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Transformation in Canadian Nursing and Nursing Education

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Delaine Lloyd

on 18 May 2016

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Transcript of Transformation in Canadian Nursing and Nursing Education

Professional view
education leads to professional status
Self-regulated, governing agencies
Defined scope of practice, standards and competencies

Social view
Nursing defined by social relations, public interpretations and stereotypes
Nursing not defined independently; rather in the construct of the health care organization including policy, finance, and resources
By; Jessica Anastasi, Delaine Lloyd, Krystina Zelem, Amena Begum, George Yue
Transformation in Canadian Nursing and Nursing Education
The Transformation of Nursing
Development of Nursing in Canada
Since the establishment of nursing training in Canada, nursing, as an occupation and career, has transformed
In the beginning, 1874, nursing was viewed as a "service" or a labour focused skillset; based on the characteristics of Christian dedication, Victorian femininity and medical faith
Nursing has now progressed towards being recognized as a established and self-regulated professional designation based on technical knowledge, credentials, competencies and standards, specialization, research, and health care advocacy
Presentation Objectives
1. To describe the transformation of nursing in
Canada, highlighting the challenges and upstream
forces influencing the transformation of nursing
from a subordinate service provider to a
specialized and recognized professional occupation.

2. Examine the outcomes of development of nursing education throughout Canadian history, past and present.

3. Examine current trends and the social, economical, political and structural factors that have influenced the transformation and development of nursing education.

4. Provide relevant recommendations for the sustainability and future of nursing education transformation.
Transformation of Nursing as a Profession
First Canadian training school for nurses opened in St. Catherines Ontario, 1874
Nursing was regarded as a "service" provided for the patient and the doctor
Hospital based training system, that produced a cheap, subservient and readily available nursing work force

Nurses and Professionalism
Contradicting viewpoints on whether nurses
have adequately transformed and risen to the
requirements needed to be recognized as a
professional organization.
Viewpoints of Nursing Status
Nurses as Salaried Employees
On average nurses make about 1/3 of
physicians' wages, justified by a "payoff" or
reward for an income-education linkage
Nurses are recognized as:
Having less education and training
Having less authority
Mediators between physicians and support workers
Providing an indispensable service that is replaceable
Nursing Work and Education in the Canadian Context
Vocational training:
Education obtained outside of formal system
Focused on specific tasks, and the establishment of productive workers
Occurred in the hospital setting
Rising cost to the hospital
Corporate and state intervention
Personal transformation efforts of nurses themselves
Academic education:
training that focuses on theory and application, a balance between the classroom and clinical setting
Content studied includes psychology, child development, sociology, anatomy and physiology (CNA, 2015)
The History of Nursing Education in Canada
Nurses were employed to carry out doctors orders
Early 20th Century
Nursing was a female based
occupation at this time
with focus on
caring not curing

Nursing was beginning to be recognized due to the contribution and efforts of Florence Nightingale
American Society of Superintendents for Training Schools for Nursing was formed for the purpose of implementing a higher quality and more uniform nursing education standards
First nursing university degree
program established
at the University of British Columbia
Canadian Nurses Association was established and helped
bring legislative recognition to trained nurses
Late 19th Century
2-3 year training period with study time viewed as a "privilege"
in return for unpaid ward duty
This cost service provision was used by nurse leaders in their efforts to enhance nursing profession transformation. Leaders bargained for changes including reductions in workday, continuing education opportunities, and formalized structured academic instruction.
Hospital Training
Due to the recommendations of the
George Weir 1932 report: Survey of Nursing Education in Canada
, health care service became institutionalized moving training from hospital to the provincial education system.
With the economic crisis of the 1930s, allotted
health care expenditures declined, forcing the
health care system to operate more efficiently
while corporate interest began to play a role
in the provision and social establishment of the
nursing profession.
Royal Commission on Health Services in Canada
Nursing education is "haphazard, outdated, educationally unsound and inadequate for the needs of nurses and the health care system"
(Bolaria & Dickinson, 2009, p. 108).

