Tag Archives: Leadership

Breaking Down Healthcare Barriers for Transgender British Columbians, by Zak Matieschyn, BSN, MN, RN, NP(Family)

I am always amazed, and a bit shocked, when I think about how much the world has changed in the 20 years since I began my nursing career as a student at the University of Victoria. We were still in the early days of the Internet back then, and had no idea that two decades later we would all be carrying mini computers and smartphones around everywhere we went. We were plugged into our discmans in the pre-iPod era and were still recording TV shows on big black VHS tapes. Healthcare was a completely different world – HAART therapy had still not been unleashed on the AIDS epidemic, smoking was still prevalent in nearly half of the population, the Botox era hadn’t started and no one had even considered that there could be a vaccine like HPV for teens that could prevent cancer later in life.

In the midst of all of these changes, complicated social debates that had previously seemed irreconcilable were firmly decided and put to rest: gay marriage, access to abortion, medical assistance in dying and the legalization of marijuana. Much was done to reduce stigma for those living with HIV and mental health issues. Healthcare and society have undergone significant positive change.

One of the most important changes for B.C. occurred in July, when the province amended its human rights code to ban discrimination on the basis of gender identity and expression.

I can’t profess to understand the emotional, psychological or physical challenges faced by those whose gender expression varies from what they are assigned at birth. But as a health practitioner and a human being, I recognize the systemic barriers that transgendered individuals feel when seeking health services in a system that forces you to tick ‘female’ or ‘male’ on most paperwork. And while transgender health services will hopefully become an aspect of health as routine as managing a thyroid condition, it is still considered a specialized area, with many healthcare practitioners feeling inadequate and uninformed when it comes to providing transgender health services.

Earlier this year, the sole healthcare practitioner who had been offering specialized care for transgendered people in my region needed to close his doors to any new referrals. This would effectively leave people needing to travel to larger centres in our province for their appointments (at least a four hour drive). Not only do people have the right to caring, non-judgemental health services, they should also be able to access them close to home wherever possible. In light of this, I was happy to complete some further studies and step in to fill this gap. I can truly say that this is some of most fulfilling work that I do – to help support and facilitate someone’s process towards their true gender expression.

I believe that most of us have the best interest of all patients at heart, and I know I still have a lot to learn about how to support and provide care for those who identify as transgender. I also know that it is part of my responsibility to understand, to learn and to continue to grow so that the divisions and barriers that these individuals currently face when seeking health care, are permanently eradicated. The truth is that our society, and by extension, our healthcare system, is still very entrenched in two gender, what-you-were-born-with-is who-you-are understanding. Just last week Saskatchewan announced that it would cover up to 100% of gender reassignment surgery – an important and groundbreaking move that will give hope to thousands of people. And yet the public reaction to this announcement has been overwhelmingly laced with homophobia, anger, distrust and scorn. This is not the response that we, as a society, need to be giving to a group of individuals that already face significant challenges.

As a profession, nursing could be better at preparing nurses to support transgender individuals. It goes further than just helping to ensure specialized transgendered care exists regionally where people need it. We all need to work towards a healthcare system that is barrier and judgement free. Great progress has been made over the past decades towards reducing discrimination on the basis of race and sexuality (although the work is certainly not yet complete). General acceptance of a broader comprehension of gender identity and expression is really still in its first steps.

I urge all nurses to consider what actions you might need to take to change the healthcare experience of the transgender patients you meet. For individuals, Trans Care BC has some modules they offer to targeted social service and healthcare workers who specifically work with trans people. For organizations such as ARNBC, there are programs like the VPD Safeplace program, of which we are a proud member. Safeplace allows anyone from the LGBTQ community who feels unsafe to seek out our office where staff will ensure they can talk to someone, rest and call police if necessary.

By our actions, by our willingness to learn, by our assuredness that every single person has the right to express themselves in the way they see fit – we can model leadership for the healthcare community. More importantly, we can demonstrate our belief that every single Canadian deserves competent, supportive and accessible health care.


Zak Matieschyn-cleanZak’s interest in health and healing began at the early age of nine years old when he would carry a small first aid kit while playing with friends. Since then, his passion for healthcare and health policy has been unwavering. He was particularly inspired by concepts of family, community and societal health, as well as the social determinants of health during his undergraduate (BSN UVic, 2000), graduate work (MN UVic, 2008), and clinical experience in urban, rural and remote B.C. communities.

Zak has served on numerous boards and committees, including the BC Nurse Practitioner Association Executive and was the first Nurse Practitioner in B.C. to be invited to sit on a Division of Family Practice Board (Kootenay Boundary, 2010 – 2014). Through this work he has gained valuable experience in member engagement, optimizing board governance, and relationship building among diverse stakeholders. In his clinical practice, Zak has worked med/surg, emergency, intensive care, vascular access and outpost nursing. After obtaining his NP education in 2008, he began a practice in a West Kootenay family clinic, providing primary healthcare to the general public with a focus on marginalized populations. Zak is President of the Association of Registered Nurses of BC.

Nurses Aren’t Just Clinicians, by Katherine Villegas, RN

During my four years in the Kwantlen BSN program, I have had placements in various clinical areas which have enabled me to work with different populations in multiple specialities. While these learning opportunities have been invaluable, until my final preceptorship, it never really occurred to me how necessary it was for nursing schools to offer learning opportunities outside of the clinical setting. In my final semester, I was given an incredible opportunity to complete a practicum with the Association of Registered Nurses of British Columbia (ARNBC), where I learned that the clinical aspect of nursing is only one part that makes up the nursing profession.

If you were to ask a group of new nursing students, your friends, family or people in the public to draw a picture of what they thought nurses do, you would probably see something along the lines of a person at the bedside with his or her stethoscope tending to a patient, or an individual behind a stretcher or wheelchair transporting a patient. However, we know that this is a very narrow perception of what nurses do. As nursing has evolved, the role of nurses has expanded beyond the clinical setting into areas of health and nursing policy, research, administration and education.

