Chapter 4: Issues in Contemporary Nursing Leadership

Situating the topic: the nature of the issue

 leadership is something that happens to us, rather than something that each of us participates in
 professional nursing leadership is a shared project in which we are obligated to participate
 3 ways of being in a relationship with a leader
1. participate in leadership endeavor by following or accepting authority of the designated leader
and to take the “lead from the leader” = similar to mentorship model
2. participate reciprocally – strengths of each person is drawn on and responsibilities are negotiated
3. Take a position to be willing to critique the leaders or challenge decisions and practices that
benefit from new knowledge = creates space for people outside of traditional hierarchy of
leadership (students, new graduates).

Leadership and Management

 “a great deal of attention is given to management and very little to leadership”; however, leadership
necessarily tied to position of authority but each of us as a professional nurse has the potential to provide
leadership

Attributes of Contemporary Nursing Leaders

 Translating vision into action
o Successful nursing leaders demonstrate vision when their ideas bond with the mission
o Successful nursing leaders take their insights and create a vision that compels the participation of
others.
o Innovation because they envision what will happen in the long run
 Knowledge
o Successful nursing leaders need to have comprehensive knowledge about larger society and
about different area of the health care system
o Nurses can envision health care needs and assist others by having knowledge of the health care
needs of the society, knowledge of the health care system, and knowledge of professional
nursing practice
 Confidence
o Presents most personal and least tangible of the attributes of the attributes associated with
successful leadership
o Need confident leaders who have self esteem and are able to live with insecurity
o Think about outside the box
o Express ideas that oppose to the current understandings
o They challenge those practices that do not align with professional practice goals
 Visibility
o Healthcare organizations continue to eliminate nursing positions at the policy and senior-
management levels of healthcare agencies
o Run the risk of becoming invisible or disposable -> lower standards of care

Articulating the Issue

  Often the institution and governments who exert influence on the decision making for and leadership in
nursing practice
 Goals of professional nursing practice are often misaligned with the goals of the institution

Historical Analysis
 asks:
o under what conditions did the current situation originate?
o what has contributed to the evolution of the issue over time?
o What has influenced the position that people have taken on this issue?
 loss of purpose and autonomy -> consequences of the quality of care and delivery of services
 efficiency replaced the effectiveness as a standard of practice
 this leads to decreased patient care and mistrust due to the decreased commitment and job performance

Social Analysis
 sometime after WW2 N.A began changing from industrial to a service economy
 by 1960s society placed an increased importance on the rights of and needs of individuals
 Alvin Toffler – instead of behaving as a passive consumer of health m individuals now behave as active
“prosumers” (combination of produce and consumer)
o Therefore, as patients become more responsible with their own care, we can expect to decrease
the paternlisitic, authoritative,, physician –centered thinking
 Emergence of nurse practitioners testifies to a public willingness for nurses to expand their scope of
practice
 Patients view nurses as social and economic equals
 Nurses help patients become informed consumers and manage their own health
 Nurses can expect their job titles to disappear as healthcare systems devise new, multiskilled teams

Economic Analysis
 Nurses had to negotiate among the sometimes conflicting demands and obligations f their employers,
health care organizations and those for whom they care
 With increased economic constraints, nurses are limited to resources to respond to client situations and
with a limited capacity to exercise control over their practice
o Therefore, nurses caught between professional practice needs and the economic demands of the
institution or organization

Ethical Analysis
 Is concerned with the delivery of professional nursing practice and the influence of broad societal issues
and health and well being of Canadians
 The CAN code of ethics = ethical basis in which nurses can advocate for quality work environments that
support the delivery of safe, compassionate, competent and ethical care
 Dominance of political and economic discourses overrides opportunity to address ethical framework
 Code of ethics = directs leaders and learners to advocate for and work toward eliminating social
inequities

Political Analysis
 questions posed about the connection between knowledge and power and asking how
 how these ideologies influence nurse leaders and managers
  decisions to direct care are guided by powerful ideologies
 Ceci = nurse leaders and managers risk of being caught by 2 realities: professional practice knowledge
of nurses and the privileged knowledge reflecting organizational goals
o States that we do in fact have choices about how we will conduct ourselves

Barriers to Resolving the Issue

1. Barriers to excellence in nursing leadership arise when there is a dissonance (disagreement) between
goals and vision of organization and those of professional nursing practice
2. Leaders and management face complex decisions of where to align themselves
a. Although leaders want to support professional nursing goals they may feel obligated to support
conflicting organizational goals (source of leader’s power and authority)
3. Leadership strengths of creativity, vision, and residing uncertainty inhibited due to over focus on short
term problem solving, rational decision making, and need to keep things under control

Strategies to Resolving the Issue

 Reforms
o Health, not just health care
o More health services in the community, not just hospital
o Multidisciplinary networks of practitioners, educators, researchers, and managers, not just solo
players
o Public participation in shaping the system, not just public consultation
o Inter-sectoral health , not just healthcare
o Appropriate technology, not just high ‘tech’
o Attention to ecology, not just environment
Chapter 5
Questions one in the objective is a general questions for this topic.

Objective Number 2:
Types of Policy
Public Policy is whatever government choose to do or not to do. It is a conscious choice of action, inaction,
decisions and nondecisions toward an end. Eg rules, laws
a. Health policy includes directives and goals for promoting the health of the public.
b. Nursing Polic is influenced by the public policy (Provincial and territorial, free trade agreements) as
well as a component of institutional (clinical practice guidelines, care maps, and critical paths). Nursing
policy also includes organizational policy of the nursing association (policy and position statements,
nursing practice and educational standards and competencies)
c. Organizational policies such as those of professional nursing associations are the rules governing and the
positions taken by an organization. Some organizational policies may be determined by the public policy
(RN or health professions acts and scope of practice regulations) whereas other association specific
(education standards and registration and continuing competency requirements. Recent trends have been
for public policy to significantly determine nursing policy that is of a regulatory nature.
d. Institutional Policy such as those of a hospital or healthcare agency, comprise the rules governing
workplaces (Policies responsibility and accountability of health authorities and accreditation standards
whereas others such as mission, vision and core value statements are institution specific.

Note: The difference between public policies such as health policy and institutional, nursing and organizational
policies is that government does not necessarily have the total policy responsibility for institutional, nursing and
organizational policy. The responsibility belongs to others such as professional regulatory body, governance
board of an agency, and managerial staff of a department. However, there is interplay and influences between
these types of policies are shaped by politics and power.

Distinguishing Policy from Power

POLICY
Deals with should and oughts
Based on values, goals and principles
Frequently proactive – negotiable
Stages of development from formations of the
problem through adoption of the policy
implementation, and evaluation
Objective is to evidence based (using research,
epidemiology, databases in health information,
surveys)
The chosen theoretical perspective with its
values and principles determines details of the
policy process
POWER
Focuses on conditions
Uses power to persuade and influence
Primarily reactive- non-negotiable
Political process is the way policy is developed
– requires identification of true issues and
stakeholders and their goals and interest.
Foundations is philosophical – party oriented
(liberal, conservative, socialist)
Shape the content for the policy and the policy
process

Note: In both policy and political processes, individuals require the following skills and quantities
Analytical thinking, visionary perspective (future and goal oriented, force of commitment, communications of
goals, reliability and integrity.

POWER
-is not generally associated in nursing. Public image and society are remarkable to consider
-expand expertise and restricted practice aim to use each nurse’s competencies’ and knowledge level
- Nurse who are valued scarce resources and knowledgeable workers who cannot be spared to do lower-level
tasks.
- New legal powers that legitimize various nurses’ roles such as NP and public acceptance of these roles
integrated into the healthcare system.
- New roles in such are clinical nurse specialist in informatics that provide clinical expertise as well as
contribute to the system-level responsibilities such as quality assurance, research and evidence based practice
-change in perception
-nurses who are advocates
-nurse educators
-Knowledge is power.
-Enhance skills and knowledge.
-Good working relationship
-Assertive
-Good communication skills

PROFESSIONALISM
-the nursing profession contributes to the delivery of care and health startus of the population. The ultimate
reason for enhancing nurses’ political influence and empowerment, be it in a workplace, community,
government, or professional organization, is to improve the healthcare received by clients.
Nurses and their knowledge are pivotal to advocating for and ensuring that health and nursing policies promote
quality client care through professional nursing practice in any nursing setting. Policy, politics and power are
essential components of professional nursing practice, just as the professional practice of nursing must inform
public policy.