In response, nursing organizations, educational
institutes and the Ontario government
cooperated in an initiative to establish a
nursing diploma program in 1964 at
Ryerson Polytechinal Institute

, full time enrollment in academic
based university education was 3x that of hospital
based programs
(Canadian Nurses Association, 1981)
Current Changes in Nursing Education

Initiatives to shift care from hospital to community based care
Community health centres
Hospital closures/system consolidations
Expansion of private alternatives
Community Care Access Center (CCAC) integration and collaboration
Integrated health care teams
Nurses diverse their practice to incorporate elements of resource management
Recent Trends in Nursing Education and Nursing Labour Force
Past three decades, two
predominant Canadian
educational streams for
entry into nursing practice
for Registered nurses
Community college=diploma
In addition to these two streams, there is also a stream of
immigrant educated nurses (IEN)

nurses are educated outside of Canada and enter into practice within Canada
Until the end of the 20th century, diploma and IEN programs produced considerably more new entrants into the nursing profession then
did university degree programs
Currently, this trend has shifted, and it is now required for RNs to have a university level degree
This shift is due to:

Canadian Nurses Association
using adoption strategies for greater professional recognition, the CNA negotiated with the government and nursing education institutions to develop adequate health care services as a major policy priority (CNA, 2013)

Provincial Nursing Associations
complementary position on the need for "entry into practice", which called for a minimum requirement of baccalaureate degree as a standard, initially targeted for year 2000, but achieved Canadian wide by 2005.

limited commitments to invest in new education, evidenced by :
heavy reliance on IENs and diploma nurses who are over represented in hospital and institution settings

Academic institutions

Minimal support for increased degree training programs, evidence by:
Inadequate training for new technological advancements
insufficient access to upgraded courses
lack of time off and flexibility needed to attend classes
Lack of finical assistance for tuition
The shift to the new Canadian wide requirement, a bachelor degree for RN registration, was not well received by everyone and created a strong division between nursing unions and professional associations, and increased mounting tension between staff nurses and nurse administrators (Mansell, 2004, p.197-98)

While the attainment of a university degree is associated with professional gains for nursing, it lacked in guaranteeing and assuring that nurses were able to gain greater decision making ability and increased authority and autonomy in their practice.
Segregation: Places and Positions
Educational credentials have a bearing on the kinds of places and positions nurses are employed in

Upstream Influences in the Transformation of Nursing and Nursing Education
Reorganization of institutional health care

Increased centralized managerial control to
maximize employee productivity but takes the
individual leadership away from nurses themselves
Assumes a business model with less attention on nurses needs and capabilities
Nurses have lack of autonomy and control in practice

Diversified Nurse Training Programs
Classic medical, technical and knowledge based advances
Workplace change and organization
Cultural awareness
Social diversity and acceptance

Politics and Structure

Segregation and hierarchy leads to asymmetrical distribution of services and skills
Increased fiscal and administrative support needed to maintain nursing education as there are concerns Canada is entering a period of sustained and severe shortage of registered nurses.
CNA prediction a deficit of 113,000 RNs in Canada by 2016
Annual number of admissions to nursing schools would have to increase by 3x in order to meet continuing demands
Nursing Demands vs. Cost and Control
Mounting tensions in health care sector, have forced nurses across Canada to engage in strikes over the past two decades
Several nurses who belong to hospital and institutional organizations are now considered an essential service and are no longer able to strike (Canadian Foundation for Labour Rights, 2015)
Nurses also involved in other militant actions to defend their profession
public relations campaigns
active involvement in unions
Regulated Health Professionals Act-1991
Canadian Associations of Schools of Nursing
Entry to Practice Examinations
The scope of practice of nursing is regulated under the health professionals act
Within this act, each provincial college:
regulates the practice, standards and competencies of the profession
works with educational institutions to regulate knowledge, skill, and professional mandates, as well as establishing necessary hours and types of education required
Establishment of systems of accountability and credentialing process
Jurisprudence Examination:
(College of Nurses of Ontario, 2015)
Assesses students knowledge and understanding of nursing profession in Ontario by examining:
Scope of practice
Responsibility and accountability
Ethical practice
Nurse client therapeutic relationship


(National Council of State Boards of Nursing, 2015)
Beginning January 5th 2015, nursing students will now write the NCLEX-RN examination for purposes of licensure/registration in Canada
The transition to the NCLEX-RN is due to the collaborative efforts of provincial regulatory
bodies and the Canadian Council of Registered Nurse Regulators

Accreditation of Education Programs
Canadian Association of Schools of Nursing (CASN) is the
national accreditation body of nursing education in Canada.