Currently, students in most nursing schools are only given the option of requesting preceptorship placements within clinical areas, which has created little to no opportunities for students to learn or experience nursing in other domains outside of clinical practice. It’s also very clear that students’ exposure to organizations that support nursing in B.C. are quite limited, and usually consists of a one to two hour classroom PowerPoint presentation (but with lots of free pens, lanyards and pins of course!) This has led to a lack of knowledge regarding how the regulatory college, union, and professional association all support nurses and nursing.

Graduating nurses these days are expected to be much more than a clinician. We’re expected to be advocates and leaders for our patients and our healthcare system. But how can we do this to the best of our ability when we aren’t provided with opportunities to expose ourselves to settings that can help foster our skills in leadership, advocacy and policy? Many of these aspects can be difficult to teach in a classroom or clinical setting. While there is no doubt that providing nursing students with a range of placements within clinical settings will prepare us to become great clinicians, providing us with placement opportunities in organizations such as the ARNBC is equally important to ensure we gain the leadership, policy and administration skills needed. While dedicating a whole semester to this may be difficult, there are many options that schools could begin to explore such as expanding our community visits to nursing organization events like ARNBC’s Policy Forum or the BCCNA Day at the Legislature.

Throughout my internship at the ARNBC, I have been able to learn about the valuable work of a professional association, how health and nursing policy is developed, and ways to strengthen and advance the nursing profession as a whole. I attended multiple meetings and events such as the BCCNA’s 3rd Annual Day at the Legislature where I had the opportunity to network with nurses, educators and MLAs. I witnessed firsthand the power of nurses in using their voice to create positive changes in healthcare through a facilitated discussion with the Ministry of Health representatives. I felt empowered knowing that I was able to contribute to the discussions, and I was honoured to be a part of the nursing voice. I sat in on a BC Coalition of Nursing Associations meeting where I watched nurses from all disciplines (NPs, RNs, LPNs, RPNs and Nurse Educators) collaborate with one another. I learned the importance of all nurses coming together to form a strong united voice when positioning ourselves to tackle system wide issues. Last, I also attended the launch of the ARNBC’s Student and New Graduate Program, which really inspired me to become a leader to support other nursing students and new graduates who are experiencing hardships during their transition into the workforce.

My internship with the ARNBC opened my eyes to the many exciting options that we as nurses have in our careers. If we want nurses to excel in all nursing domains, we must all work collaboratively to ensure opportunities like the one I had, are available to all nursing students throughout their undergraduate education. These experiences build leadership, foster innovation, and teach us how to be collaborative, all of which are skills needed when working within the clinical setting as well. These aspects of nursing should be supported and cultivated throughout our education and training, and not thought of as something of less importance than our ability to insert an IV, perform an assessment or monitor changes in our patients. Our responsibilities as nurses go far beyond what we do at the bedside. We identify policy issues, we research and analyze the problem, and we collaborate to make changes at every level of the healthcare system.

Let’s try to the change that picture of what people think we do and what we think we do, because nurses aren’t just clinicians. We’re policy makers, administrators, researchers and educators. It’s time for all nurses to embrace our potential


katherineKatherine recently graduated from the BSN program from Kwantlen Polytechnic University in Langley BC.  Previous to nursing, she was pursuing a career in accounting. However, she knew that she wanted a career that was fulfilling, challenging and put to use her genuine care for others in a practical way. Through her clinical placement at Lionsgate Hospital in North Vancouver at the Neurosurgical unit she realized that nursing was for her. She hopes to continue to gain experience and fulfillment to one day work towards sharing her love for nursing through teaching.

Innovation Series: Advancing Foot Care Nursing in B.C. One Step at a Time, by Sandra Tetrault, RN

When Judy, a registered nurse, moved to B.C. in the late 1990’s, she arrived having taken a foot care course from a Podiatrist in Ontario. In fact, she had been practicing in Ontario as a foot care nurse for 10 years before moving to B.C. On her arrival to register with what was then the RNABC, they told her they had never heard of a foot care nurse working for herself. Judy set out to prove them wrong! She shortly met another R.N., Ruth who was a mobile foot care nurse locally, and together they started an interest group of about eight Foot Care Nurses.

Even within the nursing profession today, many nurses are unaware of what Foot Care Nurses do (although the title may sound obvious). Foot care nursing is not a new practice, and has been delivered for decades by the Victorian Order of Nurses. However, only within the last 15-20 years have nurses begun owning and operating their own foot care business.  Currently, any nurse regardless of designation (LPN, RN, RPN, and NP) who has completed a foot care course is considered a Foot Care Nurse. Most of these nurses own their own foot care business, providing clinical care, education and referrals in variety of settings including home care, senior centre clinics, assisted living and complex care facilities.

Clinical care typically involves nail care, and care for corns, calluses, dry or cracked skin, as well as short term padding for off-loading as needed until new shoes or a Pedorthist may be seen for orthotics.  We’re trained to assess diabetic patients for peripheral neuropathy using the monofilament test or tuning fork, provide education to patients, families and healthcare providers, assist in the prevention of foot issues, and make referrals to other healthcare professionals such as Wound Care Nurses, General Practitioners, Podiatrists, Pedorthists or diabetic clinics.

However, with the lack of established competencies, the quality of care being delivered has been an on-going issue within the foot care nursing community. While nursing has a long history of delivering foot care, ensuring nurses are providing the safest and highest quality of care while utilizing best practices has been difficult to do. Recognizing this issue, a group of nurses met in 2007 at a conference in Ontario and started Foot Care Canada with the goal of developing national guidelines for foot care nursing. In 2010, Foot Care Canada became the Canadian Association of Foot Care Nurses (CAFCN), with provincial and territorial advisors from each province.

Fast forward to spring 2015, CAFCN voted to hire two student nurses to gather information on the various foot care courses being taught across Canada. In the summer/fall of 2015, Dr. John Collins who had been contracted to facilitate the process of competency development asked members of CAFCN for volunteers to go through all of the competencies found in the foot care courses being taught across the country. Subsequently, the group identified a list of standard competencies for foot care nursing.

