Tag Archives: Multidisciplinary Teams

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.

Why We Need ARNBC: The Comox Valley Experience, By Betty Tate, Trish Sanvido and Jessie Shannon

We are saddened by the legal action BCNU has taken against ARNBC and CRNBC and have been reading with interest the comments nurses are making. We hear some nurses asking why we need three organizations to represent nursing and in particular why we need the ARNBC. The ARNBC was the impetus for us to develop a community of dedicated and passionate practicing, retired and student nurses in the Comox Valley and continues to support us to advocate for the health care needs of members of our community. We would like to share our development and actions as an example of why we need ARNBC working in collaboration with BCNU and CRNBC in B.C.

In the fall of 2012, a group of 4th year nursing students at North Island College, as part of their leadership practice, researched the mandates of CRNBC, BCNU and ARNBC, understood the difference between their three roles and decided the Comox Valley needed a local ARNBC network to enhance the professional voice of nurses locally. The students distributed information, visited nurses in practice, talked with nurses who had been engaged in the Comox Valley RNABC Chapter and in Dec 2012 the first meeting of the Comox Valley Network of the ARNBC was held. Nurses who attended the meeting were very enthusiastic about having a forum to discuss local nursing issues and to move forward with action on some of the health issues in our community.

Since then our network has grown to over 100 retired, practicing and student nurses and we have:

  • Provided a valuable forum for nurses across multiple contexts of nursing practice to relationship build, support one another, find their professional voice and address issues
  • Engaged in the development of a new hospital being built in our community to increase the nursing and nursing education voice in the design
  • Engaged with the CEO on the plans for re-development of the existing hospital in our community and what services will be provided there
  • Connected with the Division of Family Practice on their primary heath initiatives in the community
  • Advocated for a renewed Federal-Provincial Health Accord
  • Engaged with Canadian Nurses Association to be informed about and participate in national nursing initiatives
  • Attended a Day at the Legislature organized by ARNBC where we met with the Minister of Health, Opposition Health Critics (both NDP and Green Party) and Ministry of Health staff to advocate for nurses and nurses voice at provincial policy tables.
  • Formed a Political Action Committee to address homelessness in the Comox Valley and to promote primary health care. To date we have been very successful with a campaign to vote yes on a referendum to support a tax to reduce homelessness in our community, lobbying local politicians to move forward with a housing project and begin a process to develop a regional service to address homelessness.

None of these activities would be possible without the ongoing Board, staff and financial support from the provincial ARNBC. For example, ARNBC has assisted us to be politically active by working with us in two workshops where we learned to define an issue, develop a campaign around the issue, write and present a brief to politicians and engage other members of the community in our advocacy. ARNBC has assisted us to connect with other nurses provincially and nationally. We have formed a bond between retired nurses, practicing nurses and student nurses in our community and we continue to reach out to more and more local nurses. We are respected in the community as a voice for nurses and feel empowered to continue to speak up for our rights and the rights of our community.

In our view neither BCNU nor CRNBC could or would have provided us with the support we needed to develop and grow – it simply is not within either of their mandates. We feel that ARNBC has filled the void that came about when CRNBC became a regulatory college and we lost local chapters and a professional association. As much as we respect and value the work of BCNU we know they did not fill this void in the years after local RNABC Chapters ceased nor can they speak for all nurses in B.C. as the ARNBC does.

We ask that BCNU stop the legal action with ARNBC and CRNBC and allow all three organizations to flourish and support nurses in B.C. to raise their voices in unison to positively impact nursing, health and health care across our province.


CVThe Comox Valley Network was formed in 2012 by a group of students who recognized the need to enhance the professional voice of nurses locally.  The group has continued to grow and has become a strong political and policy voice for health and nursing policy in the Comox Valley.  For more information contact comoxvalleyarnbcnetwork@gmail.com




Budget Lockup: Insights from ARNBC, by Zak Matieschyn, NP

Recently, I had the privilege of joining Joy Peacock, Executive Director of ARNBC, in the B.C. Budget Lockup. For those who are not aware, this is a secured room wherein around 200 stakeholders have an advanced preview of the details of the budget and service plans. This is also where the media interviews these stakeholders in order to get their stories aired in a timely manner following the budget speech.

