Being responsible for your practice means understanding major issues and their impact on health care
Legalization of marijuana. Truth and Reconciliation recommendations. Homelessness and poverty. Medically assisted dying. These topics—some of which are new, others ongoing—are top of mind for many people. This is doubly true for nurses who experience (sometimes daily) the impacts these issues have on practice as health-care professions attempt to stay on top of major developments.
“We’re seeing big issues that are changing history and impacting us as professionals,” says Nicole Simpson, academic coordinator in the Centre for Professional Nursing Education (CPNE). “And they’re all hitting at the same time.”
Here, CPNE faculty, practicing nurses and government bodies offer their perspective on how these big issues can and are impacting nursing practice.
Care in vulnerable sectors: Homecare for the homeless
Forget everything you think you know about homeless populations in Canada, because homelessness is not simple. Canada is a diverse nation, and the causes of and solutions for homelessness and poverty are as well.
In 2014 Statistics Canada reported that one in 10 Canadians experienced “hidden homelessness,” that is, temporary living arrangements with family or friends, or in a vehicle or elsewhere because they lacked a permanent place to live. In addition, according to the Wellesley Institute, three million Canadians are “precariously housed,” meaning they live in conditions that are unaffordable, below standard and, or, overcrowded. The Canadian Observatory on Homelessness reports that youth make up 20 per cent of the homeless population, and Indigenous people are vastly overrepresented in homeless populations, particularly in Canada’s urban centres. Mental illness and addiction are health factors that commonly increase homelessness.
“ A central challenge is people’s attitudes toward the homeless.”
Dr. Elizabeth Burgess-Pinto
The facts are overwhelming, but how does homelessness impact your nursing practice? While a significant percentage of Canada’s population is affected by homelessness, many nurses, depending on where their practice takes them, may not interact with patients who are homeless.
For those who do, there are many challenges to overcome, including how to provide homecare services to patients without stable accommodation.
Dr. Elizabeth Burgess-Pinto, assistant professor in the Bachelor of Science in Nursing program at MacEwan University, observes that of the many challenges linked to working with this vulnerable population, one of the biggest is administrative.
“For someone who is homeless, care is dependent upon having a health-care card, and if you don’t have a health-care card, you’re not going to get care of any kind,” says Burgess-Pinto. Edmonton’s Boyle McCauley Health Centre, she notes, does not require a health-care card.
As well, stigma attached to homelessness affects how health-care professionals interact with patients.
“A central challenge is people’s attitudes toward the homeless,” says Burgess-Pinto. Not only can health-care professionals develop negative attitudes toward those they perceive as “repeaters,” but homeless patients may also try to avoid hospital visits—and the scrutiny that comes with seeking care—even to their detriment.
Where can nurses get more information?
Stay aware of trends and current issues by reviewing journals to learn about contemporary research. “The Public Health Agency of Canada and the National Collaborating Centres are good sources because they’re constantly doing research,” notes Burgess-Pinto. She also recommends reading about the experiences of nurses in your area who work with homeless patients.
Street nurse Cathy Crowe’s Dying for a Home: Homeless Activists Speak Out.
Truth and Reconciliation recommendations
Canada has a rich history of multiculturalism and celebrates its diverse population. In light of the 2015 Truth and Reconciliation Commission (TRC) report, however, we must acknowledge that this wasn’t always so. Residential schools (the last of which closed in 1996) have affected generations of Indigenous people in profoundly negative ways and contributed to the complex health needs many First Nations peoples experience today.
“Health Canada recognizes that the difficult experiences of former residential school students have affected many aspects of their whole health,” says Jocelyn Andrews, Health Canada’s regional executive officer for the First Nations and Inuit Health Branch, Alberta Region. “Whole” health, in Indigenous traditions, refers to the balance of mental, physical, emotional and spiritual health.
“Given the longstanding and intergenerational impacts of colonization and residential schools, Health Canada nurses sometimes face challenges…building trust with patients, but working with understanding and openness to learning sets the stage for developing good relationships,” says Andrews.
Good relationships are key to providing care to Indigenous patients and their families. In one of the seven health-related TRC Calls to Action (Andrews urges all Canadians to familiarize themselves with the full list), the commission advises integrating Aboriginal healing practices in the treatment of Indigenous patients when requested.
“ Working with understanding and openness to learning sets the stage for developing good relationships.”
“For nurses, in particular, some of the recommendations signal changes ahead for health education and the delivery of health services,” notes Andrews. “Nurses who are starting their schooling might soon have Indigenous health issues and traditional healing as part of their curriculum. They might learn how to treat patients in collaboration with Elders and receive cultural competency training as part of their core education, to cite just a few of the TRC’s Calls to Action.”
Where can nurses get more information?
For information and to identify potential areas for continuing education, Andrews urges nurses to read the TRC recommendations.
To stay on top of social and political issues that affect nursing practice, Andrews adds, “Many nurses here at Health Canada in Alberta subscribe to newsletters and updates from professional associations, like the College and Association of Registered Nurses of Alberta, the Canadian Nurses Association, Canadian Indigenous Nurses Association and the International Council of Nurses. At Health Canada, we are also fortunate to have both regional and national media monitoring services that help keep us up to date on news stories that are relevant to our work.”
She emphasizes that the First Nations and Inuit Health Branch of Health Canada is committed to working with communities to improve health outcomes, strategies for which nurses can learn about in the branch’s strategic plan, A Shared Path to Improved Health.
Truth and Reconciliation Commission of Canada: Calls to Action.