The group involved in this process consisted of nurses from all across Canada with varied nursing experience from varied foot care nurse career paths-many of us were educators in foot care programs. We met approximately weekly on “Google Hangouts” between October 2015 until April 2016 with Dr. John Collins as our facilitator. While it was a challenge for the nine of us to meet, considering our busy work schedules and time differences, we finished the competencies, and sent them out to 40 volunteers for peer review. Feedback back was subsequently reviewed, and a draft was developed.

Just a few months ago in May, the draft competencies were presented to the delegates at the CAFCN conference in Montreal, Quebec. With feedback from the conference delegates, the competency document is now currently being put together to be shared with external stakeholders before being finalized.

Some may ask: why bother with developing competencies in foot care? Well, first, they promote standardized foot care education across Canada. Currently courses range from anywhere from 8 to 180 hours, which has implications on the safety of patients. It also ensures that foot care nurses are following best practice guidelines, eliminates out-dated practices, and protects the public.  Last, it helps with looking to the future to regulation and certification of Foot Care Nurses.

Pioneers such as Judy and Ruth have truly advanced foot care nursing over the past 20 years. From owning their own foot care businesses to mentoring many new Foot Care Nurses, these retired nurses are still involved in the meetings of the Lower Mainland Foot Care Nurse Interest Group and continue to have a part in assisting new Foot Care Nurses. There have been so many positive changes within foot care nursing over the past two decades, and the nurses that have been involved in advancing this specialty have been true leaders and innovators. As we continue to see the development of foot care nursing competencies, I am sure we will enhance our ability to provide the highest quality and safest care possible.


Sandra has been practicing as a Foot Care Nurse for 8 years. She is a Certified Foot Care Nurse (CFCN) with the Wound, Ostomy and Continence Nursing Certification Board (WOCNCB- U.S. Certification), and currently works as Foot Care Nurse Educator. She is the B.C. Advisor to CAFCN, ARNBC Network Lead for Foot Care Nursing, Co- Instructor for Foot Care Nursing programs at Vancouver Community College and Co- writer of online foot care nursing program for Camosun College, Victoria. She is also the owner of Healthy Feet Foot Care, and Co-Owner of Pededucation: B.C. Centre for Nursing Foot Care Education and Clinical.

Innovation Series: Developing Education and Practice Support for Skin and Wound Care in Home and Community Care, by Kerstin Lewis, RN

There are around 800 clinicians in home and community care, of which approximately 550 are RNs and LPNs across the 14 health units in Island Health. Nurses practicing in home and community care are skilled professionals with a wide knowledge base. They care for some of the most complex and diverse patients such as those living with developmental disabilities, individuals with interventional type needs, and those requiring palliative care. While these clinicians see patients in every environment with every condition possible, many may not know that skin and wound care actually takes up about 52% of the work load for nursing staff.

Having worked as a home and community care nurse for nine years, and supporting clinicians in my current role for two years, it was clear to me that the clinicians needed improved access to education and educational support for skin and wound care. After identifying this issue, I began to think of ways to solve this problem. How could we provide easily accessible education and educational support to clinicians out in the community so that they aren’t wading through pages and pages of material from different sources just to find what they are looking for?

I first gathered a small working group of subject matter experts (SME’s) to complete an analysis to answer the question: “What does the interprofessional team need to know and do to perform evidence-informed skin and wound care within the scope of practice in Home and Community Care?” This group included home care nurses, enterostomal therapists, and a leader representative, where we focused on the needs of direct care nursing staff.

The group unanimously identified that what our staff really needed was a better foundation first, where etiology specific modules could be built based on a solid foundation. In fact, we determined it was about what they needed to “know” more than what they needed to “do” in wound care. This is because there are very few absolutes in skin and wound care, and what the staff needed was the knowledge to assess thoroughly, and subsequently make the most appropriate client specific treatments. The knowledge supports the professional decisions that we make, and will allow for clinical decision making to be better supported.

Once the SMEs identified the key themes and content that home and community care clinicians needed, the next step was to establish what type of education and practice supports would make the most sense. For example what needed to be face-to-face? When could we consider e-learning? Could supports built into the daily process support practice? Once the learning plan was built with these components identified, a work plan was developed.

The big question then became, where would all of the content live? After looking at several options, a website specific to Home and Community Care Skin and Wound made the most sense. We launched the website “Skin and Wound Care for Community Services” in January of 2016, and it currently houses three pages off of the landing page:

  • A product support page which contains resources for the skin and wound products on formulary. Most content on this page is external links to videos, and instructions for use from the company and Product Information Sheets from www.clwk.ca.
  • A Negative Pressure Wound Therapy Learning HUB. This page is designed to provide the staff all of resources in one location to provide NPWT, and follows a liner process for obtaining information. For example all of the resources needed for “Obtaining and order for NPWT” are located beside that task, including clinical order sets. Some resources that were developed for this learning HUB include: red flags for NPWT, process documents, and a step by step guide for clients for an alternate dressing. Also included on this page are tip sheets and therapy guidelines specific to NPWT Pump that we use in out setting.
  • A Q & A forum for Skin and Wound in HCC. This forum is a place that staff can pose general questions. However, currently it is used to post the answers for any commonly asked questions that come from staff or leaders. We also post any email/practice alerts on this site, and there are short PPT learning bursts posted. For example, there is a seven minute PPT with voice recording that outlines our procedures and guidelines for Wound Photography in HCC.

Three more Learning Hubs are currently being developed:

1. Foundational knowledge for Skin and Wound care
Including: factors impacting healing, the DIME principals, product categories for wound care, documentation standards, why wounds become chronic, etc.

2. Assessing the client and assessing the wound
Including: wound measurement and wound bed assessment, wound bed pain, medical and social history.

3. Care Planning, Treatment Planning and Providing Care
Including how to integrate the foundational knowledge to support the client to meet their goals, implementing and revision of treatment plans, and environmental considerations when providing care.