This was the first time ARNBC was invited to participate in the Budget Lockup – an event that can only be attended by invitation of the Finance Minister. Beginning January 1 of this year, ARNBC entered a new phase, and is now a member-driven organization representing all B.C. registered nurses and nurse practitioners. Being invited to participate in Budget Lockup was a strong signal of how government views the importance of the Association and the work we’ve been mandated to do.

The budget itself was a relatively benign affair for healthcare. Increases to healthcare spending will be a very modest 2.9% per year. My review of the Ministry of Health service plan noted much of the same language as last year: commitments to primary disease prevention and health promotion, improving primary/community care through inter-professional teams, and improving rural healthcare to name a few. From a theoretical perspective – this is music to the ears of the nursing profession. As we know and have been educated, these points are among the mainstays of what are needed to reform healthcare. What is concerning is a lack of a blueprint of how we get there. We are talking about a fundamental shift in how healthcare is delivered to become more up-stream, integrated, and team-based. Uttering the correct words is a fine start, but such an objective will require dedicated monies to operationalize this plan, as well as an understanding that this will be a front heavy, longer term process. That is, the benefits will be slower to materialize than can fit in a single budget year or government election cycle. The other point lacking is collaboration with nursing. Registered nurses and nurse practitioners possess exactly the knowledge and expertise of a healthcare system described in the service plan. It is simply a waste of available talent, capacity and leadership to exclude nursing from the spheres of policy planning and implementation.

Also disappointing was the lack of mention of nurse practitioners when commenting on plans for improving access to full service primary care. Over the past 10 years, NPs have slowly been implemented to improve access for British Columbians to primary health care – both in urban and rural settings. Once again, new NPs find themselves without an existing hiring initiative, let alone a robust funding model, to permit them the opportunity to improve primary healthcare access to regions of the province in desperate need of help.

On the brighter side, I was pleased to observe the significant step of eliminating the clawback of child-support payments for single parents on income or disability assistance. This is a relatively low cost intervention (costing only $19 million annually but helping to lift nearly 6000 children out of poverty) which directly impacts the health of these individuals and the health of our society. Nursing has long known the impacts of social determinants on health and government would do very well to continue to explore these evidenced based health and social policy reforms.

The media scrum that occurred towards the end of lockup was a chaotic scene – throngs of stakeholders and reporters mobbing each other. I noticed a friend of mine in the crowd representing another group. “How does this thing work?” I asked. “You just grab the next available reporter and talk to them” she expertly answered. Seemed simple enough yet daunting to the novice that I am, but as I observed the goings on, there did seem to be an order amongst the madness. I did manage to speak with a few reporters about our associations’ reactions to the budget and with luck they may use the story.

I will sharpen my elbows for the next opportunity.


Zak’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 nursing 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 Practitioners Association Executive and is the only Nurse Practitioner in B.C. who has been invited to sit on a Division of Family Practice Board (Interior). 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 six years ago, 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-elect of ARNBC.

How nurses can contribute to transforming cancer care systems, by Tracy Truant, RN and Sally Thorne, RN

Recent commentaries by oncology health professionals, patients, journalists and the Minister of Health about the state of cancer care in British Columbia (BC) have revealed significant challenges to delivering timely, high quality cancer care in that province. It is likely that these challenges are actually felt across the country, and are not unique to B.C. Oncology health professionals, including nurses are working to their maximum with the vision to deliver care that is person centred, compassionate, effective and timely, yet many would agree that the system in which they try to operationalize this care is in fact one of the barriers they must overcome.

While exceptional leadership and collaborative relationships across both the BC Cancer Agency and the Provincial Health Services Authority are essential to delivering timely high quality cancer care, other significant shifts must also occur. Much of the dialogue in the media has focused on timely access to care and containing costs, which are important, but other elements of high quality care must also be considered when looking for solutions. In fact, some have suggested this focus on timely access to cost contained care is a distraction from the real goal, that being maximizing value for patients. Instead, Porter and Lee (Leading Health Care Innovation, Harvard Business Review) suggest that organizing care around patient needs is more likely to achieve system transformation.

Nursing has long advocated for a transformed system of care that aligns resources with patient and family needs. Perhaps this time of reflection on how well the cancer care system in BC is performing is an opportunity for nurses to add their voice to solution-focused approaches to addressing the challenges.