Legalization of marijuana
Although relevant legislation won’t likely be introduced in the House of Commons until this spring, the implications of legalizing marijuana are already top of mind for many health-care providers—including occupational health (OH) nurses.
Occupational health nurses work with employers, who are responsible for maintaining safe and healthy workplaces. Although many employers already have policies connected to substance use and smoking and impairment. The legalization of marijuana means employers need to take a fresh look at each of those policies.
“Part of occupational health and safety is fitness to work—making sure that employees are fit to do their job—and that is tied to policies around impairment, substance use and substance abuse in the workplace,” explains Sharon Chadwick, coordinator of CPNE’s Occupational Health Nursing and Disability Management in the Workplace programs. “Having clear policies, procedures and practices around marijuana is going to be critical.”
“ If marijuana use becomes legal, employers will need to be able to define impairment, and that is an issue that government and law enforcement are still grappling with.”
When marijuana was illegal, the consequences were clear. If a test showed the drug was in an employee’s system, that employee was in contravention of the law. But marijuana itself presents some unique challenges. Unlike alcohol, marijuana can remain in a person’s system for up to three weeks, which makes testing for impairment a challenge.
“If marijuana use becomes legal, employers will need to be able to define impairment,” says Chadwick, “and that is an issue that government and law enforcement are still grappling with.”
While safety is paramount, employers will also need to consider human rights tied to their duty to accommodate employees with addiction.
“If someone is ill due to substance addiction, employers need to consider their responsibilities related to bringing people back to work while ensuring safety in the workplace,” says Chadwick.
Legalization of marijuana does not change an employer’s responsibilities when it comes to safety, fitness to work or duty to accommodate, but it does make an already complex area even more challenging.
The best strategy for nurses who want to stay informed?
“Pay attention to what’s happening in the media, talk to employers and employee assistance programs,” says Chadwick. “Be proactive, stay alert and watch for decisions that will impact your practice.”
Medical assistance in dying (MAID)
Just a few weeks before Bill C-14 received royal assent and medical assistance in dying (MAID) became legal in Canada, Jo Heggerud began working with the Alberta Health Services North MAID Care Coordination team as a “navigator.”
“My role is to assist individuals through the process,” Heggerud says. “It begins with a patient expressing interest in learning more about MAID, and, for a lot of people, that’s also where it stops. They just want to know that this is available and an option for them.”
When an individual opts to go through with the MAID process, Heggerud is there to support and help the patient, their family and their care providers with paperwork, assessments, ethical and spiritual care needs, and the provision of MAID.
“Every case is new and unique,” says Heggerud, whose 20 years of nursing experience includes emergency room, oncology and continuing care. “I’ve seen a lot of suffering through end of life, and a lot of really good end-of-life experiences as well. This role is challenging, and I’m happy to be part of a pioneering project that can establish guidelines and help create a successful program.”
Heggerud knows that not every nurse will feel the same way. “MAID is new, and it creates quite a few different opinions and viewpoints. It touches all of the morals and ethics we have ever worked through in nursing.”
“ It begins with a patient expressing interest in learning more about MAID, and, for a lot of people, that’s also where it stops. They just want to know that this is available and an option for them.”
She says that’s why the issue demands that nurses reflect deeply on their own beliefs. “I think it’s really important for nurses to be aware of how they feel about MAID, and to take a look at how their individual beliefs, ethical values and morals fit on the spectrum,” Heggerud says. “It’s important to know where you stand, to acknowledge your values and beliefs and to maintain professionalism while respecting the morals and values of your colleagues.”
If you want to learn more about MAID, Heggerud suggests starting with the regulations (federal, provincial and CARNA’s regulatory college standards) and to then look for further education, including in-service opportunities.
“If you need more concrete information, are unsure, want to chat about what you’re experiencing or have questions, definitely reach out to our MAID care team,” she says.
Nurses have a professional responsibility to understand these issues and other current trends. Policies, directions and statements from your employer or regulatory college are standard sources of information, but as issues continue to evolve, policy makers are challenged to keep up.
Nurses who seek to stay informed may also feel overwhelmed.
“That’s part of the quicksand nurses are feeling,” says Simpson. But nurses are not alone: the professional bodies they work for face the same challenge.
No one has all the answers because the issues have many facets and layers. Some are linked to recent laws, which push them into focus, but all are connected to society’s need for greater cultural competency and empathy.
What you can do
Your responsibility is to understand current issues and how they impact your practice. You may also need to explore your personal opinions on matters such as the legal use of marijuana and medically assisted dying. If you work within the Catholic health-care system, for example, policies may support assisted dying but may transfer patients to public health-care facilities. An important first step is to consider how these issues may make you feel personally, whether or not they align with your ethics, and what implications they have with respect for your practice if you don’t agree with a particular piece of legislation.
Like most health-care organizations—including your regulatory body and your employer—CPNE is aware of these subjects and monitors their development to understand how best to incorporate new knowledge into its course offerings through discussions, papers and additional learning opportunities.
“We want nurses to know that CPNE is aware of the issues that impact their practice and that we’re doing our best to address them,” says Simpson.
You’re not alone in your practice, and while you may not yet have the answers you need, policy makers understand your need to remain open-minded and educated about topics that impact your work. Because of the broad scope of today’s nursing practice, nurses are expected to advocate and think critically.
“As nurses, we need to be able to stay current in our skills of assessing information because we’re going to have patients who are very much engaged in the information they’re asking about,” says Simpson.
“At the end of the day, these four topics are not the only ones that affect us,” continues Simpson. “There are many things that impact nursing practice, but these are ones you read about in newspapers on any given day.”
The Centre for Professional Nursing Education provides continuing education for nurses and health-care professionals.