External process conducted by the CASN to determine
how each individual organization (university) compares
to developed standards
1987- First undergraduate program accreditation, now a required core function for
baccalaureate nursing programs across Canada
Accreditation ensures that education within institutions meets quality dimensions,
standards for governance, key elements (domains) of study and patient care delivery.
Accredited, entry to practice (ETP) degree educations are offered at 86 universities with
a total admission of 15,129 students in 2012 (Canadian Nursing Associations, 2013).
Upon graduation, individuals hoping to enter the nursing profession from an ETP
program must apply for license registration exams (Canadian Nursing Associations, 2013).
"Nothing is more transforming to health care than the way professionals are educated" (National Expert Commission, 2012, p. 45)
(College of Nurses of Ontario, 2014)
Bachelor of Science in Nursing (BScN)
Efficiency and Accountability
Instructional Media/Self Directed Learning
Numerous forms of multimedia tools are used as teaching modalities to expand nursing education (Zwirn & Muehlenkord, 2009), including:
Online instruction and participation boards (Moodle)
Virtual simulation videos (Mosby)
Social media/Networking sites/Applications (Linkedin, Facebook, smartphones)

High-fidelity simulators are used in nursing education to replicate real clinical experiences so the student nurse can learn procedural, instrumental and critical skills as well as more dynamic, interpersonal perspectives (Dunnington, 2014).
Beginning of 21st century, progression of nursing towards:
Technical knowledge
Health care advocacy
School based training system, a combination of:
academics, college and university
clinical based hands on experience.
Why Transformations in Nursing and Nurse Education is
Important for Canadians
Registered Nurses (RN) and Registered Practical Nurses (RPN) represent the largest regulated health care provider groups in Canada
There is an increased demand for high quality and efficient health care, therefore the emphasis is on the proper training and education of nurses in Canada to deliver competent, safe and ethical care
Nurses must be able to adapt to the current issues and trends of the Canadian health care system, including focus on client-centered and culturally-sensitive care, emergence of medical and information technology, globalization of healthcare and social/gender inequality
Nursing education needs to be re-examined as the roles and responsibilities of nurses change in the Canadian healthcare system.
VIDEO-"The Importance of Education in Nursing"
Please watch the video posted below; the visual and very powerful words within this video depict why we feel the transformation of nursing education is vitally important for students and future nurses
What Challenges Are Faced in Nursing Education Transformation?
Emergence of Nursing Informatics and Technology
Involves integrating nursing science with computer
and information science to communicate
knowledge, data and information
(Mathieu, 2007)
Increased emphasis on the use of nursing informatics and technology to improve patient safety and quality of care (Duncan, Thorn, Van Neste-Kenny & Tate, 2012)

Why this remains a challenge in nursing
The adaptation to nursing informatics is not part of the standard curricula.
Essential NI skills must be included in the current nursing curricula to prepare new graduates to adapt to NI in the workplace, as well as providing the necessary training to existing nurses to deal with the challenges of new technology (Mathieu, 2007).
Globalization of Nursing Profession
More immigrating healthcare professionals are seeking to become nurses in Canada (Sochan & Singh, 2007)
These internationally educated nurses (IEN) must receive adequate training and knowledge to provide competent care (Newton, Pillay & Higginbottom, 2012)

Barriers to transition for IENs include:
Differences in practice expectations
Difference in patient/family expectations
Language and understanding
Obtaining necessary credentials for ETP
Limited programs offered for integration
(College of Nurses of Ontario, 2007)

Gendered Nursing and Stereotypes
"Clinical education of students is a
critical component of nursing
education yet it is difficult to identify
"best practices" in clinical nursing
education" (CNA, 2004, p. 4)

Why is this a challenge in nursing education
Expansion, and transformation in current RN programs is limited by the capacity of clinical environments to absorb more students
Clinical placement of students is often dependent on the convenience and need of the institution, rather then what is in the best interests of the students education and experience
Retention Rates and Enrollment
Retention rates in Canadian nursing education programs are approximately 74% (CNA, 2013)
Issues relating to attrition include, personal student factors (stress, grades, lifestyle choice) and lack of necessary educational resources (CNA, 2004).

