolies le plus rapidement possible, et ce, afin d’assurer une
meilleure qualité de soins à la population, au meilleur cout possible, et de favoriser la pérennité
du système public de santé.
23
Programme de recherche SIPA, Un système de services intégrés pour les personnes âgées en perte d’autonomie,
évaluation de la phase 1, juin 1999 à mai 2000. [En ligne]. [www.solidage.ca/docs/SIPA_1f.pdf].
24
Ibid.
69
English Translation:
BRIEF
SUBMITTED TO THE
CNA NATIONAL EXPERTS
COMMISSION
7 December 2011
Canadian Nurses Association Consultation
70
The Fédération interprofessionnelle de la santé du Québec – FIQ [Quebec interprofessional
health care federation] praises the initiative of the Canadian Nurses Association (CNA) in
conducting a consultation through a national experts commission to develop recommendations
for transforming the health care system so it meets public needs more effectively. FIQ believes
that this initiative is fully consistent with the actions emerging from its last convention, in June,
at which members made the decision to be bold, to act and to influence, in part to trigger changes
and suggest solutions for issues faced by the health care system. In fact, nurses, nursing
assistants, respiratory therapists and perfusionists in Quebec want to be initiators of change. FIQ
members therefore will mobilize to develop new models that meet the needs of the public and
health care professionals.25
FIQ believes that one key problem affecting the health care system is poor management of
chronic diseases, due mainly to lack of integrated services to the people affected. At present,
chronic diseases are one of the leading causes of lengthy waiting times to access primary care
services, especially in emergency rooms. In fact, 50 percent of short-term care is required by just
5 percent of patients, most with chronic diseases.26 Furthermore, the services delivered to them
are not the most effective in meeting their needs.
FIQ believes that to ensure sound management of chronic diseases, we must deliver integrated
care and services to the public. In Quebec, this was also the ultimate goal of Bill 25, An Act
respecting Local health and social services network development agencies,27 which “by
establishing an integrated health and social services organization, seeks to bring services closer
to the public and make it easier for people to move through the network.”28 Following that, each
agency had a mission to “establish an integrated services organization in its area of
jurisdiction.”29
When the Bill was tabled, Minister Couillard stated that the intended purpose was to correct the
following situation.
[translation] […] frequent overcrowding in emergency rooms is evidence of fragmentation and lack of integration of
our primary care services. Each emergency room crisis acts as an indicator, a spotlight on our difficulty in
25
Fédération interprofessionnelle de la santé du Québec, Oser, agir, influencer, le changement passe par nous
[being bold, acting, influencing: change occurs through us], 9th convention, 6 - 10 June 2011, [online].
[www.fiqsante.qc.ca/congres2011/documents/A11-C-I-D6_thematique.pdf].
26
Commissaire à la santé et au bien-être du Québec [Quebec commissioner of health and wellness], Le défi des
maladies chroniques au Québec : prévenir, organiser, outiller et soutenir [the challenge of chronic diseases in
Quebec: preventing, organizing, equipping and supporting], news release, 13 May 2010.
27
First session, 37th legislature, 2003, Chapter 21.
28
Explanatory note, Bill 25.
29
Ibid.
71
effectively meeting the needs of the public, especially people with chronic diseases or frail health, respiratory or
heart disease, or mental problems, thus the most vulnerable among us.30
We are forced to note that the situation described when the Bill was tabled still prevails. The
difficulty of managing chronic diseases clearly indicates that the reform advocated to ensure
better service integration has not been adequately implemented. From the outset, FIQ had taken a
stand against the establishment of local networks in Quebec, but did voice support for service
integration, subject to certain conditions. At that time, it objected to the hospital-centred trend,
which was hard to justify, in part because experts were predicting that in future, 70 percent of
health care would be delivered outside hospitals.31 Even then, FIQ was advocating the
involvement of health care professionals in integrating services, especially nurses, who play a
crucial role in promotion, maintenance and recovery of patient health and who represent 25
percent of all personnel in the system.32 Despite its relevance, this recommendation has yet to be
implemented by government. In FIQ’s opinion, there is no question that nurses must play a
greater role in integrating services and thus, that they increasingly must be able to move away
from hospitals.
In this regard, the review of implementation of local services networks conducted by the
Ministère de la Santé et des Services sociaux (MSSS) [ministry of health and social services] in
May 2010, is very revealing. On the issue of amalgamating institutions, the report states:
[translation] It appears that the program-based approach and clinical projects are
more likely to induce change in the area of service integration. Moreover,
throughout the review process, questions have been raised about the need to
amalgamate institutions to optimize networking.33
This assessment also reveals that despite some advances in monitoring users, such as systematic
tracking of people with chronic diseases, [translation] “few changes have been observed overall
in the availability and use of services delivered by CSSSs” [health and social services centres].34
FIQ notes that some of the conditions it deemed essential for service integration—involvement
of health care professionals, sharing of information and support for change, especially through
30
Quebec National Assembly, Journal des débats de l’Assemblée nationale, 37th legislature, 1st session, Tuesday
9 December 2003, Vol. 38, No. 38.
31
Fédération des infirmières et infirmiers du Québec [Quebec nurses federation], Pour l’avenir des services publics
… des projets de loi : inutiles, incomplets et dangereux [for the future of public services… draft legislation: useless,
incomplete and dangerous], December 2003, p. 21.
32
Ibid., p. 27.
33
Ministère de la Santé et des Services sociaux [ministry of health and social services], Évaluation de l’implantation
des réseaux locaux de services de santé et de services sociaux, Évaluation Santé et Services sociaux [review of the
implementation of local health services and social services networks, health and social services assessment], May
2010, p. 89.
34
Ibid., p. 85.
72
training in multidisciplinary work35—have not been advanced and have proved to be
shortcomings in the assessment of networks.36
Today in Quebec, there is no optimal strategy for managing chronic diseases.37 Some projects
have been developed but have failed to achieve the anticipated outcomes due to lack of concerted
action. In fact, the health care system remains more concerned with acute diseases and lacks
sufficient focus on preventing chronic diseases, at a time when care must be delivered through an
integrated and ongoing approach.38
Quebec would benefit from a greater focus on the contribution of nurses and other health care
professionals to integrating services to the public, especially people with chronic diseases. These
professionals could also play a vital role in promotion and prevention: key factors in sound
management of chronic diseases. On this point, FIQ agrees with CNA that nurses must:
Support the development of an integrated approach to chronic disease prevention
that focuses common major risk factors, and that integrates primary, secondary
and tertiary prevention, health promotion, and related programs across sectors
and disciplines.39
FIQ deems important the research conducted by CNA showing that investment in nursing has a
direct impact on health care costs, especially by reducing length of hospitalization and number of
emergency room visits. There are also significant effects on quality of care, given reduced
waiting times, improved monitoring and the decline in number of patients hospitalized.40
A number of projects have achieved success through the contribution of nurses to service
integration. For example, under the Défi Santé [health challenge] program, CSSS des Sommets
decided to ensure better service integration for the greatest health care consumers to avoid
systematic reliance on emergency rooms. This project was modelled on the Chronic Care Model
developed by the World Health Organization (WHO), in which patients are at the centre of
decisions affecting them that require the involvement of a case management nurse or outreach
35
Fédération des infirmières et infirmiers du Québec [Quebec nurses federation], op. cit., note 7, p. 20.
Ministère de la Santé et des Services sociaux [ministry of health and social services], op. cit., note 9, pp. 85, 93.
37
Ibid., p. 81.
38
Commissaire à la santé et au bien-être du Québec [Quebec commissioner of health and wellness], Rapport
d’appréciation de la performance du système de santé et de services sociaux 2010, État de situation portant sur les
maladies chroniques et la réponse du système de santé et de services sociaux [assessment report on performance of
the health and social services system 2010, status report on chronic diseases and response by the health and social
services system], p. 76.
39
Canadian Nurses Association, Chronic Disease and Nursing: A Summary of the Issues, CNA Backgrounder,
October 2005, p. 6.
40
Canadian Nurses Association, Registered Nurses: On the Front Lines of Wait Times—Moving Forward, March
2011.
36
73
nurse.41 For an investment of $100,000 a year, the project cut emergency room visits by this
client group by 72 percent, and hospitalization days by 90 percent.42
A similar project was implemented by the Agence de la santé et des services sociaux de la
Capitale-Nationale [national capital health and social services agency], the Alliance program for
managing heavy service users. As part of that project, case management services took
responsibility for 1,500 patients who accounted for a total of 21,000 emergency room visits a
year.43 Surprisingly, 95 percent of these patients had a family physician,44 which shows that just
involving the physician is not enough and that service integration is required.
Other projects have also been implemented in secondary and tertiary services, where nurses act
as the hub in multidisciplinary oncology teams. They play a vital role in terms of information
given to patients about their disease and its treatment as well as continuity of procedures among
health care professionals. This coordination effectively reduces the stress experienced by cancer
patients at all stages of their disease.45
Some of the projects developed specifically target elderly people and can serve as models for
service integration. For example, the Programme de recherche sur l’intégration des services pour
le maintien à domicile (PRISMA) [research program on home support service integration]
produced interesting results: a 7-percent reduction in loss of independence, greater satisfaction,
enhanced self-reliance, more effective use of CLSC services and stabilization in the number of
hospitalized patients.46
The SIPA project also targets elderly people with a:
41
Centre de santé et de services sociaux des Sommets [Sommets health and social services centre], Les défis de la
chronicité : le suivi clinique intégré et intensifié des clientèles cibles [the deficits of chronic illness: integrated and
intensified clinical monitoring of target client groups], France Laframboise, DQSS and Jean Mireault, medical
coordinator, Défi Santé [health challenge] project, 24 April 2008.
42
Ariane Lacoursière, “Désengorgement des urgences : mode d’emploi” [clearing emergency room backlogs: user’s
manual], La Presse, 3 October 2011.
43
For more information see: Agence de la santé et des services sociaux de la Capitale-Nationale [national capital
health and social services agency], Alliance program www.rrsss03.gouv.qc.ca/SP-programmeAlliance.html.
44
Ariane Lacoursière, op. cit., note 18.
45
Charles Meunier, “L’alliée du patient travaillant en équipe multidisciplinaire, les infirmières pivots en oncologie
assument un rôle essential” [patient’s ally working in a multidisciplinary team, nurse navigators in oncology take on
a key role], Perspective infirmière [nursing perspective], November/December 2008, p. 27.
46
Réjean Hébert and Michel Raîche, “Résultats de l’étude d’impact PRISMA-Estrie, Méthodologie, implantation et
efficacité” [Findings of the PRISMA-Eastern Townships impact study, methodology, implementation and
effectiveness], www.prismaquebec.ca/documents/CIFGG/Hebert_et_al-1.pdf
74
[translation] Community-based system of integrated care delivering primary and
secondary health care and social services, including short-term and long-term
care delivered in the community and in institutions.47
This project also proved very successful in its impact by reducing hospitalization and emergency
room rates. In turn, spending remained balanced through a transfer from institutional costs to
costs linked to resources in the community, including homecare.48
In each project mentioned, one constant remains: impact on health determinants is greater if
attention is focused on the patient and thus on preventive, community and population-based
aspects. Integrated, continuous home care is recommended but must be adequately funded and
nurses must recover their outreach role with the patient.
Nurses in fact have seen their relationship with patients change as knowledge has advanced and
the health care system has developed. Their workplace has become increasingly institutional. Of
course, this reality has fostered the development of new skills among nurses to equip them better
to deliver care and services within institutions. In their daily work, however, they are much less
involved in their social and professional role that includes community health education,
prevention of some health problems and identification of needs for access to health services,
especially among certain vulnerable client groups. New communications technology cannot
replace the close relationship between nurses and citizens. A return to the community by nurses
is essential, especially to support more effective management of chronic diseases.
FIQ therefore believes the time has come to develop new care delivery models and thus to seek
support from governments. The barriers to genuine service integration must be eliminated as
quickly as possible to ensure better quality care for the public, at the lowest possible cost, and to
promote a sustainable public health care system.
47
SIPA research program, A System of Integrated Services for the Frail Elderly, Evaluation of Phase 1, June 1999
to May 2000. [online]. [www.solidage.ca/docs/SIPA_1e.pdf].
48
Ibid.
75
Community Health Nurses of Canada (CHNC) Submission:
Canadian Nurses Association (CNA) National Expert Commission
Community Health Nurses of Canada (CHNC): Brief in Response to the CNA National Expert
Commission Call for Submissions.
Submitted to:
Michael Villeneuve
Executive Lead, National Expert Commission Secretariat
50 Driveway
Ottawa, ON K2P 1E2
[email protected]
Submitted by:
XXX
Chair: CHNC Political Action and Advocacy Standing Committee
Submitted on behalf of the Community Health Nurses of Canada and the CHNC Political Action
and Advocacy Standing Committee
XXX
Community Health Nurses of Canada
182 Clendenan Avenue
Toronto, ON, M6P 2X2
[email protected]
76
The Community Health Nurses of Canada (CHNC) Brief
Creating a System for (Community) Health
If we are serious about improving the health of all Canadians we must shift our voice and
share power and responsibility differently.
Aboriginal Peoples and Communities: Health Care reform conventionally does not
simultaneously include the health and health care of Canadian Aboriginal peoples; they are often
addressed separately as a ‘vulnerable’ population subject to unique legislation and governance.
This approach permits us to continue to overlook their spectrum of experience - including
capacities and unique knowledge - but more importantly some situations of abject circumstances
that should not be a part of any Canadian landscape.
The Impact of Expertise: The present Health Care System (HCS) reflects ‘expert’ driven
solutions, decision-making and resource allocation. Yet there is consensus opinion that the
current HCS is unwieldy and inefficient. Predicted demographic and epidemiological trends that
include an aging population and ever increasing mental and chronic illnesses require better
understanding of the drives of health care costs (CIHI, 2011). Conventional HCS reform
typically includes repeating the same; by people who are ‘experts’ at reproducing the norm
(Maioni, 2011; Denis, 2011). We need to acknowledge power and whose voice has most impact
on HCS decision-making, while honestly appraising their qualifications to determine
infrastructure and functioning of a HCS. Experts and governments tend to seek quick fixes for
high visibility issues such as wait lists without careful attention to the upstream ‘symptoms’ that
create burden of demand for certain health services (Maioni, 2011). This contributes to cycles of
short term allocation of resources without long term benefit to the HCS or the recipients of care.
Public Participation: There is a critical lack of citizen voice at all levels beyond tokenism. This
is contrary to the value that Canadian health care providers, organizations and governments place
on the principles of Primary Health Care (PHC). The Canadian people are experts in the impact
of policy on the conditions of their daily lives (CSDH, 2008). They have solutions to offer about
the type and quality of services needed and the conditions to deliver care and to protect dignity.
The Importance of Place: Despite rhetoric that values PHC, Tertiary Care continues to be
prioritized in terms of resource allocation, overlooking the important ‘places’ where care is most
needed. Home Health services are essential to provide care to support Canadians’ health,
comfort, healing and dignity. Home Health care delivers increasingly complex services to
Canadians experiencing acute and chronic illness and to families who require end of life support.
Demographic and epidemiologic trends will exert greater pressure and need for Home Health
services across Canada over time. Public Health programs and Community Health Nurses (CHN)
contribute to essential health promotion in the places where Canadians live, work, learn, worship
and play (CHNC, 2011).
77
A Principled Approach: The principles that support the current Canada Health Act are valued,
but insufficient. The principles do not extend to the home. Canadians have inequitable access to
the medications and technologies to support their chronic illness and prevent complication.
Service demands erode the principles of the Canada Health Act resulting in increasing use of
private health services (Steinbrook, 2006). Health professionals are drawn to private
organizations, depleting the human resources needed to deliver equitable public services. Health
care is becoming an asset for those who are able to pay. Governments have not established
satisfactory accountability mechanisms to ensure equitable access to care for all Canadians.
Parallel HCS: We have created a parallel HCS through our reliance on community-based
organizations to provide essential services to our most vulnerable populations (CPRN, 2009;
Goldenberg, 2004). Some Canadians may not fit conventional norms of conduct or expression.
Consequently they may experience inequitable access to institutional health services. The result
over time is increased economic and human cost and failure of institutions and organizations to
fulfill their original mandates.
Health and Wellbeing: Despite our concerns about the HCS we must not lose sight of the
reality that OECD rankings reveal Canadian health outcomes remain enviable (cited in Denis,
2011); a reminder that health services have limited impact on life expectancy or quality of life.
The most important determinants of health are the social and environmental factors that
influence the conditions of daily life for all Canadians, including Aboriginal peoples. It is
important that the HCS run effectively and efficiently, but we must ensure that emphasis on HCS
benchmarks do not create increased inadvertent risk to the health, wellbeing and quality of life of
all Canadians.
Healthy Public Policy: In 2005, Canada signed on to contribute as one of twelve country
partners of the WHO Commission on Social Determinants of Health, committing this country to
act on any recommendations forthcoming. This should mean “seeking to frame policies and
programmes, across the whole of society, that influence the social determinants of health and
improve health equity” (CSDH, 2008). Given current trends we can predict Canadians will
experience increased disability and need for care-giving. This will require flexible Public Policy
to support maximum citizen capacity and engagement for health service recipients and their caregivers (family and others). For example, Canadians with full or partial disability and their
caregivers require access to social benefits that provide sufficient income support regardless of
employment status so as to protect their quality of life, in addition to access to respite care.
Economic Models: Conventional approaches to economies of savings include reallocation of
tasks to less expensive care providers and application of cost-benefit models to prioritize access
to service and technologies. This approach may have short term budgetary benefit but are less
reliable in supporting health and sustaining budgets over time (Drummond, 2011). Additionally,
78
focus on Gross Domestic Product (GDP) in health and economic policy may obscure important
factors that support Canadians’ health and quality of life (CIW, 2001).
Access without Appropriateness: Emerging literature reveals that expert response to ‘priority’
arenas for action in response to wait lists may simply create increased demand in competing
domains (Maioni, 2011). More importantly in terms of human and economic cost is the reality
that increased access to technology, including pharmaceuticals, may result in inadvertent harm to
Canadians who submit to unwarranted and costly testing and intervention. This trend has been
linked to a cost-benefit approach that does not fully calculate the risk of certain technologies and
treatments (Deber, 2008).
Health Human Resources: Canadian’s have long believed they should have access to a
physician to protect their health; physician shortage issues make prime news and are a major
source of concern. In contrast, the CHNs who are ideally situated to work with and for Canadian
families; who can monitor and report on the impact of policy on the conditions of daily life; who
can and do contribute to upstream health promotion remain largely invisible to Canadians and
policy makers. Consequently there is a significant dearth of research and evidence to support the
contribution CHNs make to the health and wellbeing of all Canadians, including vulnerable
isolated and marginalized populations. CHNs are not able to exert their full contribution to
Canadian society as they are not working to full scope of practice (CHNC, 2011).
Professional Teams: The accepted consensus is that integrated health teams are required to
contribute to seamless care across the PHC continuum. Team work and service delivery require
new competencies. Current economic models and the genuine desire to improve access within
reasonable costs result in task shifting to low cost service providers; which may decrease long
term health outcomes. Decisions need to be informed by evidence (CNA, 2005) and take into
account the general community population profile (CIHI, 2001).
The CHNC Brief: Recommendations
We must walk the talk via collective action to endorse the principles and values we espouse.
Status Quo is Unacceptable: We must seek innovation and simple solutions while taking
collective ownership of our capacity and responsibility to speak and act across all levels of the
Health Care System (HCS). We need to stop accepting the difficulties navigating the HCS
simply because ‘that’s the way it’s done’. We need to redefine ‘expertise’ to include the voices
of all Canadians and a range of intersectoral partners.
The 2014 Health Accord: must prepare the terrain to expand the Canada Health Act (CHA)
across the PHC continuum to include home, palliative and pharma-care for all Canadians. A
renewed CHA must reflect full implementation of the Ottawa Charter for Health Promotion
values and strategies. This will ensure upstream PHC health promotion and illness/injury
prevention in balance with curative, restorative and maintenance services. The CHA must
79
expand the definition of essential services to include those provided by CHNs. We must ensure
accountability to Canadians by collectively determining pragmatic ways to support and enforce
an improved, renewed CHA. We propose the addition of ‘Appropriate’ as a grounding principle
to support evidence informed care. This will serve to support the PHC principle of ‘appropriate
technology’ within decisions about ‘access’ to care. Desired outcomes include improved value
for and application of low tech physical health assessment skills and better use of expensive,
potentially risk-inducing high technology.
Integrate the UN Declaration on the Rights of Indigenous Peoples into HCS renewal.
CHNC recognizes solutions must involve all Canadians working in partnership to address the
issues and strengths of our Aboriginal peoples. It will be important to build on the Canadian
Government’s endorsement of the UN Declaration on the Rights of Indigenous Peoples. We are
more likely to improve integrated and reciprocal knowledge transfer if we address Aboriginal
health simultaneously within the general Canadian HCS renewal context. While acknowledging
the complexity of integration over time, we do encourage addressing built environments –
including transportation and housing adapted for climate conditions - and education to improve
access to equitable opportunity for health and culturally acceptable health services.
Citizen Engagement and ‘Voice’: We must listen carefully to solutions generated within and
beyond the conventional health sector. Most importantly, we must listen to the stories and
solutions offered by the Canadian people; including Indigenous peoples who have unique
experience, perspective and evidence to contribute. It is essential that all players in Health
Accord and HCS renewal establish structures and processes to require that the ‘voice’ of
Canadians contribute in meaningful and substantive ways to policy decisions and delivery of
health care services.
Intersectoral Collaboration: Intersectoral approaches promote long term action and
government accountability for public policy (Mendel, 2009). We need to partner with architects,
engineers, economists, city planners etc… to create health care environments, processes and
policies conducive to clientele and workers. We should investigate the feasibility of adapting
successful workplace initiatives to the PHC context. One example is the TCAB initiatives that
involve nurses in transformative care (O’Connor, 2011; Rutherford, Moen, & Taylor, 2009).
We Support the Canadian Index of Wellbeing (CIW): as a mechanism to achieve balance in
resource allocation to the health care system versus the determinants of health and quality of life
(2011). The index provides an evidence base to ensure progressive policy that better reflect the
‘voice’ of Canadians in terms of values and broad determinants of health. The CIW provides a
template to expand the definition of health service ‘benchmarks’ within upcoming Health Accord
discussions. Governments, decision-makers and health professionals should adopt the CIW and
endorse it with the public.
80
Healthy Public Policy: must be flexible and responsive so as to protect the dignity of all
Canadians. Healthy Public Policy is a mechanism to balance attention to the HCS with those
factors that contribute to wellbeing and quality of life. Examples of flexible policy include
adapted disability criteria to supplement part time work with social benefits and flexible
employment options, conditions and pay mechanisms for care-givers. Health inequalities
resulting from difference in social determinants of health should be seen as unacceptable in a
society that places a high value on equal access to good health. The reduction of income
inequality and measures to reduce poverty should be pursued as priority health strategies
(Toronto Public Health, 2008).
Economic Models: We should supplement cost-benefit models with risk-benefit approaches,
appropriate use of technologies, pharmaceuticals and health promotion; and avoid excess focus
on GDP. Solutions that do not rely on privatization and respect the Canada Health Act should
inform Health Accord and Canada Health Act renewal (Falk, Mendelsohn & Hjartarson, 2011).
Health Human Resources: All Canadians should know their Community Health Nurse.
CHNs are essential partners in navigating the determinants and systems that influence health.
CHNs “take collaborative action to promote, protect and restore the health of Canadians within
the context of the important places and experiences of their daily lives” within a continuous
lifespan approach (CHNC, 2011, p. 2). Canadians should know about the range of health
promotion and protection activities developed and delivered by CHNs. Canadians should be
informed that they can and should have access to their local CHN in equity with access to