Objective Number Three and Four:

Understanding the complexity of Policy
None theoretical perspective is consistently taken in the policy process. The perspective differs depending on a
variety of factors including the specific policy issue, timeframe for resolution, the political agenda, and power
relationships. What is important for nurses to understand and learn is how to become part of the process and
use their knowledge and expertise to enlighten and influence specific policy processes, regardless of the
theoretical perspective taken.

1. Sphere of Nurse Involvement

- Our challenge is to exercise our power and influence and use the political process to help bring about
a major change in the delivery of nursing services to society. Professional nursing holds significant
plausible solutions to current crises in healthcare.
- Nurse leaders are increasingly aware that all health issues, no matter how seemingly remote from
nursing, will have an impact on the direction of health policy and, thus, eventually in nursing. (Ie,
today’s nursing shortage is the result of policy decisions made in the mid 1990’s to reduce the
number of hospital beds and at the same time reduce number of beds and at the same time reduce the
number of students accepted into nursing schools. Other policy decisions such as regionalization,
reduction in funds for certain services,

2. Workplace: the healthcare institution

- At the institutional level, evidence-based policy is required not only to address management and
financial issues (health and human resource deployment and health information systems) but also to
 make critical interdisciplinary clinical decisions (practice guidelines) and develop work
environments supportive of quality care and professional nursing practice.
- Clinical practice is a political endeavour because nurses must effectively influence the allocation of
scarce resources. Collaborate in evidence-based clinical decision setting.
- Involvement in the policy process may be related to clinical practice guidelines specific to nursing
care, patient safety issues for interdisciplinary care or system-wide quality assurance initiatives.
(nurses in a interdisciplinary actions for their patients)
- A healthcare mission, vision and core are the foundations for operational policy and decision making
as well as making as well as strategic planning. Nurses have responsibility to contribute to the
development of their institution’s policy and foundations and to the philosophy of nursing and client
care at both institutional and unit levels. It is the role of

nurse leaders and senior executive nurses to ensure that a process is in place to facilitate nurses carrying
out this responsibility. Nursing practice councils are one structure that has been used to encourage and
support nurses’ participation in these institutional policies. Nurses must be aware of their institutions’
key policies : (power) the organizational charts with their lines of communications and responsibility,
(organizational culture) mission statements goals objectives, (expectations) policy and procedure
manuals.
3. Government
-nursing is a self-regulating and self-governing profession; government provides society with a legal
definition of nursing and what is within or beyond its scope of practice. Nursing associations and
colleges and individual nurses advocate with government to ensure that nursing legislations and
subsequent rules are in the best interest of the public – that they facilitate and support the full
participation of nursing practice to achieve the goal of safe and appropriate healthcare.
- Government also determines who will get what kind of level of healthcare (needle exchange site and
medications). Government also helps in facilitating research practice in nursing.
-the CNA’s advocacy role in federal policy and politics has been increasingly evident at the turn of the
century, as it has its involvement of individual members and provincial and territorial nursing regulatory
and professional associations and colleges
-without nurses’ unfaltering involvement in research and sharing their nursing knowledge and evidence,
research-funding agencies would not recognize the value of supporting nursing research. In turn, nurses
would not be able to make significant contributions of knowledge to improve the healthcare of the
public.

4. Professional Organizations and Unions

- Professional nursing organizations are instrumental in shaping nursing practice. They develop
standards for nursing practice, education, ethical conduct, and continuing competence. They lobby
for progressive changes in the scope of nurses practice and play a role in collective action that
influences workplace policies. Whether the issue of concern is primarily nursing or healthcare,
nurses have responsibilities to use their political skill and nursing expertise to contribute to their
associations’ leadership role in public policy development – policy that aims to improve the health
of communities and to ensure the provision of high-quality nursing care.
-
- Unions representing nursing are primarily concerned with the development of legally binding
agreements that regulate staff nurses’ salaries, working conditions, and other negotiable benefits.
However, unions also advocate for health and nursing policy related to other issues.
- Professional organizations and unions have some common goals, including the welfare of members
and the improvement of their working conditions. They share a concern for professional ethics,
 although it is the professional organization that is responsible for ensuring that the standards of
professional conduct reflected in the codes of ethics are practised.

5. Educational Institutions
- Both faculty and students have opportunities and responsibilities to be involved in public
professional education policy. Such involvement may be in government-level policy etc

6. Community
- As members of the community, nurses have a responsibility to promote the welfare of the
community and its members.
- Nurses’ contributions through community development and participation in community initiatives
provide another credible and trusted voice in the policy process.
- Nurses must also consider the cultural background, religious and any form of traditions that are part
of their clients’ way living.

Objective Number 4: Conceptualizing The Policy Design Process

Policymaking, a dynamic and cyclical process can be conceptualized as a model of systemic and functional
activities aimed at exploring the causal links between problems and solutions.
8 Phases
1. Identifying the issue
- Problems are identified through situations that produce needs or dissatisfaction for which relief is
sought. The strengths of political and cultural influences are often determined by geographic location
(rural vs urban), language (French vs English), ethnicity (majority vs minority, and values principles
(public vs private).
- Problem definition develops as values, beliefs, and social attitudes toward a concern are delineated
and policy approaches are considered.

2. Setting Priorities : The policy Agenda

- Ideally, policymaking involves interested parties coming together to formulate ideas and solutions to
given circumstances or problems. In reality, struggles for power are and always have been, principal
factors in motivating change. At provincal and federal levels, commissions have been formed to
help identify policy issues, priorities, and strategies.
- Although such commissions provide information for decision making and priority setting they are
frequently linked to politics and the political party of the time. Thus, findings and recommendations
are often not acted on because of change in government or political priorities. However, with policy
advocacy from many stakeholders, including nursing organizations and individual nurses.
- Policy issues and priorities may also arise from research. There is gaps in research and policy
.Besides gaps between researchers and policymakers and the re-examination of issues through
commissions and challenges to nurses’ consistent and meaningful involvement in setting policy
agendas are related to ff:
a. Dominance of the medical profession
b. Culture, values, and structures of predecessor healthcare systems
c. Invisibility of nursing
d. Stability od the “iron triangle” of civil servant , politician, and physician
 3. Uncovering the Evidence
-discovering reasons for policy involves discovering the data on which policies are based. However,
sometimes there is no data just someone’s idea of what should be.
- Ideally, policy depends on data – data gathered from existing information and summarized and
synthesized with a particular question in mind. Existing data must be used in the policy process include
published and unpublished reports. During data analysis – a systematic description and explanation of causes
and consequences of action and inaction.
- the role of nurses in data analysis is part expert advisor and part advocate in providing unique
professional nursing perspective for policy decisions.
4. Choosing instruments for Policy Formulation
- instruments may include passage of law regulation, the expenditure of money, an official speech , or
some other observable act.
- factors to be considered:
a. political considerations
b. past experiences
c. personal values of key decision makers
Some of the policy instruments or products particularly relevant to nurses, but also used in other public policies
are the ff:
a. Endorse positions (CNA Code of ethics
b. Brief position statements and official messages (CNA response to the Health Services on
Healthcare in Canada
c. Strategic policy (mission, vision,, core values )
d. Standards (practice standards and care and accreditation standards)
e. Rule and regulations (infection control
f. Legislations (nurse registration and health profession acts)

4. Adopting and Implementing the Policy\

-Adoption of the Policy or enactment of legislation occurs before implementation of the policy,
Considerations must be given to ensuring that stakeholders are aware. For example : most professional
nursing organizations publish new or revised positions and policy statements, practice and standards in a
form that all members receive.
-Implementation is about doing: accomplishing the task, achieving goal. Policy implementation is the
process of transforming goals associated with policy into results. Policymakers do not always know
exactly what they want, their instructions are sometimes imprecise or even conflicting.
-Goals must be set, well articulated, understood and translated into programs with budget and funding
appropriations.
-Implementation involves such activities as applying the rules, interpretating regulations, enforcing laws,
and delivering services.
5. Communicating the Policy
-communication is the vital link between goals and implementation. Without clear communication –
policy will never be accomplished.