The work plan for these three HUBs includes 40+ e-learning modules (all to be 15 minutes long or less) and roughly 50 job aids, practice supports, and tip sheets. The intent is to provide the clinicians with shorter pieces of information that they can access as required. For example, one module will be on how medications effect healing-this will be a stand-alone component so that the learner does not need to wade through an hour of other content to review the information that they need. Having the material in “bite-size” pieces will also allow the material to be updated easier. With the increase use of mobile devices and access to technology, moving the majority of formal learning to a virtual platform allows easier access to ongoing knowledge development.

The last phase will then be to develop etiology specific “modules” that will support evidence informed practices and pathways. An example of a module that is being developed is for pressure injuries. This module will support best practice, and meet the required organizational practices for Accreditation Canada. We will be utilizing the Provincial Nursing Skin and Wound Committee decision support tools for prevention and treatment of pressure, friction and sheer, and will also access supports from the National Pressure Ulcer Advisory Panel.

Leading a project of this scale has not come without its challenges. One of the biggest challenges is the lack of recognition in the complexity of wound care, and the effects that it has on the client living with a wound. I continue to spend a lot of my time speaking with leadership, trying to gather support for this project, and to educate colleagues on why this is needed. Other barriers include the lack of funding and access to wound care clinicians to aid in the development of the resources. There’s also always something that is going on- a restructure, the development of the electronic health record, staff turnover- just a few of the competing priorities that have impacted the timeline of this project. Further, I am also concerned about the ability for the staff to truly utilize the material and e-learning due to the busyness of the work environment.

However, as professionals we are responsible for managing our own learning, and my role is to provide my colleagues with the opportunity to learn and develop. As nurses, we are all responsible for improving the way we deliver care, and when we identify issues, we must come up with solutions to fix them. While this can be challenging, from my experience, I believe we are all capable of leading and innovating.


Kerstin Lewis works as a Practice Support Nurse with Home and Community Care in Island Health. Her passion and focus is to support evidence based practice for skin and wound in the community. She is Chair of the Island Health Skin and Wound Clinical Care Collaborative and a member of the Provincial Nursing Skin and Wound Committee. As well, she is a contributing member for the Canadian Association of Wound Care. Kerstin has been a strong voice and advocate for supporting clients and staff with evidence based care, taking part in initiatives at the program level, provincial level, and on a day to day basis with helping Island Health clinicians develop their skin and wound clinical skills. She has helped to create numerous practice support tools and resources and continues to help move skin and wound practice forward in Island Health. Kerstin graduated from the University of Victoria with a BScN in 2005 and will likely turn her sights towards a Masters in Nursing. She has worked in acute care and made the move to working in Home and Community and has never looked back. She lives and works in Ladysmith, BC and enjoys a very busy life with her husband, 2 young daughters, dog, cat and whatever creature her daughters sneak home in their backpacks. Other future plans include a nice long nap and enjoying a well-deserved glass of wine with her husband.




My Experience with SNAP: Political Engagement and Keeping Perspective, by Cedar McMechan BSN Student

As students, we are fed many different messages about nursing. Entering the profession, we’re told it is going to be hard and push our limits. We’re told that school will overwhelm us (but don’t forget self-care!). It’ll be a catalyst for transformation and growth. We’re told to persevere and that, in the end, the reward will out-weigh the struggle.

As we learn more about the profession of nursing, our reasons for choosing this path become more diverse. Some of us seek out nursing for our sense of fitting the nursing persona: the über-caring, self-sacrificing, hard-working fountain of kindness, a destination felt to be set by fate or something similar. For others, it’s a fascination with the science of it. As one of few remaining bachelor degrees with guaranteed employment prospects, many of us also choose nursing for practicality’s sake.

I was led to nursing as a result of a passion for the political and social aspects of health. I chose nursing because it seemed like a sturdy vehicle where I could navigate the complex issues of people and their wellbeing. I envisioned (and continue to) that the profession would serve as a platform to deconstruct social issues, understand people in their historical context, and change the status quo. As the meeting place of people from all walks of life, a crossroads between public and private sectors, and an institution rooted in historically paternalistic practices, surely there are few better places to be politically active than in healthcare.

Given these interests, I was thrilled when I received news that I was chosen to attend the CNA board meeting in Ottawa this past March, through ARNBC’s Student Nurses in Action Program (SNAP). I had finally (thankfully) overcome my fear of needles, blood, and vomiting, and it seemed fitting to realign myself with my original motivations of becoming a nurse. I was not let down.

My experience with the CNA proved to be inspiring on many levels. The people, for one, were extraordinary. Where I thought I might find a group of nurses tainted by years of working in an infinitely resource-challenged system, I found a group of individuals that care deeply and passionately for the future of nursing. The meeting was carried out with grace, respect, a true sense of a shared vision and allied intentions. As a student, I was welcomed wholeheartedly and felt valued as a contributor in the room.

Perhaps the most profound aspect of this experience was the reminder of the importance of political engagement as a means of keeping perspective. As students, our perspectives on nursing are often limited to our patient interactions. It’s tempting (and sometimes necessary) to ignore the other aspects of the profession, and become fixated on the clinical skills we’re taught, or the content we need to memorize for an exam that week. However, when we do this, we run the risk of reducing nursing to a set of actions and tasks, and success in the learning process becomes confined to evaluation of these tasks. It’s easy to lose sight of the context in which all of our actions as nurses are performed. I certainly had lost this perspective prior to going to Ottawa.

Witnessing leadership on this level and being reminded of the political nature of health, on the other hand, reopened my awareness to how big this job truly is. I by no means intend to undermine the extraordinary importance of bedside work, but rather mean simply to express my realization that remaining politically active as a student creates a drive greater than that of the grades you receive. In staying connected to the challenges faced by nursing and healthcare as a whole, I am able to sustain my motivation beyond what school requires of me this week or the next. The privilege of being with those who have their hands in this kind of work made me feel better equipped to take part in the process of change, both as a student now, and a nurse in the future.

It’s a funny thing – to straddle the worlds of student nurse and professional nurse. Right when I think I might appear to be fitting seamlessly into the level of competence and professionalism at the CNA, I find myself in my hotel room, eating salad from a bag, without a fork – and remember I have a very long way to go before I can truly count myself among these inspiring leaders. Alas, there is a long, but exciting road ahead of me!


