Collectively, nurses need to be willing to work together to reach good outcomes for their patients and for themselves. Canada has fine examples of nurses involved in collective action to make a difference through both provincial nursing organizations and through the CNA, including specific foci during provincial and federal elections.
Nurses also need to use the knowledge gained through nursing education and nurse–patient rela- tionships to focus attention on the determinants of health. Frank and Mustard (1994), and many before them, demonstrated the relationships between illness and socioeconomic factors. In addition to noting how the job hierarchy influences health, these authors suggested that “ . . . an individual’s sense of achievement, self-esteem, and control over his or her work and life appears to affect health and well-being” (p. 9). As nurses come to know their patients, they see the effects of these variables on patient well-being and on their own health. That is important knowledge to be utilized in dialogue with politicians or bureaucrats.
Working collectively toward the goal of primary healthcare for all is also critical work for nurses today. Nurses in advanced nursing practice make a difference in patient care and can improve the health system overall. The persistence of nurses in moving toward patient-centered goals continues to make a difference within specific areas and has a spillover effect over time (Pauly et al., 2004).
Individually, nurses can also be ready to speak, to question, and to spread hope (Broughton, 2001). As nurses, we may not have all the answers but we do know most of the questions. With regard to information about the political economy discussed earlier in this text, an individual nurse may not have complete knowledge but can question politicians and government bureaucrats, as well as other civil servants, neighbors, friends, and colleagues to make them think and potentially to influence their actions however large or small they may be. This is to move against a place of powerlessness.
SUMMARY
N
urses need to understand what drives today’s healthcare system, particularly in regard to the underpinnings of Medicare, the international economic manipulation of resources available for healthcare, and the related disempowerment of healthcare professionals.The same value conflicts that we see today were inherent in the development of Canadian poli- cies and programs since their inception: a focus on individual responsibility and self-reliance versus collective responsibility; a free market system versus more socially oriented collective policies and
programs in healthcare (the privatization debate); an emphasis on scientific discovery and techno- logic imperatives versus humanism and care for the disadvantaged; and those who believe that all have equal opportunities to healthcare versus the reality that gender, race, and class differences affect the way in which healthcare is delivered.
These are some of the influences that keep Canada’s healthcare system focused on primary care as opposed to primary healthcare: “Primary care is a medical concept referring to a situation wherein the physician provides diagnosis, treatment, and follow-up for a specific disease or problem” (CNA, 2000b). Primary healthcare, as adopted by WHO in 1978 as the basis for the delivery of health serv- ices, most effectively involves both “a philosophy and an approach” to the way health services are deliv- ered. It includes health promotion, disease prevention, curative services, rehabilitative care, and supportive or palliative care (CNA, 2000b). Primary healthcare involves a shift from traditional prac- tices and power dynamics in healthcare to a system in which all health professionals are utilized to their maximum potential to effect good patient outcomes in care. NPs, advanced practice nurses, and staff nurses alike are able to practise to their full scope of practice in this model.
This is the model of care Canadian nurses have sought for almost three decades, and it continues to be a model worth pursuing. In fact, it is one of the CNA’s two key goals in this millennium; the other goal is achieving improved quality of work environments for nurses.
Nurses can influence change by attending to the history, current status, and future projections for healthcare; by being listening and caring caregivers; and by taking action individually and collectively to pro- mote greater attention to social determinants of health and better healthcare provision for their patients.
As nurses, we need to be clear about our own values and opinions and be able to stand by them so our voices can help shape better approaches to healthcare. If we are not prepared to do so, nursing and nurses will have little to say in the healthcare system of tomorrow.
52 ● NURSES, NURSING, AND THE HEALTHCARE SYSTEM
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1 In what ways do you think the Canadian healthcare system would have been different and less subject to political influence if the Fathers of Confederation had chosen to assign principal responsibility for healthcare and education to the federal government rather than to the provinces?
2 If medical care insurance had been introduced before the introduction of hospital insurance, what differences might we have seen in the formation of health facilities? What contributions do you think this might have made in controlling the costs of technology? Would primary healthcare likely have become the norm?
3 Do you believe that healthcare costs are out of control? Why or why not?
4 In reflecting on what you know about nurses’ individual or collective actions to influ- ence better healthcare, what types of knowledge have they utilized to influence change?
5 To what degree have you felt powerless or powerful against business interests in healthcare? Why have you felt that way?
Canadian Nurses Association www.cna-nurses.ca
Health Canada www.hc-sc.gc.ca
Canadian Health Services Research Foundation www.chsrf.ca
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Dr. Judith Shamian’s leadership has been instrumental in influencing and developing professional policy to move forward the agenda of nursing and patient care, influencing healthcare all levels. (Used with permission.)