6) Recognizing Barriers to Implementation

a. attitudes and beliefs of program administrators
b. territorialism and reluctance to give up that which is considered to be one’s own
c. external stakeholders’ interest
d. political culture

7. Evaluating the outcome

 - Feedback about the process
- Successful strategies involve early partnerships among evaluators and researchers. Policymakers and
program implementers as well as the identification of appropriate measurable outcome indicators.
- Difficulties:
a. Realizing the quantity does not necessarily mean
b. Accepting the policy that may be nebulous and use language such as promoting, protecting and
improving something
c. Interest of the politicians

8. Revising the Policy

- Finding the strategies if the policy is satisfactory of not. If the original policy goals are unmet then it
need to start the cycle again with further clarification of the policy problem.

Objective Number five: Challenges to nurse involvement:

1. Nurses often experience of not being listened to of not finding suitable channel through which are
their voices will be heard and their contribution to policy valued.
2. Nurses feel powerless when they believe any resistance or any attempts to effect change in specific
issues would be hopeless.
-Yet the clinical knowledge and expertise of nurses are their greatest assets in the policy process
3. Nurses need to feel empowered with the authority commensurate with this knowledge and expertise closest to
clients and proportionate to their numbers. They need power to ensure their ability provide competent,
humanistic, and affordable care to people, provide to help shape health policy and alter disproportionate
leverage of physicians, and power to ensure that nursing is an attractive career option for women and men who
expect to influence and improve nursing, healthcare and health policy.
4. The fundamental source of empowerment is Self-confidence

Objective Number Six: Strategies for Involvement

It is essential for nurses to be knowledgeable about current policy directions, to be aware of the expected
outcomes of the programs, and to participate in the development of policy in many sectors influencing health
and nursing.

Guidelines for influencing the policy process:

1. Educate yourself about the issue
2. Vote for policymakers who support humanistic policies
3. Participate in your professional nursing association’s work.
4. Join a professional organization with goals and philosophies that shape your nursing life
5. Use media
6. Volunteer to serve as member of local health or nursing advisory committe
Chapter 6 – Policy: The Essential Link in Successful Transformation
1) Describe the relationship between research and policy.

Policy utilizes research findings to implement change and develop new policies regarding the
research area. However, research may not always cause a change and development of new
policies.

2) Explain why credible research is insufficient to effect policy change on its own.

Credible research is insufficient to effect policy change because (1) the timing may not be right
and (2) the topic may not be considered an important issue in the political agenda. There is not
enough weight, according to the policymakers, to cause a policy change and that a change is not
necessary at this time.

3) Identify and explain the key components of effective research-policy linkage

1. Interface between research and policy development
- There must be a linkage between all steps of the research and decision-making processes
(from definition, policy priorities to the dissemination of research results and policy
implementation).
2. Sensitivity to Context
- Consideration of the context (social, political, and economic environmental aspects
surrounding the decision-making processes).
3. Appreciation for Stakeholders’ Attitudes
- The three main stakeholders are: researchers, decision makers, and members of the
community. It is important to include all three of these stakeholders into the process.
4. Astute Use of Research Outputs
- The ability to tease out from complex research methods and findings a limited number of
clear, concise, and relevant messages is very important. Ideas that are related to the
current problems are more likely to be implemented.
5. Role of Mediators
- The use of role mediators (such as research brokers and skilled mediators) can help link
the differences between the researchers and the policy decision makers and eventually
helping them to come up with a decision they both agree to (their differences between
priorities, time constraints, language, and culture).

4) Apply a basic-change formula to analyze and plan for change

D (dissatisfaction) x V (vision) x F (first steps) > R (resistance)

All three components of the left hand side must be greater than the resistance in order for change
to occur. If any one of these components are close to 0 (zero), then change will not occur.
Change occurs when: (1) there is enough dissatisfaction towards the old policy from the
members, (2) a good vision of the idea, and (3) the steps needed to implement the change are in
place.

5) Identify the steps in the policy cycle and give examples of ways the various steps might play out with a
real-world issue of concern to nurses.
1. Values and Cultural Beliefs
- Healthy Nurses, Healthy Workplace:
o Canadians are firmly in support of the principles of the Canada Health Act.
o Nurses are an essential part of the healthcare delivery system.
o To offer both access and quality, the healthcare system needs nurses.
o The public trusts nurses.
- Identifying these values will ensure that the policy is value based and it connects others
who share those values.
2. Emergence of problem or Issue
- Policy windows are not always open hence it is important to be alert to opportunities.
- E.g. the dissatisfaction from nurses regarding their workplace and how it negatively
affects their productivity and performance but also their personal health.
3. Knowledge and Development of Research
- At this step, the research must decide if there is enough solid evidence to support the
anecdotal perceptions.
- Researchers undergo many research and surveys to obtain information regarding the
issue.
4. Public Awareness
- Creation of broad-based awareness of the issue and the solution based on research
(getting the message across).
- E.g. continuing on from the example discussed earlier, the targeted audience for the
nurse’s workplace issue are the nurses and nursing organizations, employers, unions,
providers, politicians, and the general public.
5. Political Engagement
- In order for an issue to be placed on the agenda, it must be “softened up”; meaning
people must get use to the idea.
- This step is decided to create ripple effect that will eventually cause a wave of support for
the issue.
- Uses various strategies to accomplish the following:
o Know the gov’t structure, committees, caucus, and key members of parliament
o Target individuals with interest, information, passion, or influence regarding your
topic
o Utilize carefully considered, person-to-person contacts.
o Customize the message for each contact person.
o Keep these individuals regularly updated regarding your activities, your progress,
and your specific needs for ongoing support.
6. Interest Group Activation
- Repeat the message whenever possible and engage other interest groups.
- E.g. having direct dialogue with key members, publications (in newspaper) etc.
7. Public Policy Deliberation & Adaption
- Occurs when interest and support is great enough.
- Brings topic to the tables so it can be debated and policy can be formulated.
8. Regulation, Experience & Revision
 - At this stage, the proposed action becomes a formal policy, law, or regulation. The new
policy becomes the new cultural value or norm.
- At this step, the policy is continuously experiences and revised until a new issue arise.

6) Describe the connection between political acumen and policy influence.

Political acumen is the final requisite for influencing policy (pg. 104). There are many events
occurring in the society and these events influences the decision-making behaviour. (For
example, the terrorist attacks of September 11, 2001, the severe acute respiratory syndrome crisis
of 2003.) These events cause policy makers to make quick accurate judgements about these
events and hence create new policy that will be beneficial for the situation at hand (i.e. new
policies in place to protect nurses and health care providers when taking care of patients with
SARS).

7) Identify ways in which political acumen may be leveraged in the advancement of nursing policy.
Nurse and nursing should become politically involved in order to influence and formulate policy.
Therefore, nurses who are politically involved can identify the problems at the table before the
issue becomes too big. There are many different problems that arise in today’s society and it will
be beneficial if the issue is identified early and hence a new policy is created to solve the issue.
Chapter 15
The nature of nurses’ work
- Lack of clarity in defining nurses’ work is due in part to the lack of clear boundaries between nurses’
work and non nurses’ and increasing expectation of non nursing work for nurses.
- Nurses have been often taking work that are usually performed by others
o Leads to nursing practice by auxiliary workers
- Nurses also have an increased burden for themselves.
- Faced with lack of control. (diminished support and resources)

Nature of nurses’ workplaces

- Nature of nurses’ work and the workplaces themselves are interrelated. Both contribute to the nurses’
o Job satisfaction
o Recruitment and retention
o Wellbeing
- Many researchers linked Canada’s current nursing shortage to inadequate and inferior environments
- Baumann says that the work environment burns out the experienced and discourages new recruits.
- As more desirable environments are created, nurses already in practice will be attracted to these
employment situations.