Cedar is entering her third year studies of the BSN program at Camosun College in Victoria. After completing three years of a previous degree in Global Health and Health Studies at Memorial University of Newfoundland and the University of Toronto, Cedar felt inspired to seek out nursing as a practical way to put these background studies into action. With two summer practicums in Whitehorse under her belt, she hopes to gain further experience working in Canada’s North and one day pursue a future as a Nurse Practitioner.

Overdose Deaths in B.C. – Time to Scale up Supervised Consumption Services, by Dr. Bernie Pauly, RN

In the first six months of this year, 371 British Columbians died due to an overdose. This is a 74.2% increase from the previous year. Almost one quarter of these deaths are people in their 20s, 30s and 40s. Fentanyl, a powerful synthetic opiod was detected alone or in combination with other drugs in up to 60% of overdose deaths. Frequently, people consume Fentanyl unknowingly.

Overdose deaths are now the leading cause of unnatural death in B.C. For many British Columbians, the harsh reality of these numbers is hard to understand until you compare overdose deaths to motor vehicle accident deaths:

In 2015, there were 300 deaths due to motor vehicle accidents. In that same time, there were 474 drug overdose deaths.

This rising number of overdose deaths signalled a crisis so serious that it prompted Dr. Perry Kendall, the BC Provincial Health Officer, to declare a public health emergency on April 14, 2016. The province warned that without additional steps to combat overdoses, B.C. could see 600 to 800 overdose deaths in 2016.

So it seemed strangely surreal that the primary response to this public health emergency was a call for ‘real time information’ alongside the scale up of Naloxone distribution. Collecting real-time information on both the user and the circumstances of an overdose is one way to help guide a public health response. For instance, if a number of people overdose in one rooming house, officials can assign a nurse to that building to ensure everyone is trained and has access to naloxone. Nevertheless, this response to a public health emergency seemed out of sync in a province that had made history by establishing the first supervised injection site in Canada, where harm reduction is official provincial policy and there are strong voices for a public health approach to the decriminalization of illicit drugs. It seemed surreal that these overdose deaths were not seen as a clarion call to expand supervised consumption services (SCS) across the province, alongside ramping up the distribution of naloxone, increasing opiate substance therapy and detoxification services, and an increasing call for drug policy reform.

As early as 2008, the Health Officers Council of B.C. sent out an advisory urging health authorities to implement SCS where needed. Yet no new sites have been established since that time. Finally, eight years later and after the declaration of a public health emergency, there are reports from at least three heath authorities indicating that SCS are either being explored or planned.

Registered nurses have been at the forefront of the drive for SCS. In May, 2011, nursing organizations including the Association of Registered Nurses of British Columbia (ARNBC), BC Nurses Union (BCNU), Canadian Nurses Association (CNA), and the Registered Nurses’ Association of Ontario (RNAO) spoke out publically and in the Federal Supreme Court in support of Insite because of the abundant evidence as to its effectiveness and the care provided by nurses.

This action was possible because of the vision of many nursing leaders. Five years before the Federal Supreme Court hearing, the Canadian Association of Nurses in HIV/AIDS Care (CANAC) put forth a resolution at a CNA Annual Meeting requesting the development of a discussion paper on illicit drug use and harm reduction. Alongside Irene Goldstone, I had the privilege of conducting the evidence review and co-leading the development of the CNA discussion paper on harm reduction that was released the same day as nursing organizations appeared as intervenors before the Supreme Court of Canada. The decision of the Supreme Court was that closure of Insite would prevent access to essential health services and endanger the health and safety of people who use drugs. This would also undermine the intention of the Controlled Drugs and Substances Act and violate the Charter of Rights and Freedoms. Instead, Insite would remain open while having to apply annually for an ongoing exemption.

With this decision, there was hope that other supervised consumption sites would open elsewhere in Vancouver Coastal Health (VCH) and Canada. However, the Federal Government quickly moved to develop stringent guidelines in the form of Bill C-2. In early 2016, when VCH applied for an exemption for the first time since the enactment of the Respect for Communities Act (Bill C-2), VCH stated that, “In order to meet the 27 new conditions for exemption, VCH was required to submit additional volumes of information. In practical terms, these new requirements make it onerous for Insite and other supervised injection services to obtain an exemption.”

Cities like Victoria, Toronto, and Ottawa have identified a need and plans to establish SCS. However, there has been only one new site approved in Canada to date. In January 2016, the Dr. Peter Centre (DPC) in Vancouver became the second approved site in Canada. The DPC delivers an integrated model of SCS and has been operating under the auspices of professional and ethical nursing standards for nearly a decade. Current B.C. Minister of Health, Terry Lake, has identified the need for more SCS in B.C. and says he has written to the Federal Government asking them to reconsider Bill C-2, and reduce the barriers to opening more SCS. To date, there has been no response. Prime Minister Trudeau and Minister of Health Jane Philpott have spoken in support of SCS but to date there has been no shift in the requirements for establishing a site.

We need action if we are to prevent overdose deaths. At the current rate, 61 people per month are dying. There is an urgent and immediate need to establish SCS and expand opiate substitution therapy to prevent further deaths. Taking a public health approach to illicit drugs and decriminalization of drugs is equally as important as a long-term policy reform to prevent the harms of illicit drug use. Today, as nurses, we can continue to lead by calling for a scale up of harm reduction services (supervised consumption services and opiate substance therapy) and an end to drug policy that criminalizes use.

Further Reading:

Illicit Overdose Deaths in BC
Nursing Positions on Harm Reduction:  CNA, BCNU
ARNBC Blog on Insite
Research on Insite
BCCDC Naloxone Program:
Public Health Approach to Illicit Drugs


Dr. Bernie PaulyDr. Bernie Pauly is an Associate Professor in the School of Nursing, a Scientist with the Centre for Addictions Research of BC, member of the Renewal of Public Health Services Research Team, and priority lead for the Canadian Observatory on Homelessness. The primary focus of her research is reducing health inequities associated with substance use, poverty and homelessness.