As more cancer treatments are delivered in ambulatory settings where patients manage much of their cancer treatment effects at home, there may be opportunities to explore positioning of oncology health professionals, including specialized oncology nurses, outside of specialized cancer centres, into primary care and home care settings. Innovative models of care, such as the Infermiere Pivot enOncologie (known as “IPO” or “Pivot Nurses”) in Quebec have demonstrated improved quality of life and patient outcomes when Pivot Nurses care for patients from the point of diagnosis throughout their cancer treatment and care, and into the survivorship period. In this way, instead of tying oncology nursing resources to treatment systems, nurses are positioned where patients and families may benefit from their expertise most, as their needs change across the cancer trajectory.

In addition, nurses caring for cancer patients within the specialized treatment setting may be optimally positioned to practice to their full scope in a way that best meet patients’ needs in the context of the interprofessional team. Rather than working in silos, which further fragments care and can create workflow issues, a renewed focus on interprofessional care needs to be initiated.

As more patients survive cancer and experience long term effects as a result of cancer treatment, positioning specialized oncology nurses and/or Nurse Practitioners in primary care settings to care for the holistic needs of survivors after primary treatment ends may be beneficial to reduce the volumes of survivors still being seen in cancer treatment settings. With survivors’ renewed focus on health promotion, cancer prevention and the need for long term symptom management, oncology nurses’ skills and knowledge align well with survivors’ needs at this point in the cancer trajectory.

Sometimes missing from the design of cancer care systems is the voice of patients and families, including those who experience marginalizing conditions within society. While many organizations have begun to include patient engagement strategies, truly effective cancer care systems will not add patient/family voices in as an afterthought to an efficiency driven and access-focused system – rather, systems of care must be built around the beliefs, values, goals and needs of patients and families to achieve high quality care.

So instead of using our voice to add to the dialogue about enhancing access and infusing more resources, let’s pause and reflect on what we are championing better access to – It’s time for nurses to advocate for high quality care and to be very clear on how we may position our unique knowledge and skills to align with patient and family in a way that infuses value for them.


Links to Media

October 17, Gary Mason, Globe & Mail – http://www.theglobeandmail.com/news/british-columbia/sad-decline-of-bc-cancer-agency-must-be-addressed/article21154744/

October 20, Don Carlow, Vancouver Sun – http://www.vancouversun.com/health/Cancer+Agency+lost/10294565/story.html

October 21, Carl Roy, Vancouver Sun. http://www.vancouversun.com/health/Opinion+defence+Cancer+Agency/10311601/story.html

Nov 5, Gary Mason, Globe & Mail – http://www.theglobeandmail.com/life/health-and-fitness/health/leading-oncologists-take-aim-at-troubled-bc-cancer-agency/article21451692/



Tracy Truant is currently a doctoral candidate at the UBC School of Nursing and the President-Elect of the Canadian Association of Nurses in Oncology. She is a former professional practice leader at the BCCA Vancouver Centre and is currently conducting research on systems of care for cancer survivorship.




Sally Thorne is a professor at the UBC School of Nursing with a longstanding program of research in communication in cancer care. Former Board Chair of the BC Cancer Agency and Board member of the Canadian Partnership Against Cancer, she has been actively involved in cancer policy and strategy over many years.


Pine for PINE!!! by Joanne Ricci, RN, MScN

The recent decision to close several of the main primary care clinics in Vancouver Coastal Health has brought to the forefront grave concerns for not only the public but those of us in higher levels of education who are teaching the principles of primary health care and population health.

The UBC School of Nursing has had a long standing partnership with Pine Clinic where our nursing students at both the undergraduate and graduate levels have had an opportunity to work with the expert nurses at the clinic. As a result, there are a few points which are of particular concern to me.

We believe that it is important to discuss the clinic as a regional service for youth – not just a Westside or Kitsilano clinic. Young people access the Pine Clinic from across the city – it serves the ‘community of Youth’ without barriers of residency, insurance, diagnoses or other barriers such a fear of judgment, lack of privacy/confidentiality – perceived or real – which youth fear at walk-in clinics or family physicians’ offices. Youth often present with a medical concern or sexual health concern but, once trust has developed with the expert professionals at Pine, they are able to disclose other concerns such as high risk behaviours, mental health or addiction concerns. Early identification of concerns during this vulnerable age is a critical part of the work that is carried out at Pine.