The significance of nurses’ work issues

- issues of the nature of nurses’ work relate directly to the:
o recruitment and retention of nurses
o Health of nursing workforce
o Quality of care nurses are able to perform.
- There is growing number of RN shortages by 2011.
- According to C N A, nurses have an obligation to their patients to demand practice environments and
human support allocations necessary for safe, competent and ethical nursing care.
- The C N A holds that development of practice environments are responsibilities for the nursing
practitioners.

Characteristics of Quality Practice Environments

1. Communication and collaboration
2. Responsibility and accountability
3. Realistic workloads
4. Leadership
5. Support for information and knowledge management
6. Professional development
7. Workplace culture

Issues arising in nurses’ work and workplace.

- Too few nurses to fill current positions and predictions that the shortage will worsen.
- Despite the positive outcomes, the realities consist of:
o Professional and social isolation
o Disrupted workplaces (alienate employers and nurses)
o Inadequate educational, mentorship and orientation,
o Decreased support
Increasing demands of nurses’ works
- It is important to not to overlook the demands of increasing acuity and complexity of patient care.
- The care provided by nurses is thought to be more complex than ever.
o Acuity of patients has increased since 1994.
o Added responsibilities.
o Hospital downsizing and restructuring have intensified nurses’ work.
o Simultaneous demands were apparent in many situations.
Qualitative work overload
- overload to nurses who are unfamiliar with the work.

Nurses’ by their competence and experience are responsible directly for the care of the patients assigned to
them and also responsible indirectly for the patients assigned to other nurses on their unit.

Incongruities between nurses’ work as taught and practiced.

- Lack of clarity about what constitutes nurses’ work and increasing demands of nurse; work have
hindered development of a professional role for nurses.
o Nurses find themselves “unable” to nurse as they had envisioned.
- Important to recognize that nurse have a different experience than others in the health care system.
- Professional role of nurses develop through both education and practice experiences.
- When faced with demanding workloads, nurses’ work become reconfigured as tasks.
- Sense of being incorret when nurses’ interpretations are excluded in policy discussions.

Lack of control over nurses’ work

- Using the “Commitment and care: the benefits of healthy workplaces for nurses, their patients and the
system,” by Bauman, they identified 6 principles that make an optimal work environment
- Bauman supported that nurse input into patient-care decisions.
- For nurses to experience control over their work, they must be central in policy decisions that direct
work-life issues (scheduling, full time, part time ratios, casual nurses)
- Nurses who are satisfied with their work show a higher commitment to their practice.

Lack of support for nurses’ work

- central to the discussion of nurses’ work is the decline of emotional and cognitive support.
- In full time positions, support came from the managers, supervisors, and colleagues.
- Cognitive support came from preceptors, mentors, and organizational policies.
- In the absence of leaders to protect them from overwork, some nurses turned to absenteeism.
- Financial and professional support diminished at a time when there is an increasing pressure for nurses
to account for continued competency.

Workplace isolation
- A review of literature on social support in the workplace and an examination of employer practices
suggest that nurses’ commitment to their employing organizations has decreased.
o Due to a belief that employers no longer support them.
o Dismissal of senior nursing figures would result in less professional support for nurses.
o Nursing teams have been decimated due to redeployments

Experiences of rural nurses

- whereas nurses working in rural locations have more independence in their practice than other nurses
have, they have other issues to attend to.
- Rural nursing includes both impatient and outpatient practice areas.
- “expert generalists”, because they must know a great deal about a variety of practice areas.
- Nurses may find themselves alone with professional care and decision making while being highly visible
to the community.
o Highly visible and experience diminished personal and professional boundaries.
o Unlike nurses in larger centres, rural nurses cannot avoid social interaction with patients and
their families.

Community as workplaces
Although much of the distance nurses experience from leaders, peers and other professionals can be attributed
to restructuring and the deployment of nurses in some cases ,
- leads to undermining of relationship of nurses and leaders.
- Home care nurses remain invisible to administrators.
- Nurse administrators who supervise home-care nurses are also caught in the tension. Conflicts are
different.
Mentorship and orientation programs for new graduates.
 - another group of nurses for whom the professional practice environment is an issue is new graduates.
- Adapting to a constantly changing environment produces a “functional” nurse.
- Numerous innovative programs across the country support new graduates and their mentors. (ex: St.
Michael;s hospital)

Disrupted workplaces
- During restructuring, healthcare organizations decreased level of support for professional development.
- Shift to program management meant that monitoring and evaluating junior nurses became less common
and resources for continuing education is eliminated.
- Hospital downsizing have undermined existing leadership structures and the vision the C N A
documents provide for nursing.

Framing and analyzing issues arising from the nature and conditions of nurses’ work
- not new
- Clearly, more than the temp. provision of resources or superficial changes in nurses’ working conditions
is at stake in this issue.

Historical understandings of nurses’ work

- Reviewing historical literature = get a sense that the nature of nurses’ work has been idealized.
- Implications for long term planning of health care provision.
- Many nurses now see their career as professional than rather a servititude.
Social and cultural analysis
- Priorities placed on nurses’ work and the value attributed to society and by nurses have often been
linked to economic rather than social realities.
- Must include consideration of the realities of the lives of women in our society.
- Prevailing attitudes in society suggest that work and personal lives are separate domains.
- Professional organizations and individual nurses have lobbied and continue to lobby.
- Despite a growing awareness of how professions whose members are female are disadvantaged,
decisions are being made by non-nurses.
- Dominant views of society regarding the devaluing and dispensability of older workers threaten to
undermine the contributions that nurses make.

Political analysis
- asks who benefits from this issue being resolved and who benefits from things staying the same.
- Nurses and patients will benefit from resolution from the issues.
- Employers MAY benefit from some of these issues being staying the same.
- When nurses are engaged in non-nursing work in addition to their patient care, it is the patient care, the
real work of nurses that is being compromised.

Critical feminist analysis

- directs us toward the consideration of power structures and ideologies and to the question of what it
means to be the subject of one’s own life.
- Highlights how realities, such as other people defining and controlling nurses’ work, influence how
nurses see themselves.
- As subject in their own life, nurses would retain control of their work.
- Complicit in the maintenance of power structures when they fail to make central of their own beliefs.
o Complicity = refers to nurses perpetuating power structures and unexamined ideologies that
work against them.

Ethical Analysis
- Professional codes such as C N A code of ethics direct nurses to advocate for patients in the provision
for healthcare.
- Legislative acts such as Canada Health act and Health Professions act mandate nurses as professionals to
provide competent, ethical care.
- Ethical questions are raised about the health of nurses and the healthcare provided to the patients.
o May also evolve from added responsibilities whose competence is compromised by overwork
and other burdens.

Economic Analysis
- highlights how the force of supply and demand work in a particular issue.
 - For nursing workplaces, one may explore the influence that nurses leaders have in challenging purely
cost-containment strategies when the health of Canadians is thought to be in risk.
- Sochalski reminds us that economics provide the framework for the allocation of resources and the
economics question facing nursing is not what the value of nursing care is but rather how to allocate the
resources to meet the health care needs of our patients and population.
- Difficulty = overlooking other costs.
o May waste resources.