Physicians. It is imperative that governments support CHN by redirecting research priorities to
include CHN practice, education and administration; to capture the impact of CHN processes and
care on individuals, families, groups, populations and communities.
Health Care System Renewal Initiatives: should recognize the limitation of task shifting
models and include professional development initiatives to help health care providers prepare for
expanded responsibilities and new contexts in care delivery; including team work, networking
and case management. “A strong community health system has the potential to effectively and
efficiently address disease and injury issues upstream to prevent them from occurring, delay their
onset, or care for those affected closer to home to restore health” (CHNC, 2011, p. 17). Essential
to any reform is proactive planning in anticipation of population trends and need. We must also
ensure that all health professionals enact the competencies necessary to deal effectively and
humanely with society’s marginalized peoples; and that physical spaces are designed to protect
dignity, confidence and trust. We must free our community based organizations to fulfill their
potential to be a force for the type of social innovation that creates a prosperous, just and caring
Canadian society (Goldenberg, 2004).
Respectfully submitted by: Community Health Nurses of Canada.
81
Use of the term ‘Community Health Nurse’ in this brief includes health professionals commonly known as
community health nurses, home health nurses and public health nurses, amongst other nurses who provide care in
physical settings outside the Tertiary Care health system.
The term ‘system for (community) health’ represents CHNC’s endorsement of the Ottawa Charter for Health
Promotion’s values and strategies; and builds on Carolyn Bennett’s call to transform health care systems into
‘systems for health’ (CHNC, 2011).
Reference List
Canadian Index of Wellbeing. (2011). How are Canadians Really Doing? Highlights: Canadian
Index of Wellbeing 1.0. Waterloo, ON: Canadian Index of Wellbeing and University of
Waterloo.
Canadian Institute for Health Information. (2001). Future Development of Information to
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ISBN 978-1-55465-985-2.
Canadian Nurses Association. Evaluation Framework to Determine the Impact of Nursing Staff
Mix Decisions. CNA, October 2005. ISBN 1-55119-942-9.
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Play a Critical Role in Social Innovation and the Economy. CPRN. Retrieved from
http://www.cprn.org/documents/51874_EN.pdf.
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generation: Health equity through action on the social determinants of health. Final report of
the Commission on the Social Determinants of Health. Geneva, World Health Organization.
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Systems. McGill University, Institute for Health and Social Policy 2011-2012 Seminar Series on Healthier Societies: Strategies
for Health Care Quality, Equity and Sustainability. Presentation. November 1 st, 2011.
Drummond, D., (2011). Therapy or Surgery? A Prescription for Canada’s Health System.
Toronto, ON: Benefactors Lecture, 2011.
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Canada’s Healthcare System. A Shifting Gears Report. Mowat Centre and School of Public
Policy & Governance at the University of Toronto with KPMG. ISBN 978-1-927350-08-9
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Canadian Hospice Palliative Care Nurses Group Submission:
Canadian Hospice Palliative Care Nurses Group
Submission to the CNA National Commission
January 2012
1. What are the most pressing health challenges facing Canadians today?
One of the most pressing issues facing Canadians is the aging of the population and people living
longer with chronic illnesses. Due to increasing numbers of people living longer with more
complex care needs, options for quality hospice palliative and end-of-life (HPEOL) care are
becoming more urgent than ever before. Former Senator Sharon Carstairs understood this need
and advocated tirelessly to advance awareness, services and education1. The creation of the
Secretariat for Palliative and End-of-Life Care by Carstairs enabled funding to be granted to
health professional education institutions for the development and integration of HPEOL
competencies into curriculums. For example, a significant grant was awarded to medical schools
to integrate these competencies into medical students’ curriculum. In the last 3 years smaller
amounts of funding have been provided to nurses and social workers to do similar work. This
funding has partially allowed the effort required to fully integrate HPEOL education into
colleges and universities in Canada. Further funding is needed to ensure that every nurse,
physician, social worker, chaplain, and pharmacist has this education as a student and
opportunities for high-quality continuing education as a professional. HPEOL education is also
critical for family caregivers, para-professionals and unregulated staff working in acute,
residential, and tertiary care facilities. But education is only one aspect of what is needed to
address this growing concern.
2. What do we need from nurses, other health professionals, governments and the public
to address the challenges we’re facing?
What is needed first and foremost is an understanding of what constitutes HPEOL care and a
commitment by all to ensure its provision. Basic HPEOL care encompasses 24-hour access to
high-quality, competent and compassionate care delivered to both patients and families by
skilled team members prior to the death of patients and including the family during a period of
bereavement. Services include 1) dedicated HPEOL units/settings in every region of Canada
according to the needs of the population; 2) improved home care services – including supplies
and medications; 3) improved HPEOL care and education in long term care (LTC) facilities and
acute care (AC) hospitals (where most people die); 4) palliative teams (doctors, nurses, advance
practice nurses, such as clinical nurse specialists and nurse practitioners, social workers,
chaplains, therapists, pharmacists, and volunteers) to consult in the care of patients in LTC and
AC facilities and to support the primary nurse/physician team. Many LTC and AC facilities do
not have access to these services despite the fact that most people in Canada die these
1
Carstairs, S. (June 2000). Quality end-of-life care: the right of every Canadian. Final Report to the Subcommittee to update ‘Of
Life and Death’ of the Standing Senate Committee on Social Affairs, Science and Technology
Health Canada. Palliative End-of-Life Secretariat found at: http://www.hc-sc.gc.ca/hcs-sss/palliat/index-eng.php
Carstairs, S. (June 2005). Still not there: Quality End-of-Life Care: A Progress Report
Carstairs, S. (June 2010). Raising the Bar: A Roadmap for the Future of Palliative Care in Canada
Reports found at http://sen.parl.gc.ca/scarstairs/PalliativeCare/PalliativeCare_e.asp
84
institutions. Research supports that dying in LTC and AC is oft-times not as good an experience
as it could be with effective supports.2,3
Health care staff must ensure they are familiar with available resources, consultation procedures,
culturally-specific requirements, and the underlying philosophy of HPEOL care. Some health
care professionals and members of the public hold misunderstandings about this practice area—
potential benefits and resources—and therefore may ‘shy away’ from initiating or accepting
services/referrals (i.e. HPEOL care may be seen as ‘death care’ or ‘giving up’). Health care
providers who understand the benefits of HPEOL care may facilitate early access and thereby
higher quality of life for both patients who may benefit and their and family members.
Canadians and their governmental representatives can support advances in research and
policy. One area which requires further support is First Nations people do not have the same
coverage for important medications, supplies, or equipment as others. This creates a whole
different challenge for providing ethical healthcare where we know what people need but cannot
access it.
3. What can nurses do to have the greatest impact on the health outcomes of all
Canadians?
Nurses can advocate for better HPEOL care across all sectors of health care in Canada,
including education, infrastructure, accountability measures, services, supplies, medications and
other needs specific to each community. Expert HPEOL care nurses (e.g. those with CNA
certification in hospice palliative care nursing) in various settings and educators at undergraduate
and graduate levels can serve as HPEOL care champions.
Nurses can become more knowledgeable about how to deliver excellent HPEOL care to
the population they serve through attending continuing education programs, working with
mentors, becoming certified in hospice palliative care nursing with the CNA, and mentoring
students, new nurses, and other team members. Nurses can work collaboratively with health care
team members, the patient/client and his/her family to provide the best possible HPEOL care.
Team work is especially important in HPEOL care because patients’ needs are often complex;
care provision can be physically, emotionally, and spiritually challenging for both the providers
and the patient/family.
Nurses can participate in HPEOL care research whenever possible and provide
opportunities for other health care providers and patients and families to participate. For
example, currently in BC the Michael Smith Foundation for Health Research has funded a 4-year
nursing initiative called iPANEL: Initiative for a Palliative Approach in Nursing: Education and
Leadership4. In this project nurses and others from all care sectors across BC are being invited to
participate in a variety of activities such as surveys, interviews, on-line communities of support,
webinars, forums, and other events in an effort to promote a ‘palliative approach’ to all people
who are living with a life-limiting, chronic, end stage illness, regardless of setting. Initiatives
such as this include opportunities to educate health care providers and the public about high
2
Stajduhar, K.I., Funk, L., Cohen, S. R., et al (2011). Bereaved family members’ assessments of the quality of end-of-life car:
what is important? Journal of Palliative Care, 27(4); 261-269.
3
Heyland, D., Groll, D., Rocker, G., Dodek, P., et al. (2005). End-of-life Care in Acute Care Hospitals in Canada: a Quality
Finish? Journal of Palliative Care, 21(3); 142-150.
4
www.ipanel.ca
85
quality HPEOL care and why it is important that all people who could benefit should have access
to such services.
4. If you could make one change to improve the health of Canadians, what would it be?
The one change we would want is for all Canadians to understand how HPEOL care
enhances the quality of living-dying of patients and their family members, and how that
contributes to the community/society at large. In turn development and improvement in access,
education and services would result in excellent HPEOL care for all Canadians, regardless of
age, gender, ethnicity, income, religion, sexual orientation, geographical location, and/or care
setting.
Nurses, as the largest number of care providers who are ‘at the bedside’ of patients 24/7,
want to ensure that all Canadians who can benefit from HPEOL care are offered access to
HPEOL care. The Canadian Hospice Palliative Care Nurses Group will continue to advocate and
work towards this end.
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Quality Palliative Care – Long Term Care Alliance (QPC-LTC Alliance)
Submission:
Long-Term Care Homes: Hospices of the Future
Submission to the Canadian Nursing Association Expert Commission
Presented by the QPC-LTC Alliance
Contact: XXX, Associate Professor School of Nursing Lakehead University
87
Introduction
Palliative care is a philosophy and a specialized set of care processes that encompasses
the physical, emotional, social, psychological, spiritual and financial needs of residents of long
term care facilities and their families. Therefore, Palliative Care aims to enhance quality of life at
the end-of-life in order to provide a “good death” when death is inevitable. While, LTC homes
have become a major location of death in Canada, most do not have formalized Palliative Care
programs.
In Ontario, almost 50% of the residents who live in LTC homes die each year. This
means approximately four deaths per month for a home with 110 residents. Without a doubt,
LTC homes are now in the “business of caring for people who are dying.” The majority of
residents who die in LTC have Alzheimer’s disease or related dementias in conjunctions with
several other chronic and terminal illnesses.
The new LTC Act in Ontario has recognized this new reality by mandating the provision
of palliative care education for all staff providing direct care to residents in LTC homes. The
Quality Palliative Care in Long Term Care (QPC-LTC) is working on creating a “tool kit” of
best practices for long term care homes to develop formal palliative care programs. Please refer
to Appendix A for Project Background.
The nurse to resident ratio is low in LTC compared to other settings that provide end of
life care. Providing quality nursing care to residents is difficult as they have multiple and
complex chronic and terminal illnesses that must be managed. Thus, it is important that the
Canadian Nurses Association (CNA) advocate supporting all nurses working in LTC homes.
The Alliance recognizes that many of the principles of the CNA’s political agenda are
compatible with a position statement regarding Providing Nursing Care at The End of Life
(2008) and the Hospice Palliative Care Nursing Certification (2009) with specialty competencies
for registered nurses. The Alliance asks that the expert commission consider the uniqueness
of providing palliative care in long term care homes by reviewing the recommendations
listed in the following brief.
This brief is based on data from the Quality Palliative Care in Long Term Care research
project. For more information regarding this project please visit our website at
www.palliativealliance.ca. The recommendations are separated into three categories which
include: education and professional development, funding, and regulations. A summary table of
the project recommendation can be found in Appendix B.
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Human Resources,
The CNA policy brief The Long-term Care Environment: Improving Outcomes Through
Staffing Decisions (2008) highlights lack of staff or the right mix of regulated and unregulated
providers to provide quality and quantity of care, lack of sufficient funding and inadequate staff
education. The QPC-LTC data indicate that LTC home staff lacks knowledge, skills, and
confidence in providing P/EOL care. While nursing staff are highly motivated to provide care at
the EOL, they identified the need for more education, more assistance from volunteers and
consultants, better communication and improved team work. Nursing staff expressed the feeling
that their important contribution to P/EOL care was not recognized. In response to these issues
our project has worked to build external community linkages that enhance existing human
resources, provide grief support for staff, promote education about palliative end-of-life care,
and promote empowerment of PSWs and their role in the interprofessional care team,.
Education and Professional Development
Building External Linkages
All staff reported a lack of human resources and a shortage of time to provide enhanced
care at the EOL. Building linkages with community organizations is one way to supplement LTC
staff as well as creating more time and specialized knowledge and skills in the homes. Many
community organizations have a mandate to provide services in LTC, but the homes do not
always engage these services. In our project, some key organizations that proved beneficial for
LTC homes included: Pain and Symptom Management Consultants, Alzheimer Societies,
multicultural and multifaith groups and hospices / hospice volunteer groups. Local Hospice Units
can provide significant assistance by providing 24-hour consultations, referring staff to
community experts, and written resources (e.g. books, brochures, directories), and can provide
education and mentoring to LTC staff. Nurse Led Outreach Teams can provide assistance to staff
when residents are transitioning towards P/EOL goals of care and support staff to provide EOL
care. They help prevent unnecessary transfers to hospital at EOL. If the resident is transferred to
hospital, the Nursed Led Outreach team can ensure smooth transitions during this period by
sharing information with both the hospital and the LTC home. Pain management is an important
component of P/EOL care and was outlined in the new LTC Act as one of the four mandatory
programs that LTC homes must provide. Currently LTC homes have access to Pain and
Symptom Management Consultants however these consultants are responsible for large
geographical areas and several organizations. Providing LTC homes with dedicated Pain and
Symptom Management Consultants would enhance LTC staff education and better manage
resident pain.
Increase Palliative and EOL Care Education within College and University Programs
Nursing staff, both regulated and unregulated, felt unprepared to provide P/EOL care
after basic education from a college or university program. They stated they had little to no
P/EOL content within the curriculum. The staff commonly said they learned to provide PC
through on-the-job experience caring for the dying. Also, to the knowledge of the Alliance there
are no competencies for PCWs in PC and EOL care. The Alliance is working towards identifying
educational competencies for PCWs providing PC. We are also advocating for these
competencies to be included in PCW curriculum in the Ontario colleges. This will increase role
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clarity for other members of the interprofessional team including the registered nursing staff. The
Alliance would also like to highlight the importance of targeting health care providers who are
motivated to provide palliative care and encourage them to consider working in LTC homes as
traditionally LTC has not been an attractive please for health care professionals to practice.
Provide Continuing Education Opportunities for Staff Working in LTC Homes
LTC staff indicated that there are few ways to receive education in palliative care.
Currently one of the most effective ways they learn about PC /EOL care is through mentoring by
other staff. The Alliance has used a variety of continuing education methods with the LTC staff
including: arranging for LTC staff to shadow nursing staff from local hospices, encouraging LTC
staff to receive the Palliative Care for Front Line Workers training developed by the Centre for
Education and Research on Aging & Health (CERAH) at Lakehead University, and connecting
staff with community organizations that have relevant expertise. Technology has been used to
increase opportunities for nursing staff to receive palliative care continuing education. Some
examples include using high fidelity simulation labs to give staff opportunities to practice having
EOL conversations with residents and families and using the Ontario Telemedicine Network
(OTN) to provide staff with access to education from other areas of the province.
Grief Support for Staff
One PCW participating in the project stated: “it’s hard to watch people die for a living.”
This is a common feeling among the staff. Staff members become very attached to the residents
and consequently carry a heavy burden of grief when residents die. Currently, providing grief
support to staff as a routine part of staff health and wellness programs does not commonly occur.
This lack of recognition of the emotional impact of grief and bereavement for staff can
contribute in staff burnout and increased sick time. Social Work graduate students conducted
eight individual staff interviews and prepared a report highlighting workplace wellness strategies
that would address grief and loss in LTC. The goal is to develop organizational policies that
normalize the staff’s experience with grief and formalized programs available to all LTC staff.
Reduce Professional Hierarchies in LTC homes
Professional hierarchies that exist within LTC homes are detrimental to developing P/EOL
programs requiring teamwork. Professional hierarchies impede communication when Personal
Support Workers (PSW) or Personal Care Workers (PCW) who know residents and families the
best are unable to participate in care planning or to communicate directly with physicians and
nurse practitioners. The development of a PC team where each professions role and scope of
practice is respected and complimentary facilitates communication and provides a structure for
collaborative care planning. The team should have member representation from all departments.
Funding Recommendations
Fund a Long Term Care Centre for Learning, Research, and Innovation dedicated to PC
and EOL care in Ontario
The Ontario Ministry of Health recently funded three Centres for Learning, Research, and
Innovation. It is recommended that a fourth centre be funded with a focus on P/EOL care.
90
Increase Funding for Providing EOL Care in LTC
Currently, the MDS-RAI 2.0 includes an indicator for EOL care. J5 asks staff to indicate whether
the resident is “end-stage disease; 6 months or less to live.” This indicator is not currently
attached to funding. Providing quality EOL care in LTC requires enhanced human resources and
we recommend that this indicator be attached to enhanced funding.
Fund a Marketing Campaign to Promote LTC as a setting that provides Palliative Care
Data indicated that residents and families do not understand that PC can provided in LTC homes.
When this is clearly communicated, most families express a preference to have the resident
remain in their LTC home until the EOL. In order for the LTC sector to transition itself to be a
place that is known to provide residents with quality P/EOL care, LTC homes need to market
themselves differently. If LTC homes could market P/EOL care as an essential part of quality
resident centred care there would be many benefits to staff, families, residents, and the health
care system. These benefits could include more people choosing to die in LTC homes, more
communication about P/EOL care, and more opportunity for advance care planning.
Recommendations for Regulations
Adopting CHPCA models of PC
Our research indicates that the current culture within LTC is dominated by the medical
model with a focus on restorative care. Currently Advance Care Planning is limited in most LTC
homes to the medical directives. It is important that LTC homes move beyond solely discussing
medical directives and begin to incorporate advance care planning around social, spiritual, and
psychological care needs of the resident and family. This will help residents and families to
better understand the scope of care that LTC homes may provide at EOL life and allow staff to
learn more about EOL care goals of the resident and family in a more systematic way. The
Canadian Hospice Palliative Care Association (CHPCA) provides models of care that LTC
homes can use to guide them in providing palliative care concurrently with restorative care. The
CHPCA model was adapted by the Alliance to better reflect the fluctuating care needs of
residents in LTC with chronic health conditions. This model demonstrates that providing care to
residents within LTC homes can simultaneously be restorative and palliative. A common
misconception is that when someone is benefiting from palliative care they no longer benefit
from restorative care. However, a more appropriate model for providing care within LTC homes
is to have both restorative and palliative goals of care and have the focus of care change
depending on the illness trajectory. CHPCA also has another model called the Square of Care
and Organization. This model outlines the common issues faced by residents and families, the
process to providing palliative care, and the different organizational functions and resources that
are required to provide a formalized palliative care program. Please see Appendix C to view the
CHPCA square of care and organization model. Both of these CHPCA models can be used by
LTC homes to guide the development of their palliative care programs.
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Use MDS-RAI 2.0 to Identify LTC Residents Needing PC or EOL Care
The MDS-RAI is now mandated for use in all LTC homes in Ontario. The MDS-RAI is a unique
tool that could be used for earlier identification of residents who would benefit from a P/EOL
care plan. Research shows that earlier identification of residents improves satisfaction and
quality of life for residents and families. There has been work done in Canada, Europe and the
USA to identify indicators within the RAI tool that should trigger a Palliative Care or EOL care
plan. Using RAI data provides homes a systematic way of determining residents eligibility for
their programs.
Increased Acknowledgment of Palliative Care and EOL Care in the Ontario LTC ACT
The Ontario LTC Act 2007 stipulates for the first time that LTC homes must provide EOL and
palliative care training for staff providing direct care. In the future the Alliance hopes to see
palliative care become a mandatory program for LTC homes that is reflective of the CHPCA
holistic philosophy.
Palliative Care Accreditation for LTC
Currently, LTC accreditation standards do not specifically include P/EOL care. Having an
accreditation with special recognition for palliative care programs would provide an incentive for
LTC homes to formalize their programs. It would also assist with marketing LTC homes as
locations where excellent palliative care can be received.
Section #3: Conclusion
The role of LTC in the health care system has changed drastically in the last 20 years. LTC
homes are now a major location of death in Ontario and trends suggest that their role in
providing EOL care will increase into the future. The LTC homes participating in our research
embrace their new EOL care role, viewing it as part of the continuum of resident centred care
they provide. Our project has demonstrated many successful innovations some of which can be
found in the project research posters in the Appendices. At the same time, our project has
identified challenges and barriers for LTC homes to implement formalized palliative care
programs. Formalized PC programs have been shown to increase resident satisfaction and quality
of life in other settings where people die. In an effort to advance the provision of P/EOL care in
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LTC, we have provided a series of recommendations. We have also compiled some supplemental
resources including relevant research and projects from around the world. We would welcome
the opportunity to discuss these recommendations or any other issues relevant to implementing
formalized palliative care programs in LTC homes.
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Appendix A: QPC-LTC Project Background
In 2009, the Social Sciences and Humanities Research Council funded the Quality
Palliative Care in Long Term Care Alliance (QPC-LTC) for five years to address the
need to develop formal palliative care programs in LTC homes. The Quality Palliative
Care in Long-Term Care Alliance is comprised of 31 researchers and 43 organizational
partners who actively contribute their expertise to the research project entitled, Improving
Quality of Life for People Dying in Long-Term Care Homes (see Appendix A for list of
Alliance members). The Alliance’s primary goal is to develop sustainable, person-focused
palliative care programs consistent with the Canadian Hospice Palliative Care
Association's Square of Care using a capacity development process. For further
information please see the project website www.palliativealliance.ca
The Principal Investigator is Dr. Mary Lou Kelley from Lakehead University Thunder
Bay Ontario. The research is conducted with four key partners; Lakehead University,
McMaster University, the Municipality of Halton and St. Joseph’s Care Group in
Thunder Bay. The QPC-LTC Alliance partners are municipal, provincial and national
organizations that represent individuals, families, caregivers, health care providers,
educators and other stakeholders. There are four long-term care (LTC) homes in Ontario
that are study sites for the project: Bethammi Nursing Home and Hogarth Riverview
Manor in Thunder Bay, and Allendale Village in Milton and Creek Way Village in
Burlington.The primary goal of the research is to improve the quality of life of people
dying in LTC homes by developing palliative care programs which integrate the
Canadian Hospice Palliative Care Model of Care (see Appendix C). The specific project
objectives are:
1. to empower PSWs to maximize their role in caring for people who are dying and their
families and support them to be catalysts for organizational changes in developing
palliative care
2. to implement and evaluate a 4-phase process model of community capacity development
in four LTC sites, and create an evidence-based tool kit of strategies and interventions to
support this development.
3. to create sustainable organizational changes that will improve capacity to deliver
palliative care programs though empowering PSWs, developing palliative care teams and
programs within LTC homes and strengthening linkages with the community partners.
4. to develop knowledge and skills in palliative care and participatory action research
The QPC-LTC methodology is participatory action research (PAR), which has two
unique features.