The benefits of a broad approach to youth care in terms of prevention and early treatment is the crux of primary prevention and can result in long term savings for the health care system. If services become targeted only to high risk youth, there is concern that other youth, vulnerable youth, may not feel comfortable accessing care. There may be a corresponding impact on STI rates, associated complications, and pregnancy rates. Opportunities to work with youth with early mental health and substance abuse issues may also be missed. It should be noted that the current professional staff at Pine have specialized training and experience in addictions, eating disorders, street involved youth, LGBT care, primary care, psychiatry, post sexual assault care, HIV care, Emergency Room care. Youth benefit from this spectrum of skills because they are able to follow through at one site and often with one clinician.

Pine is currently configured as a stand-alone clinic that the younger generation trusts – it is not affiliated with schools or other agencies. Youth appreciate the casual and very youth friendly environment and organization of the clinic.  If they require referral to other agencies they are assisted in navigating the complex systems which increases trust, compliance and better outcomes.

The Clinic provides a team approach – collaboration between nurses in an expanded role, physicians with a specialized youth focus and counselors.   Youth benefit from the urgent care model of the drop-in format and the ability to spend time with a clinician regarding several concerns in one visit.

Research clearly indicates that outcomes for healthier populations rely on accessibility, equity, creating a supportive environment, appropriate technology, attention to health promotion and protection, intersectoral cooperation, public participation and focus on the determinants of health.  Pine clinic for the past 40 years has adhered to these components of Population Health.

It is truly a travesty that the professionals who are passionate about youth health were not involved in the decision to close Pine and that the individuals who are served by this agency were not given a voice.  Short term gain does not equate with long term savings when it comes to the health of our populations!


joanneJoanne Ricci is a tenured Senior Instructor at the UBC School of Nursing. She received her BScN and MSN from UBC and has been teaching at UBC for 37 years. She has taught in various areas of nursing during her time at UBC from basic skills, maternity, surgical, Post RN and for the past 20 years in population and public health. Joanne has not only demonstrated expertise in the area of public health but is also an exemplary clinical instructor and has been instrumental in supervising masters and Nurse Practitioner students.

She has developed strong relationships with her partners in the community and has contributed to countless hours on many committees and boards. Her passion for health promotion and illness prevention of infant children and youth is evident in all aspects of her work.


It’s Time to Talk about CDMR, by Paddy Rodney, RN

For quite some time we have been hearing about Island Health’s1 Care Delivery Model Redesign (CDMR)2, a patient care model that, according to Island Health:

… not only improves patient care, it enhances the work environment for nursing staff by supporting nurses to work in collaborative teams. The Patient Care Model is based on nurses utilizing the full scope of their high level of training, knowledge and practice, and gives them a key role in health care planning and assessment.”3

While the intent behind the CDMR model is admirable, ARNBC has become increasingly concerned by the first-hand stories we have heard from point-of-care nurses working under CDMR.  These nurses have indicated that they are struggling with several aspects of the CDMR program, and that staff and patients are suffering as a result.

Specifically, nurses have told us that under this model, their patient loads have increased to the point where they do not believe that they are able to deliver the safe, competent, compassionate and ethical care that their profession mandates. For example, nurses have told us that one RN may be responsible for managing the care of 10 or more acutely ill patients with inadequate professional nursing support because unregulated care aides have replaced so many RN and LPN positions.

Point-of-care nurses report that it is almost impossible to deliver an appropriate level of patient care when overseeing the needs of so many acutely ill patients.We have also heard that there are nurses in management positions who are navigating conflict and uncertainty as these changes unfold.

In other words, rather than helping nurses and other health providers to provide better patient care, what we are hearing is that this new CDMR model is causing nurses undue stress and may be putting patients at risk.

On February 27, 2014, ARNBC was pleased to participate on the panel of MLA Andrew Weaver’s Town Hall on CDMR along with nursing colleagues from the BCNU and the University of Victoria.  We heard more first-hand stories from nurses as well as members of the public who are concerned about the impact CDMR is having on their communities. Along with our other nursing colleagues, we believe that it is time to speak up in support of good patient care and a healthcare system that values the health and well-being of its employees.

The Need for Evidence

As time has gone on, we have become increasingly concerned about the lack of evidence and outcome data that has been released by the Health Authority that either supports or refutes CDMR.  At the Town Hall Meeting we heard that despite requests from nursing groups and at least one FOI (freedom of information) request, the nursing community in B.C. continues to have no official data to work with when analyzing the impact of CDMR on nurses and on patients.  The only information we have to assess the situation is anecdotal stories from nurses who have been directly impacted.