Barriers to resolving work and workplace issues

- One of the largest barriers to making decisions about the amount/nature of work is if there is any
consensus on what nurses’ work is and what is not.
- Incomplete assessment of what nurses know and do in their practice results in nursing effort and
expertise being inadequately recognized or compensated.
- Nurses’ view of the world is overshadowed and undermined, this mindset places nurses in an
uncomfortable position of being credible.
- Second barrier = failure of Canadians to acknowledge the impact of the nature’s of nurses’ work on
nurses’ health and patients.
- 3rd barrier = staffing decisions are based on funding rather than the preparation of the nurse.
- 4th barrier = balancing of the ratio of registered nurses to aux. workers. Again, with difficulty in
assessing and distinguishing nursing work.
- 5th barrier = failure to see the link between job security and nurses’ absenteeism from work, nurses’
organizational commitment and nurses; satisfaction/dissatisfaction from work.
Chapter 19

1.
2. Since nursing is a professional and a career option, it does not depend on a particular gender. Therefore
it doesn’t matter about man or woman; they both share the same responsibilities and rights in order to
provide the best care of them. For example, placing a man for a male patient is comfortable than
assigning a female nurse. But the goal is same that is cure the patient and provide the best care for that
person according to the needs. In my understanding, I do accept the fact that, nursing is a career and
therefore I have to look at is through the career option instead of taking it personally.
3. Feminists think that it is not suitable to arrange female nurses for men. But in reality they think that
female nurses are supposed to be treated very properly as male nurses and try not to be abused
emotionally or sexually. For example, there are some critical issues since there are lots of female nurses
working than male nurses. Therefore, they have to do everything and work hard in order to give the best
out from them. They undergo stressed life and having hard time at work. If there is gender
discrimination at work place, women are affected much more than male.
4. By assigning both men and women nurses at hospital equally and let them work with each other
supportively may help to reduce the gender discrimination at the work place. Since nursing is a career,
everyone has to take it as a professional. There is nothing wrong in support to opposite gender. But it is
management’s responsibility to give the much guaranty to nurses and make sure that working
environment is not polluted with any kind of gender discrimination.
Chapter 22
Environmental Health and Nursing

Introduction to Chapter
-Globalization and global warming are beginning to be seen as having significant impact on the health of
Canadians as a result of our human connection with our environment. *We are closely linked to our
environments”
-Environmental hazards have continued to have adverse health outcomes for all humans.
-Important for nurses, regardless of their practice setting to be aware of its importance.
- As a result of our connection with the environment if it is damaged it can have adverse affects on our health.
-Chapter deals heavily with freedom from illness related exposure to environmental contamination, hazards, and
toxins that are detrimental to health.
- As our scientific knowledge around the subject changes, so does our pollution position on the subject.
- In 2005, the CNA developed a paper titled “The ecosystem and natural environment, and health and nursing:
A summary of the issues” in which they state that “The natural environment has a significant impact on our
quality of life, our health, and sustainability of our planet. And that “Increasing population, urbanization, and
industrialization are having a negative impact on the equality of the air we breathe, water we drink and food we
eat.” (p. 1)
-Increasing importance of this impact is showing in nursing education, research and in policy development

History
-This concept is not new and has been linked or talked about in nursing theories.
-Plague is an example given as an historical event of having a massive impact on the health of individuals as a
result of the environment.
-The increase of urbanization has been a result of the industrial revolution in the 1700s
Is beginning to be seen as having a major role in POPULATIION HEALTH
-Many charters, summits and agreements have been held to examine the health of the world’s population.
-Access to safe water and food, global warming, socio-political causes of and impact of poverty, and economic
disparity between nations all within the text of a “sustainable global ecosystem”
-An example of such a thing is the Kyoto Accord that involved the reduction of carbon dioxide emissions and
was agreed among several nations.
-A MAJOR CONCERN EXISTS REGARDING THE ABILITY TO POLICE THESE AGREEMENTS AND
END ENVIRONMENTAL CRIME THAT IS FUELED BY GREED AND THE SELF INTEREST OF
INDIVIDUALS, CORPORATIONS, AND GOVERMENTS.
-In all nations poorest residents tend to live in substandard housing.

Environmental Health Hazards

Around the world, life expectancy gas increased and morbidity and mortality have decreased as a result
of significant improvement and availability of safe water and sewage systems, better nutrition, and
housing. Individuals, communities, and governments need to be conscious that these gains do not
overshadow current and developing environmental problems.
-U.N agencies have undertaken the investigation of the impact these environmental health hazards pose, and in
response to the need to undertake a global consensus on the subject.
FIVE COMPONENTS IN TRACING SOURCES IMPACTED HEALTH RESULTING FROM
ENVIRONMENTAL HAZARDS
1. Source of contamination (Emissions, waste water, and contaminated deposit sites)
2. Medium through which contaminant travels (Water soil air etc)
3. Point in which person comes into contact with contaminant
4. Person animal or plant that is receptor of contaminant
5. Route of exposure (inhalation, or ingestion)
-Highlighted because it is important when assessing exposure to environmental contaminants to take a broad a
perspective as possible and take al potential factors into account.

Water Safety
- Fundamental to all life on the planet
- Areas of abundance of water, areas that suffer from shortage.
- United Nations has made improvements in the access of water and water supplies for children
worldwide. (United nations children’s fund)
- In countries such as Canada with abundance has lead to waste to this resource.
- Water you drink is a minor source of most pollutants
- Principle source of exposure to micro organisms.
- Most of our drinking water comes from public water systems
- Global warming is causing increased retention of water vapour in the atmosphere and is starting to
decrease our global supply.
- Corporations are selling bulk amounts of water to the united states and are using desalination in ocean
water to artificially produce fresh water. Environmental impact not yet known.
- Need for a safe water supply was highlighted in the E. Coli break in Walkerton.
- Reverse osmosis, proper filtration, and distillation are all process that must be used to ensure that
organisms are removed from the water supply.
- Even regions in Canada that go without a safe supply of water.
- Particular concern is for the aboriginal community in which water contamination is a serious problem
and has been linked to negative health outcomes for this population.
- Minimal improvement in Canada, as of 2001 no national regulation in Canada for water safety, an
indication that outbreaks and contamination can still occur. (linking legislation and regulation with
improved health outcomes remember this point*

Air Pollution
-Many nations of the world suffer from air pollution and has been linked to illness and death.
The very old and young suffer more from air pollution as they breath faster then middle aged adults. (Increasing
exposure)
-Wide range of negative effects from air pollution. Impaired pulmonary function, decrease in physical
performance, multiple hospital visits, and premature death.
- Asthma can be triggered by air pollutants.
-Has been linked to cardiovascular problems and cancer development.
-An increase in the incidence of asthma occurred in the 1990’s.
-Acute bronchitis and pneumonia has been attributed to summer pollutants ozone and sulphates. (Health
Canada)
-TABBACO SMOKE HAS BEEN HIGHLIGHTED AS IMPORTANT IN THIS CHAPTER
-Some solutions involve the creation of cleaner vehicles.
-A link between the destruction of ozone as a result of air pollutants has been made, causing increased radiation
penetration of the earth. (Highlights the interconnectedness of the entire concept)
- These pollutants accumulate in the food chain and are consumed.

Chemical Pollution
-Excessive use of fertilizers, pesticides, arsenic, lead and mercury has polluted the land.
-Diffuse contamination occurs through run off from fields, motor vehicle emissions and acid rain. Linked to
power plants, coal and nuclear, and factories.
-Also linked to disproportionately affecting children as a result of high surface area in lungs and increased rate
of breathing.
-Can also adversely affect children through development stages.
These chemical pollutants stay in the environment for a very long time.
-Focus on long-term arsenic ingestion (linked to skin and bladder cancer)
-Effects of long term low level exposure is unknown, but is focusing on immune suppressive effects
neurological and behavioural changes, and the roles these play initiating the development of cancer.
-Pesticides on lawns and agriculture have also become a recent focus.
-According to the CNA, risks have been associated with pesticide use, particularly in children. (an example on
how an organization making a position statement can affect the education process to address these issues,
education has been identified as a barrier to resolving this issue)
-Growing concern for those who live on toxic waste sites. (Associated with low socio economic status, as
knowledge of these contaminated sites grow standards may be changed, exposure to these toxins may
occur and may be undetected for long periods of time, exposure to contaminates may occur through
multiple pathways and enter the food chain making detection more difficult, action to curb exposure to
contaminants has not kept pace with societies ability to detect these contaminants, Canada is without
longitudinal research regarding the effects of individual contaminants as well the combined effects from
multiple sources of contamination.)