Participatory means that those people and organizations that will benefit from the
research also fully participate and guide the research

Action means that the goal of the research is to create social change.
94
Over the past two and half years, the study has explored issues that serve as barriers to
implementing palliative care in LTC homes, and is now assisting facilities in creating
environments and specialized services for their residents. Together, researchers,
organizational partners and LTC home staff have assessed the needs, implemented
interventions and evaluated the results. This is an ongoing process for the next two years.
The outcome is development of an evidence based "toolkit” of interventions which can be
used by other LTC homes to develop their own palliative care programs. Consequently,
this project has benefit to residents, families and LTC homes nationally and
internationally. The research also contributes to existing theory on organizational
capacity development in a LTC home by implementing by implementing and evaluating a
community capacity model to guide the organizational change process. This model
outlines a four phase non-linear process for developing palliative care in LTC from the
ground up.
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Appendix B: Summary of Recommendations
The following table summarizes the recommendations listed above.
Education and
Professional Development
 Build external linkages
with key community groups
such palliative pain and
symptom consultants,
Alzheimer’s society,
hospice volunteers in order
to supplement human
resources
Increase education
regarding palliative and end
of life care in regulated
college/ university
programs that prepare
people to work in LTC
Enhance PC continuing
education using innovative
methods such as simulation
lab training, hospice visits,
mentoring and specialized
Palliative Care for Front
Line Workers curriculum
Funding
 Fund an additional
LTC Centre for
Learning, Research, and
Innovation dedicated to
palliative and EOL care
 Increase funding for
resident care when
resident is expected to
die within 6 months (J5
in RAI-MDS)
 Fund a provincial
marketing strategy that
promotes LTC as place
where quality P/EOL
Care can be provided
Regulations
 Encourage a more
holistic model of care by
adopting the CHPCA
models of palliative care
Increase recognition of
the importance of Palliative
and EOL care within the
LTC Act
Include P/EOL care in
Accreditation process to
provide incentives for LTC
homes to develop,
formalize and market their
programs
Make grief support
programs for staff of LTC
home mandatory
components of workplace
wellness programs
 Reduce professional
hierarchies in LTC homes
and promote
interprofessional
collaboration and team
work between PSW,
registered staff, and medical
directors
96
Appendix C: CHPCA Square of Care
97
98
Appendix D: QPC-LTC Alliance Additional Resources
Please visit http://www.palliativealliance.ca/conference-abstracts for all our conference posters
and presentations. Topics include but are not limited to:






Developing palliative care programs in LTC homes
Personal Support Worker competencies
Simulation lab communication tool
Multi-Sensory Simulation Lab or Snoezelen therapy
Resident and family perspective on palliative care in LTC
Grief and Loss
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Ordre des infirmières et infirmiers du Quebec (OIIQ) Submission:
100
À QUAND UN FINANCEMENT ADÉQUAT DES SOINS
INFIRMIERS DANS LA COMMUNAUTÉ?
La santé de notre nation, l’avenir de notre système de santé
Mémoire de l’OIIQ présenté à la Commission nationale
d’experts sur l’amélioration du système de santé de
l’Association des infirmières et infirmiers du Canada
Mars 2012
101
Édition
Coordination et rédaction
Johanne Lapointe
Directrice
Direction, Affaires externes
Production
Service des publications
Sylvie Couture
Chef de service
Claire Demers
Adjointe à l’édition
Direction des services aux clientèles et des communications, OIIQ
Révision linguistique
Jocelyne Tétreault
Ordre des infirmières et infirmiers du Québec
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Westmount (Québec) H3Z 1V4
Téléphone : 514 935-2501 ou 1 800 363-6048
Télécopieur : 514 935-3770
[email protected]
www.oiiq.org
Dépôt légal
Bibliothèque et Archives Canada, 2012
Bibliothèque et Archives nationales du Québec, 2012
102
ISBN 978-2-89229-557-3 (version imprimée)
ISBN 978-2-89229-558-0 (PDF)
© Ordre des infirmières et infirmiers du Québec, 2012
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Note – Conformément à la politique rédactionnelle de l’OIIQ,
le féminin est utilisé uniquement pour alléger la présentation.
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TABLE DES MATIÈRES
Introduction ...................................................................................................................... 143
1.
Mandat de l’OIIQ
144
2.
L’infirmière, pierre angulaire du contexte changeant des soins de santé 145
2.1. Soins plus complexes 145
2.2. Une première ligne forte dans la communauté 146
2.3. L’avis des experts
147
2.4. Regard sur quelques actions internationales
147
2.5. Progression accélérée du rôle des infirmières partout dans le monde
148
2.6. Un champ d’exercice infirmier dynamique au Québec 150
3.
2.7. L’infirmière et la collaboration interprofessionnelle
151
2.8. À l’affût d’un cadre adapté de prestation de soins
151
Cadres de prestation des soins de santé au Québec et au Canada
3.1. Cadre de la santé au Canada
153
3.2. L’esprit de la Loi canadienne sur la santé
3.3. Nouveau contexte canadien
4.
153
155
3.4. Contexte des soins de santé au Québec
157
3.5. Le Québec finance-t-il les bonnes cibles?
160
L’incohérence du financement des soins à domicile et de longue durée 162
4.1. Peut-on éviter les hospitalisations?
162
4.2. Avons-nous fait le virage qui s’impose en soins à domicile?
162
4.3. Avons-nous fait le virage qui s’impose en soins de longue durée?
5.
164
Le panier assurable : mise en contexte pour le Québec 165
5.1. Quels sont les « trous » dans le panier assurable québécois?
6.
153
Recommandations
166
169
ANNEXES .......................................................................................................................... 170
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Introduction
Le 26 mai 2011, l’Association des infirmières et infirmiers du Canada (AIIC) lançait
officiellement la Commission nationale d’experts sur l’amélioration du système de santé,
intitulée La santé de notre nation, l’avenir de notre système de santé. Le mandat de la
commission est de présenter des solutions politiques (avec entre autres des innovations
infirmières) qui contribueront à transformer le système de santé pour en faire un
système mieux équipé pour répondre à l’évolution des besoins en vue du
renouvellement de l’Accord sur la santé du Canada en 2014.
L’AIIC a formellement invité l’Ordre des infirmières et infirmiers du Québec (OIIQ) à
présenter un mémoire articulant les positions et préoccupations de l’Ordre quant à ce
renouvellement. Nous avons accepté cette invitation avec plaisir. Tout comme l’AIIC,
l’OIIQ estime que les infirmières et infirmiers sont un élément central des soins de santé
au Québec (et au Canada) et qu’il faut en tenir compte dans la transformation d’un
système de soins viable tourné vers la communauté.
La Commission a traité de nombreuses questions clés similaires aux enjeux que l’OIIQ
promeut, entre autres : la formation, l’utilisation optimale des ressources,
l’interdisciplinarité, la prévention et la promotion de la santé, le transfert des soins vers la
communauté, le rôle accru des infirmières pour prévenir et traiter les maladies
chroniques etc. Nous l’en félicitons.
Le secteur de la santé est en constante évolution et il est influencé, entre maintes
variables, par la mondialisation, les technologies, le vieillissement de la population, le
transfert vers la communauté, l’augmentation et la mutation des maladies, les
connaissances des travailleurs du secteur et la qualité des soins au patient. Les
conditions et caractéristiques du secteur d’aujourd’hui ne sont plus ce qu’elles étaient en
1984, au moment de l’introduction de la Loi canadienne sur la santé (LCS).
Ce mémoire met en relief le rôle incontestable que peut jouer l’infirmière dans la
transformation du système de santé québécois, ainsi que l’importance pour elle d’avoir
les leviers pour occuper pleinement son champ d’expertise, et pour qu’elle puisse le
faire dans un environnement de soins dynamique, axé sur le patient, bien financé et
favorisant le plus grand accès à tous les citoyens. L’OIIQ profite de ce mémoire pour
faire connaître ses opinions sur les facteurs qu’il juge prioritaires en matière d’allocation
de ressources dans le contexte du renouvellement de l’Accord – notamment le
financement aux soins à domicile et de longue durée – et qui devra tenir compte d’un
panier de soins assurables conséquent, plus particulièrement un financement adéquat
pour les soins infirmiers en dehors du milieu hospitalier.
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MANDAT DE L’OIIQ
L’OIIQ, dûment constitué en vertu des dispositions de la Loi sur les infirmières et les
infirmiers, L.R.Q., c.1-8, est un ordre professionnel dont la fonction principale est
d’assurer la protection du public, conformément au Code des professions du Québec,
L.R.Q., c.C-26, en contrôlant notamment l’exercice de la profession d’infirmière par ses
membres. L’OIIQ est un organisme voué à l’amélioration continue de la qualité des
soins.
Rappelons que toute personne qui veut exercer au Québec la profession d’infirmière et
en utiliser le titre doit détenir un permis de l’OIIQ et être membre en règle de celui-ci,
comme l’exige l’article 32 du Code des professions. Avec plus de 71 000 membres,
l’OIIQ figure parmi les partenaires majeurs du réseau de la santé et des services
sociaux.
L’OIIQ adopte des orientations en matière de pratiques cliniques et de formation à la fine
pointe des connaissances scientifiques dans le domaine des sciences infirmières. Il fait
aussi la promotion de rôles infirmiers particuliers et les documente. L’OIIQ fait
également valoir son point de vue sur des sujets d’actualité qui interpellent les
infirmières dans leur pratique et en matière de déontologie.
À cet égard, le présent exercice nous amène à nous poser des questions capitales.
Dans quel contexte l’infirmière devra-t-elle être outillée pour répondre aux exigences
futures du système de santé centré sur la première ligne dans la communauté?
Comment peut-elle assumer un plus grand rôle dans la prestation de ces soins,
notamment ceux de longue durée et dans la communauté? A-t-elle les leviers
nécessaires pour remplir, au maximum de sa capacité, son champ d’exercice actuel?
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L’INFIRMIÈRE, PIERRE ANGULAIRE DU CONTEXTE CHANGEANT
DES SOINS DE SANTÉ
La science infirmière s’enrichit perpétuellement au rythme des découvertes et des
connaissances approfondies dans tous les milieux de soins. En synergie avec le besoin
de réorienter la prestation, le financement et le panier assurable des soins de santé au
Québec, l’infirmière est au cœur de la dynamique de soins. Elle est, en quelque sorte, le
catalyseur dans les changements que nous proposons dans ce mémoire à la
Commission nationale d’experts. Elle le sera encore plus dans le futur, notamment dans
la communauté, lorsque les soins de première ligne y seront développés à leur pleine
capacité. Tous vantent les mérites et le nécessaire virage des soins dans la
communauté, entre autres le Commissaire à la santé du Québec et l’AIIC qui prévoit que
75 % des infirmières exerceront dans le milieu communautaire en 202053.
À l’heure actuelle, la profession d’infirmière, parce qu’elle comporte un grand nombre de
membres et à cause de la variété de milieux de soins dans lesquels elle évolue, est
certes l’acteur le plus significatif de toute réforme visant une amélioration du système de
santé au Québec. Les chiffres parlent d’eux-mêmes : le nombre d’infirmières et
d’infirmiers inscrits au Tableau de l’OIIQ atteignait 71 399 en 2010-2011. Rappelons que
le nombre de membres de l’OIIQ a dépassé la barre des 70 000 pour la première fois en
2007-2008; il est demeuré stable au cours de la dernière année. La grande majorité des
infirmières du Québec sont embauchées par le secteur public. Ce secteur est composé
principalement des établissements du réseau public de la santé et des services sociaux
(RSSS) qui emploient 82,2 % de l’effectif, soit quelque 55 150 infirmières. Plus de la
moitié de ces infirmières travaillent dans une ou plusieurs des installations (mission CH,
CHSLD, CLSC ou GMF) des centres de santé et de services sociaux (CSSS) de la
province, et environ le tiers dans un centre hospitalier universitaire (y compris les
centres affiliés et les instituts universitaires). Le secteur privé emploie, quant à lui, un
peu moins de 8 000 infirmières, soit 11,8 % de l’effectif.
Qu’attend-on pour donner à l’infirmière québécoise une plus grande capacité d’action?
N’est-elle pas déjà la mieux placée pour répondre au désengorgement des institutions et
à la complexification des maladies et des soins ainsi qu’à leur prestation en première
ligne, dans la communauté?
53
Michael Villeneuve, Jane MacDonald (2006). Vers 2020 : visions pour les soins infirmiers. Association des infirmières et
infirmiers du Canada.
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2.1.
SOINS PLUS COMPLEXES
La complexité des besoins de santé ira en grandissant, en raison notamment des
multipathologies, du vieillissement de la population, de la chronicité, des troubles
mentaux, de la persistance d’habitudes de vie nuisibles et des inégalités en santé.
Le déplacement des soins vers le domicile et les services de proximité accordera
davantage de place au maintien et à la promotion de la santé ainsi qu’à la prévention
des risques et de la maladie, d’où une évolution des stratégies d’intervention et des
modes de prestations de soins. Le patient doit être le point de convergence des soins de
santé : avec une continuité des soins répondant à ses besoins.
On peut voir d’autres tendances se dessiner :

le maintien des patients dans leur milieu qui nécessite une prise en charge par
des infirmières;

l’éducation des patients;

le développement accéléré et spécialisé des connaissances scientifiques et
technologiques;

le développement de la première ligne;

l’évolution des rôles au sein des équipes de soins;

l’évolution du contexte international des soins, davantage basés sur le patient,
élargissant le rôle de l’infirmière dans une recherche d’efficacité;

le rehaussement de la formation initiale partout au monde;