It’s important that provincial research on CDMR be made publicly available so that nursing organizations, nurse researchers and others can thoughtfully and carefully analyze the impact of the program on nurses and other staff, as well as patients and their families. Through better transparency about the planning and evaluation of CDMR, nurses in B.C. would be in a stronger position to collaborate and support Island Health in their goals to improve patient care and enhance the work environment for nursing staff.  The well-being of nurses is linked to the well-being of the patients and families they serve.4

There are currently warnings emerging from the United Kingdom about what can happen if we get nurse staffing and care delivery models wrong. A recent report from the United Kingdom discussed a series of public inquiries revealing serious breaches of duty on the part of the Mid Staffordshire NHS Foundation Trust.5

One nurse expert stated that problems were “fuelled by the hospital management being driven by the achievement of targets – set centrally by the Department of Health – that were paper-based indicators of ‘quality care’ and ‘success’. These were inextricably linked to financial imperatives, which created a culture where, if the numbers look right, then it was assumed that the hospital was providing quality care.”6

In addition, a recent article published in The Lancet clearly identifies the significant problems that can arise when staffing mix decisions are not carefully thought out.7

ARNBC’s Priorities for Staff Mix/Models of Care

Our main priorities as the professional association that represents B.C. Registered Nurses and Nurse Practitioners are to:

1)      Ensure that the health of British Columbians is the first and foremost priority of all decision-makers and stakeholders as we work through the complexities of staff mix and care delivery models.

2)      Ensure appropriate, evidence-informed decisions are being made about staff mix and care delivery models on the basis of planning and outcome data that are publicly accessible and peer reviewed.

3)      Compel government and health authorities to collaborate with nurses around staff mix and care delivery models, and be transparent and accountable for the decisions they make.

4)      Promote registered nurses to be supported in every aspect of their professional work and have a safe place to share their concerns.

Fortunately, there are some good national guidelines that can help. In February 2010, the CNA established the Staff Mix: Regulated Nurses and Unregulated Care Providers Working Group.  This pan-Canadian group was comprised of RNs, licensed practical nurses (LPNs), registered psychiatric nurses (RPNs), unregulated care providers (UCPs) and a research consultant. The working group defined staff mix decision-making as the act of determining the mix of the different categories of health-care personnel employed for the provision of direct client care. The work resulted in the publication of the Staff Mix Framework which provides direct care nurses and nurse managers with excellent direction and identified five guiding principles that were agreed upon by all participants:

  • Decisions concerning staff mix respond to clients’ health-care needs and enable the delivery of safe, competent, ethical, quality, evidence-informed care in the context of professional standards and staff competencies.
  • Decision-making regarding staff mix is guided by nursing-care delivery models based on the best evidence related to (a) client, staff and organizational factors influencing quality care and work environments, and (b) client, staff and organizational outcomes.
  • Staff mix decision-making is supported by the organizational structure, mission and vision and by all levels of leadership in the organization.
  • Direct care nursing staff and nursing management are engaged in decision-making about the staff mix.
  • Information and knowledge management systems support effective staff mix decision-making.

Next Steps for ARNBC and How You Can Help

While we have been monitoring the situation in Island Health and listening to the concerns of nurses, ARNBC has become increasingly aware that tensions and stress are rising.  We have written about staff mix previously in our blog and with an issue statement, but we are increasingly concerned about the lack of availability of outcome data and related information around CDMR.

In the absence of actual evidence, we can only base our analysis of CDMR on the anecdotal evidence we hear from nurses.

Some components of the CDMR program are good for the healthcare system, good for patients and good for nurses and other team members.  As a professional nursing association, ARNBC will work with Island Health and with nurses to have an honest, frank discussion about the program, the outcomes, the stories and the data – and we would hope this discussion could help Island Health to make changes and improvements to CDMR — changes that would be a win-win for everyone.

ARNBC will undertake further policy work to explore, analyse and make recommendations around Staff Mix and CDMR.  We anticipate that this work will further refine ARNBC’s position on staff mix and care delivery models, and will provide a number of recommendations for next steps that can be taken in British Columbia.