Inside Environments
-Adequate Shelter has a major effect on health.
-1 in 5 Canadians living in substandard housing. (Making it a relevant issue for our political bodies to take
action in regards to this social problem.)
-People who live in these conditions are usually single parent families; parent’s younger than 30, people with
mental health problems, senior citizens, aboriginal communities.
-Canadians spend up to 90% of their time indoors.
-Outdoor contaminants can be found indoors may contain tobacco smoke, formaldehyde, vapours from cleaning
products, carbon dioxide, bacteria, fungi mould etc.
-Health can be affected if the levels of these contaminants raises to high.
-Well insulated and closed heated buildings run a risk of contamination build-up.
-Principle contaminant of indoor environments is tobacco smoke, including side stream smoke.
-Second hand smoke accounts for 300 deaths annually from lung Ca alone.
- Environmental tobacco smoke or ETS is considered a significant cause of cardiovascular disease and death in
non smokers. (remember the larger surface area and breathing rate of children, this causes them to be
significantly effected)
-ETS has been linked to causing asthma, bronchitis etc.
-Early child hood exposure has been linked to increased pulmonary disease and Ca.
Contaminated Social Environments
- Environmental health is not limited to just pollution, hazards and contaminated environments.

- Improvised neighbourhoods with substandard housing, abject poverty, homelessness, visible signs of
substance abuse and distribution, violence and crime in the community are all examples of contaminated
social environments.

- All of these have a major impact on the physical, psychological, and emotional health.

- These social contaminates can be compounded by toxic pollutant as these communities commonly
reside on toxic sites or near industrial environments.
- We as professionals need to take into account the entire environmental context of the people and
communities in which they are working.

Barriers and Strategies

- One of the biggest barriers to achieving “environmental health” has been a lack of public knowledge or
education about the reality about the increasing health risks associated with the environment.

- The more we know, the more willing we as a society to provide the economic support and political will
to make the changes that are needed.

- One way to overcome this lack of knowledge in the public domain is for professional organizations
to take a position on these issues and to make these position statements public.

- CNA has done this. “The Environment is a determinant of health” (CNA, 2000)

- Of particular concern are the effects these hazards pose especially in the long term to developing
children.

- CNA and CMA agree that a healthy environment is fundamental to life and attention to the effects
environmental health has on people in attaining health for all

- CNA code of ethics also mentions the creation and maintaining environments that are conducive to
health and well being.

- Secondly Nurses in Canada as professionals have the power to influence political decision making
directly through lobbying members of parliament and also indirectly through publishing position
statements that exert pressures on governments, politicians, and health authorities.

- Thirdly, all nurses are in a position to raise awareness of the environmental issues that affect the
health and well being of their clients.

- Nurses have the capacity to participate and lead in the efforts to address environmental issues, the
changes in smoking practices in Canada over the last 20 years are a perfect example in overcoming the
seemingly impossible barriers related to change.
Chapter 24: Challenges for the New Millennium: Nursing in First Nations
Diversity of the First Peoples

 There are 560 First Nations in Canada

 Many of them are grouped into tribal councils, which provide greater unity, greater political power, and
combines resources among nations
 Each First Nation has its own reserve land base, traditional territories, culture, and language
 First Nations are part of a larger group of Aboriginals (composed of First Nations, Inuit, & Metis)
 The Indian Act (1876) legally defines First Nation members as “Indians”, though currently First Nations
people prefer to be called First People/Native American
 The Indian’s Act purpose is to 1) administer programs to Indians for the purpose of assimilating them
into Canadian society and 2) sets out legal definition of who is defined as “Indian”
 It’s had many revisions but its purpose remains the same  each person who is legally deemed as
Indian has a registration number to reflect their population number within their band or First Nations
community
 Some members also have “treaty” status  some First Nations signed 20 international treaties (1817 –
1929) with Britain or Canada (who represented British government at that time)
 Treaty Nations agreed to cede certain land for use and settlement in exchange for specific guarantees 
1) Reserved lands and resources for continued use and existence as First Nations
2) Specific social and economic rights to ensure continued strong First Nations
government (i.e. right to hunt, trap, & fish except for commercial use)

European Relationship with First Nations

 Colonialism (a result of colonization) is considered to be control by a power over a dependant area or

people. It also refers to policy based on such control
 First Nations had their own system of government, trade, and health care
 After Confederation, Canada began to displace First Nations to make room for incoming European
settlers
 Government policies were made to protect, civilize, and assimilate First Nations people into Canadian
society  resulted in cultural genocide (destroy their culture, traditions, etc.)
 The inherently oppressive and suppressive nature of these policies has had far-reaching negative effects
on First Nations people mentally, spiritually, and physically. It has also affected their (self-)governance
and cultural identity

Cooperation Among Nations

 Initially the relationship between First Nations people with the French, and then the British, was one of
mutual respect and tolerance
 Social, cultural, and political differences between these societies were maintained
 This tolerance reflected how First Nations related with each other  they formed alliances and had good
relations with diverse groups to access and distribute tribal resources

Colonization and the Effect on First Nations

 No single event marked the beginning of colonial practices  they began with attitudes of the time that
laid foundations for a series of actions that deemed First Nations as inferior beings
  Government law still carries this attitude today  perpetuates a colonialistic attitude
 The Indian Act helped establish the reserve system where Indians were placed in isolated, fixed
locations where they could be educated, converted to Christianity, and trained to be farmers
 Goal was to eradicate First People’s values through education, religion, new economic and political
systems, and a new concept of property
 An Indian could become”enfranchised” by being educated, having no debt, and showing good moral
character  he would receive portion of land from the reserve and get the rights of a normal citizen
(such as the right to vote)
 The government assumed First Peoples would cut ties to their roots and embrace colonial living and
values
 British North American Act (1867) made Canada into a nation and put First Nations and the lands
reserved for them unto federal control
 The Indian Act was amended almost yearly to deal with unforeseen problems and because First Nations
people were resisting the changes to their values and cultural ways
 Changes to the Act were also performed to:
o Erode protected status of reserve lands: achieved by leasing reserve lands to European settlers if
the Indian owners weren’t farming it
o Undermining traditional political processes used by First Nations communities: federal officials
controlled when elections were held, they could interfere with community’s decisions, chief and
councilors had a narrow scope of policies they could affect, could remove chief or councilors
based on criteria that were open to interpretation, and only males over 21 years could vote
o Suppress traditions and values of First Nations: banned the performance of traditional
ceremonies and restricted movement from one reserve to another. This kept First Nations people
from organizing and sharing information/traditions/beliefs
 Residential schools were the biggest insult of all  took First Nations children from families and tried
to instill Christian/North American beliefs into them
 It left rippling, cumulative, intergenerational effects on First Nations communities  loss of culture,
language, spirituality, identity, pride, self-respect, and ability to parent
 Communities felt trapped between remaining traditional ways and fear of bringing more mainstream
Canadian culture into reserve life
 Still has destructive effects on families and communities  repercussions for the relationship between
First Nations people and their healthcare providers

Cultural Resurgence of First Nations and Community Development

 In 1951 the Indian Act was revised and allowed First Nations to travel between reserves  they began
to organize, discuss issues, and look for potential ways to change community conditions
 At that point, federal policies controlled most aspect of their lives (i.e. a woman could lose their Indian
status depending on who they married)
 First Nations people created national and provincial organizations that challenged the belief that the
federal government’s ways were the only ways to deal with First Nation’s issues
 First Nations people wanted to shift away from being wards of the government and begin to govern their
own affairs  basis for developing community-specific health and healing systems

Miyupimaatissium: Being Alive Well

 Miyupimaatissium (Being Alive Well) is seen as an interdependent relationship people have with the
natural world and with keeping one’s spirit strong
 Miyupimaatissium is a holistic concept encompassing people in relation with their environment and all
that is within the universe  holism is an integral part of Aboriginal health and healing systems
 Health Status of First Nations People in Canada