The role of street nurses in increasing access to health care for marginalized populations, by Meaghan Thumath, RN, BScN, MSc PH

The downtown eastside is a fascinating place to practice nursing with a rich history, diverse population and artistic flair. It is also a place where many people struggle daily without adequate housing, employment or support to manage substance use and mental health issues exacerbated by trauma and pain.

But there are numerous individuals who have made it their life’s work to support and encourage the community to thrive. Street nurses are some of the most forthright, committed and determined healthcare professionals in the country. They have made an enormous difference in the lives of those who are marginalized in places like the Downtown East Side, and they will continue, with minimal applause or accolades, to work with individuals who many others have simply written off.

While the history of street nursing in Canada has been largely undocumented, Vancouver appears to be an early pioneer of street nursing in Canada. Following the sexual revolution in 1960s-1970s, four nurses also known as “street nurses in blue jeans” began providing oral contraceptive pills and sexually transmitted infection (STI) treatment to youth. In 1988, the HIV/AIDS epidemic in Vancouver led to the creation of BC Centre for Disease Control’s (BCCDC) AIDS Prevention Street Nurse Program.

Much of the success of street nursing in Vancouver can be attributed to Liz James, the first nurse to be hired by BCCDC to provide outreach services. Sadly, Liz passed away earlier this year, but she has left a legacy of caring for those who are marginalized and struggling in Vancouver.


Liz James

Liz began working in Venereal Disease control in the 1970s and later found herself working in Vancouver city jail, where she found her passion for working with marginalized populations. Liz epitomized what it meant to build a trusting, non-judgemental therapeutic relationship with clients – many of the women she worked with saw her as a mother figure. With the rise in HIV/AIDS in the 1980s among men who have sex with men (MSM) and injection drug users in the 1990s, Liz worked with community members and purchased needles from a sympathetic pharmacist to begin a needle exchange. For every used needle she collected from clients, she would exchange one clean needle in return. Starting out as a program which targeting those that were at high risk of HIV and STIs such as injection drug users, and MSM, Liz’s needle exchange expanded to provide services to other marginalized populations such as sex workers, the broader LGBT community, and those involved with the correctional system. While the program’s primary mandate was to control and prevent the spread of HIV/AIDS and STIs, nurses like Liz also addressed the broader social determinants of health by providing resources to increase her client’s access to health and social services. Throughout the 1990s, street nurses such as Liz were determined activists, and were among the first to advocate for supervised injection services, bringing harm reduction services to correctional facilities, and education related to alcohol detoxification, to those who wouldn’t seek treatment otherwise.

According to “From the grey nuns to the streets: a critical history of outreach nursing in Canada” the grey nuns started public health visits for the sick poor in what is now known as Quebec. During the first half of the 19th century, the grey nuns spread all over the northern and western parts of Canada, where they founded many of the first hospitals within those regions. Moving into the mid-19th century, several prominent nursing leaders such as Florence Nightingale, Lillian Wald, and the Victorian Order of Nurses (VON) began to understand the relationship between the broader social determinants of health, such as housing conditions and income, and the need to reform policies that would improve the health of individuals.

The social reform movement during the turn of the 19th century led to the belief that introducing nurses into areas where people were at high risk of disease would reduce those risks, which subsequently led to the introduction of public health nurses across the country. However, with the dominance of the medical model in the early 20th century, many nurses were removed from health promotion activities. During the late 20th century, despite the presence of a universal health coverage model, the growing inequities in access to health care and determinants of health led to what we now call street nursing in large urban areas. Street nurses began working predominantly with individuals who were marginalized such as the homeless.

Street nursing today not only focuses on controlling the spread of infectious diseases such as HIV/AIDS and STIs, but also on the broader social determinants by connecting individuals to health and social services. Street nurses work in a variety of settings ranging from clinics to alleys and parks, to detox centres and correctional facilities, to name a few. The ability of nurses like Liz to build trusting, non-judgemental and non-threatening relationships with their clients is a significant contributor to the positive outcomes of these clients. She demonstrated the importance of the humanistic side of nursing, and that being empathetic and listening to the needs of patients is at the core of good nursing practice.2001 street nurse group in alley

If this history teaches us anything, it’s that nurses have the ability to improve the lives of individuals and communities, not only through knowledge, but by building trusting relationships, empowering patients to take control of their health and well-being, and speaking out for the needs of patients. Liz James’ passing serves as an opportunity to reflect back on the incredible individuals who have not only transformed the role of street nurses, but shifted the discussion around harm reduction and improved the health of marginalized populations by challenging inequities and refusing to succumb to the status quo. While our roles as nurses become increasingly complex, nurses like Liz will always serve to remind us that we should never underestimate our ability to be leaders and influence policy.

In the words of Liz’s colleague and former street nurse Janine Stevenson in the film Bevel Up “Nursing is a very political act. It is also, potentially, a revolutionary force that asks what kind of society do you really want to live in?”

The author would like to acknowledge the generous contributions of street nurses Caroline Brunt, Fiona Gold and James Tigcehlaar who provided valuable insight into the history of street nursing and their colleague Liz James.


Meaghan Thumath is a registered nurse and public health leader in HIV and drug policy. A former coordinator at Insite and leader of BC’s provincial HIV strategy she has over 10 years of clinical and health policy experience. Her research interests include drug addiction, health equity and gender.

Unleashing Nursing’s Potential to Improve Aboriginal Health, by Laurie Dokis, RN

With the release of the Truth and Reconciliation Commission’s report last summer, and the commitment from the Federal government to move the Aboriginal health agenda forward, there has been a renewed commitment to improve the health of Aboriginal peoples. We have also witnessed Aboriginal leaders being represented at the highest levels of decision-making, including the Honourable Jody Wilson-Raybould, Minister of Justice and Attorney General of Canada, and Melanie Mark, who recently became the first Indigenous woman elected to the B.C. Legislature.