In the meanwhile, we invite nurses who have concerns about CDMR to share your stories anonymously in the comments section of this blog (you will be prompted to share your name and email address – please don’t hesitate to make up a name and email address if you are concerned about sharing your information).  Or you can email us at aburton@arnbc.ca.  Lastly, you can make an anonymous phone call to our Communications Director, Andrea Burton, by calling 604.730.7402. We believe that hearing your stories and impressions of what is happening under CDMR will contribute to ARNBC being better able to support quality health care delivery in British Columbia.

It is time to talk more openly about CDMR, and to take a balanced, thoughtful approach to finding the middle ground between the goals of health authorities and the needs of patients and healthcare providers.


Paddy Rodney, RN, is a nurse educator with a specialty in ethics. Paddy is currently an Associate Professor at the UBC School of Nursing and is affiliated with the UBC Centre for Applied Ethics and the Canadian Bioethics Society. Over the last 25 years, she has lectured and consulted on nursing ethics for nursing associations and unions.  Paddy is on the ARNBC Board.


  1. Formerly Vancouver Island Health Authority
  2. CDMR is the acronym for Island Health’s Patient Care Model – similar models may be employed in other health authorities under different names
  3. http://www.viha.ca/NR/rdonlyres/63276A4E-5CD2-4755-892E-0E420089B75F/0/BoardQAMay2013.pdf
  4. Rodney, P., Buckley, B., Street, A., Serrano, E., & Martin, L.A. (2013). The moral climate of nursing practice: Inquiry and action. In Storch, J., Rodney, P., & Starzomski, R. (Eds.) Toward a moral horizon: Nursing ethics for leadership and practice (2nd ed.; pp. 188-214 ). Toronto: Pearson-Prentice Hall
  5. Francis, R. (2013). Letter to the Secretary of State. In The Mid Staffordshire NHS Foundation Trust Public Inquiry, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: Executive summary (pp. 3-5). London: The Stationery Office
  6. Hayter, M. (2013). The UK Francis report: The key messages for nursing. Journal of Advanced Nursing, Vol. 69, No. 8, pages e1-e3, August 2013.  Article first published online: 1 Jul 2013 DOI: 10.111/jan.12206
  7. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study, February 26, 2014

Nurse Practitioners: Essential Health Care Professionals, by Carrie Murphy NP

The Royal College of Physicians and Surgeons of Canada recently released a report entitled What’s Really Behind Canada’s Unemployed Specialists.  A subsequent Vancouver Sun article noted that the report doesn’t address whether there are too many specialists for the Canadian health care system, but does identify a number of possible reasons why newly certified specialists are having trouble finding work (i.e., competition for resources such as operating rooms, hospital beds and money to pay their fees).  However, the report also references “relatively new categories of health professionals encroaching on doctors’ territory, such as advanced practice nurses, nurse practitioners and physician assistants.”

As a family nurse practitioner (NP) who has worked in B.C. for seven years, I initially chuckled at the idea that anyone could think an NP would do the work of a cardiac surgeon.  But then I began to consider whether or not this decline in specialist positions might actually be, in part, because nurse practitioners and other primary health care providers are helping more British Columbians focus on prevention and health promotion solutions rather than waiting until they have a health crisis to see a physician.

Nurse Practitioners have expert communication skills – we partner with patients and families to promote health and prevent or manage disease; spend time listening to patients, identifying their health goals and priorities; provide expert information and advice on choices they can make to achieve their health goals and improve their chances of living a healthy, vital life.  Nurse practitioners practice holistically – we understand that patients often have challenges in the socio-economic aspects of their lives that impact their ability to achieve their health goals, and we support patients to develop action plans that are practical, based on their individual situations.  For those patients who are already struggling with chronic disease, we provide advice and support to help them understand and self-manage their health challenges to stay as healthy as possible, for as long as possible.

More and more British Columbians are seeking the services of nurse practitioners – in part, because we work closely with people to help them understand how to avoid preventable diseases and live a balanced, healthy lifestyle, that will help keep them out of the specialist’s office.  We are essential health care professionals and that is at the heart of what British Columbians need to understand about NPs.

What would happen if every British Columbian was supported to avoid preventable diseases by eating right, exercising daily, and having access to timely checkups and prevention programs at all stages of life?  Government has been warning that our health care costs are outpacing our tax revenue, and one solution is for each and every citizen to make choices that will help them avoid heavy use of the health care system.  The nursing profession has advocated for greater attention to the determinants of health such as housing, food security, community support and social programs as fundamental conditions to improving people’s health.  If we invested more in prevention and health promotion, could we spend less on curing or mitigating disease?