 The First People had good health in North America  with the coming of Europeans, decimation and
extinction of many First Nations followed
 Infectious diseases were devastating to the health and cultures of First Nations people
o Reduction in population
o Strong sense of personal and collective loss
o Declining fertility among infected women; also unable to carry pregnancies to term
o Lack of partners to conceive with
o Loss of family  Loneliness, grief, and depression
o Loss of leaders/warriors/hunter  lack of protection, cannot defend territories, loss of food
gatherers

Use of a Population Health Approach to Address Inequity

 Look at the social determinants of health to see how community health can be improved
 Many First Nations identified the significance of clean drinking water, safe, uncontaminated food,
reliable sanitation, comfortable housing and workplaces, and adequate employment as essential for the
health of the population
 The health of a community is largely determined by the food available, nature of the environment, and
behavior of its residents
 Poverty is also an important issue  due to low socioeconomic status, marginalization, and imposition
of alien values on local and regional culture
 Health is more than physical wellness  has social and political aspects, as well as relationship a person
has with their environment
 Community development is an avenue for facilitating active participation of each member in a
community
 Their goal is to give control back to the community and get enough resources to design health, social,
and political systems that reflect their culture
 Aboriginal people want access to health and healing services and to achieve the same level of health
equal to that of the general Canadian population

Access to Healthcare: A Fiduciary Responsibility

 Federal government has a fiduciary responsibility to ensure the delivery of health care to the members of
the First Nations community
 Federal government has not acknowledged this responsibility so far  any healthcare to be delivered to
First Nations is based on the medicine chest clause of Treaty Six (1876). There are two parts to the
clause
1. If the Indian people suffer famine or pestilence, the Queen (government) will provide relief
according to her chief Superintendent of Indian Affairs
2. A medicine chest will be kept in the house of each Indian Agent to the use and benefit of Indians
at the discretion of the Agent
 Treaty Six reflected relationship between the government and First Nations people (colonial)

Healthcare in Northern and Isolated Communities

 From the end of the 19th century, semi-trained government agents, RCMP, and missionaries provided
health care
  First Nation healthcare was not a priority and was largely ignored until the government began to develop
a system of primary care clinics, a public health program, and regional hospitals, mostly done to stave
off the threat of TB to the general Canadian public
 Traditional medicine and healing was devalued  seen as witchcraft and sorcery  traditional healers
went underground with their practices
 Nurses and doctors (employed by federal government) became integral to providing healthcare since the
start of the 20th century
 Established nursing station model  field nurses provided primary care with only radio contact with
physicians. Patients moved to southern hospitals if they needed more treatment
 Currently many nurses also collaborate with community health representatives & social workers

Widening the Scope of Health: A First Nations Perspective

 First Nations protested that the government had violated treaty rights by trying to change the terms
without consulting them
 They claimed the government was trying to reduce noninsured health benefits such as prescription drugs
and eyeglasses, dental work, and transportation costs for medical services
 In 1979 the government acknowledged that:
1. Community development was key to improve First Nations health
2. Continuing responsibility of federal government for health and well-being of First Nations
people and Inuits
3. Essential elements of Canadian healthcare system (federal and provincial jurisdiction)
 Justice Thomas Berger (1980) suggested First Nations consultation in development of community
controlled healthcare  seen as “radical” thinking by some in the government
 Canadian government continued to refuse legal responsibility for Indian health (i.e. exclusion of
noninsured health benefits)
 The government only transferred control of certain health programs to First Nations (not upholding
recommendation to create culturally-appropriate, community-based health practices)  education
required to develop culturally appropriate systems wouldn’t be funded (no upgrading and clinical
training for nurses and others)

Transfer of Healthcare Services to First Nations

 As of March 22, 2002, 284 (out of 599) First Nations community (who are eligible for transfer) have
taken over administrative responsibilities for healthcare services (41 communities are in the process of
transfer)
 These communities are the ones who hire nurses and other Healthcare Providers
 The extent and manner in which traditional view about health is used in developing and running the
system depends on each community
 There will likely be many variations of healthcare delivery systems for First Nations  self-
determination is essential for development of community healthcare systems
 The Royal Commission on Aboriginal Peoples (1996) propose all Aboriginal health and healing systems
embody four characteristics:
1. Pursuit of equity in access to health and healing services and in health outcomes
2. Holism used in approaches to problems, their treatment, and prevention
3. Aboriginal authority over health systems  community control when feasible
4. Diversity in design of systems and services to accommodate differences in culture and
community realities

Climate for Change: Nursing in First Nations Community

  Nurses play a vital role in delivery healthcare  create more effective ways of delivering nursing care
that reflects the community’s health and healing practices/beliefs
 Economic development and participation in transfer of healthcare services can be vehicles for change
 Nurses should therefore be aware of the First Nations community/tribal council view on health and
healing, what is being planned, and what has already been done
 This info provides context to the nurse and an understanding of the community’s healthcare priorities 
population health approach
 Many challenges First Nations communities face are:
1. Scarce resources: government capped increases in spending for Aboriginal healthcare
2. No real autonomy for First Nations communities that have taken administrative responsibility
for health services: limited resources, education, training, and planning to obtain trained
personnel to fill specific roles in desired healthcare system developed by the community
3. Emphasis on curative processes: Limited resources are focused on treatment only
4. Emphasis on physical health: Ignores holistic approaches and culturally-based programs
5. Lack of health promotion and disease prevention: Focused on treatment
6. Lack of health service integration: Lack of coordination between federal, provincial, and
community health services. No unified approach to address determinants of health such as
economic development, employment, housing, and education.
7. Diminished traditional roles for women: Reflecting western models, indigenous role of women
as central in sustaining health is weakened
8. Legacy of enforced dependency: Communities have had to depend on government-directed
approaches to health; therefore, they had no opportunities to deliver health their way
 Issues that can affect the delivery of nursing care to First Nations are:
 Population demographic in relation to healthcare needs
 Effects of transfer of healthcare services and community development
 Development of cultural competence through education, research, and practice
 Barriers to accessing services in the health care system
 Scarcity of First Nations people in health professionals

Population Demographics

 Compared to the Canadian population, First Nations population are projected to increase by 40% and
remain youthful
 It is also projected that more First Nations people will be living in reserves compared to off-reserve
 Demographic profiling serves as a valuable frame of reference within which to determine appropriate
healthcare programming now and in the future
 Fertility and mortality affect the age and sex configuration among First Nation peoples
 Though still higher than general population, fertility rates have decreased since 1960 due to increased
use of contraceptives  size of Aboriginal families decreased numerically, and native women are
having them later and spaced farther apart
 Mortality rates for First Nations have declined since turn of the 20th century, but it’s still shorter than the
general populace
 The increase of First Nations people’s life expectancy is due to decreased in infant mortality (still higher
than national average) and the influx of Bill C-31 registrants, who tended to be relatively young
 Bill C-31 amended the Indian Act by eliminating certain discriminatory provisions (i.e. Indian women
losing their status when marrying non-Indians)
 As a result, 105,000 people had regained their Indian status
 Infant, child, and teenage health programs are essential to prevent chronic diseases from developing
during middle years in First Nation adults
 First Nations people tend to migrate bi-directionally (to and from reserves and large cities) but more are
moving to reserves  more people to serve
 Women, younger families, and single-parent families are the most mobile (most move to cities)