le contexte de mobilité internationale.
2.2.
UNE PREMIÈRE LIGNE FORTE DANS LA COMMUNAUTÉ
Les modèles performants de soins favorisent la pratique collaborative et
interdisciplinaire, la coordination des soins et une vision de responsabilisation à l’égard
des communautés. Les moins performants sont ceux qui fournissent un contact sans
prise en charge. La première ligne de soins est une assise sur laquelle on peut bâtir une
transformation du système. Les systèmes de santé qui ont une première ligne forte
obtiennent de meilleurs résultats, à moindres coûts.
Aux yeux de plusieurs, la continuité des soins serait la clé de services de qualité en
matière de soins de première ligne. Pour les patients, cela correspond à une circulation
fluide de l’information, au développement d’une relation de confiance avec les
professionnels et à des services qui s’adaptent à leurs besoins et caractéristiques. Nous
espérons que les prochaines réformes du système de santé québécois viseront à faire
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transiger graduellement les soins vers la communauté et le domicile du patient, dans
une perspective d’accroissement de la prévention, d’allègement de la pression sur les
urgences, les services en centre hospitalier, les soins de santé liés au vieillissement de
la population et à la gestion accrue des maladies chroniques.
De par son approche professionnelle, il est reconnu que l’infirmière est celle qui pratique
généralement selon une méthode axée sur le continuum des soins. Ce n’est pas pour
rien qu’elle est perçue comme un instrument de progrès essentiel pour moderniser le
système de santé et le centrer sur les services de première ligne dans la communauté.
2.3.
L’AVIS DES EXPERTS
Nombre de commissions et de groupes de travail sur la réorganisation des soins de
santé ont, depuis une douzaine d’années, recommandé de nouveaux rôles pour les
infirmières, notamment la Commission d’étude sur les services de santé et les services
sociaux (Rapport Clair, 2000) et la Commission Romanow sur l’avenir des soins de
santé au Canada (2002). Dans tous les cas, la perspective mise de l’avant était double:
utiliser les infirmières comme ressource pour dénouer des problèmes d’accessibilité aux
services et les ramener dans des rôles qu’elles seules peuvent exercer dans la
prestation des services infirmiers et médicaux.
Le Commissaire à la santé note que, présentement, le médecin de première ligne est
utilisé pour répondre à l'ensemble des besoins des personnes, y compris des services
que d'autres professionnels seraient habilités à rendre. Le Commissaire reconnaît que la
participation du personnel infirmier aux équipes médicales a fait l'objet de plusieurs
études et les preuves quant à l'augmentation de la satisfaction des personnes à l'égard
des soins reçus sont importantes54.
En raison de leurs compétences approfondies et du fait qu’elles risquent de coûter
moins cher au système de santé que les médecins de première ligne, les infirmières
devraient davantage faire partie des stratégies de réforme des soins de santé primaires.
Dans les soins primaires, les infirmières peuvent effectuer une bonne partie du travail de
promotion de la santé dans la pratique de famille, et elles peuvent jouer un rôle clé dans
la gestion de maladies chroniques telles le diabète, l’asthme, et les maladies du cœur.
Les commissions et les études passent, mais le même constat est toujours le même. La
première ligne de services demeure faible et elle est pourtant la clé d’un système de
54
Commissaire à la santé et au bien-être (2010). Rapport d'appréciation de la performance du système de santé et de
services sociaux 2009 : Un portrait de la performance du système, particulièrement celle de sa première ligne de
soins.
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soins plus performant adapté au vieillissement de la population et à la recherche d’une
meilleure efficacité.
Dans cette perspective, l’infirmière pourrait devenir la voie d’accès à des services de
soins complets. D’autres pays ont décidé d’agir. Ceux-ci voient le rehaussement des
rôles infirmiers servir à la fois la qualité des soins au patient, l’efficacité du système et la
profession d’infirmière elle-même. Qu’attend-on au Québec pour agir en ce sens?
2.4.
REGARD SUR QUELQUES ACTIONS INTERNATIONALES
L’OIIQ s’intéresse aux modèles internationaux de soins infirmiers. Les modèles
d’organisations de soins qui atteignent une meilleure performance favorisent la pratique
de groupe, la multidisciplinarité, la coordination des soins et une vision de
responsabilisation à l’égard des communautés desservies et des rôles infirmiers de
pointe et innovants.
Voyons quelques exemples. Au Royaume-Uni, le NHS and Social Care Model promeut
l’emploi d’infirmières à titre de « community matrons », qui sont le pivot de l’organisation
et de la prestation des soins aux patients (au moyen d’un mécanisme d’évaluation et de
gestion de cas complexes) en interdisciplinarité (avec le soutien des spécialistes), en
collaboration avec les patients et leurs proches ainsi qu’en partenariat avec la
communauté.
En Californie, Kaiser Permanente axe son orientation stratégique sur la qualité des soins et la
satisfaction des patients, avec un financement par habitant où l’argent suit le patient. Kaiser a
identifié huit champs cliniques prioritaires. Les mesures de satisfaction de la clientèle font partie
de la performance clinique. Kaiser a créé des incitations organisationnelles et financières à la
performance clinique et a graduellement mis en place des systèmes d’information clinique et
d’aide à la décision clinique pour soutenir cette stratégie. Ce modèle implique une participation
active des infirmières afin qu’elles jouent un rôle clé au sein d’équipes interprofessionnelles.
Le Veterans Health Administration (VHA), un système public de santé américain, a amorcé dans
les années 1990 une réforme organisationnelle, orientée en l’orientant vers la qualité des soins
et la satisfaction de la clientèle. Le VHA a mis en place un système intégré d’information clinique
pour supporter ce virage. Les gestionnaires du VHA ont délaissé le coût unitaire pour mettre de
l’avant la notion de valeur, définie comme le rapport entre la qualité atteinte et le coût. Les
infirmières y contribuent significativement. En moins d’une décennie, le VHA est passé du pire
système de santé aux États-Unis, en termes de qualité, à l’un des meilleurs.
Il ne faut pas par ailleurs négliger de souligner l’amélioration des soins aigus en milieu
hospitalier, notamment les Magnet Hospitals. Ceux-ci sont un prix décerné par l’American
Nurses' Credentialing Center, une filiale de l’American Nurses Association. Ces hôpitaux
remplissent une série de critères qui mesurent la force et la qualité des soins infirmiers. Les
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infirmières y offrent des soins de haute qualité avec des résultats probants pour les patients,
une grande implication clinique dans la prise de décision et une satisfaction au travail assurée.
Ces hôpitaux promeuvent une communication ouverte entre les infirmières et les autres
professionnels de la santé.
Nous devrions commencer à considérer des modèles similaires en analysant leur
application au Québec et en vérifiant leur capacité d’adaptation à la « sauce »
québécoise. Les infirmières peuvent assumer un plus grand leadership dans tous les
milieux de soins et contribuer aux virages qui s’imposent. Les modèles performants
d’organisation de services reposent toujours sur une meilleure intégration des services
assurés et sur une participation active des infirmières au sein d’équipes
interprofessionnelles.
2.5.
PROGRESSION
ACCÉLÉRÉE DU RÔLE DES INFIRMIÈRES PARTOUT DANS LE
MONDE
L’ampleur des défis liés à la santé et aux sciences infirmières a été confirmée par des prises de
position et recommandations émises par l’Organisation mondiale de la santé (OMS), le Conseil
international des infirmières (CII) et le Secrétariat international des infirmières et infirmiers de
l’espace francophone (SIDIIEF), entre autres.
À l’échelle mondiale, les infirmières prennent de plus en plus de décisions cliniques, autant dans
l’environnement hospitalier que dans le communautaire. L'infirmière peut jouer un rôle
significatif et efficace dans la mise en place de nouvelles modalités de prestation de soins dans
la gouverne clinique.
Les soins du futur – qu’on prévoit plus nombreux et plus complexes – exigeront beaucoup des
infirmières et leur permettront d’exercer davantage de leadership dans la prestation des soins.
On s’attendra à ce qu’elles jouent un rôle croissant en soins directs, en soins de longue durée,
en soins palliatifs, en première ligne, dans la gestion des maladies chroniques, dans la continuité
des soins centrée sur le patient – à la fois dans des établissements et dans la communauté. Une
plus grande partie de leur travail se fera dans la communauté. Elles exploiteront davantage les
systèmes d’information et les technologies de pointe55.
Elles joueront certes aussi un rôle actif dans la prévention, la promotion et le maintien de la
santé, dans le soutien de l’autogestion de la santé et la qualité accrue des soins. Les infirmières
seront plus impliquées dans les évaluations, les diagnostics, les traitements, la prescription de
médicaments, l’orientation des patients et l’évaluation de l’efficacité des soins. Ici comme
ailleurs, le rôle de l’infirmière est donc appelé à s’enrichir significativement en milieu hospitalier
et dans la communauté dans un contexte interprofessionnel d’équipes. On s’attend à ce qu’elles
55
Michael Villeneuve, Jane MacDonald (2006). Vers 2020 : visions pour les soins infirmiers. Association des infirmières et
infirmiers du Canada.
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coordonnent les soins et les équipes de soins en milieu institutionnel et communautaire (la
collaboration et la coordination entre professionnels et établissements seront la norme)56.
L'OIIQ est constamment soucieux de la sécurité du patient et a toujours soutenu
l'infirmière dans le rôle qu’elle joue dans la transformation du système. Nous sommes
intéressés par l’avenir de la profession et par ses capacités dans le temps à améliorer
l’accès, l’efficacité et les soins au patient. Les patients du Québec ont certes droit aux
mêmes soins infirmiers qu’ailleurs au Canada et que partout dans le monde.
Les systèmes de santé internationaux misent sur l’infirmière et sur l’introduction de rôles
infirmiers de pointe pour améliorer leur performance. Ceci implique une belle synergie
entre les décideurs, les milieux de soins et ceux de l’éducation. Qu’est-ce qui nous
retient d’entreprendre ici au Québec de pareilles démarches? Le Québec s’est doté en
2002 d’un champ d’exercice infirmier qui permettrait portant des progrès similaires pour
la profession, au bénéfice du patient.
2.6.
UN CHAMP D’EXERCICE INFIRMIER DYNAMIQUE AU QUÉBEC
Il y a déjà une décennie que des moyens ont été pris au Québec afin que l’infirmière
devienne une pierre angulaire du désengorgement en première ligne, de l’appui au
médecin de famille, de la prévention, de la promotion de la santé, de la gestion des
maladies chroniques, avec les 14 activités qui lui sont confiées par la Loi sur les
infirmières et infirmiers du Québec, la « Loi 90 » (voir l’Annexe 2).
En effet, en 2002, la « Loi 90 » a conféré aux infirmières du Québec un champ
d’exercice et une réserve d’activités particulièrement généreuse que d’autres provinces
et pays nous envient. Il faut l’occuper pleinement. Il faut donner à l’infirmière la capacité
de l’occuper pleinement. Malheureusement, la place prévue pour l’infirmière ne s’est pas
complètement concrétisée, faute de planification et d’organisation dans les milieux et de
financement adéquat de la première ligne de soins.
Ce champ d'exercice, avec les activités réservées qui en découlent, témoigne du rôle
accru des infirmières en matière de soins de santé. Il leur confère une grande autonomie
et reconnaît leur jugement clinique, notamment pour l'évaluation de l'état de santé d'une
personne, en leur permettant d'initier des mesures diagnostiques ou des traitements
selon une ordonnance, ou encore pour la surveillance clinique et le suivi infirmier des
personnes qui présentent des problèmes de santé complexes, y compris la
détermination et l'ajustement du plan thérapeutique infirmier (PTI).
56
Michael Villeneuve, Jane MacDonald (2006). Vers 2020 : visions pour les soins infirmiers. Association des infirmières et
infirmiers du Canada.
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Bien qu'il ne soit pas exclusif, le champ d'exercice décrit la profession en termes
généraux – ce qui la caractérise –, afin d'en cerner la nature et la finalité. En précisant
les principales activités professionnelles des membres de la profession, il établit les
balises à l'intérieur desquelles s’exercent les activités réservées et, par le fait même, il
circonscrit la portée de ces activités (OPQ, 2003, p. 2). L'article 36 de la Loi sur les
infirmières et les infirmiers définit le champ d'exercice de la profession comme suit :
« L'exercice infirmier consiste à évaluer l'état de santé d'une personne, à
déterminer et à assurer la réalisation d'un plan de soins et de traitements
infirmiers, à prodiguer les soins et les traitements infirmiers et médicaux
dans le but de maintenir la santé, de la rétablir et de prévenir la maladie
ainsi qu'à fournir les soins palliatifs ».
Le Québec paie un prix élevé en n’encourageant pas les infirmières à remplir leur
champ d’exercice tel que défini par la « Loi 90 ». Il importe de donner à toutes les
infirmières les moyens d’assumer l’ensemble des responsabilités que leur confère la loi.
L’élargissement du champ d’exercice selon la « Loi 90 » doit être occupé pleinement par
les infirmières.
Il y a obligation que la formation initiale au Québec corresponde à la définition de
l'exercice infirmier (chapitre 36, « Loi 90 ») et à l'étendue de la pratique selon cette
définition; la formation en soins infirmiers (180.A0 et 180.B0) non complétée par le
baccalauréat en sciences infirmières est devenue insuffisante pour cette
correspondance dans le contexte actuel des soins de santé. Vous n’êtes pas sans
savoir que l’Ordre est d’avis que la formation initiale pour l’exercice de la profession
d’infirmière au Québec soit au niveau du baccalauréat en sciences infirmières comme
dans l’ensemble du Canada.
L’occupation du champ d’exercice permettrait d’intensifier le nécessaire accroissement
de l’interdisciplinarité. L’apport de la profession d’infirmière ouvrirait la voie à une valeur
ajoutée significative dans les équipes de soins. On gagnerait ainsi en impacts
systémiques majeurs grâce au nombre d’infirmières et à leur polyvalence accrue.
2.7.
L’INFIRMIÈRE ET LA COLLABORATION INTERPROFESSIONNELLE
La réforme de notre système professionnel par la « Loi 90 » (2002) et par la « Loi 21 »
(2009) s’est définitivement inscrite dans un cadre de collaboration interprofessionnelle.
Dans sa pratique courante, l’infirmière collabore et interagit avec différents
professionnels :
médecins,
pharmaciens,
nutritionnistes,
ergothérapeutes,
physiothérapeutes, psychologues, travailleurs sociaux, etc. L’infirmière se trouve au
centre de tous ces professionnels et on lui demande, dans ses fonctions, de jouer un
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rôle de généraliste requérant une variété de capacités analytiques et décisionnelles
dans un contexte de coordination et d’interdisciplinarité.
Les infirmières sont celles qui peuvent contribuer grandement à améliorer la prestation
des soins de santé au Québec. Les infirmières devraient faire davantage partie des
stratégies de réforme des soins de santé primaires.
Les infirmières peuvent fournir des soins de haute qualité dans les domaines de la
prévention, le suivi régulier des patients atteints de maladies chroniques et le premier
contact avec les personnes atteintes d’une maladie bénigne.
L’infirmière ne veut pas remplacer le médecin. Les infirmières ont à cœur de travailler en
collaboration avec les médecins afin d’améliorer la qualité des soins et du système.
L’infirmière aimerait voir le médecin prendre en charge, comme il le désire, les cas plus
compliqués. L’infirmière de la relève, encore mieux formée, pourrait rendre les soins
accessibles à plus de patients et permettre au médecin de se concentrer davantage sur
les activités strictement médicales. À cet égard, la Fédération des médecins
omnipraticiens du Québec (FMOQ) affirme que les infirmières sont d'une aide précieuse
en cabinet. Elle suggère qu’augmenter les ressources pour embaucher des infirmières
les aiderait beaucoup à rencontrer davantage de patients en cabinet57.
2.8.
À L’AFFÛT D’UN CADRE ADAPTÉ DE PRESTATION DE SOINS
Les sections précédentes ont mis en évidence le fait qu’on s’attend des infirmières
qu’elles participent activement à la transformation du système de santé québécois, et
qu’elles utilisent une variété de capacités analytiques et décisionnelles dans un contexte
de coordination et d’interdisciplinarité. Les besoins du patient sont grandissants dans un
système de santé en évolution. La science infirmière évolue dans tous les milieux où elle
exerce.
À la lumière de ce que nous savons, est-ce que l’organisation et le financement des
soins de santé suivent les priorités des patients? Une autre question se pose. Les
cadres législatifs québécois et canadiens ont-ils évolué pour autant? Reflètent-ils la
multitude de changements économiques, cliniques et systémiques qui marquent la
prestation de soins de santé dans la province et au pays? Analysons la Loi canadienne
sur la santé (LCS) et la dispensation des soins au Québec.
57
Pierre-Olivier Fortin, Le Soleil (9 décembre 2011). Migration des pédiatres dans les hôpitaux : poids pour les
omnipraticiens.
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MÉMOIRE
3.
CADRES DE PRESTATION DES SOINS DE SANTÉ AU QUÉBEC ET AU
CANADA
3.1.
CADRE DE LA SANTÉ AU CANADA
Au Canada, en vertu de l’article 92 (7) de la Loi constitutionnelle de 1867, l’organisation
et la gestion des politiques de la santé relèvent, dans les 10 provinces, de l’autorité
ministérielle responsable de la santé au gouvernement provincial. Chaque province met
en place les institutions de gestion et de dispensation des soins de santé. Chaque
province et territoire est libre d’établir les règles de financement, d’allocation, et de
gestion des soins de santé qui lui semblent appropriées eu égard à sa population et à
ses besoins, dans le cadre de la Loi canadienne sur la santé (LCS).
Les gouvernements provinciaux déterminent l’étendue des services « médicalement
nécessaires » au sens de la LCS couverts par l’assurance publique. La libre
détermination des caractéristiques des systèmes de santé par les gouvernements
provinciaux est en effet à relativiser en raison de l’encadrement financier par le fédéral.
Chaque système d’assurance-maladie provincial couvre, selon ses priorités, des
services qui pourraient être considérés comme médicalement requis, mais qui ne sont ni
dispensés par un médecin ni rendus dans un hôpital. C’est particulièrement le cas de
certains médicaments sur ordonnance, des services ambulanciers et des services
d’optométrie. En dehors du champ d’application de la loi fédérale, pour les services non
requis médicalement, il y a une plus grande disparité de l’intervention des
gouvernements provinciaux.
3.2.
L’ESPRIT DE LA LOI CANADIENNE SUR LA SANTÉ
La LCS est en vigueur depuis le 1er avril 1984. Elle vise à établir les critères et
conditions en vertu desquels le gouvernement fédéral est autorisé à octroyer et à verser
« une pleine contribution pécuniaire pour les services de santé assurés […] en vertu de
la loi d’une province ».58
La LCS énonce cinq critères auxquels les régimes des provinces doivent se conformer
pour recevoir la participation financière du gouvernement fédéral – soit la gestion
publique, l’intégralité, l’universalité, la transférabilité et l’accessibilité :
58
Marlisa Tiedemann (2008). Le rôle fédéral dans le domaine de la santé et des soins de santé. Bibliothèque du
parlement, parlement du canada.
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
gestion publique : le régime doit être géré sans but lucratif par une autorité
publique qui relève du gouvernement provincial et qui est assujettie à la
vérification de ses comptes et de ses obligations financières;

intégralité : le régime doit assurer tous les soins de santé fournis par les
hôpitaux, les médecins et les dentistes et, sur autorisation, les services de santé
fournis par les autres professionnels de la santé;

universalité : toutes les personnes assurées d’une province ont droit aux services
de santé dispensés dans le cadre du régime selon des modalités uniformes;

transférabilité : lorsqu’une personne s’établit dans une autre province, la province
d’origine doit assumer les coûts des soins de santé assurés pendant le délai
minimal de résidence ou de carence imposé par la nouvelle province de
résidence, délai qui ne doit pas excéder trois mois;

accessibilité : le régime doit prévoir des soins assurés selon des modalités
uniformes et l’accès des assurés aux services de santé assurés doit être
satisfaisant, sans faire obstacle au régime, directement ou indirectement, par un
mécanisme de facturation ou autrement; le régime doit également prévoir une
rémunération raisonnable des médecins et dentistes pour les soins assurés qu’ils
fournissent ainsi que le versement de montants aux hôpitaux, relativement aux
coûts des soins de santé assurés.
En 1984, la LCS avait pour but explicite d’interdire les paiements par les usagers et la
facturation d’honoraires par les médecins, en plus de ceux couverts par les régimes
provinciaux. Les soins de santé assurés, définis par la LCS, incluent les services
hospitaliers nécessaires et les services médicaux nécessaires fournis par un médecin
ainsi que les services de chirurgie dentaire médicalement nécessaires ne pouvant être
fournis convenablement que dans un hôpital. Donc, à plusieurs niveaux, les fondements
des systèmes de santé provinciaux sont demeurés les mêmes qu’en 1984, malgré les
changements profonds dans les connaissances, les technologies, les modèles de soins
et les attentes des patients.
Les provinces demeurent libres, sous réserve des droits constitutionnels de leurs
citoyens, de légiférer comme elles l’entendent pour tout ce qui est exclu du champ
d’application de la LCS. Les dispositions contraignantes de la LCS devraient faire place
à un cadre facilitant l’adaptation des systèmes de santé provinciaux, basé sur le respect
de leur compétence59.
Outre ces cinq conditions, la LCS énonce deux interdictions qui doivent être respectées
pour l’octroi des transferts fédéraux. Les gouvernements ne peuvent permettre la
59
Patrick a. Molinari (2007). L’interprétation de la loi canadienne sur la santé : repères et balises.
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surfacturation ni les frais modérateurs. Sur la base de la première interdiction, les
médecins n’ont pas la possibilité de demander aux patients un montant plus élevé pour
leurs soins que ce qui est autrement autorisé par le régime public. La deuxième
interdiction empêche que les soins couverts par le régime d’assurance-maladie
provincial ou territorial fassent l’objet d’une contribution directe complémentaire des
usagers; il n’est donc pas possible de requérir un « ticket modérateur ». Ce sont
principalement ces deux interdictions qui déterminent la spécificité des systèmes de
santé au Canada.
La LCS a eu pour conséquence de concentrer l’allocation publique des ressources au
Québec et au Canada autour des soins médicaux et hospitaliers, laissant ainsi au privé
certains secteurs des soins de santé fournis en dehors de l’hôpital ou par d’autres
professionnels que les médecins tels que les médicaments, les soins dentaires, les
services psychologiques, diététiques, esthétiques, optométriques, etc. C’est donc
presque exclusivement la sphère des soins médicaux et hospitaliers qui est assortie
d’une garantie universelle d’accès; pour le Québec, cet accès est prévu et défini dans
Loi sur l’assurance-maladie et la Loi sur l’assurance-hospitalisation60.
À notre avis, ce cadre législatif historique explique en grande partie le sous-financement
chronique des soins de première ligne dans la communauté dont la prestation est
principalement offerte par les infirmières. Cela explique aussi pourquoi, dans la
communauté et dans certains contextes de soins dispensés à l’hôpital, l’infirmière doit
recourir à la prescription ou à l’autorisation du médecin pour certaines activités qui font
partie de son champ d’exercice, ou qui devraient en faire partie, pour la continuité et la
qualité des soins offerts au patient.
Permettre à l’infirmière d’exercer à sa pleine capacité son champ d’exercice priverait,
dans certains cas, le médecin de revenus qu’il retire de prescriptions ou d’autorisations.
Prenons pour exemple de lui permettre de demander les radiographies à l’urgence. Il en
irait de même d’éventuels pouvoirs de prescriptions pour des affections mineures ou les
soins de plaies qui permettraient d’offrir les soins en continu et avec une bien meilleure
efficience. D’autres cas : initier des mesures diagnostiques et thérapeutiques selon une
ordonnance, entamer des mesures diagnostiques à des fins de dépistage et effectuer
des examens et des tests diagnostiques invasifs, selon une ordonnance. Dans ces cas,
le principal enjeu est que ces services infirmiers deviennent assurables comme la
prescription médicale.
3.3.
60
NOUVEAU CONTEXTE CANADIEN
Catherine Régis, Anne-Marie Savard (2009-2010). L’accès aux soins et aux médicaments au Québec; entre l’idéal et la réalité.
Université de Sherbrooke.
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En décembre 2011, le ministre des Finances du Canada a proposé aux provinces un
accord de financement non négociable et sans condition : les transferts fédéraux
augmenteront de 6 % par année jusqu'en 2016-2017, après quoi l'augmentation
dépendra du taux de croissance, sans toutefois descendre sous 3 %.
Les provinces feront ce qu'elles voudront avec les fonds fédéraux. Le gouvernement
fédéral a décidé, sans consulter les provinces et les territoires, de changer la façon de
calculer les transferts pour le financement des soins de santé. Le mode de calcul se fera
par ailleurs en fonction du produit intérieur brut (PIB) par habitant.
Le ministre Flaherty a déclaré que les provinces devraient réviser leur façon de fournir
les soins de santé, afin de maximiser leurs investissements. Les provinces ne
s'attendaient pas à être placées devant un nouveau mécanisme de financement, elles
croyaient plutôt qu'elles discuteraient de la manière dont pourraient être menées les
négociations. L'entente 2004-2014 prévoyait une hausse annuelle des paiements de
transfert en santé accordés aux provinces de 6 %. Le Québec reçoit environ le
cinquième de ses dépenses annuelles en santé des transferts fédéraux.
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TABLEAU 1
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L’entente proposée semble sans appel. Le Premier ministre du Canada a été
catégorique à cet égard. Le cadre des transferts est ferme, fixé, et les gouvernements
provinciaux pourront dépenser les transferts fédéraux à leur guise, comme bon leur
semble. Ces nouveaux développements suscitent plusieurs questions, particulièrement :

si le fédéral se retire du financement lié aux normes, qu'arrivera-t-il à la Loi
canadienne sur la santé?

la Loi canadienne sur la santé sera-t-elle modifiée? Si oui, comment?

le financement sera-t-il encore lié au respect de la Loi canadienne?

ce financement sera-t-il assez élevé pour répondre aux besoins à venir?

quels seraient les impacts pour le système de santé au Québec?

depuis son adoption, cette loi n’a pas fait l’objet de modifications significatives.
Cette loi ne devra-t-elle pas, tôt ou tard, être adaptée aux réalités d’aujourd’hui?
Indépendamment de cette nouvelle situation – et des rebondissements qui pourraient
surgir d’ici 2014 – l’OIIQ porte ici un regard objectif sur la dynamique de financement
des soins au Québec, notamment le panier de biens assurables. Nonobstant la
participation et l’implication du gouvernement du Canada, ou des modifications à la loi,
ce panier assurable devra clairement refléter les besoins des patients et des milieux où
ils se font soigner.
Les conséquences de ne pas modifier les composantes de ce panier seraient
significatives. Le renouvellement de l’Accord constitue une belle occasion de réorienter
le financement des soins de santé dans le sens des changements actuels et à venir.
L’OIIQ est d’avis que le panier assurable et le financement devront suivre les tendances
dans la prestation des soins de santé, notamment la capacité d’assurer les soins
infirmiers, plus particulièrement ceux dans la communauté.
3.4.
CONTEXTE DES SOINS DE SANTÉ AU QUÉBEC
Selon le Commissaire à la santé, chaque année on dénombre près de six millions de
personnes qui reçoivent des services médicaux et plus de 600 000 hospitalisations de
courte durée61.
Selon le dernier rapport Comptes de dépenses 2009-2012 du MSSS, on compte environ
500 000 chirurgies et plus de 260 000 patients qui reçoivent des services infirmiers à
domicile.
61
Commissaire à la santé et au bien-être (2010). Rapport d'appréciation de la performance du système de santé et de services
sociaux 2009 : Un portrait de la performance du système, particulièrement celle de sa première ligne de soins.
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Le tableau suivant du ministère de la Santé et des Services sociaux (MSSS) présente
l’évolution du volume et de la nature des soins prodigués.
TABLEAU 2
Les coûts des services de santé au Québec représentent le poste budgétaire le plus
important du gouvernement du Québec, près de la moitié du budget total (44%).
En 2010, selon l'ICIS, les dépenses publiques et privées en santé effectuées par les
Québécois représentaient 40,0 milliards de dollars, soit 12,6 % du PIB. De ce montant,
28,5 milliards de dollars (71 %) provenaient d'un financement public et 11,5 milliards de
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dollars (29 %) provenaient du secteur privé. Des années 1980 jusqu'au début des
années 2000, l'importance relative de la santé dans l'économie a oscillé entre 8,5 % et
10,5 %. C'est à compter des années 2000 que le poids des dépenses de santé s'est mis
à progresser plus rapidement62.
Au cours de la dernière décennie, les dépenses de santé ont progressé beaucoup plus
rapidement que l’économie et que l’ensemble des recettes fiscales fédérales et
provinciales. Ceci a soulevé certaines préoccupations quant à la capacité de soutenir
ces dépenses, tant financièrement qu’en pourcentage du PIB. L’affectation de
ressources de plus en plus considérables n’entraîne pas nécessairement de meilleurs
soins de santé. Le Québec dépense moins par habitant que toute autre province
canadienne (4 735$ versus 5 235$ dans l’ensemble du Canada)63. Cette tendance tend
à s'accentuer avec le temps. Par ailleurs, le Québec consacre une part plus importante
de sa richesse collective à financer son système de santé que la moyenne des autres
provinces canadiennes. Cet écart tend également à s'accroître avec le temps.
TABLEAU 3
62
63
Ministère des Finances du Québec. Le système de santé québécois : survol et enjeux.
[http://qe.cirano.qc.ca/g/2011-f27-1]
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3.5.
À QUAND UN FINANCEMENT ADÉQUAT DES SOINS INFIRMIERS
DANS LA COMMUNAUTÉ?
LE QUÉBEC FINANCE-T-IL LES BONNES CIBLES?
En 2009 et 2010, le Commissaire à la santé et au bien-être a porté son attention sur
deux facteurs majeurs de la gestion du système de santé québécois, soit la gestion des
maladies chroniques et la gestion de la première ligne de soins. Ce n’est pas un hasard,
car ces deux variables mobilisent une part croissante des effectifs de notre système de
santé. Au Québec, un peu plus de la moitié de la population âgée de 12 ans et plus est
atteinte d’au moins une maladie chronique (52,6 %) (Cazale et autres, 2009) et leur
prévalence risque de s’accroître au cours des prochaines années64.
Le Commissaire faisait état du fait que les systèmes de santé de première ligne
semblent encore fondés sur une perspective de soins aigus. À l’instar de nombreux pays
développés, les systèmes de santé canadien et québécois sont principalement axés sur
les soins aigus (Tsasis et Bains, 2008). En plus d’être particulièrement réactif, ils ne sont
pas reconnus pour la continuité de leurs services (Freeman et autres, 2007; Tsasis et
Bains, 2008). Enfin, les processus de soins utilisés sont trop rattachés aux différentes
spécialités médicales, dans l’optique qu’une maladie n’a qu’une seule cause et que
chacune doit être traitée isolément (Plochg et autres, 2009)65.
Au Québec, le taux de consultation à l'urgence figure parmi les plus élevés au monde.
De plus, le temps d'attente à l'urgence est parmi les plus longs. Cela pourrait donner à
penser que le système québécois ne prend pas en charge le patient au bon endroit, et
que le patient n'a alors d'autre choix que celui de consulter là où il peut, vu le manque
d'accès à des ressources de premier contact et le non-financement de certains soins
lorsqu’ils sont donnés dans la communauté plutôt qu’en institution de santé.
D’autres données sont source d’inquiétude :
64
65
66