Media Portrayal of Nurses and Nursing Education
The image of the nurse has changed throughout history
"Angel of Mercy"
"Girl Friday"
"The Heroine"
"The Mother"
"The Sex Object"
"Respected Professional"
(Work in progress)
A non profit organization that seeks to increase public understanding of the central, front line role nurses play in health care and also promote a more balance and frequent media portrayal of nurses (Truthaboutnursing.org, 2015)

Nursing empowerment campaigns are what is needed to build the profession and reflect on public image and stereotype

Please watch the video below:
Nurses in the Media
There are many TV shows that promote a negative image for nurses, showing nurses as submissive, not giving enough credit to their work, sexualizing their image, poking fun at males in the occupation, and down playing their vital role
Examples ER, Grey's Anatomy, and Road Trip
Television Shows and Movies
Positive Media Image
Even though there is a lot of media outlets that portray inaccurate images of nurses, there are some that highlight the vital role of a nurse
Examples: Call the Midwife (won the award for best media portyrayl in 2012), Nurse Jackie shows the limitation of nurse autonomy
Ideal Image for Nurse
Nurses should be depicted as science professionals who are educated and knowledgeable to make critical assessment calls and interventions
They do not just "follow orders" rather are able to make informed decisions and practice safe and ethical care
(Geller, 2014)
Why is it important to change the
negative nursing image?

Public health research shows that the media affects how people think about and act toward nursing.
To encourage or attract other students to enter the profession.
To get funding for nursing research, advance training, and education.
To show that nurses are not replaceable, but rather play a vital role in the Canadian health care system

Role of Media in Nursing Education

Different organizations and institutes encourage nursing
programs to incorporate nursing informatics,
and technology competencies

Social media is a platform that can assist nursing faculty to help students gain
greater understanding of communication, professionalism, healthcare policy,
and ethics.

With media platforms, students can learn outside of the traditional classroom,
creating flexibility and breaking through barriers of time and distance

Recommendations/Strategies Suggested to Improve Health Care, Nursing and Nursing Education
Based on providing a universal health care system that provides safe and quality outcomes, and adequate investment in nursing education
1. Developing and Improving the "Image" of Nursing
a. Benefits and value of nursing career should be promoted and enhanced

b. Creating a broader scope of recruitment to nursing reflecting diversity and gender equity, therefore creating a more balanced image

c. Breaking the stereotypes of how nurses are portrayed in the media by creating a fresh new image of current nurses
a. Undergo continuing education opportunities to maintain and enhance their professional competence and skill set

b. Continuing education should be inclusive of all changes and consistently evolving informatics and technology

c. Employers should financially support any continued education because it is in their best interest to better their employees.
(Heath, 2002)
2. Continuing Clinical Development of Nurses
a. Promoting ongoing development of practical competencies in the workplace ensuring that skills are still "fresh" and well-practiced

b. Do this by ensuing that funds are dedicated to this specific area of development

c. Support of clinical development for nurses at all levels should be inclusive of programs, classes and varied types of training

d. Transition programs should be apparent for new nurses (RN, IEN) and returning nurses.
(Heath, 2002)
c. Promote Lifelong Learning and Nursing Competencies
(Heath, 2002)
4. Prepare and enable nurses to lead change and advance health
a. Nursing programs, organizations and associations should support and prepare nurses to take responsibility in leadership positions in all levels of care

b. Along with continuing education; leadership should be integrated into all educational programs, including clinical practice

c. Nursing associations should provide leadership development, mentoring programs and opportunities to lead all members.

d. Nurse that are leaders today need to help mentor and prep art he future nurse leaders of tomorrow
Matching Theory to Clinical Relevance
Truth About Nursing
(Bolaria & Dickinson, 2009)
(Bolaria & Dickinson, 2009)
(Bolaria & Dickinson, 2009)
(Bolaria & Dickinson, 2009)
(Bolaria & Dickinson, 2009)
The main education stream has moved away from hospitals, but issues still remain with training and maintaining an adequate supply of nurses, required to address contemporary and changing health care needs.
Public education, through academic institutions, has ensured that certain levels of funding, facilities and standards are maintained for nurse training

sheltered from individual hospital administration needs

Now forced to compete for resources and maintain instructors with high education priority and necessary credentials
there are many products/brands that portray nurses inappropriately
(sexy/naughty object)
Examples Skechers, Schick, Coors, and Denyne
(Bolaria & Dickinson, 2009)
Canadian voice for nursing education, research and scholarship
2014 National Nursing Education Framework
Six guiding principles

(Canadian Associations of Schools of Nursing, 2014)
(Bolaria & Dickinson, 2009)
Nursing profession has traditionally
been dominated by women and
viewed as a feminized occupation
Stereotypes exist in society and media regarding the image of nurses and the feminization of nursing profession