Within our own nursing community, there has also been increased discussion and commitment among nurses in positioning themselves to lead this change – and what better way to do this by engaging in these complex, difficult, yet inspiring discussions, at the Aboriginal Nurses Association of Canada (A.N.A.C) conference, held in Montreal this past February. It was truly an honor and privilege to attend this conference in my capacity as ARNBC’s Regional Director: First Nations, alongside the ARNBC President-Elect Tania Dick, ARNBC Executive Director Joy Peacock, and France Gascoyne, the winner of ARNBC’S STAND competition.

Nursing has a long standing history of engaging in political action and advocacy, and this conference truly illustrated the need for nurses to continue to speak out and address the inequalities and injustices that exist. This year marked the 40th anniversary of A.N.A.C, and it was an absolute pleasure to listen to many founding members of A.N.A.C’s lived experiences about how Aboriginal nursing has changed throughout the years. I’ve been a member of A.N.A.C for two decades, and it’s been truly inspirational to witness and experience the on-going commitment and passion of my long-time and new colleagues in improving Aboriginal health nursing and Aboriginal health.

Several brilliant speakers were in attendance, and two presenters particularly stuck with me. One of them was Marie Wilson, the Truth and Reconciliation Commissioner, who spoke and encouraged us to familiarize ourselves with the Truth and Reconciliation recommendations related to healthcare. Cindy Blackstock, Executive Director of the First Nations Child and Family Caring Society of Canada, delivered a moving presentation that focused on the work she has done to break down the systemic and discriminatory barriers in the area of Aboriginal child welfare. Cindy’s work has directly contributed to the current push to restructure child welfare systems across Canada to ensure that Indigenous knowledge is at the centre. She encouraged each one of us at the conference to do our part by bringing concerns about substandard care forward for discussion and action. Cindy also implored that we all use the United Nations Declaration on the Rights of Indigenous Peoples as our framework to inform policy change.

My experience at this year’s A.N.A.C conference has reinforced my commitment to political action that is grounded in my indigenous nursing values and cultural beliefs. With support from our national professional associations, CNA and A.N.A.C who signed a partnership accord to commit to collaborating on Aboriginal health nursing to improve the health outcomes of Indigenous peoples, as well as ARNBC’s commitment to work with stakeholders to advance Aboriginal health nursing, I feel empowered to continue the legacy of indigenous nurse leaders before me, and those who are now beside me to ensure that the health care system in BC and in Canada recognizes that:

  1. Aboriginal people matter
  2. Healthy aboriginal people are an integral part of Canada
  3. Aboriginal people should be treated fairly and have access to quality health care services

This work cannot be done alone. We must continue to build and foster collaborative and respectful relationships, and most importantly, actively listen to the needs of Aboriginal peoples, as they see them. We must make a commitment to engage and listen to Aboriginal people to truly understand what is important to them. We have an extensive nursing family that includes LPNs, RNs, RPNs and NPs. We are joined together by our college, association and union, like the braid of sweetgrass, which strengthens our collective commitment to public safety, advancing the profession and ensuring that we have quality workplaces so that we can deliver safe, competent and ethical care. Together we can ensure that the recommendations of the TRC are implemented here in BC, and together we can ensure that Aboriginal people’s rights to quality health care are realized.

I encourage all nurses to speak up for Aboriginal health issues, and to come together as a nursing family to move towards reconciliation. With the commitment of government at all levels, we as nurses, must seize this opportunity to lead change. Collectively, we can truly improve the health of Aboriginal peoples, by challenging the systemic issues that continue to compromise this population. We can no longer accept the status quo.


Laurie Dokis earned her MN at Athabasca University in cultural competence with an Advanced Nursing Diploma and her undergraduate BScN/BA in Psychology at UofA. She has numerous additional certifications.  She is a past president of NINA and has been a member of ANAC for 20 years.  Laurie is a proud member of Dokis First Nations and is committed to seeking ways to share and apply her passion for nursing by connecting, engaging and creating respectful relationships with nurses and others who are interested in improving access to culturally safe, competent and ethical nursing for Aboriginal peoples. Laurie is the Regional Director, First Nations for ARNBC.

The Challenges of Working in Rural Health, by Michael Sandler, RN

Approximately eighty five percent of British Columbians live and work in a city or within a short distance of a town that has a population of at least 1,000 residents. This has an important impact on healthcare as certain services can only be found in cities and towns with a large population base. If you live in a large or even moderate sized city, and you need to navigate through the healthcare system, you will enjoy relatively easy access to a long list of essential services including walk-in clinics, emergency rooms, specialist consults, physiotherapy, speciality rehabilitation services and many other healthcare essentials. Most of us never really think about the challenges faced by those who live further from the centre of a city, or in the case of B.C., the southwestern corner of the province.

Canadians are proud of our universal health coverage and the tenets that support our vision of health, including equal and equitable access to care (accessibility), portability, universality, comprehensiveness and public administration. What we don’t realise is that these pillars of the Canadian healthcare system are not equally applied. Those of us who live in rural areas often struggle with accessibility, universality and comprehensiveness, issues that are not as prevalent in larger centres.

Rural British Columbians understand why it’s more efficient to locate specialized services in Vancouver, Kelowna or Victoria, where most of the population lives. However, with centralization should come a commitment to ensure that the foundational tenets of the Canadian Health Act are adhered to for those of us who live in rural areas. Services like maternity, which used to be available in most rural and remote communities throughout B.C., are now primarily focused in the larger centres. With centralization, rural community healthcare needs have changed. The need for care has not changed, just the location it is provided in, and the need to ‘move’ patients has increased. Yet despite need, changing how rural patients access services has yet to be developed to a point where our access is equitable.

A second risk to downsizing and centralization, a risk that has so far received little attention, is the ‘reduction’ effect on rural scope of practice. What can be handled in smaller centres has started to shrink, mainly because the human health resources are no longer available. The less rural healthcare providers are exposed to a given clinical situation, the less we know about that clinical situation – and ultimately, the less we can do about it when we are presented with it. This is not a failing, it simply highlights why specialized medical services exist, and why they are concentrated in areas that will see enough clinical situations to maintain competence. There are many examples in many rural communities throughout B.C. where changing services levels have led to changing outcomes in certain clinical situations.