If all British Columbians had the opportunity to work with an NP on a regular and timely basis – for  holistic primary health care that includes health promotion, and disease prevention and management – including the small things that can grow to become significant health challenges – maybe the end result would be less visits to specialists.  In fact, perhaps what we are seeing right now is that nurse practitioners and other primary health providers have begun to shift the population into taking better care of themselves, thereby reducing the need for specialists.

Shouldn’t our priority be helping every single person achieve optimal health?  Wouldn’t it be better if our B.C. population was so focused on wellness and health promotion that only a rare few ever required the services of a specialist?

Perhaps we need to worry less that new specialist graduates aren’t getting jobs, and start celebrating that the need for specialists is being reduced!


carrieCarrie Murphy is a Family Nurse Practitioner and member of an interdisciplinary team in a full service family practice in Langley, B.C.  Her clinical focus is seniors’ health including frail seniors living in residential care facilities.   She has 20 years of experience in older adult health in various clinical and management roles but finds the NP role the most rewarding.  Carrie sits on the Executive Committee of the BC Nurse Practitioners’ Association (BCNPA) as the Regional Representative for Fraser Health Region.  Visit www.bcnpa.org for more information.

After the Error: How the Nursing Profession is Saving Lives, by Robin Wyndham and Susan McIver

Three years ago I began working with Susan McIver on a book about Canadians who had endured personal tragedy as a result of medical errors. After the Error: Speaking Out About Patient Safety to Save Lives (April 2013, ECW Press, Toronto) tells the stories of these patients and their efforts to prevent similar suffering of others.

The book provides numerous examples of what has been done to promote safer health care and reminds readers that errors continue to devastate lives, despite increasing efforts to prevent them. The latter chapters offer information on how to prevent errors when making end-of-life decisions, how to work with the media and how to organize large amounts of information such as medical records to facilitate investigations. The final chapter offers insights into medical malpractice.

During my 34 years as a registered nurse, I worked in neonatal intensive care, surgery, psychiatry and residential care and had a special interest in palliative care. I studied nursing at Vancouver General Hospital and English at the University of British Columbia. The diversity of my nursing experiences and skill as an editor complemented Susan’s background as a community coroner in British Columbia and a professor and research scientist in the basic science section of the Faculty of Medicine at the University of Toronto.

In preparing After the Error, I was naturally drawn to the role of nurses associated with medical errors. I was proud of the behaviour and accomplishments of some nurses and my heart went out to others who found themselves in difficult situations.

The response of a group of British Columbia nurses to the death of an elderly woman in February 2000 was a proud moment for the nursing profession. The woman died 15 days after entering hospital for elective hip surgery and the coroner’s report released two years later revealed disturbing deficiencies in 10 areas of care. Immediately, members of the Registered Nurses Association of BC (now the College of Registered Nurses of BC), assisted by a representative of the health region, began working with the nurses at the hospital where the woman had died. In 2003, this group launched the Acute Care Geriatric Nurse Network (ACGNN) and subsequently the Geriatric Emergency Nursing Initiative (GENI). Representatives of the ACGNN tell the woman’s story at staff orientations and at regional and national conferences. The story is also used in nursing schools throughout Canada. (See http://esthersvoice.com/Pages8-10.pdf)

Nurses are one of the target markets of After the Error which also includes other health care providers and people who have been affected by medical errors. A 2009 study in Healthcare Quarterly reported that approximately one in six Canadians said they had experienced at least one medical error in the past two years. A 2012 report stated that approximately 38,000 to 43,000 deaths occur annually in Canada in connection with health-care delivery.

After the Error has received considerable media coverage. A highlight was Susan’s interview on CBC radio’s The Current. An email we received following the interview stated “I was struck by a line in the book stating a common experience following medical errors is isolation. The book has allowed me to see I am not alone and there are others out there committed to making changes that are so desperately needed.”

The book also received coverage in The National Post, Globe and Mail, Toronto Sun, Okanagan Saturday and The Georgia Straight. A nursing instructor at Red River College in Winnipeg wrote a review for the Winnipeg Free Press. Articles have also appeared in various health-related publications such as Health Action and Update.