selon un sondage CROP-AQESSS, 54 % des « baby-boomers » (nés entre 1946
et 1966) ne seront pas en mesure de contribuer à leur bien-être une fois devenus
aînés. En fait, deux tiers des « baby-boomers » ne jouissent d’aucune épargne
pour leurs vieux jours66;

les premiers nés issus de la vague des « baby-boomers » ont eu 65 ans en 2011
et les cadets auront 65 ans en 2031;

en 2031, une personne sur quatre au Québec sera âgée de 65 ans ou plus.
L’indice de dépendance des aînés – la proportion de gens de 65 ans et plus par
rapport au nombre de travailleurs actifs – grimpera de 66 % durant la période
Commissaire à la santé et au bien-être (2011). Rapport d'appréciation de la performance du système de santé et de
services sociaux 2010 : État de situation portant sur les maladies chroniques et la réponse du système de santé et
de services sociaux.
Commissaire à la santé et au bien-être (2011). Rapport d'appréciation de la performance du système de santé et de services
sociaux 2010 : État de situation portant sur les maladies chroniques et la réponse du système de santé et de services sociaux.
Association québécoises d’établissements de santé et de services sociaux (2011). Vieillissement.
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2010-2025. Le rapport population active/aînés devrait se situer à deux aînés
pour cinq travailleurs en 2025 (versus un ratio de un sur quatre en 2010)67;

c’est vers 75 ans que l’impact du vieillissement se manifeste davantage. C’est à
85 ans que les besoins sont les plus criants. Les difficultés d’accès à un médecin
ont contribué à une augmentation de 15,8 % du nombre d’aînés de 75 ans et
plus sur civière à l’urgence entre 2005-2006 et 2009-2010. L’Association
québécoise d’établissements de santé et de services sociaux (AQESSS) estime
qu’une hospitalisation sur trois des personnes âgées fragiles est reliée à un
problème de pharmacothérapie. Dans 57 % des cas, ces problèmes étaient
jugés évitables68;

c’est en 2021 que les plus vieux de la catégorie « baby-boomers » auront
75 ans. Les cadets auront 75 ans en 2041. Il nous est impossible de prédire
l’espérance de vie en 2021 et en 2041. Nous pouvons constater par contre que
le système de santé, s’il n’est pas modifié ou s’il ne s’adapte pas, subira une très
vive pression entre 2021 et 2051.
Les soins de santé donnés ne satisfont plus aux besoins. À nos yeux, il est très clair que
les prochaines réformes du système de santé québécois devront viser à faire transiger
graduellement les soins vers la communauté et le domicile du patient, dans une
perspective d’accroissement de la prévention, d’allègement de la pression sur les
urgences et les soins donnés en établissement et de gestion accrue des maladies
chroniques. Il faudra modifier les priorités quant à l’allocation des fonds pour appuyer les
services qui réduisent les dépenses dans les secteurs à coût élevé, par exemple en
accélérant l’augmentation du financement des soins et services communautaires.
67
68
Association québécoises d’établissements de santé et de services sociaux (2011). Vieillissement.
Association québécoises d’établissements de santé et de services sociaux (2011). Vieillissement.
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4.
L’INCOHÉRENCE DU FINANCEMENT DES SOINS À DOMICILE ET DE
LONGUE DURÉE
L’espérance de vie en bonne santé croît sans pour autant que décroisse la demande en
soins de santé. Compte tenu du vieillissement de la population, la demande de soins à
domicile, de services d’hébergement, de soins de longue durée consacrés aux
personnes âgées en perte d’autonomie devient de plus en plus forte.
4.1.
PEUT-ON ÉVITER LES HOSPITALISATIONS?
Avec le « virage ambulatoire » du milieu des années 1990, le MSSS du Québec visait à
rapprocher les services des milieux de vie et de favoriser une médecine moins invasive
et moins lourde. Le virage ambulatoire n’a pas donné les résultats escomptés au niveau
de la baisse souhaitée quant au recours à l’hospitalisation.
Selon l’Institut canadien d’information sur la santé (Les soins de santé au Canada 2010),
en 2008-2009, il y a eu 92 000 hospitalisations qu’il aurait été possible d’éviter si des
soins à domicile adéquats avaient été disponibles. Sur ce total, 62 % ont duré plus d’une
semaine et 24 %, plus d’un mois.
Les lits de soins de courte durée ne devraient pas être occupés par des gens qui ont
besoin de soins de longue durée qui, autrement, pourraient recevoir des soins chez eux,
ce qui réduirait à terme les besoins pour des lits d'hébergement. Il faudrait aussi réduire
le recours à l’hôpital pour les 85 ans et plus. Il faut réduire le recours à l’hôpital comme
milieu de soins mais aussi comme point d’entrée dans le système.
Le système de santé est actuellement axé sur les soins aigus et épisodiques et non sur
un modèle de gestion des maladies chroniques. Pour que les patients évitent une
utilisation trop fréquente de l’hôpital, il faut encourager une première ligne forte ainsi que
des mesures qui permettront aux patients de recevoir des soins à domicile et, enfin, de
demeurer le plus longtemps possible à domicile, tout en réduisant l'utilisation
inappropriée de l'hôpital pour héberger des personnes. Les services à domicile sont
significatifs car ils offrent les soins appropriés aux patients qui ont besoin de soins de
courte durée tout en réservant l’hospitalisation aux personnes à qui il faut donner des
soins plus complexes. De plus, ils permettent de favoriser et de prolonger l’autonomie
des personnes et ainsi d’augmenter leur qualité de vie.
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4.2.
À QUAND UN FINANCEMENT ADÉQUAT DES SOINS INFIRMIERS
DANS LA COMMUNAUTÉ?
AVONS-NOUS FAIT LE VIRAGE QUI S’IMPOSE EN SOINS À DOMICILE?
En 2009-2010, plus de 83 % des interventions réalisées par les services à domicile du
programme perte d'autonomie liés au vieillissement des CSSS l'ont été auprès des
personnes de 75 ans et plus. En 2009, la majorité des aînés de 65 ans et plus
demeuraient à domicile (traditionnel ou résidence privée avec services). C'est surtout
vers 85 ans que des changements surviennent en matière d'habitation. L'Institut
canadien d'information sur la santé estimait à près de 5 000 $ par personne les sommes
consacrées aux aînés de 65 à 69 ans, contre plus de 20 000 $ pour les personnes de
85 ans et plus69.
Demeurer plus longtemps à domicile nécessitera d'augmenter l'intensité des services
d'aide à domicile. L’expression « soutien à domicile » a une portée très générale, en ce
sens qu’elle désigne l’ensemble des services de base et spécialisés offerts au domicile
des usagers par le réseau public de la santé et des services sociaux. Ces services sont
offerts près du milieu de vie des usagers et ils s’appuient sur des infrastructures et des
technologies légères.
Le vieillissement de la population et les maladies chroniques qui l'accompagnent
obligent à prioriser les soins à domicile. Or, le Québec ne consacre aux soins à domicile
qu'un peu plus de 587 millions $, soit un peu plus de 2% du budget de la santé (et moins
du cinquième des sommes allouées aux soins de longue durée). Cette insuffisance de
l'aide à domicile ajoute une pression au plan de la responsabilité des soins aux proches
aidants. On estime qu'au Québec, de 70 % à 85 % de l'aide apportée en perte
d'autonomie provient de proches aidants. Quelque 300 000 personnes remplissent ce
rôle auprès d'aînés, permettant à ceux-ci de demeurer à domicile70. Les proches aidants
vieillissent aussi et deviendront moins nombreux. L'OIIQ estime qu'il faut les appuyer
davantage.
Il est urgent d'investir dans les soins à domicile, mais aussi de changer l'approche et la
structure de financement. À plus long terme, la priorité aux soins à domicile permettra de
contrôler l'augmentation des coûts associés au vieillissement de la population et de
limiter le fardeau financier des générations futures. Le Rapport Clair (2000) proposait la
création d’une caisse d’assurance pour les soins à domicile, laquelle permettrait d’offrir
les soins à domicile sous forme de prestations en nature ou de paiements.
Le maintien dans la communauté suppose également la mise en place de soins de
première ligne adaptés, notamment en donnant à l’infirmière les leviers pour exercer au
maximum son champ d’exercice et offrir ainsi à ses patients des services complets et
continus dans la communauté. Il faudra aussi une approche adaptée au vieillissement
69
70
Association québécoises d’établissements de santé et de services sociaux (2011). Vieillissement.
Association québécoises d’établissements de santé et de services sociaux (2011). Vieillissement.
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dans les services médicaux de première ligne, notamment en moussant l’intégration
d’IPS de première ligne dans les soins aux personnes âgées. Dans un CHSLD de
Winnipeg, l’embauche d’une IPS a permis de réduire : les transferts à l’urgence (20 %),
l’utilisation d’antipsychotiques (60 %), les médicaments (17 %), les résidants prenant
neuf médicaments ou plus (50 %).
Justement, nous y revenons encore. L’infirmière est la clé pour assurer la vigueur des
soins à domicile. Pourquoi ses soins ne sont-ils pas assurés?
4.3.
AVONS-NOUS FAIT LE VIRAGE QUI S’IMPOSE EN SOINS DE LONGUE DURÉE?
Les soins de longue durée doivent être réservés à une clientèle qui a des besoins
complexes et qui requiert des soins spécialisés. Les ressources à l'hébergement ne
doivent pas être utilisées pour héberger précocement des personnes qui auraient pu
faire le choix de demeurer à domicile avec l'intensité de services requis.
Nous n’avons pas fait le virage qui s’imposait par rapport aux soins de longue durée. Il
existe déjà un continuum d’interventions infirmières adapté à l’évolution du
vieillissement : de la gestion des maladies chroniques à l’application de programmes de
plus en plus spécialisés (plaies, chutes, delirium, douleur, etc.). Ces programmes ont fait
leurs preuves. Mais le système de santé a peine à implanter un modèle de gestion des
maladies chroniques. Il est dur de passer à l’action.
Il faut adapter les soins à la nouvelle réalité : 65-74 ans – prévention; 75-84 ans – soutien à
domicile; 85 ans et plus – soins de longue durée en hébergement.
La grande partie du financement public en soins de longue durée est attribuée à
l'hébergement institutionnel. Faute de moyens, les aînés sont très souvent contraints
d'opter précocement pour l'hébergement. Selon Réjean Hébert (coprésident de la
Consultation publique sur les conditions de vie des aînés en 2007), les personnes en
perte d'autonomie devraient recevoir les services appropriés, financés par l'État, et ce,
peu importe leur lieu de résidence. M. Hébert constate aussi un système à deux
vitesses, car faute de moyens, l'État limite l'accès des personnes vivant en résidences
privées aux services à domicile auxquels elles devraient pourtant avoir droit. Ces
personnes doivent donc payer pour recevoir des services sans qu'aucune norme
n'existe pour évaluer les besoins, tarifer les services rendus ou s'assurer de leur
qualité71.
Le Rapport Clair (2000) avait proposé la mise en place d’un régime d’assurance contre
la perte d’autonomie liée au vieillissement.
71
Réjean Hébert (2011). Soins à domicile - Passons de la parole aux actes. Le Devoir, 16 décembre 2011.
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Le financement des soins de santé doit donc suivre le patient qui vieillit et dont la
prestation de soins nécessite des changements. L’OIIQ croit que l’argent doit suivre le
patient. Actuellement, les services rendus à la population reposent essentiellement sur
un paradigme de soins et de services curatifs basé sur le modèle médical. Il appert
naturel aussi que le panier de services assurés soit cohérent et reflète la nouvelle réalité
des soins en mettant un accent beaucoup plus marqué sur les soins à domicile et de
longue durée.
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5.
À QUAND UN FINANCEMENT ADÉQUAT DES SOINS INFIRMIERS
DANS LA COMMUNAUTÉ?
LE PANIER ASSURABLE : MISE EN CONTEXTE POUR LE QUÉBEC
Le panier de soins de santé fait référence à la totalité des services, activités ou biens
couverts par un régime d'assurance-maladie. Le système canadien de santé publique
couvre les soins médicaux et hospitaliers et les médicaments pour les personnes non
couvertes par une assurance collective. Il couvre également, sous réserve de conditions
d'admissibilité, des soins de longue durée. Il reste donc une large gamme de services
non couverts tels que les soins dentaires, les services des optométristes et les soins
paramédicaux, les frais ambulanciers et tous les autres soins et services dispensés par
des professionnels autres que des médecins, particulièrement ceux dispensés dans la
communauté.
Il n’y a pas, au Québec, un éventail de taux de remboursement des actes médicaux à
l’instar de la pratique du ticket modérateur, telle que mise en place en France
notamment. Deux situations sont possibles : soit le service médical est couvert par le
régime public géré par la Régie de l’assurance-maladie du Québec (RAMQ) (le patient
n’a pas à contribuer directement en contrepartie de ce service), soit le service n’est pas
pris en charge par ce régime (le patient, en l’absence d’assurance supplémentaire
privée qu’il aurait contractée, prend en charge l’intégralité du coût du service).
Alors que les soins de première ligne et les soins ambulatoires sont partout reconnus
comme des solutions plus efficientes que l’hospitalisation, la LCS privilégie les soins
hospitaliers et médicaux par rapport aux autres formes de soins. À l’ère des soins
ambulatoires, des soins primaires et du maintien à domicile, la couverture exclusive de
l’hospitalisation continue de placer la priorité là où elle ne doit pas être.
La RAMQ administre un certain nombre de programmes en vertu des lois et règlements
en vigueur, et en conformité avec les ententes conclues entre différentes fédérations de
professionnels et le MSSS du Québec. Les services médicaux, les services dentaires,
les services optométriques, les services pharmaceutiques et les aides techniques (ex. :
prothèses, prothèses auditives ou visuelles) sont autant de services, liés à ces
programmes, qui sont dispensés par des professionnels rémunérés par la RAMQ.
Certains services sont assurés pour l’ensemble de la population résidant au Québec
(ex. : services médicaux), alors que d’autres s’adressent uniquement à des clientèles
spécifiques (ex. : services dentaires).
Remarquons que, parmi les professionnels, l’infirmière n’est pas désignée. Elle n’est
donc pas assurée par le régime public.
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Les services médicaux couverts par le régime d'assurance-maladie sont ceux qui sont
nécessaires sur le plan médical et rendus par un médecin omnipraticien (appelé aussi
« médecin de famille » ou « médecin généraliste ») ou par un médecin spécialiste. Ces
services sont, entre autres :

les examens;

les consultations;

les actes diagnostiques;

les actes thérapeutiques;

les traitements psychiatriques;

la chirurgie;

la radiologie;

l'anesthésie.
Sauf en de rares exceptions, ces services sont couverts, quel que soit l'endroit où ils
sont rendus. C'est le cas notamment :

en cabinet privé;

en centre hospitalier;

en centre local de services communautaires (CLSC);

en centre d'hébergement et de soins de longue durée (CHSLD);

en centre de réadaptation;

au domicile du patient.
La RAMQ a pour fonction d’appliquer et d’administrer le régime d’assurance-maladie
institué par la Loi sur l’assurance- maladie, celui de l’assurance médicaments, ainsi que
tout autre programme que la loi ou le gouvernement lui confie. Elle doit, entre autres,
assumer, conformément à la loi, aux règlements, aux ententes et aux accords, le
paiement ou le remboursement des services et des biens prévus aux divers
programmes sous sa responsabilité, ainsi que le contrôle de l’admissibilité aux différents
régimes. En termes concrets, elle rémunère les médecins, tant en établissement qu’en
cabinet, ainsi que les autres professionnels – dentistes, optométristes, pharmaciens –
qui dispensent des services assurés aux clientèles spécifiques désignées par la loi.
Il existe deux types d'assurance pour soins de longue durée. L'une règle les dépenses
admissibles engagées par l'assuré pour une journée donnée, jusqu'à concurrence d'un
maximum fixé d'avance. L'autre prévoit le versement d'un revenu mensuel dont le
montant est fixé d'avance. Chaque demande d'assurance pour soins de longue durée
est évaluée individuellement, et le montant de la prime dépend d'un certain nombre de
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facteurs. La couverture entre en jeu lorsque l’assuré ne peut plus accomplir au moins
deux des actes essentiels de la vie de tous les jours.
5.1.
QUELS SONT LES « TROUS » DANS LE PANIER ASSURABLE QUÉBÉCOIS?
À l’instar des conclusions des commissions Clair, Romanow, Castonguay, etc., l’OIIQ
croit qu’il faut moderniser l’assurance-maladie pour qu’elle reflète la réalité actuelle de la
prestation des soins. Comme il l’a fait pour l’assurance-médicaments (qui était un
maillon faible du virage ambulatoire), le Québec doit faire preuve de leadership.
Les conditions de la LCS liées au financement fédéral ont fait que la liste des soins
assurés par les régimes publics d’assurance-maladie et d’assurance-hospitalisation
provinciaux et territoriaux (le « panier de soins ») s’est concentrée autour des soins
médicaux et hospitaliers. Par conséquent, cela laisse une multitude de soins et services
non couverts par cette loi devant une possibilité de financement privé, dont les
médicaments, les soins de longue durée et à domicile, les services de psychologie, etc.
De plus, la définition des soins hospitaliers (de même que l’absence de cadre de
référence du « médicalement nécessaire »), peut rendre difficile l’introduction d’une
analyse de la valeur, tant dans l’allocation que dans l’utilisation des ressources. Par
exemple, doit-on offrir tous les soins hospitaliers tels que définis par la loi, même si
certains d’entre eux ne sont pas jugés prioritaires après analyse? Doit-on fournir tous les
soins définis comme « médicalement nécessaires » même si l’analyse de la valeur
démontre qu’ils ne sont pas efficaces et efficients?
Il y a plusieurs manquements dans le panier assurable de la santé québécoise. Nous
avons vu dans les sections précédentes les carences dans le financement et
l’assurance des soins à domicile et pour les soins de longue durée. Pour l’OIIQ, assurer
ces services est la priorité des priorités et une condition sine qua none au
développement d’une véritable première ligne. Les soins de longue durée ne sont pas
entièrement couverts par le système public. Ils entrent dans la catégorie des services
complémentaires de santé et, par conséquent, il incombe aux particuliers de régler en
tout ou en partie la facture. Laissant ainsi aux assureurs privés un rôle crucial et
complémentaire pour aider les Québécois à gérer leurs besoins en matière de soins de
longue durée. Pourquoi le secteur public ne peut-il pas mieux assurer des services plus
diversifiés et mieux adaptés à la réalité des soins d’aujourd’hui et aux organisations de
soins tournées vers la communauté, jugées les plus efficaces?
L’interdisciplinarité n’est pas financée non plus. Il faudra trouver un moyen de la financer
et de l’assurer. Les services infirmiers dans la communauté ne sont pas assurés. Il n’y a
pas de régime d’assurance pour les soins infirmiers.
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Par exemple, l’infirmière praticienne spécialisée (IPS) et la sage-femme constituent deux
professions qui remplacent en quelque sorte des soins de médecins, sans que toutefois
que leurs soins soient reconnus comme médicalement requis au sens de la loi, donc
assurables. Il y a une dizaine d’années, la Commission Romanow recommandait
l’introduction significative d’IPS. Pourquoi ne pas en avoir davantage dans le réseau
actuellement? Pourquoi le système ne financerait-il pas les services de l’IPS?
Ce n’est que dernièrement que le MSSS du Québec a accepté de financer 500 postes
d’IPS de première ligne. Ce financement se situe en dehors des soins assurés et a fait
l’objet d’une gymnastique financière. L’IPS est embauchée par un hôpital, elle est donc
sur la liste de paie de l’hôpital et « prêtée » à un point de service de première ligne.
Ainsi, elle est couverte par le régime d’assurance-hospitalisation et non couverte par le
régime d’assurance-maladie. L’impossibilité de permuter des soins médicalement requis
ou entre différents professionnels à la RAMQ freine la possibilité d’innover dans le
système de santé. La France, à cet égard, reconnaît les soins à domicile fournis par une
infirmière comme étant assurés par la sécurité sociale.
Ne pas adapter la structure du financement public entraîne inévitablement d’autres
inégalités d’accès. Ainsi, le secteur privé joue un rôle important à l’échelle du pays. La
proportion de financement privé dans les soins de santé représente environ 30 % du
total des services fournis et 52 % des dépenses liées aux médicaments prescrits.
L’accès aux soins et aux services offerts par le secteur privé demeure basé sur la
capacité de payer des individus et la possibilité d’adhérer à un régime d’assurance par
un employeur ou un regroupement professionnel; en conséquence, des inégalités
d’accès sont conséquemment inévitables.
L’OIIQ propose d’étendre le financement de l’assurance-maladie au-delà des soins
médicaux et hospitaliers pour qu’ils reflètent les besoins et pratiques en soins, qu’ils
tiennent compte du transfert vers le communautaire et qu’ils tiennent compte d’autres
variables comme la promotion et la prévention, les soins de longue durée, les soins liés
aux maladies chroniques, laissant ainsi les hôpitaux se concentrer sur les soins aigus.
Pour parachever le virage ambulatoire, un régime d’assurance qui couvre les soins
infirmiers à domicile est nécessaire. Ce régime doit assurer, sans exigence de
prescription médicale ou reconnaissant des « prescriptions infirmières » dans certains
contextes de soins et pour des affections mineures, les soins donnés par des infirmières
(soins posthospitaliers, soins spécialisés, soins de plaies). L’OIIQ réclame un régime
d’assurance des soins à domicile qui inclurait les services infirmiers.
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MÉMOIRE
6.
RECOMMANDATIONS
La profession d’infirmière ne peut rester indifférente au renouvellement de l’Accord sur
la santé du Canada. Celui-ci fournit une occasion d’effectuer les virages requis depuis
longtemps concernant nos modes et nos structures de financement public. Notre regard
sur la question est porté vers le futur. Nous devons nous pencher sur les conditions
dans lesquelles les Québécois pourront avoir accès au continuum général des soins.
Voici les recommandations de l’OIIQ :
1. Instaurer un régime d’assurance public qui couvre les soins à domicile donnés
par les infirmières, comme les soins posthospitaliers, les soins spécialisés, les
soins de plaies, au même titre que l’assurance-hospitalisation :

