The Estates General on the nursing profession will be held on May 20 and 21. Initiated by the OIIQ (Ordre des infirmières et infirmiers du Québec), in the last several weeks over 58 notices, 42 briefs, and hundreds of comments have been sent to the designated...
The Estates General on the nursing profession will be held virtually on May 20 and 21. The FIQ and FIQP jointly submitted a brief in light of this important event. Leading up to it, we will be posting some important information here.
In Quebec, nurses do not always get fair recognition for their true value as healthcare professionals. The FIQ and FIQP have identified several factors as the main obstacles to deploying nurses’ roles and competence: managers who offload their responsibilities to the detriment of nurses, the total lack of consideration for direct care nurses’ expertise, the code of silence, the penalizing management practices, and the rapid deterioration of working conditions. Putting nurses’ competence and skills to work is essential to their work satisfaction and to meeting the population’s needs. Action must be taken to promote full use of their essential skills and to ensure their health and well-being for the health and social services network (RSSS).
But before looking to the future, it is necessary to fully understand the context in which nurses must currently practice their profession.
Nursing knowledge and skills: better use for better care
The FIQ and FIQP find that there is a lack of nursing leadership at the provincial level and low engagement among healthcare institutions in deploying nurse competencies. It is imperative that nursing care managers be able to influence human resource management when it comes to the safety and quality of care. Moreover, when there is a labour shortage, everyone involved must work to break down barriers in the nursing practice, better utilize nursing skills and restore meaning to nurses’ work.
It is deplorable how little the nursing profession has been listened to, during the pandemic, and for many years before that. Their expertise is not taken into account in care-related decision-making. When management does not respect nurses’ clinical judgement, it translates into a lack of recognition for the independence of direct care professionals by managers and decision-makers. Instead of promoting the profession and improving the safety and quality of care, they are reinforcing a code of silence and excessive control.
Over the last several years, we saw managers prioritize measurement tools and management methods intended to streamline resources, effectively relegating concern for care quality and safety and patients’ rights to the back of the line (e.g., Lean, Six Sigma, Time and Motion Study). The current human resources and measurement management culture devalues nurses’ work. In the health network, it is clear that the right of patients to receive safe, quality care is no longer a priority for management.
This brief situation overview gives a glimpse at how far we must go to better recognize and utilize nursing skills. It also highlights the importance of stakeholders’ concerted actions to getting there. The FIQ and FIQP have proposed actions, in addition to being able to play a role in several of them. A few examples:
Immediately implement safe healthcare professional-to-patient ratios that ensure fully staffed, stable teams and help to develop a progressive implementation plan. Such ratios promote safe workloads and an enriched practice, while freeing up the time needed to carry out all required patient care. They also constitute leverage that can be used to take back nursing leadership in terms of care safety and quality.
Clinically, professionally, and legally recognize the nurses’ role as one that defends and promotes patients’ rights (advocacy), both individually and collectively.
Simply explain and raise awareness around nursing activities in concrete ways, like other professions (e.g., pharmacists), to favourably position them in politics, the public eye and among other professions..
Fully deploy existing nursing roles and powers in compliance with the professional norms and standards (e.g., prescriptions) to improve working and practice conditions. Insist that RSSS employers deploy the roles that help to enrich the nursing practice.
Amend the Code of ethics of nurses by inserting the responsibility of nurses with management duties related to decisions that affect the quality and safety of care and patients’ rights and making the sections of the Code of ethics applicable to their activities.
Reposition the role of nurses to promote health and information, and prevent disease, accidents, suicide and social problems among individuals, families, and communities; develop and promote the nurse’s consultation role with patients in order to professionalize it.
Significantly involve direct care nurses in developing and publishing concrete practice guides to take into account the organizational context of an institution under the Act Respecting Health Services and Social Services (ARHSSS). Plan clinical support and adjustments to the organization of work to deploy and apply them.
Implement nursing care standards and provincial guidelines, with accountability measures, that ask healthcare institutions to deploy the full scope of the nursing practice.
Broaden the scope of the Regulation respecting certain professional activities that may be engaged in by a nurse (nursing prescription) and make it mandatory to deploy it in clinical settings via a provincial mechanism.