We have been invited speakers for events from Montreal to Vancouver Island. A particular highlight was being featured speakers at the national meeting of the Canadian Gerontological Nursing Association held in Richmond. Another highlight was the opportunity to speak at the Risk+H conference in Montreal. In Winnipeg and Calgary several MLAs and prominent individuals in the respective health regions attended our presentations. Susan and I always welcome opportunities to speak about our book.

Our overall goal is to help make health care safer and facilitate discussions on how this can be achieved. Openness about errors at all levels is crucial. Health authorities, administrators, doctors, nurses and other health care staff must work together to help patients who have been harmed and to ensure that the same situation will not be repeated. Meaningful remedies should be developed and personalized to each case. At the same time, compassion and understanding are essential for both those who have made an error and those who have suffered from one.

Through working on the book and from years of experience as a registered nurse I have seen many areas where nurses can make a difference. These range from speaking up in the workplace to becoming politically active. Errors should be reported and areas of risk identified and remedied. Nurses must speak up about their concerns around patient safety at the bedside, in their practice community and in the community at large.

No discussion of patient safety is complete without addressing the question of funding. In this time of financial constraint it is imperative that patient safety not be compromised. A particularly relevant statement was made by an independent advisory group on patient safety in England: “The failures of leadership at M.S. Hospital had to do with attention. Their attention was on their finances – understandable and even appropriate these days. But attention isn’t limitless, and faced with financial and business model pressures unlike any we’ve seen, it’s easy to spend too much of it on the wrong things. All of us need to pay attention, in person, to the work at the front lines. We need to pay attention to our systems for building effective teams to execute work and to improve. And we need to pay attention to creating and maintaining reliable ways to seek, hear, and integrate the voices of our teams and the voices of our patients.”

For information about the book visit www.ecwpress.com/aftertheerror.


MWRobin Wyndham studied English at the University of British Columbia and nursing at the Vancouver General Hospital School of Nursing. She worked in neonatal intensive care, surgery, psychiatry, and residential care with a special interest in palliative care.

Susan McIver holds a PhD in entomology/microbiology, was a professor at the University of Toronto with appointments to the Faculty of Medicine, and a department chair at the University of Guelph. Subsequently, she served as a community coroner in British Columbia. She is also the author of Medical Nightmares: The Human Face of Errors.

Taking a Stand for Better Primary Care, by Susan Duncan RN PhD

The ARNBC has joined with the British Columbia Nurse Practitioner Association (BCNPA) and the Licensed Practical Nurses Association of B.C. (LPNABC), to convey concerns about recently announced changes to primary care in British Columbia.

Nurses have expressed their frustration that government is moving ahead with plans to ‘solve the physician shortage’ without considering the numerous ways nurses and other health professionals can, and do, improve primary care. We know that nurses are confronted on a daily basis with patients’ unmet needs and are frustrated because they know better solutions are possible. Our three Nursing Associations are committed to finding collaborative ways to bring nurses’ voices and ideas to this critical policy issue.

We have recently conveyed our concerns and our proposed solutions in an op-ed published in the Vancouver Sun, a news release and a letter to the Minister of Health.  In formulating our position and proposed solutions, ARNBC takes direction from evidence-informed policies, some of which were recognized decades ago. These include the Hastings Report on the Community Health Centre Project, the Romanow Report and the most recent Expert Commission on Nursing and Health Care. We also look to emerging models, such as the inception of family care clinics in Alberta, as a way of opening up choices in primary care providers through collaborative, interprofessional, patient-centred, community based clinics with increased hours of access. Other provinces and territories have also shown demonstrable impact on population health through implementing interdisciplinary community health centres.

ARNBC, BCNPA and LPNABC have asked government to strike an interprofessional advisory committee of nurses, physicians and other health professionals to advise the Minister on what is needed to shift the focus of care from physician office services to models of care that are in sync with real patient needs.

In late March, ARNBC will launch a dedicated Elections webpage which will share our position on primary care and other key election issues, and provide nurses with tools and ideas for communicating these issues to candidates. Our hope is that all MLAs will head to Victoria with a solid understanding of the issues facing primary health care, and a resolve to make positive, lasting health policy decisions for all British Columbians.

In the meantime, please add to this blog post with your experiences and ideas — we need to hear from you!


Dr. Susan Duncan is a faculty member at Thompson Rivers University in Kamloops. She has over 30 years of experience in nursing practice, education and leadership roles. Susan has represented nursing on regional health and hospital boards and completed a term on the Board of Directors of the Canadian Association of Schools of Nursing in 2011.