s’assurer que ce régime repose sur la « prescription infirmière » pour l’accès
à ces soins à domicile dans certains contextes de soins et pour des
affections mineures et qu’il reconnaisse l’infirmière comme « gate-keeper »;

modifier le régime d’assurance-maladie pour s’assurer que les fournitures et
équipements nécessaires aux soins donnés à domicile par l’infirmière soient
remboursés.
2. Introduire des services médicaux supplétifs tels l’infirmière praticienne
spécialisée et les sages-femmes dans le panier de soins médicaux assurables
au niveau du programme d’assurance-maladie.
3. Modifier les priorités budgétaires pour accélérer l’augmentation du financement
des soins et services dans la communauté et en implantant un modèle de
prévention et de gestion des maladies chroniques.
4. Consolider l’offre de services aux personnes âgées en première ligne afin qu’elle
soit adaptée à la nouvelle réalité (65-74 ans – prévention; 75-84 ans – soutien à
domicile; 85 ans et plus – soins de longue durée) et ajuster le financement en
conséquence.
5. Faire réviser périodiquement le panier de soins assurables par un comité
d’experts ayant les moyens de procéder à une analyse de son contenu et de
proposer des modifications basées sur les données scientifiques à jour en
matière de systèmes de santé les plus performants.
6. Revoir l’organisation du travail pour s’assurer que l’infirmière joue des rôles où
elle assume pleinement son champ d’exercice dans toutes les sphères des
services publics.
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ANNEXE 1
ANNEXE 1
HISTORIQUE DE L’OIIQ
Voici un bref aperçu de dates qui ont marqué l’histoire de l’Ordre :
1917
Création de la Graduate Nurses’ Association of the Province of Québec, première
association québécoise de gardes-malades diplômées.
1920
Une loi crée l’Association des gardes-malades enregistrées de la Province de Québec. Le
titre de « garde-malade enregistrée » est dès lors réservé aux seuls membres de
l’association.
1925
Instauration d’un examen d’admission.
1943
Création de 12 districts appelés aujourd’hui « ordres régionaux ».
1946
L’Association des gardes-malades enregistrées de la province de Québec devient
l’Association des infirmières de la province de Québec. Entrée en vigueur d’une loi qui
autorise l’exercice exclusif de la profession aux seules personnes accréditées par
l’association.
1965
Lancement de la Journée internationale des infirmières par le Conseil international des
infirmières. Le 12 mai a été choisi pour souligner l’anniversaire de Florence Nightingale.
1969
Modification de la loi permettant aux hommes d’intégrer la profession. L’Association
des infirmières de la province de Québec devient alors l’Association des infirmières et
infirmiers de la province de Québec.
1973
Création de l’Insigne du mérite. Cette distinction annuelle souligne la contribution
remarquable d'une infirmière du Québec aux soins et services de santé, ainsi qu’au
développement de la profession d'infirmière.
1974
Adoption du Code des professions qui établit le champ d’exercice exclusif des membres
de l’Ordre des infirmières et infirmiers du Québec. Ce sera le dernier changement de
nom pour l’organisation qui a maintenant pour fonction principale d’assurer la
protection du public en contrôlant l’exercice de la profession par ses membres.
1976
Adoption du Code de déontologie des infirmières et infirmiers.
1987
Création de la Fondation de recherche en sciences infirmières du Québec (FRESIQ) dont
la mission est de promouvoir l’avancement continu des soins infirmiers au Québec par le
soutien de la recherche et le transfert des connaissances.
OIIQ [mars 2012]
MÉMOIRE
À QUAND UN FINANCEMENT ADÉQUAT DES SOINS INFIRMIERS
DANS LA COMMUNAUTÉ?
ANNEXE 1
1995
Création du concours Innovation clinique. Remis annuellement, les douze prix régionaux
et le Grand prix visent à mettre en valeur la contribution clinique des infirmières de
toutes les régions du Québec à la qualité des soins offerts à la population, à l'efficacité
et à l'efficience des services de santé, ainsi qu'à l'avancement de la profession
d’infirmière.
1995
Création du Colloque des CII. Ce rassemblement annuel permet à tous les conseils des
infirmières et infirmiers du Québec d’échanger sur de grands dossiers et des nouveautés
en matière de soins infirmiers.
1996
Tenue des États généraux de la profession sur le thème Pour soigner notre avenir – Les
infirmières à la croisée des chemins.
1997
Création du Comité jeunesse dont la mission consiste à véhiculer avec dynamisme les
intérêts des jeunes infirmières et infirmiers et de promouvoir la profession auprès des
étudiants en choix de carrière.
2000
Création du Secrétariat international des infirmières et infirmiers de l’espace
francophone (SIDIIEF) qui a pour mission de faciliter le partage des expériences et des
savoirs infirmiers dans tout le monde francophone afin de contribuer à l’amélioration de
la qualité des soins et des services offerts aux populations.
2000
Nouvel examen québécois d’admission à la profession et création du programme
d’externat.
2002
Création du programme DEC-BAC qui offre un parcours condensé pour l’obtention du
baccalauréat après cinq années d’études, soit trois au cégep et deux à l’université, tout
en maintenant la possibilité d’obtenir un permis d’exercice de l’OIIQ après le DEC et de
concilier travail-études par la suite.
2002
Création d’une journée annuelle à l’intention des responsables des programmes de
formation infirmière, aujourd’hui appelée Rencontre des partenaires de la formation
infirmière.
2003
Création des prix Florence. Dans huit catégories, les prix Florence soulignent les actions
et les réalisations remarquables de membres qui contribuent au bien-être et à la santé
de la société québécoise.
2003
Entrée en vigueur de la « Loi 90 » sur la modernisation du système professionnel et le
nouveau partage des champs d’exercice des professionnels exerçant dans le domaine de
la santé.
2006
Les premières infirmières praticiennes spécialisées commencent à exercer dans trois
domaines de spécialité : néonatalogie, cardiologie et néphrologie.
OIIQ [mars 2012]
MÉMOIRE
À QUAND UN FINANCEMENT ADÉQUAT DES SOINS INFIRMIERS
DANS LA COMMUNAUTÉ?
ANNEXE 1
2007
Reconnaissance par le gouvernement du Québec des infirmières praticiennes
spécialisées (IPS) en soins de première ligne.
2009
Intégration du plan thérapeutique infirmier (PTI) dans la pratique infirmière.
2010
Entente avec le ministère de la Santé et des Services sociaux (MSSS) et la Fédération des
médecins omnipraticiens du Québec (FMOQ) pour l’introduction de 500 infirmières
praticiennes spécialisées en soins de première ligne au Québec.
2010
Entente Québec-France pour la reconnaissance mutuelle des qualifications
professionnelles des infirmières et infirmiers.
2011
Création d’une spécialité infirmière en prévention et contrôle des infections.
2011
Adoption d’une norme de formation continue.
2012
Plan de promotion du baccalauréat comme diplôme donnant accès à la profession.
OIIQ [mars 2012]
MÉMOIRE
À QUAND UN FINANCEMENT ADÉQUAT DES SOINS INFIRMIERS
DANS LA COMMUNAUTÉ?
ANNEXE 2
ANNEXE 2
CHAMP D’ACTIVITÉS DE LA LOI SUR LES
INFIRMIÈRES ET LES INFIRMIERS DU QUÉBEC
Champ d’activités de la Loi sur les infirmières et les infirmiers du Québec
« L'exercice infirmier consiste à évaluer l'état de santé d'une personne, à déterminer et à
assurer la réalisation d'un plan de soins et de traitements infirmiers, à prodiguer les
soins et les traitements infirmiers et médicaux dans le but de maintenir la santé, de la
rétablir et de prévenir la maladie ainsi qu'à fournir les soins palliatifs ».
Les activités réservées
Dans le cadre de l'exercice infirmier, 14 activités sont réservées à l'infirmière et à l'infirmier :
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Évaluer la condition physique et mentale d'une personne symptomatique
Exercer une surveillance clinique de la condition des personnes dont l'état de santé
présente des risques incluant le monitorage et les ajustements du plan thérapeutique
infirmier
Initier des mesures diagnostiques et thérapeutiques, selon une ordonnance
Initier des mesures diagnostiques à des fins de dépistage, dans le cadre d'une activité
découlant de l'application de la Loi sur la santé publique (chapitre S-2.2)
Effectuer des examens et des tests diagnostiques invasifs, selon une ordonnance
Effectuer et ajuster les traitements médicaux, selon une ordonnance
Déterminer le plan de traitement relié aux plaies et aux altérations de la peau et des
téguments et prodiguer les soins et les traitements qui s'y rattachent
Appliquer des techniques invasives
Contribuer au suivi de la grossesse, à la pratique des accouchements et au suivi
postnatal
Effectuer le suivi infirmier des personnes présentant des problèmes de santé complexes
Administrer et ajuster des médicaments ou d'autres substances, lorsqu'ils font l'objet
d'une ordonnance
Procéder à la vaccination, dans le cadre d'une activité découlant de l'application de la
Loi sur la santé publique
Mélanger des substances en vue de compléter la préparation d'un médicament, selon
une ordonnance
Décider de l'utilisation des mesures de contention
OIIQ [mars 2012]
137
Lorsque la réforme législative (« Loi 21 » modifiant le Code des professions et d'autres
dispositions législatives dans le domaine de la santé mentale et des relations humaines)
de 2009 entrera en vigueur, les trois activités suivantes s'ajouteront aux
14 précédentes :

décider de l'utilisation des mesures d'isolement dans le cadre de l'application de la Loi
sur les services de santé et les services sociaux et de la Loi sur les services de santé et les
services sociaux pour les autochtones cris;

évaluer les troubles mentaux, à l'exception du retard mental, lorsque l'infirmière ou
l'infirmier détient une formation de niveau de deuxième cycle universitaire et une
expérience clinique en soins infirmiers psychiatriques déterminées dans le cadre d'un
règlement pris en application du paragraphe g de l'article 14;

évaluer un enfant qui n'est pas encore admissible à l'éducation préscolaire et qui
présente des indices de retard de développement, dans le but de déterminer des
services de réadaptation et d'adaptation répondant à ses besoins.
INFIRMIÈRE PRATICIENNE SPÉCIALISÉE
L’article 36.1 de la Loi sur les infirmières et les infirmiers définit le cadre de pratique de
l’infirmière praticienne spécialisée.
36.1. L'infirmière et l'infirmier peuvent, lorsqu'ils y sont habilités par règlements pris en
application du paragraphe b du premier alinéa de l'article 19 de la Loi médicale (chapitre M-9) et
du paragraphe f de l'article 14 de la présente loi, exercer une ou plusieurs des activités
suivantes, visées au deuxième alinéa de l'article 31 de la Loi médicale:
1° prescrire des examens diagnostiques;
2° utiliser des techniques diagnostiques invasives ou présentant des risques de préjudice;
OIIQ [mars 2012]
138
3° prescrire des médicaments et d'autres substances;
4° prescrire des traitements médicaux;
5° utiliser des techniques ou appliquer des traitements médicaux, invasifs ou présentant des
risques de préjudice.
2002, c. 33, a. 12.
OIIQ [mars 2012]
139
English Translation
HOW MUCH LONGER UNTIL
ADEQUATE FUNDING IS PROVIDED
FOR COMMUNITY NURSING SERVICES?
The health of our nation, the future of our health system
OIIQ brief submitted to the
Canadian Nurses Association
National Expert Commission on
Transforming the Health-Care System
March 2012
OIIQ [mars 2012]
140
Publication
Coordination and Editorial
Johanne Lapointe
Director
External Affairs Branch
Production
Publications
Sylvie Couture
Unit Head
Claire Demers
Publication Assistant
Client Services and Communications Branch, OIIQ
Language revision
Jocelyne Tétreault Ordre des infirmières et infirmiers du Québec
4200 Dorchester Blvd W
Westmount QC H3Z 1V4
Tel: 514 935-2501 or 1 800 363-6048
Fax: 514 935-3770
[email protected]
www.oiiq.org
Legal deposit
Library and Archives Canada, 2012
Bibliothèque et Archives nationales du Québec, 2012
ISBN 978-2-89229-557-3 (print version)
ISBN 978-2-89229-558-0 (PDF)
© Ordre des infirmières et infirmiers du Québec, 2012
All rights reserved
Note – Consistent with OIIQ’s editorial policy, the feminine is used solely for ease of reading.
OIIQ [mars 2012]
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TABLE OF CONTENTS
Introduction ...................................................................................................................... 143
1.
OIIQ terms of reference 144
2.
Nurses, the cornerstone in the changing healthcare context
2.1. More complex care
145
2.2. A strong frontline in the community
2.3. The experts’ opinion
145
146
147
2.4. A look at a few international actions
147
2.5. Faster growth in the role of nurses throughout the world
148
2.6. Dynamic scope of nursing practice in Quebec 150
2.7. Nurses and collaboration between professions 151
2.8. Aligned with an adapted care-delivery framework
3.
151
Healthcare delivery frameworks in Quebec and Canada 153
3.1. Health framework in Canada
153
3.2. The spirit of the Canada Health Act
153
3.3. New Canadian context 155
3.4. Healthcare context in Quebec 157
3.5. Is Quebec funding the right targets?
4.
160
Inconsistent funding for homecare and chronic care
4.1. Is hospitalization avoidable?
162
162
4.2. Have we made the necessary transition in homecare? 162
4.3. Have we made the necessary transition in chronic care?
5.
The insurable basket: background for Quebec
164
165
5.1. Where are the “holes” in Quebec’s insurable basket? 166
6.
Recommendations
169
APPENDIXES ...................................................................................................................... 170
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Introduction
On 26 May 2011, the Canadian Nurses Association (CNA) officially launched the
National Expert Commission on Transforming the Health-Care System, under the title
The health of our nation, the future of our health system. The Commission’s terms of
reference are to submit policy solutions (including nursing innovations) to help transform
the healthcare system and make it better equipped to meet changing needs, with a view
to renewal of the Canada Health Accord in 2014.
CNA formally invited the Ordre des infirmières et infirmiers du Québec (OIIQ) to submit a
brief setting out the OIIQ’s positions and concerns regarding this renewal. We were
pleased to accept this invitation. Like CNA, OIIQ believes that nurses are a key
component of health care in Quebec (and Canada) and must be factored into
transformation of a viable healthcare system focused on the community.
The Commission has addressed many key issues similar to the issues that OIIQ
promotes, such as training, optimal use of resources, an interdisciplinary approach,
disease prevention and health promotion, transfer of care to the community, and the
expanded role of nurses in preventing and treating chronic diseases. We congratulate
CNA for this initiative.
The healthcare sector is constantly changing and is influenced by countless variables,
including globalization, technology, population ageing, transfer of care to the community,
growth and mutation of diseases, healthcare professionals’ knowledge, and quality of
patient care. The sector’s conditions and characteristics today are no longer what they
were in 1984, when the Canada Health Act (CHA) was introduced.
This brief highlights the undeniable role nurses can play in transforming Quebec’s
healthcare system, and the importance of having the levers to fully occupy their field of
expertise, in a dynamic care environment focused on the patient, that is well funded and
promotes the greatest possible access for all citizens. OIIQ is using this brief as an
opportunity to voice its opinions on the factors it deems a priority in resource allocation in
the context of renewal of the Accord—especially funding for homecare and chronic
care—which must consider a consistent basket of insurable care, especially adequate
funding for nursing care outside hospital settings.
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7.
OIIQ’S TERMS OF REFERENCE
OIIQ, duly established under the terms of the Nurses Act (RSQ c. I-8, is a professional college or
association whose key function is to ensure protection of the public, pursuant to Quebec’s
Professional Code, RSQ c. C-26, specifically by regulating practice of the nursing profession by its
members. OIIQ is an organization dedicated to continuing improvement of the quality of care.
It must be remembered that all persons wishing to practise the profession of nurse in Quebec
and to use the title must hold an OIIQ licence and must be an OIIQ member in good standing, as
required by section 32 of the Professional Code. With more than 71,000 members, OIIQ is a
major partner in the health and social services system.
OIIQ adopts directions in matters of clinical practice and training on the leading edge of
scientific knowledge in the field of nursing. It also promotes and documents specific roles of
nurses. OIIQ also advocates its views on current issues involving nursing practice and ethics.
In this light, the current exercise leads us to raise crucial questions. In what context
should nurses be equipped to meet future requirements of the healthcare system
centred on primary care in the community? How can they take on a greater role in
delivery of this care, especially chronic and community-based care? Do they have the
necessary levers to fulfil their current field of practice to their full capacity?
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8.
NURSES, THE CORNERSTONE IN THE CHANGING HEALTHCARE
CONTEXT
Nursing is perpetually expanding in step with discoveries and a deeper understanding in
all areas of care. In synergy with the need to refocus delivery, funding and the insurable
basket of health care in Quebec, nurses lie at the core of the dynamics of care. To some
extent, they are the catalyst in the changes we are proposing in this brief to the National
Expert Commission. They will continue to play this role in future, especially in the
community, once primary care has been fully developed in that setting. Everyone is
vaunting the merits of and need for a transition to community-based care, including
Quebec’s health commissioner and CNA, which is forecasting that 75 percent of nurses
will be practising in a community setting by 2020.72
At present, because it has a large membership and practises in a variety of care
settings, the nursing profession is definitely the most significant player in any reform to
improve Quebec’s healthcare system. The numbers speak for themselves: In 20102011, the number of nurses registered on OIIQ’s rolls reached 71,399. We must
remember that OIIQ’s membership passed the 70,000 mark for the first time in 20072008 and has remained stable over the past year. The vast majority of nurses in Quebec
are hired by the public sector, which consists primarily of institutions in the public health
and social services system (RSSS), which employs 82.2 percent of this work force, or
some 55,150 nurses. More than half of these work in one or more facilities (hospital,
CHSLD, CLSC or FMG) of the province’s health and social services centres (CSSS),
and about a third work in a university hospital (including affiliated centres and university
institutes). In turn, the private sector employs slightly less than 8,000 nurses or 11.8
percent of the total.
What are we waiting for to give Quebec nurses greater capacity to act? Are they not
already the professionals best placed to respond to the congestion in institutions and the
growing complexity of diseases and care, as well as delivery of primary care in the
community?
8.1.
MORE COMPLEX CARE
The complexity of health needs will continue to grow, due in particular to multiple
pathologies, population ageing, chronic disease, mental problems, persistent unhealthy
lifestyles and inequity in care.
The transition of care to the home and services close to home will assign a greater role
to maintaining and promoting health as well as preventing risks and disease, thus driving
72
Michael Villeneuve, Jane MacDonald (2006). Toward 2020: Visions for Nursing. Canadian Nurses Association.
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a shift in treatment strategies and methods for delivering care. Patients must be the
convergence point for health care, with continuity of care that meets their needs.
Other trends are also clearly emerging:

Keeping patients at home will require intake by nurses;

Patient education;

Faster and specialized growth in scientific and technological knowledge;

Development of primary care;

Changing roles within healthcare teams;

A changing international care context, based more on the patient and expanding
the nurse’s role in a drive for effectiveness;

Upgraded initial training throughout the world;