Nursing Issues Related to Transfer of Healthcare Services

 When administration of health services were transferred from federal control to tribal/community
control, nursing service delivery also became the responsibility of the community
 Many were unprepared for setting up an effective system of nursing care delivery (communities didn’t
have the experience, expertise, or funding)
 Some of the pertinent issues are (Aboriginal Nursing Association of Canada [ANAC]):
1. Developing Best Practice Guidelines for practicing in Aboriginal communities
2. Supervision of nurses in First Nation communities
3. Community orientation for newly employed nurses
 Some key components for nursing services are:
1. Nursing management and supervision
2. Orientation
3. Ongoing education
4. Professional development
5. System for performance appraisal and evaluation
6. Liability coverage
7. Standards to practice nursing in advanced roles
 Standards of practice are regulated by provincial nursing organizations but only a few have guidelines
for use by employers and nurses in advanced nursing roles
 The nursing services provided before the transfers did not match the nursing services needed afterwards
 Communities developed systems through trial and error; some had resources to re-design nursing
services while other communities struggled in isolation
 Recommendation to share information between communities who had already transferred services, those
in the process of transferring, and those considering transfer
 ANAC identified key issues related to transfer of healthcare to First Nations communities:
1. Nurses, employers, and professional nursing associations lack understanding about liability
coverage as it pertains to scope of [advanced] practice (each province has their own rules)
2. Nurses are uncertain how to support their community –employer in the design of new programs
(unsure how to fund and find skilled personnel who work in programs that incorporate traditional
and cultural knowledge)
3. New nurses are unsure how to become involved with their communities (can be negatively seen
as being part of Western healthcare, or are only there to “parachute”  there for a short time and
then move elsewhere)
4. Nurses can become unsure where accountability for a program lies (First Nation community or
federal government?)
5. In some communities, nurses must report to non-nursing supervisors and/or community leaders
 may accidentally overturn nursing decision, therefore eroding quality of care
6. Nurses may not be aware that nurse managers are key to creating community-based nursing
services (they interact with community leaders, health services directors, community members,
and nursing staff)
 Other issues are:
1. Nurses may feel lack of respect by the community when there is interference with the nurses’
decisions
2. Retention of First Nations nurses  depends on quality of practice environment
3. Employers may not be aware of the need for professional performance evaluation

Cultural Competence and Effective Healthcare Programming

  For many nurses, working in culture not their own presents opportunities to positively affect nurse-
patient relationships
 Nurses who see themselves as partners with the community recognize that community strengths can be
built upon to organize and improve the health of the community
 Deeper understanding and patience will help convey an attitude that will help First Nation patients
manage their healthcare needs
 Cultural competence includes an understanding of perspective and behaviours patients have about
health, illness, family healthcare decision, treatment expectations, compliance with treatment plans
 Nurses should try to fit into the patient’s worldview  can also use this in prevention and treatment of
chronic diseases

Access to Services

 First Nations people experience a sense of isolation and marginalization when using general Canadian
healthcare services
 This led to some not use it willingly or avoiding it
 Isolation can stem from having to leave home/community to travel great distances, but also because they
often face racism, prejudice, and insensitivity by HCPs
 Should assess the experiences of First Nations using general health services  identify barriers and
supports  apply health policies and practices to address those issues
o It’s important to ask Aboriginal clientele about themselves, their needs, and priorities in
accessing healthcare services
o Provide support in tandem with services
o Culturally supportive services
o Use patient health outcomes as indicators for effective services
o Be familiar with socioeconomic issues relevant to patients
o Be aware of daily living contexts of patients
o Knowledge of the history of community social supports
 Nurses are ethically to respect culturally diverse clients
 To provide patient-centered care, nurses must recognize patient’s culture, the nurse’s culture, and how
both will impact nurse-patient relationship

Chapter Reflections

1) How have teachings regarding First Nations healthcare been included in your nursing program?
None, as far as I can remember ….
Where are you able to obtain further information?
At the end of this chapter, there are sites listed where more info can be obtained

2) Using determinants of health, examine impact on the health of First Nations members and their
community.
Poverty, lack of housing, food security (high prices and mostly canned/processed food on reserves),
unemployment, lack of rights (federally controlled), racism, environment (some reserves are isolated,
infertile land, cold, etc), lack of education, lack of physical activities, lack of social support (i.e.
community centers)  negative health impact

3) Name four healthcare needs in First Nation communities and some strategies to deal with them
Lack of education initiatives for more teachers and facilities on reserves. Help train community
members to become teachers. Give incentives for children to attend school (grants, scholarships,
rewards). Teach healthy eating using culturally relevant foods. Perform other health teaching using
culturally relevant information.
 Lack of nurses/health professionals  encourage the training of community members to become nurses
or other health professionals, create BPGs for working with First Nations, educate community leaders
about roles of nurses and need for evaluation

Lack of culturally congruent healthcare  develop feasible plans on how to provide community-based
health care, lobby for more funds, appeal to the community to find/train healers that can perform desired
healing processes

Lack of health promotion and disease prevention collaborate with communities to create strategies for
health promotion and disease prevention (i.e. screening, immunization). Educate community members
and lobby for more resources needed to achieve goals

4) Using demographic data, determine two health issues that could become priorities in 2020.
Unhealthy lifestyle choices of teens will probably result in an increase in chronic illnesses (diabetes,
hypertension, etc.) in their middle aged years by 2020 in reserves. In cities, women and younger families
face fertility and pediatric issues.

5) Identify 4 approaches that will enhance nurse-patient communication with a First Nations person
Patience, willingness to listen and ask patients their POV, respect, some basic understanding of their
culture
Chapter 20

When Difference Matters: The Politics of Privilege and Marginality

Objectives:

1. Discuss multiple interpretations of difference.

- Philosophical approach to understanding difference
o Thoughtfulness; question what we already know; how we perceive and interpret our world
o eg. Difference between men and women, rich and poor, and race and cultures were informed
in their own ways of thinking the properness of social roles and hierarchies
 Generated by people who occupied positions of privilege in the same social order
they sought to justify
o Eg. People doing the drudgery (hard work routine) are in their proper place or whether larger
social and economic process limit their opportunities

2. Discuss social, political, and historical influences on our understanding of difference.

- Social
o Difference is related to awareness of the growing complexity of our societies, to increasing
racial and ethnic diversity, and to the persistence of social inequities
- Political
o Social, political, and economic arrangements create and sustain poverty
o “poor people are responsible for their poverty by virtue of their own inadequacies”
- Historical
o False Universals
o Eg. Man is = to human and women is not equal to man; therefore women is not human
 Femaleness is different from male standard that mattered in terms of their rights and
privileges in society
 Today’s society, women and men are = (but are they really?)
o Eg. Race: we can see how people have described race

3. Explore the concept of difference as a relationship.

- Dualism and Difference
o Western societies arrange many important features of the world into oppositional and
exclusive dualities
o Difference is organized in crude, yet highly effective way
o One group is dominant and other is recessive (eg. Rich vs poor; black vs white; straight vs
gay; man vs woman)
 o Dualistic way of thinking limit our understanding of the multiple and shifting ways we are
positioned in relation to others
- Difference as a Relation Between Margin and Center
o Our identification of difference can be understood as the recognition of a particular relation
between margin and center and between dominant and subordinate groups
o Categorize according to gender, race sexual orientation, and class
o Differences between individuals and groups become important political issues when they
involve relations of power

4. Critique the concept of difference as deviance.

- Processes of Differentation / Difference as Deviance
o Nurses: coming to understand the ways in which marginalized popultions are related to
dominant social center means theorizing how apparently neutral differences are the result of
structures of inequality or patterns of disadvantage affecting particular groups in particular
ways
 Having norms in physiological, social, mental aspects create inequality
o Eg. Single mothers and elderly women, greatest likelihood of living in poverty (women of
color, immigrant women, First Nations women, and women with disabilities)

5. Identify assumptions underlying ideas of normality.

- Difference as Deviance: Assumptions of Normality
o With the “supposed norm”, an individual who is not ‘WNL’ and is deviated from the norm,
these individuals are so called ‘diseased’ according to society
o Since ideas of normality are most often produced and employed by those in positions of
social dominance, the experience and values of dominant groups tend to represent that which
is then thought to be normal for everyone
 Eg. Many school-aged children were labeled feebleminded or subnormal in the early
decades of the 20th century after failing to pass standardized intelligence tests
 This test reflected the experience and values of the dominant group who
produced them
 Children not in this ‘dominant’ group will not do well because the questions
asked are outside of their experience