Develop provincial collective prescriptions that must be applied in the RSSS.
Strengthen the role of CIIs, in particular by adding resources to carry out their mandate and creating a provincial CII headed by the Ministry of Health and Social Services (MSSS).
Develop and involve nurses in professional practice cases that showcase their roles and clinical nursing judgement within the care team and with other healthcare professionals. With the FIQ and FIQP’s interprofessional dynamic, they bring a field perspective to the interprofessional component of the care team and promote dialogue, helping to inform and intervene.
Make professional practice a collective responsibility. Set up strong nursing leadership to promote and give value to the range of nursing roles, as well as ensure safe, quality care and the respect of patients’ rights. These discussions need to be held namely on joint committees on care/professional practice committees where there is nursing care governance.
Enable the various nursing stakeholders to take a united stance; stakeholders who are proposing alternatives to the management and organization of care methods that limit nurses’ clinical judgement and professional autonomy.
Nursing innovation and specialization: a pathway to the future of care
Despite a trend in nursing specialization, enhanced and advanced practices are not highly valued. Furthermore, the current approach looks a lot like specialization silos. This can fragment care, limit the ability to act when taking charge of patients’ needs and bring career advancement to a standstill. What’s more, specialization limits the nursing profession’s strength in numbers, further complicates comprehension of the nursing role, and can further separate it from the holistic approach that characterizes it.
Promoting an independent practice
The FIQ and FIQP question whether it is useful to add more specializations to the nursing scope of practice. Would it not be better to give more recognition to expertise in specific areas of practice (e.g., gerontology)? For them, this broader recognition of their field of practice without a mandatory specialization would counteract managers’ tendency to falsely believe that nurses are interchangeable, which shows utter disregard for their experience and expertise. Moreover, human resources management uses nurse interchangeability and mobility, regardless of the care field, without guaranteeing a full orientation program, creating situations that endanger public safety.
Pragmatically speaking, it would be better to consolidate the nursing practice and the specialty nurse practitioner (SNP) and nurse clinician specialist (CNS) specialization classes before adding more specializations. The advanced practice career progression is not well defined and important roles taught during training (research, teaching, supervision, advocacy) are also undervalued. If you add in that nursing care managers in some healthcare institutions don’t really encourage advanced practice and have difficulty asserting themselves when issues arise with the medical community, it further complicates things.
Respect for clinical judgement and recognition of authority in assessing health conditions are central to the emergence of any new care models if we want them to meet healthcare professionals’ and patients’ needs. However, the majority of nurses practice in a “medical-centric” environment (hospitals, FMGs), which can often stand in the way of implementing innovative practices. We have noticed that decision-makers are not very open to innovative care models led by nurses, which would allow for a deeper independent practice. It is important to develop care models that are more accessible to a varied clientele and that strive for more personalization of care for people who are marginalized or scared of getting care in traditional care settings.
In line with the situation overview above, the majority of the actions proposed by the FIQ and FIQP are related to nursing specialization.
Encourage direct care nurses to occupy all available positions of influence (professional, union, political, organizational, etc.) and promote their participation in decision-making meetings.
Fully deploy and enhance the CNS role in IPAC and ensure clinical and management leadership responsibility in this area.
Lead a campaign to promote and popularize nursing roles and advanced practice in care settings and the public in order to develop a professional nursing image.
Encourage SNPs to take on director of nursing (DON) positions, as nurses in advanced practice are well-positioned to integrate clinical practice, research, supervision, advocacy, and teaching and to take on roles of influence in decision-making structures.
Deploy care models that showcase the range of nursing roles (research, management, advocacy, etc.) and enable nurses to take on patients without automatically referring to a doctor or SNP (e.g., Archimède project).
Consolidate and develop overall nursing roles, especially in front-line care, public health/IPAC, seniors’ care, mental health, palliative and end-of-life care.
Ramp up local discussions about career progression and ongoing training for all nurses based on developing a specific expertise according to their professional interests.
Inform and train nurses on technological and digital developments related to care and health; promote their participation in these developments to support care quality and humanization. Technology should strengthen and showcase nursing care, not substitute it.
Research and develop nursing skills to work with applications and digital technology in health. As experts in care and patient needs, nurses must take on roles as stakeholders and lookouts.