The context of international mobility.
8.2.
A STRONG FRONTLINE IN THE COMMUNITY
High performance care models promote collaborative and interdisciplinary practice,
coordination of care and a vision of empowerment for communities. The models with the
poorest performance are those that provide contact with no assumption of responsibility.
Primary care is a foundation on which we can build transformation of the system.
Healthcare systems with a strong primary care component achieve the best outcomes at
the lowest cost.
In the eyes of many, continuity of care is the key to quality services in primary care. For
patients, this means a smooth flow of information, building a relationship of trust with
professionals, and services adapted to patients’ needs and characteristics. We hope the
coming reforms of Quebec’s healthcare system will foster a gradual transition of care
toward the community and the patient’s home, with a view to increasing prevention,
reducing pressure on emergency rooms and hospital services, providing health care
linked to population ageing, and expanding management of chronic diseases.
Through their professional approach, nurses are recognized as generally practising
through a method centred on the continuum of care. There is good reason why they are
perceived as the key instrument of progress in modernizing the healthcare system and
refocusing it on primary care in the community.
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8.3.
THE EXPERTS’ OPINION
Many commissions and working groups on reorganizing health care over the past 12
years have recommended new roles for nurses, especially the Clair Commission on
health and social services (2000) and the Romanow Commission in the future of health
care in Canada (2002). In all cases, a twofold perspective was advocated: use nurses as
a resource to unravel problems with access to services and bring them into roles in
delivery of nursing and medical services that only they can fill.
The health commissioner notes that primary care physicians currently are used to meet
all the needs of patients, including services that other professionals would be qualified to
deliver. The commissioner realizes that participation by nurses in medical teams has
been studied several times and there is significant evidence that people are more
satisfied with the care received.73
Given their extensive skills and the likelihood they will cost the healthcare system less
than primary care physicians, nurses should be more involved in the strategies to reform
primary health care. In primary care, nurses can perform much of the work of health
promotion in family practice and they can play a key role in managing chronic diseases
such as diabetes, asthma and heart disease.
Commissions and studies come and go, and the findings are always the same. Primary
care services remain weak yet they are the key to a higher performance healthcare
system adapted to population ageing and the drive for greater effectiveness.
In this perspective, nurses could become the gateway to full health services. Other
countries have decided to act. They view an enhanced role for nurses as simultaneously
serving quality of patient care, effectiveness of the system, and the nursing profession
itself. What is Quebec waiting for to follow their example?
8.4.
A LOOK AT A FEW INTERNATIONAL ACTIONS
OIIQ is interested in international nursing models. The organization of care models that
achieve the best performance promote group practice, a multidisciplinary approach,
coordination of care and a vision of empowerment for the communities served, and
innovative, cutting-edge roles for nurses.
73
Commissaire à la santé et au bien-être (2010). Rapport d'appréciation de la performance du système de santé et de
services sociaux 2009 : Un portrait de la performance du système, particulièrement celle de sa première ligne de
soins.
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Let’s look at a few examples. In the United Kingdom, the NHS and Social Care Model
promotes the use of nurses as “community matrons” who form the hub of organization
and delivery of care to patients (through a mechanism for assessing and managing
complex cases) with an interdisciplinary approach (with the support of specialists), in
cooperation with patients and their next of kin as well as in partnership with the
community.
In California, Kaiser Permanente centres its strategy on quality of care and patient satisfaction,
with funding per resident in which the money follows the patient. Kaiser has identified eight
priority clinical fields. Client satisfaction measurements are a part of clinical performance. Kaiser
has created organizational and financial incentives for clinical performance and has gradually
instituted clinical information and clinical decision-making support systems to support this
strategy. This model implies active participation by nurses to play a key role within interprofessional teams.
In the 1990s, the Veterans Health Administration (VHA), an American public health system,
began an organizational reform focused on a shift to quality of care and client satisfaction. The
VHA implemented an integrated clinical information system to support this transition. VHA
managers dropped unit cost in favour of the concept of value, defined as the relationship
between quality achieved and cost. Nurses make a significant contribution to this. In less than a
decade, the VHA changed from the worst healthcare system in the United States in terms of
quality to one of the best.
We also must not overlook the improvement in acute care in hospitals, especially Magnet
Hospitals. This is an award granted by the American Nurses' Credentialing Center, a subsidiary of
the American Nurses Association. These hospitals meet a series of criteria that measure the
strength and quality of nursing care. Nurses in these facilities provide high quality care with
proven results for patients, extensive clinical involvement in decision making and assured work
satisfaction. These hospitals promote open communication between nurses and other health
professionals.
We should begin to consider similar models by analysing their application to Quebec and
by checking their ability to adapt to Quebec’s “flavour.” Nurses can provide greater
leadership in all care settings and contribute to the transitions required. Highperformance models for organizing services are always based on better integration of
insured services and on active participation by nurses within inter-professional teams.
8.5.
FASTER GROWTH IN THE ROLE OF NURSES THROUGHOUT THE WORLD
The scope of the challenges linked to health and nursing has been confirmed by the
position taken and recommendations made by the World Health Organization (WHO),
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the International Council of Nurses (ICN) and the Secrétariat international des infirmières
et infirmiers de l’espace francophone (SIDIIEF), to name just a few.
At the global level, nurses are making ever more clinical decisions, both in hospitals and in the
community. Nurses can play a significant and effective role in implementing new care delivery
methods in clinical governance.
Care in the future—expected to be more extensive and complex—will require many more
nurses and will allow them to provide more leadership in delivering care. They will be expected
to play an increasing role in direct, long-term, palliative and primary care as well as
management of chronic disease and patient-centred continuity of care, both in institutions and
in the community. A larger share of their work will be performed in the community. They will
make greater use of information systems and leading technology.74
They will also definitely play an active role in disease prevention and health promotion and
maintenance, support for self-management of health, and greater quality of care. Nurses will be
more involved in assessments, diagnoses, treatments, prescription of drugs, patient orientation,
and assessment of the effectiveness of care. Here as elsewhere, the nurse’s role is expected to
increase significantly in hospitals and the community, in an inter-professional team context.
Nurses can be expected to coordinate care and care teams in institutions and the community
(cooperation and coordination among professionals and facilities will be the norm).75
OIIQ is constantly concerned with patient safety and has always supported nurses in
their role in transforming the system. We are interested in the future of the profession
and its ability over time to improve access, effectiveness and patient care. Quebec
patients certainly are entitled to the same nursing care as elsewhere in Canada and
round the world.
International healthcare systems focus on nurses and the introduction of leading nursing
roles to upgrade their performance. This involves a wonderful synergy between decision
makers, care settings and educational institutions. What is preventing us from taking the
same steps here in Quebec? In 2002, Quebec developed a scope of nursing practice
that would in fact support similar progress for the profession, to the benefit of patients.
74
75
Michael Villeneuve, Jane MacDonald (2006). Toward 2020: Visions for Nursing. Canadian Nurses Association.
Michael Villeneuve, Jane MacDonald (2006). Toward 2020: Visions for Nursing. Canadian Nurses Association.
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8.6.
DYNAMIC SCOPE OF NURSING PRACTICE IN QUEBEC
It has already been 10 years since Quebec introduced measures to make nurses the
cornerstone for decongestion in primary care, supporting family physicians, disease
prevention, health promotion, and management of chronic diseases, with the
14 activities entrusted to them by Quebec’s Nurses Act, “Bill 90” (cf Appendix 2).
In 2002, in fact, “Bill 90” granted Quebec nurses a particularly generous fields of practice
and reserved activities envied by other provinces and countries. We must occupy this
area fully. Nurses must be given the ability to assume their full role. Unfortunately, the
role planned for nurses has not been fully achieved due to lack of planning and
organization in practice settings, and lack of adequate funding for primary care.
This field of practice, with the resulting reserved activities, reflects the increased role of
nurses in health care. They are given greater autonomy and recognition for their clinical
judgment, especially for assessing a person’s health, they are allowed to initiate
diagnostic measures or prescription treatments, and they are allowed to conduct clinical
and nursing monitoring on people presenting with complex health problems, including
determination and adjustment of the nursing therapy plan (NTP).
Although not exclusive, the fields of practice describes the profession in general terms—
what characterizes it—to delineate its nature and ultimate purpose. By specifying the
primary professional activities of members of the profession, it sets benchmarks within
which the reserved activities are conducted, and thereby defines the scope of these
activities (OPQ, 2003, p. 2). Section 36 of the Nurses Act defines the profession’s scope
of practice as follows.
The practice of nursing consists in assessing a person's state of health,
determining and carrying out of the nursing care and treatment plan, providing
nursing and medical care and treatment in order to maintain or restore health
and prevent illness, and providing palliative care.
Quebec is paying a high price by failing to encourage nurses to fill their field of practice
as defined by “Bill 90.” It is important to give all nurses the measures to jointly assume
the responsibilities entrusted to them by the legislation. The expanded scope of practice
under “Bill 90” must be fully occupied by nurses.
There is a requirement to align initial training in Quebec with the definition of nursing
practice (chapter 36, “Bill 90”) and with the scope of practice under that definition;
nursing training (180.A0 and 180.B0) not completed by a bachelor of nursing has
become insufficient for this alignment in the current healthcare context. You know that
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the OIIQ believes that initial training for the practice of nursing in Quebec should require
a bachelor of nursing, as in Canada as a whole.
Occupying the field of practice would intensify the required growth in an interdisciplinary
approach. The contribution of the nursing profession would open the way to significant
added value in care teams. There would also be a gain in major systemic impact through
the number of nurses and their greater versatility.
8.7.
NURSES AND COLLABORATION BETWEEN PROFESSIONS
Reform of our professional system by “Bill 90” (2002) and “Bill 21” (2009) has definitely
been based on collaboration between professions. In current practice, nurses
collaborate and interact with various professionals: physicians, pharmacists, nutritionists,
occupational therapists, physiotherapists, psychologists, social workers, etc. Nurses are
located at the centre of all these professionals and in their duties, are called upon to act
as generalists, requiring a variety of analytical and decision-making capabilities in a
context of coordination and an interdisciplinary approach.
Nurses can make a great contribution to improved healthcare delivery in Quebec.
Nurses should be more involved in strategies to reform primary health care.
Nurses can provide high quality care in the fields of prevention, regular monitoring of
patients with chronic disease, and initial contact with people with a benign disease.
Nurses do not want to replace physicians. Nurses are committed to working in
cooperation with physicians to improve quality of care and the system. Nurses would like
to see physicians take on the more complicated cases, as they wish to do. Relief nurses,
more extensively trained, could make care accessible to more patients and free
physicians to focus more on strictly medical activities. On this point, the Fédération des
médecins omnipraticiens du Québec (FMOQ) states that nurses are valuable assistants
in a physician’s practice. It suggests that an increase in resources to hire nurses would
greatly assist physicians in seeing more patients in their practice.76
8.8.
ALIGNED WITH AN ADAPTED CARE-DELIVERY FRAMEWORK
The preceding sections have highlighted the expectation that nurses participate actively
in transformation of Quebec’s healthcare system, using a variety of analytical and
76
Pierre-Olivier Fortin, Le Soleil (9 December 2011). “Migration des pédiatres dans les hôpitaux : poids pour les
omnipraticiens.”
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decision-making skills in a context of coordination and interdisciplinary practice. Patient
needs are growing in a changing healthcare system. Nursing is changing in every
practice setting.
Given what we know, are organization and funding of health care following patient
priorities? Another question arises. Have Quebec’s and Canada’s legislative frameworks
kept pace? Do they reflect the host of economic, clinical and systemic changes that
characterize healthcare delivery in the province and the country? Let’s analyse the
Canada Health Act (CHA) and care delivery in Quebec.
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9.
HEALTHCARE DELIVERY FRAMEWORKS IN QUEBEC AND CANADA
9.1.
HEALTH FRAMEWORK IN CANADA
In Canada, under subsection 92 (7) of the Constitution Act, 1867, organization and
management of health policy in the 10 provinces falls under the provincial government’s
departmental authority responsible for health. Each province establishes institutions to
manage and deliver health care. Each province and territory is free to establish rules
governing funding, allocation and management of health care as it sees fit given its
population and needs, as part of the Canada Health Act (CHA).
The provincial governments determine the scope of “medically necessary” services
under the CHA covered by public insurance. Free determination of health system
characteristics by provincial governments must be considered relative given financial
supervision by the federal government.
Based on its priorities, each province’s health insurance system covers services that
might be deemed medically required, but are not delivered by a physician or in a
hospital. This is especially true for certain prescription drugs, ambulance services and
optometry services. Beyond the scope of federal legislation, for services not medically
required, there is greater disparity in intervention by provincial governments.
9.2.
THE SPIRIT OF THE CANADA HEALTH ACT
The CHA has been in effect since 1 April 1984. It establishes “criteria and conditions in
respect of insured health services and extended health care services provided under
provincial law that must be met before a full cash contribution may be made.”77
The CHA sets out five criteria that provincial plans must meet to obtain financial
participation by the federal government—public administration, comprehensiveness,
universality, portability and accessibility:

Public administration: the plan must be administered on a non-profit basis by a
public authority responsible to the provincial government and is subject to audit
of its accounts and financial obligations;

Comprehensiveness: the plan must insure all health services provided by
hospitals, medical practitioners or dentists, and by authorization, health services
provided by other health care practitioners;
77
Marlisa Tiedemann (2008). The Federal Role in Health and Health Care. Library of Parliament, Parliament of
Canada.
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
Universality: all the insured persons of a province must be entitled to the health
services provided under the plan on uniform terms and conditions;

Portability: when a person moves to another province, the province of origin must
cover insured healthcare costs during the minimum residency or any waiting
period required by the new province of residence, which may not exceed three
months;

Accessibility: the plan must provide insured care under uniform terms and
conditions, and access by insured persons to insured health services must be
satisfactory without impeding or precluding, directly or indirectly, whether by
charges made to insured persons or otherwise; the plan must also provide
reasonable compensation to medical practitioners and dentists for the insured
care they provide as well as payment of amounts to hospitals for the costs of
insured health care.
In 1984, the CHA was specifically intended to prohibit user payments and billing of fees
by medical practitioners, above and beyond those covered by provincial plans. The
insured health services defined by the CHA include necessary hospital services and
necessary medical services provided by a medical practitioner as well as medically
necessary dental surgery services that can only be suitable provided in a hospital. Thus,
on several levels, the foundations of provincial healthcare systems have remained the
same as in 1984, despite profound changes in knowledge, technology, care models and
patient expectations.
Subject to their citizens’ constitutional rights, the provinces remain free to legislate as
they see fit on everything excluded from the scope of the CHA. The restrictive provisions
of the CHA should make way for a framework that facilitates adaptation of provincial
healthcare system, based on respect for their jurisdiction.78
Aside from these five conditions, the CHA sets out two prohibitions that must be
observed to qualify for federal transfers. Governments may not allow extra billing or user
charges. Under the first prohibition, medical practitioners do not have the option of
asking patients for a higher amount for their care than what is otherwise authorized by
the public plan. The second prohibition direct charging of additional user fees for care
covered by the provincial or territorial medical insurance plan; a “deterrent charge”
therefore is not allowed. It is primarily these two prohibitions that determine the specific
nature of healthcare systems in Canada.
The CHA has effectively concentrated public resource allocation in Quebec and Canada
around medical and hospital care, thereby leaving in the private sector certain areas of
78
Patrick A. Molinari (2007). L’interprétation de la loi canadienne sur la santé : repères et balises.
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health care delivered outside hospitals or by professionals other than medical
practitioners, such as drugs, dental care, and psychological, dietetic, esthetic, optometry
and other services. It there remains almost exclusively the sphere of medical and
hospital care combined with guaranteed universal access; for Quebec, this access is
stipulated and defined in the Health Insurance Act and the Hospital Insurance Act.79
In our opinion, this historical legislative framework largely explains the chronic
underfunding of primary care in the community, most of which is delivered by nurses.
This also explains why, in the community and in some contexts of care delivered in
hospital, nurses must resort to a prescription or a physician’s order for certain activities
that are or should be within the scope of her practice, for continuity and quality of care
delivered to patients.
In some cases, allowing nurses to exercise the full scope of their practice would deprive
physicians of the income they earn from prescriptions or orders. One example would be
allowing nurses to order emergency X-rays. The same would apply for the ability to
prescribe in cases of minor afflictions or to provide care for wounds, which would support
continuous care with much greater efficiency. Other cases are initiating diagnostic and
therapeutic measures by an order, beginning diagnostic measures for screening
purposes, and conducting invasive diagnostic examinations and tests by an order. In
these cases, the main issue is that these nursing services would become insurable as a
medical prescription.
9.3.
NEW CANADIAN CONTEXT
In December 2011, Canada’s Minister of Finance offered the provinces a non-negotiable
and unconditional funding agreement: federal transfers would increase by six percent a
year until 2016-2017, after which the increase would depend on the growth rate, but
without dropping below three percent.
The provinces will do what they wish with the federal funds. Without consulting the
provinces and territories, the federal government decided to change the way transfers
are calculated to fund health care. The calculation method will also be based on Gross
Domestic Product (GDP) per capita.
Minister Flaherty stated that the provinces would have to review the way they deliver
health care, to maximize their investments. The provinces were not expecting to be
faced with a new funding mechanism, but instead believed they would be discussing
how the negotiations could be conducted. The 2004-2014 agreement provided for a six79
Catherine Régis, Anne-Marie Savard (2009-2010). L’accès aux soins et aux médicaments au Québec; entre l’idéal et la réalité.
Université de Sherbrooke.
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percent annual increase in health transfer payments to the provinces. Quebec receives
about one fifth of its annual healthcare expenditures from federal transfers.
TABLE 1
Federal government contributions
Annual
($ millions)
Average
Health transfers
variation1
Canadian Health Transfer
Trust for waiting time guarantees
Trust fund for development of HPV vaccine
Transfer fund to reduce waiting times2
Subtotal
Personal income tax
Notional portion of special Quebec abatement for
the Canadian Health Transfer3
Subtotal
P
Preliminary results
1
Annual average variation from 2010-2011 to 2011-2012
Other programs
2
Transfer under Part V.1 of the Federal-Provincial Fiscal Arrangements Act, granted on a per
capita basis
Agreement on the federal Youth Criminal Justice
Act
3
The notional portion of the special Quebec abatement for the Canadian Health Transfer amounts
to 62 percent of the special Quebec abatement of 13.5 percent. The remaining 38 percent is
Agreement on labour market participation by
associated with the Canadian Social Programs Transfer. Although this revenue is collected by
persons with a disability
Quebec through personal income tax, the federal government considers it transfers paid to the
Services to province.
persons infected with the hepatitis C
virus
Grants to healthcare facilities and other
organizations
Subtotal
TOTAL
In % of health and social services spending
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The proposed agreement appears to be without appeal. The Prime Minister has been
categorical on this point. The transfer framework is firm, fixed, and the provincial governments
can spend the transfers as they see fit. These new developments are raising many questions,
especially:

If the federal government is backing out of funding tied to standards, what will
happen to the Canada Health Act?

Will the Canada Health Act be amended? If so, how?

Will funding remain tied to compliance with the Canada Health Act?

Will this funding be high enough to meet needs in future?

What would be the impact on Quebec’s healthcare system?

Since it was passed, this act has not been significantly amended; should it not be
adapted sooner or later to present-day realities?
Independent of this new situation—and the ballooning that might occur by 2014—OIIQ is
taking an objective look at the funding dynamics for care in Quebec, especially the
basket of insurables. Notwithstanding the Government of Canada’s participation and
involvement, or amendments to the Act, this insurable basket will clearly have to reflect
the needs of patients and of the settings where they obtain care.
The consequences of not modifying the components of this basket would be significant.
Renewal of the Accord provides a wonderful opportunity to redirect healthcare funding
consistent with current and future changes. OIIQ believes that the insurable basket and
funding will have to follow trends in healthcare delivery, especially the ability to insure
nursing care, particularly that delivered in the community.
9.4.
HEALTHCARE CONTEXT IN QUEBEC
The health commissioner reports that approximately 6,000,000 people each year receive
medical services and more than 600,000 are hospitalized for a short term.80
The latest Comptes de dépenses 2009-2012 du MSSS [ministry of health expenditures
report] cites some 500,000 surgical operations and more than 260,000 patients receiving
nursing services at home.
The following table from the ministry of health and social services (MSSS) shows the
growth in volume and nature of care delivered.
80
Commissaire à la santé et au bien-être (2010). Rapport d'appréciation de la performance du système de santé et de services
sociaux 2009 : Un portrait de la performance du système, particulièrement celle de sa première ligne de soins.
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TABLE 2
Volume of care delivered by program and service
Program
Physical health
Service
Unit of measurement
Days present for clients
admitted
Days present
Surgery
Number of surgeries
Emergency
Visit
In-house medical
consultations
Visit
Parturitions
Number of deliveries
Institutional housing
Loss of independence
linked to ageing
Days present
Intermediate resources and
family-type resources
Days paid
Home nursing care
Homecare services
User
(all programs)
Adaptation – rehabilitation
financial statements and Med-Echo 2010-2011
Service delivery hours
Physical disability
The cost of health services in Quebec represents the Government of Quebec’s largest
Intermediate
budget item, almost half
the totalresources
budget (44 percent).
Intellectual disability
Days present
ICIS reports that in 2010, public and private
healthcare expenditures by Quebec
Residential
resources,
residents represented $40.0 billion or 12.6 percent of GDP. Of this amount, $28.5 billion
ongoing residential assistance
(71 percent) came from public funding and $11.5 billion (29 percent from the private
Days paid the relative share of health in the
sector. From the 1980s to the early 2000 years,
Adaptation and support for
the person, family and next of
kin
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User
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economy varied between 8.5 and 10.5 percent. After 2000, the weight of healthcare
Starting in 2000, the weight of healthcare spending began to rise faster.81
Over the past decade, healthcare spending has grown much faster than the economy
and total federal and provincial revenue. This has raised certain concerns about the
ability to support this spending, both financially and as a percentage of GDP. The
allocation of ever-increasing resources does not necessarily lead to better health care.
Quebec spends less per capita than any other Canadian province ($4,735 compared
with $5,235 in Canada as a whole).82 This trend is increasing over time. Quebec also
devotes a larger share of its collective wealth to funding its healthcare system than the
average for Canada’s remaining provinces. This gap is also tending to widen over time.
TABLE 3
Health and social services expenditures & funding sources1
Annual
($ millions)
Average
Health and social services expenditures
Variation2
Consolidated revenue fund program expenditures
Health and social services facility fund expenditures
Subtotal
Expenditures covered by users and others
TOTAL HEALTH AND SOCIAL SERVICES EXPENDITURES
Funding sources
Health services fund
P
Health and
social services facility fund
Preliminary
results
1
Data compiled from documents produced by the Ministère de la Santé et des Services sociaux, from public accounts and financial statements
for all organizations included within the accounting area for the health and social services mission. Data specifically include amounts linked to
Healthy
lifestylestopromotion
fund3and interest on debt service.
user
contributions
drug insurance
2
Federal
government
Annual
average
variationcontributions
calculated from 2008-2009 expenditures in health accounts, to reflect $487M of special expenditures in 2009-2010,
noted after the 2010-2011 budget.
User contributions
3
Contributions from tobacco tax revenue.
Contributions by other departments and organizations
4
For health accounts purposes, the difference is provided from other taxes in the consolidated revenue fund.
Revenue from other sources
Ministère des Finances du Québec. Le système de santé québécois : survol et enjeux.
82
Subtotal
[http://qe.cirano.qc.ca/g/2011-f27-1]
81
Consolidated revenue fund – taxes
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2012]
TOTAL FOR FUNDING SOURCES
4
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9.5.
IS QUEBEC FUNDING THE RIGHT TARGETS?
In 2009 and 2010, the Health and Wellness commissioner focused on two major factors
in management of Quebec’s healthcare system: chronic diseases and primary care. This
is no random occurrence, since these two variables account for a growing share of staff
in our healthcare system. In Quebec, slightly more than half the population age 12 or
over has at least one chronic disease (52.6 percent) (Cazale et al., 2009) and the
prevalence is likely to rise in coming years.83
The commissioner cites the fact that primary care health systems still appear to be
based on an acute-care approach. The same as in many developed countries, the
healthcare systems in Canada and Quebec are focused primarily on acute care (Tsasis
and Bains, 2008). In addition to being particularly reactive, they are not known for
continuity of their services (Freeman et al., 2007; Tsasis and Bains, 2008). Finally, the
care processes used are too attached to the various medical specialties, with the view
that a disease has only one cause and that each must be treated in isolation (Plochg et
al., 2009).84
In Quebec, the consultation rate in emergency rooms is among the highest in the world.
Furthermore, emergency room waiting times are among the longest. This might suggest
that Quebec’s system is failing to take in patients in the proper place and that patients
therefore have no alternative but to seek service where they can, given the lack of
access to initial contact resources and of funding for certain care when delivered in the
community rather than in a healthcare institution.
Other data are a source of concern as well.
83
84
85

A CROP-AQESSS poll found that 54 percent of baby-boomers (born between
1946 and 1966) will not be able to contribute to their wellbeing once they are
seniors. In fact, two thirds of baby-boomers have no savings for their elder
years.85

The cohort of the baby boomers turned 65 in 2011 and the youngest will reach
age 65 in 2031.