These issues have a direct impact on:
The recruitment of male nurses in nursing
Although the number and proportion
of male nurses is continually increasing,
male nurses represent only 9% of the toal
RNs in Canada (Service Canada, 2013)
The discrimination of male nurses by
patients and co-workers in the workplace
(Adams, 2010)
(CNA, 2004, p.48)
(Bolaria & Dickinson, 2009)
(Social Media Use in Nursing Education, 2012)
Upstream forces are the social, political, economical and structural factors that influence the transformation of nursing and nursing education
Canadian Nurses Association
"Enhancing competence through education and lifelong learning is essential to the professional nursing practice because it contributes to the quality of patient outcomes and to the evidence base for nursing practice" (CNA, 2004, p.1)
Recommends and created a education data base called
Nurse One
which provides a gateway to continuing knowledge, allowing nurses and students to remain current, credible, competent and connected to changes and shifts in professional practice (CNA, 2015)
Registered Nurses of Ontario (RNAO)
Recommends investment in infrastructure and working in partnership with the federal government to develop and fund made-in-Ontario health human resource strategy to focus on expanding the number of qualified nursing faculty, increasing the number of nursing seats and providing more clinical placement opportunities.
Established nursing education initiative grant program to support education of current and future nurses (RNAO, 2009)
(Bolaria & Dickinson, 2009)
(Bolaria & Dickinson, 2009)
(Bolaria & Dickinson, 2009)
(Bolaria & Dickinson, 2009)
Nursing Organizations Recommendations about Transformations in Nursing and Nursing education
Citizen Group Recommendations about
Transformations in Nursing and Nursing Education
Recommendations about Transformations in Nursing and Nursing Eduacatoin
Registered Nurses' Foundation of Ontario/ Canadian Nurses Foundation
Charitable organizations recommend public support and financial contributions towards scholarships in nursing education
Recommend corporate (large banks and pharmaceutical) investments to help transform nursing
Recommend that better health, better care and better value exists for all Canadians when nurses are supported to succeed in their profession

(Registered Nurses' Foundation of Ontario, 2015;
Canadian Nurses Foundation, 2014)
National Expert Commission
"Nurses through their sheer numbers and collective knowledge are a mighty force for change" (National Expert Commission, 2013, p.1)
Recommends nursing education advocates for and actively supports the recruitment, training, employment and retention of First Nation, Metis, Inuits and visible minorities in order to support diversity and equal representation of the entire Canadian population (National Expert Commission, 2013).
(Bolaria & Dickinson, 2009)
Structural Organizational Influences
Structural Organizational Influences
(Bolaria & Dickinson, 2009)
Political and Economical Influences

(Bolaria & Dickinson, 2009)
(Bolaria & Dickinson, 2009)
Growth of the health care system has shifted the focus and transformation of nursing and nursing education
Political and Economical Influences
Political and Economical Influences
(Bolaria & Dickinson, 2009)
(Robert Wood Johnson Foundation, 2011)
(Geller 2014, Donelan, Buerhaus, DesRoches, Dittus & Dutwin, 2008)
The nursing profession is continually transforming and with change comes challenges and barriers that nurses and nursing students need to overcome. It is important that nursing education continues to grow and evolve in order to keep up with current transformations in the Canadian health care system. To effective and recognized professionals, nurses need to dedicate themselves to continuing education. This can be accomplished by getting involved and staying informed through organizations such as CNA, CNO, RNAO.

With transformation comes opportunity.
Nurses need to empower their practice, advocate for their needs and support dynamic change.

We thank you for your time, and hope that you enjoyed our presentation! Please take the time to complete our following discussion questions related to this prezi.
Thank you
, Delaine, Krystina, George, Jessica and Amena
Final Thoughts
Discussion Questions
1. Being a current nursing student, could you share one transformation or area of improvement you feel the nursing education system requires and why?
2. Given the information presented within our presentation what do you feel is the largest obstacle (challenge/upstream influence) that the nursing profession needs to overcome?
Ask the expert- Reverse Role
Given our topic, the transformation of nursing and nursing education, we ask that you make a statement, pose a question, explore further inquiry or take a standpoint. We want to hear your ideas, questions and concerns and we will try our best to answer you.
(CNA, 2004)
(Bolaria & Dickinson, 2009)
Social Influences
(Bolaria & Dickinson, 2009)
(Geller, 2014)
Full transcript