This dichotomy in practice leads to unique challenges for rural clinicians. On the one hand you need to know a lot while understanding that you might not have access to the resources you need. This is a challenging practice environment and not for everyone. For this reason, it can be a struggle to recruit rural focused physicians, nurses and other healthcare providers. This leads to reduced rural services and as a result, rural emergency rooms often end up being the only place to access routine healthcare. With limited access to non-urgent healthcare facilities such as walk-in clinics, NP clinics and health centres, there is downward pressure on small town hospitals and healthcare providers to handle both the urgent acute health needs of their community as well as chronic and routine needs. This leads to high rates of burnout and makes it even more challenging to attract doctors and nurses to work in rural areas.

We should be utilizing existing health human resources to their fullest potential. Nursing must be looked at closely as a solution to bridging the existing health human resource gaps. Nurse Practitioners hold promise in increasing capacity for rural centres to manage chronic conditions of patients closer to home. Rural healthcare clinicians can also look to things such as simulation and distance education to maintain skills related to high-risk low-volume medical interventions, increasing retention of rural staff. Reviving the incentives that were previously offered to individuals willing to work outside of the big centres would help to offset the costs that rural clinicians are presented with to maintain their skills and increase the possibility of recruitment. Telehealth should be looked at closely to bring specialized care to patients where they are located, instead of moving them to the coast or larger centre. Lastly, a robust, evidence-based way to move patients to centralized specialized care, when some of the previous suggestions are not practical, needs to be fostered to prevent a continued decline in rural health outcomes.

Nursing and nurses who work in rural areas would like to have a voice in how local healthcare services are developed and implemented. We know our communities, our families and our practice are affected by our location. Bringing forward solutions-based recommendations will strengthen our practice, which will benefit patients, communities and our profession.


Michael has been working in various capacities within healthcare for the past 15 years. He recently moved into a more rural setting away from the hustle of the city and has been working with a group of dedicated professionals at improving how and where we deliver rural care.

After 10 Years, What’s Next for Nurse Practitioners? by Mark Schultz, NP

The introduction of Nurse Practitioners in B.C has just recently passed the 10 year mark. Throughout this past decade, we have had some notable successes in NP integration – some large, some small. We’re finally starting to see general acknowledgment by the Ministry of Health, the health authorities, and even some of our medical colleagues, that nurses with advanced practice education and the appropriate resources to support them can be quite useful in keeping our population healthy.

Shortly after arriving in the rural community where I’ve been practicing the last couple of years, I remember seeing an unstable patient who needed to be evaluated at the local emergency department. Based on my training, as a provider sending someone to the emergency department, it is good practice to call and give a verbal report if the receiving provider is available. On this occasion, the receiving provider was an ER physician who, before I could explain the patient’s issues, cut me off and demanded to speak to my “attending physician.” I explained I was in solo practice, didn’t have an “attending physician,” and was the patient’s primary care provider.

This was not the answer he was looking for. Further discussion culminated in me suggesting he keep me honest by calling the CRNBC to verify nurse practitioners could practice independently. I’m happy to report that a year later, this medical colleague was sending difficult patients with multiple co-morbidities to my practice for primary care in the community. This marks a small, but for me, vital example of the daily evolution of professional recognition.

The NP4BC funding initiative is an example of a larger success. Prior to this initiative, we were losing highly (and expensively) trained B.C. nurse practitioners to other provinces and the US. I was one of those NPs who was forced to seek licensure elsewhere because prior to NP4BC, there were very few NP jobs, despite a significant healthcare provider shortage. The funding helped to get NPs into the field. This in turn allowed communities and healthcare systems to experience advanced practice nursing with good results. Some health authorities are now beginning to fund some NP positions out of their operating budget. I see this as an extremely positive development and an acknowledgment of our value across diverse practice environments.

For a number of years NPs were footballs in a game of “funding chicken.” Health authorities wouldn’t hire NPs unless funding was provided by the Ministry, and the Ministry suggested to the health authorities that if they wanted NPs they could use their multibillion-dollar (but fully utilized) budgets to hire as many NPs as they wanted. We seem to have moved past this logjam, at least for the time being, as an appreciation for the solutions that advanced practice nursing can bring to the table has become more apparent. The long-term solution to advanced practice nurse funding involves inclusion of NP funding in all current relevant streams of healthcare provider funding. I think at some point, NPs are going to have to participate in MSP.

Now I know some of my esteemed colleagues disagree, but if there’s a provider funding stream, I believe nurse practitioners should be included in it.

We’re in a time of huge change in healthcare. I’ve always enjoyed the evolutionary concept of punctuated equilibrium. Yes, evolution can take place over long periods of time, but then there are those exceptional periods in the fossil record where change comes incredibly quickly. I don’t know what the healthcare system will look like in 10 years, but I’m pretty sure it’s going to look a lot different than it does now. I’m looking forward to being part of helping nursing unlock its inherent healing powers to meet the evolving demands of our patients, our medical colleagues, and our healthcare system. I enjoy being at the ground zero of change. I have come to believe that dealing gracefully with change is now a core competency for being a nurse.

I got a call the other day from a forward thinking nurse who is working with some forward thinking medical colleagues. She was wondering if they might be able to improve outcomes by including a nurse practitioner on their team in a role not traditionally performed by nurses. In thinking about the Triple Aim- improving population health, cost sustainability, and creating patient- centered care, advanced practice nursing has a lot to offer. These are the kind of discussions I love. I look forward to being part of nursing continuing to evolve towards new healthcare solutions.


Mark has been practicing as a nurse since 2003. He received his Master of Nursing, Nurse Practitioner degree at the University of British Columbia in 2006. Since then, he has been an active member of the BC Nurse Practitioner Association, where he has developed a strong interest in health and nursing policy issues. Mark has practiced as a nurse practitioner in several areas including in-patient cardiology at Vancouver General Hospital, orthopedic reconstruction at UBC Hospital, primary care at the Comox Valley Nursing Center, and urgent/emergent care at Oceanside Health Center in Parksville and Alicia Roberts Medical Center in Klawock Alaska.