In 2031, one in four people in Quebec will be 65 or over. The elderly dependency
index—the proportion of people 65 and over compared with the number of active
workers—will rise to 66 percent between 2010 and 2025. The labour
Commissaire à la santé et au bien-être (2011). Rapport d'appréciation de la performance du système de santé et de
services sociaux 2010 : État de situation portant sur les maladies chroniques et la réponse du système de santé et
de services sociaux.
Commissaire à la santé et au bien-être (2011). Rapport d'appréciation de la performance du système de santé et de services
sociaux 2010 : État de situation portant sur les maladies chroniques et la réponse du système de santé et de services sociaux.
Association québécoise d’établissements de santé et de services sociaux (2011). Vieillissement.
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force/seniors ratio should be two seniors for every five workers in 2025
(compared with a ratio of one to four in 2010).86

The impact of ageing becomes more apparent around age 75. At age 85 the
needs are most critical. Difficulties accessing a physician have contributed to a
15.8 percent increase in the number of seniors 75 and over on a stretcher in
emergency between 2005-2006 and 2009-2010. The Association québécoise
d’établissements de santé et de services sociaux (AQESSS) estimates that one
in three hospitalizations of fragile elderly people is linked to a pharmacotherapy
problem. In 57 percent of cases, these problems were deemed avoidable.87

In 2021, the oldest members of the baby boomers generation will turn 75. The
youngest will turn 75 in 2041. We cannot predict life expectancy in 2021 and
2041. We can note, however, that if the healthcare system is not changed and
does not adapt, it will be under very heavy pressure between 2021 and 2051.
The health care delivered no longer meets the needs. It is quite clear to us that the next
reforms of Quebec’s healthcare system will have to focus on a gradual transition in care
toward the community and patients’ homes, with emphasis on prevention, relieving
pressure on emergency rooms and care delivered in institutions, as well as improved
management of chronic diseases. Priorities much change for allocating funding, to
support services that reduce spending in high-cost sectors, for example, by accelerating
the increase in funding for community-based care and services.
86
87
Association québécoise d’établissements de santé et de services sociaux (2011). Vieillissement.
Association québécoise d’établissements de santé et de services sociaux (2011). Vieillissement.
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10. INCONSISTENT FUNDING FOR HOMECARE AND LONG-TERM
CARE
Life expectancy in good health is rising, with no concomitant decline in demand for
health services. Given population ageing, demand for homecare, accommodation, and
long-term care for elderly people with loss of independence continues to rise.
10.1. IS HOSPITALIZATION AVOIDABLE?
With the shift to ambulatory care in the mid-1990s, Quebec’s MSSS strived to move
services closer to living environments and promote less invasive and burdensome
medicine. This shift did not produce the expected outcomes in terms of less
requirements for hospitalization.
The Canadian Institute for Health Information (Health Care in Canada 2010) reports that
in 2008-2009, 92,000 hospitalizations could have been avoided if adequate homecare
had been available. Of this total, 62 percent lasted more than a week and 24 percent
more than a month.
Acute-care beds should not be taken up by people who need long-term care and who
could receive this care at home, which in time would reduce the need for nursing home
beds. Reliance on hospitals must also be reduced for people 85 and over. Reliance on
hospitals must also be reduced as a care setting and an entry point into the system.
The healthcare system is currently focused on acute and episodic care rather than a
chronic disease management model. For patients to avoid excessive use of hospitals,
we must encourage strong primary care as well as measures that help patients obtain
care at home and, ultimately, to remain at home as long as possible, while reducing
inappropriate use of hospitals to house people. Homecare services are significant
because they provide appropriate care to the patients who need short-term care while
reserving hospitalization for people needing more complex care. They also promote and
extend independent living and thus enhance the quality of patients’ lives.
10.2. HAVE WE MADE THE NECESSARY TRANSITION IN HOMECARE?
In 2009-2010, more than 83 percent of procedures conducted by homecare services in
the CSSS program for loss of independence linked to ageing were provided to people
age 75 and over. In 2009, most seniors 65 and over were living at home (traditional or
private home with services). It is primarily around age 85 that housing changes occur.
The Canadian Institute for Health Information has estimated at about $5,000 per person
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the funding devoted to seniors age 65 to 69, compared with more than $20,000 for those
85 or over.88
Remaining at home longer will require an increase in the intensity of homecare services.
The term “homecare” has a very general meaning that covers all the basic and
specialized services delivered in users’ homes by the public healthcare and social
services system. These services are available close to users’ living environment and rely
on light infrastructure and technology.
Population ageing and the accompanying chronic diseases require prioritization of
homecare. However, Quebec allocates little more than $587 million to homecare, just
over two percent of the healthcare budget (and less than a fifth of the funding for longterm care). This homecare shortfall increases pressure on next-of-kin caregivers
responsible for providing care. In Quebec, it is estimated that 70 to 85 percent of
assistance provided for loss of independence comes from caregivers who are next of
kin. Some 300,000 people fill this role with seniors, so they can remain at home.89 The
next-of-kin caregivers are ageing as well and their numbers will decline. OIIQ believes
they need more support.
There is a pressing need to invest in homecare, but also to change the approach and
funding structure. Over the longer term, priority on homecare will control the increase in
costs associated with population ageing and limit the financial burden on future
generations. The Clair Report (2000) proposed creating a homecare insurance fund so
homecare could be provided in the form of services in kind or payments.
Maintenance in community also requires the establishment of adapted primary care that
specifically gives nurses the levers to practise their profession to the fullest and thus
provide patients with complete, continuous services in the community. An adapted
approach to ageing will also be required in primary medical services, especially by
fostering integration of primary care specialized nurse practitioners (SNPs) navigators
into care for elderly people. In a Winnipeg CHSLD, hiring an SNP reduced transfers to
emergency (20 percent), use of antipsychotics (60 percent), drugs (17 percent), and the
number of residents taking nine or more medications (50 percent).
And this brings us right back to nurses as the key for ensuring strong, effective
homecare. Why is this care not insured?
88
89
Association québécoise d’établissements de santé et de services sociaux (2011). Vieillissement.
Association québécoise d’établissements de santé et de services sociaux (2011). Vieillissement.
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10.3. HAVE WE MADE THE NECESSARY TRANSITION IN LONG-TERM CARE?
Long-term care must be reserved for clients with complex needs who require specialized
care. Housing resources must not be used for early accommodation of people who could
have chosen to remain at home with the required intensity of services.
We have not made the necessary transition in long-term care. There is already a
continuum of nursing procedures adapted to the ageing process: from management of
chronic disease to application of increasingly specialized programs (wounds, falls,
delirium, pain, etc.). These are programs have been proved effective, but the healthcare
system is struggling to introduce a chronic disease management model. It is proving
hard to take action.
Care must be adapted to the new reality: age 65-74 – prevention; age 75-84 – home support; 85
and over – long-term care in a facility.
The lion’s share of public long-term care funding is allocated to institutional housing. For
lack of means, seniors are very often forced to opt for early institutionalization. Réjean
Hébert (co-chair of the 2007 public consultation on living conditions of seniors) maintains
that people with loss of independence should receive appropriate services, funded by
government, regardless of where they live. Mr. Hébert also notes that there is a dualstandard system, because lack of funding compels government to limit access by people
living in private homes to the homecare services to which they in fact should be entitled.
These people therefore must pay to obtain services in the total absence of any standard
to assess needs, set rates for services rendered, or ensure their quality.90
The Clair Report (2000) proposed establishment of an insurance system to cover loss of
independence linked to ageing.
Healthcare funding therefore must follow the ageing patient as care delivery requires
changes. OIIQ believes the money must follow the patient. At present, services delivered
to the public are based essentially on a curative care and services paradigm grounded in
the medical model. It would also seem natural for the basket of insured services to be
consistent and reflect the new care reality by placing much greater emphasis on
homecare and long-term care.
90
Réjean Hébert (2011). “Soins à domicile - Passons de la parole aux actes.” Le Devoir, 16 December 2011.
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11. THE INSURABLE BASKET: BACKGROUND FOR QUEBEC
The concept of a healthcare basket refers to all the services, activities or goods covered
by a health insurance system. Canada’s public healthcare system covers medical and
hospital care as well as drugs for people without group insurance. Subject to eligibility
conditions, it also covers long-term care. This leaves a broad range of services not
covered, such as dental care, optometry services and paramedical care, ambulance
costs, and all other care and services delivered by professionals other than physicians,
especially those delivered in the community.
In Quebec, there is no range of reimbursement rates for medical procedures similar to
the practice of deterrent charges, as implemented in France in particular. Two situations
are possible: either a medical service is covered by the public system administered by
the Régie de l’assurance-maladie du Québec (RAMQ) (the patient is not required to
contribute directly for use of this service), or the service is not covered by this system
(without private supplemental insurance, the patient must pay the full cost of the
service).
While primary and ambulatory care are universally recognized as more efficient solutions
than hospitalization, the CHA gives precedence to hospital and medical care over other
forms of care. In the era of ambulatory care, primary care and homecare, coverage
limited to hospitalization continues to focus priority on the wrong place.
RAMQ administers a number of programs under existing legislation and regulations,
consistent with the agreements negotiated between various professional federations and
Quebec’s MSSS. Medical, dental, optometry and pharmaceutical services as well as
technical aids (e.g. prostheses, hearing aids and corrective lenses) are all services
linked to these programs, dispensed by professionals paid by RAMQ. Some services are
insured for all Quebec residents (e.g. medical services), while others apply only to
specific client groups (e.g. dental services).
It should be noted that the list of designated professionals does not include nurses, who
therefore are not insured by the public system.
The medical services covered by the health insurance plan are those that are medically
required and delivered by a general practitioner (also called a “family physician”) or by a
medical specialist. These services include:

examinations;

consultations;

diagnostic procedures;

therapeutic procedures;
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
psychiatric treatments;

surgery;

radiology;

anesthesia.
With only rare exceptions, these services are covered regardless of where they are
delivered. This specifically includes:

in a private practice;

in hospital;

in a local community services centre (CLSC);

in a long-term housing and care centre (CHSLD);

in a rehabilitation centre;

in a patient’s home.
RAMQ’s role is to apply and administer the health insurance plan established by the
Health Insurance Act, the drug insurance plan, and any other program that entrusted to it
by legislation or the government. In part, under the legislation, regulations, agreements
and accords, it must effect payment or reimbursement for the services and goods
stipulated in the various programs under its responsibility, and control eligibility for the
various plans. In practical terms, it compensates medical practitioners in institutions or
private practice, as well as the other professionals—dentists, optometrists,
pharmacists—who dispense insured services to specific client groups designated by the
legislation.
There are two types of insurance for long-term care. One covers eligible expenses
incurred by the insured for a given day, up to a predetermined maximum. The other pays
a predetermined monthly income. Each application for long-term care insurance is
assessed individually and the amount of the premium depends on a number of factors.
Coverage takes effect when the insured can no longer perform at least two of the
essential acts of everyday life.
11.1. WHERE ARE THE “HOLES” IN QUEBEC’S INSURABLE BASKET?
In line with the findings of the Clair, Romanow, Castonguay and other commissions,
OIIQ believes health insurance must be updated to reflect the current reality of care
delivery. As it did for drug insurance (the weak link in the shift to ambulatory care),
Quebec must show leadership.
The conditions of the CHA linked to federal funding have focused the list of services
insured by provincial and territorial public health and hospital insurance plans (the
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“basket of care”) on medical and hospital care. This has left a host of care and services
not covered by this act facing the prospect of private funding, including drugs, long-term
care and homecare, psychology services, and others.
In addition, the definition of hospital care (as well as the lack of a reference framework
for “medically necessary”) can make any analysis of value difficult, whether for allocation
or use of resources. For example, should all hospital care as defined by the Act be
provided, even if some is not deemed a priority after analysis? Must all care defined as
“medically necessary” be provided even if the value analysis shows it to be ineffective
and inefficient?
There are several shortcomings in Quebec’s insurable healthcare basket. In the
preceding sections, we have seen gaps in funding and insurance for homecare and
long-term care. OIIQ believes that these services are the top priority and a sine qua non
condition for developing genuine primary care. Long-term care is not fully covered by the
public system. It falls into the category of complementary health services and thus
requires individuals to pay all or part of the cost. That leaves private insurers with a
crucial and complementary role of helping Quebec residents manage their needs for
long-term health care. Why can the public sector not provide better insurance of a
broader range of services more adapted to the reality of care today and to care
organizations focused on the community, which have been deemed more effective?
The interdisciplinary approach is not funded either. A way must be found to fund and
insure it. Nursing services in the community are not insured. There is no insurance plan
for nursing care.
For example, specialized nurse practitioner (SNP) and midwife are two professions that
to some extent are replacing physicians yet the care they provide is not recognized as
medically necessary under the Act, and therefore is not insurable. A decade or so ago,
the Romanow Commission recommended significant introduction of SNPs. Why aren’t
there more in the system today? Why would the system not fund the services of SNP?
Only recently has Quebec’s MSSS agreed to fund 500 primary care SNP positions. This
funding is outside the framework of insured care and resulted from financial gymnastics.
The SNP is hired by a hospital and therefore is on the hospital’s payroll, but is then
“seconded” to a primary care service point. That way, she is covered by the hospital
insurance plan rather than the health insurance plan. The inability to transfer care that is
medically necessary or between various professionals to RAMQ is blocking innovation in
the healthcare system. On this point, France recognizes homecare delivered by a nurse
as a service insured by social security.
Failure to adapt the structure of public funding inevitably leads to other inequities of
access. The private sector therefore plays a key role across the country. Privately
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funded health care accounts for about 30 percent of all services delivered and 52
percent of spending on prescription drugs. Access to privately delivered care and
services continues to depend on the individual’s ability to pay and join an insurance plan
through one’s employer or professional group. As a result, disparities in access are
unavoidable.
OIIQ suggests extending health insurance funding beyond medical and hospital care so
it reflects care needs and practices, allows for transfer to the community, and factors in
other variables such as promotion and prevention, long-term care, and care linked to
chronic disease, thereby allowing hospitals to focus on acute care.
To complete the transition to ambulatory care, an insurance plan that covers nursing
care in the home is necessary. Without requiring a doctor’s prescription or by
recognizing “nurses’ prescriptions” in certain care settings and for minor afflictions, this
plan must insure care delivered by nurses (post-hospital care, specialized care, wound
care). OIIQ is calling for a homecare insurance plan that would include nursing services.
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12. RECOMMENDATIONS
The nursing profession cannot remain indifferent to renewal of the Canada Health
Accord. This provides an opportunity to make the transitions needed for so long in our
public funding methods and structures. Our view of the issue is focused on the future.
We must study the conditions under which Quebec residents can access the general
continuum of care.
OIIQ recommends the following.
1. Institute a public insurance plan that covers homecare delivered by nurses, such
as post-hospital care, specialized care, wound care, in the same way as hospital
insurance:

Ensure that this plan is based on “prescription by nurses” for access to this
homecare in certain care settings and for minor afflictions, and that it
recognize nurses as “gate-keepers”;

Amend the health insurance plan to ensure that supplies and equipment
required for care delivered in the home by a nurse are reimbursed.
2. Add supplemental medical services such as specialized nurse practitioners and
midwives to the basket of insurable medical care under the health insurance
program.
3. Modify budget priorities to accelerate the increase in funding for communitybased care and services and implement a model for preventing and managing
chronic disease.
4. Consolidate delivery of services to elderly patients in primary care to adapt it to
the new reality (age 65-74 – prevention; age 75-84 – home support; 85 and over
– long-term care in a facility) and adjust the funding accordingly.
5. Periodically have the basket of insurable care reviewed by an expert committee
with the means to conduct an analysis of its content and suggest changes based
on current scientific data for healthcare systems with the best performance.
6. Review the organization of work to ensure that nurses fill roles in which they
practise the full scope of their profession in all spheres of public services publics.
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ANNEXE 1
APPENDIX 1
THE HISTORY OF OIIQ
Here is a brief timeline of the OIIQ’s history.
1917
Creation of the Graduate Nurses’ Association of the Province of Quebec, the province’s
first association of graduate nurses
1920
Creation by legislation of the Association des gardes-malades enregistrées de la Province
de Québec. The title “garde-malade enregistrée” [registered nurse] was reserved
exclusively for members of the Association.
1925
Introduction of an admissions examination.
1943
Creation of 12 districts now known as “ordres régionaux” [regional colleges].
1946
Conversion of the Association des gardes-malades enregistrées de la province de
Québec to the Association des infirmières de la province de Québec and
implementation of legislation restricting practice of the profession solely to persons
certified by the Association
1965
Launch of International Nurses Day by the International Council of Nurses, with 12 May
chosen to celebrate Florence Nightingale’s birthday
1969
Amendment of the legislation to enable men to enter the profession, with the
Association des infirmières de la province de Québec becoming the Association des
infirmières et infirmiers de la province de Québec
1973
Creation of the insignia of merit, an annual distinction highlighting the outstanding
contribution by a Quebec nurse to health care and services de santé and to
development of the nursing profession
1974
Passage of the Code des professions establishing the exclusive practice of members of
the Ordre des infirmières et infirmiers du Québec, the last name change for the
organization, the prime purpose of which is not to protect the public by regulating
practice of the profession by its members
1976
Adoption of the Code of ethics of nurses
1987
Creation of the Fondation de recherche en sciences infirmières du Québec (FRESIQ) with
a mission to promote continued advancement of nursing in Quebec through support for
research and knowledge transfer
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1995
Creation of the clinical innovation competition. The 12 regional awards and the grand
prize presented each year highlight the clinical contribution of nurses from all regions of
Quebec to the quality of care delivered to the public, to the effectiveness and efficiency
of health services, and to advancement of the nursing profession
1995
Creation of the Colloque des CII, an annual symposium that gives all nursing councils in
Quebec an opportunity for exchange on major issues and new developments in nursing
1996
Estates-general of the profession on the theme Pour soigner notre avenir – Les
infirmières à la croisée des chemins [caring for our future—nurses at the crossroads]
1997
Creation of the youth committee with a mission to dynamically convey the interests of
young nurses and promote the profession among students as a career choice
2000
Creation of the Secrétariat international des infirmières et infirmiers de l’espace
francophone (SIDIIEF) with a mission to facilitate sharing of experience and knowledge
in nursing throughout the francophone world, to contribute to improved quality of care
and service delivered to the public
2000
New Quebec examination for admission to the profession and creation of the day school
program
2002
Creation of the DEC-BAC program providing a condensed curriculum leading to a
bachelor’s degree after five years of study, three in CÉGEP and two in university, while
maintaining the option of obtaining an OIIQ licence to practice after the DEC and
reconciling subsequent work-study sessions
2002
Creation of an annual day for nurse training program officials, now known as the
Rencontre des partenaires de la formation infirmière
2003
Creation of the Florence awards, in eight categories, to highlight the outstanding actions
and achievements of members who contribute to the wellbeing and health of Quebec
society
2003
Entry into force of “Bill 90” on modernizing the professional system and new sharing of
fields of practice by professionals in the health field
2006
Start of practice by the first specialized nurse practitioners in three specialties: neonatal,
cardiology and nephrology
2007
Recognition by the Government of Quebec of specialized nurse practitioners (SNPs) in
primary care
2009
Integration of the therapeutic nursing plan (TNP) into nursing practice
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2010
Agreement with the Ministère de la Santé et des Services sociaux (MSSS) and the
Fédération des médecins omnipraticiens du Québec (FMOQ) on introduction of 500
specialized nurse practitioners in primary care in Quebec
2010
Quebec-France agreement on mutual recognition of nurses’ professional qualifications
2011
Creation of a nursing specialty in infection prevention and control
2011
Adoption of a continuing education standard
2012
Plan to promote the bachelor’s degree as the criterion for entry to the profession
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APPENDIX 2
FIELDS OF PRACTICE UNDER THE QUEBEC
NURSES ACT
Fields of practice under the Quebec Nurses Act
“The practice of nursing consists in assessing a person's state of health, determining
and carrying out of the nursing care and treatment plan, providing nursing and medical
care and treatment in order to maintain or restore health and prevent illness, and
providing palliative care.”
Reserved activities
In the practice of nursing, 14 activities are reserved for nurses:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Assessing the physical and mental condition of a symptomatic person;
Providing clinical monitoring of the condition of persons whose state of health is
problematic, including monitoring and adjusting the therapeutic nursing plan;
Initiating diagnostic and therapeutic measures, according to a prescription;
Initiating diagnostic measures for the purposes of a screening operation under the
Public Health Act (chapter S-2.2);
Performing invasive examinations and diagnostic tests, according to a prescription;
Providing and adjusting medical treatment, according to a prescription;
Determining the treatment plan for wounds and alterations of the skin and teguments
and providing the required care and treatment;
Applying invasive techniques;
Participating in pregnancy care, deliveries and postpartum care;
Providing nursing follow-up for persons with complex health problems;
Administering and adjusting prescribed medications or other prescribed substances;
Performing vaccinations as part of a vaccination operation under the Public Health Act;
Mixing substances to complete the preparation of a medication, according to a
prescription;
Making decisions as to the use of restraint measures.
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When the 2009 legislative reform (“Bill 21” amending the Professional Code and other legislative
provisions in the field of mental health and human relations) takes effect, three activities will be added
to the 14 above:

Deciding to use isolation measures in accordance with the Act respecting health services and social
services and the Act respecting health services and social services for Cree native persons;

Assessing mental disorders, except mental retardation, if the nurse has the university degree and
clinical experience in psychiatric nursing care required under a regulation made in accordance with
paragraph g of section 14;

Assessing a child not yet admissible to preschool education who shows signs of developmental delay,
in order to determine the adjustment and rehabilitation services required.
SPECIALIZED NURSE PRACTITIONER
Subsection 36.1 of the Nurses Act defines the scope of practice for specialized nurse practitioners.
36.1. Nurses may, if they are so authorized by regulations under subparagraph b of the first paragraph of
section 19 of the Medical Act (chapter M-9) and under paragraph f of section 14 of this Act, engage in one or
more of the following activities referred to in the second paragraph of section 31 of the Medical Act:
1° prescribing diagnostic examinations;
2° using diagnostic techniques that are invasive or entail risks of injury;
3° prescribing medications and other substances;
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4° prescribing medical treatment; and
5° using techniques or applying medical treatments that are invasive or entail risks of injury.
2002, c. 22, s. 12.
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