This era has seen continued work and progress in the area of nursing regulation. In the mid-90s, the Alberta Government began the process of developing umbrella legislation for all health professions. In a response to ongoing concerns expressed by AARN about the legislation, the chair of the implementation committee said AARN acted as a “catalyst for bringing different professions together to discuss common concerns.”
AARN successfully lobbied for an amendment to restrict the ability of unregulated workers to carry out activities that carry a significant degree of risk and the Health Professions Act (HPA) was finally proclaimed in 1999. During this period, AARN made progressive steps in anticipation of the requirements of the HPA including a review of its conduct processes and the development of a continuing competence program.
Over the next five years, AARN focused on drafting a new regulation for registered nurses under the HPA to reflect updated policies in every area of nursing self-governance. These include registration, discipline, continuing competence and restricted activities. The process required intense consultation with employers, government and members and on Nov. 30, 2005, the newly named College and Association of Registered Nurses of Alberta, celebrated the proclamation of the Registered Nurse Profession Regulation. This regulation marked another significant milestone in the history of registered nursing in Alberta by requiring all Alberta graduates to obtain a baccalaureate degree in nursing.
The evolution of registered nursing and of health care is relentless, and in 2007, CARNA Provincial Council directed the organization to pursue revisions to the section on restricted activities. These included RN prescribing, the ability of RNs to order and apply X-rays and the ability of nurse practitioners to order radiation therapy. There has also been work on revising the continuing competence program and in 2010 the development of a jurisprudence requirement began. This requirement will ensure that nurses can demonstrate understanding of the legislation that governs registered nursing in Alberta. CARNA continues to work with Alberta Health on these and other changes to the Registered Nurse Profession Regulation. In anticipation of the proposed changes, CARNA has already reviewed other RN prescribing programs across the country and around the world and begun work on the necessary planning and preparation to accommodate RN prescribing.
In response to changes in the broader health-care landscape, the requirements for entry-to-practice have continued to evolve. One of the most significant changes is that a baccalaureate degree has become the minimum educational requirement for initial entry-to-practice for registered nurses in Alberta. CARNA has supported the idea of baccalaureate entry-to-practice since 1979, to support entry-level nurses working in an increasingly complex health system. AARN presented the decision to make the baccalaureate degree a requirement starting Jan. 1, 2010 to the Health Professions Advisory Board in 2003. This change only applied to new Alberta graduates entering the profession and didn’t change the status of experienced nurses who originally entered the profession with a diploma. However by 2010, for the first time, the proportion of nurses working with a baccalaureate was higher than those with a diploma.
I was part of the first cohort to sit and write for the NCLEX, which is the new, national Canadian exam.”
Mia Torres, BN, RN, 2014 Graduate of the University of Calgary Faculty of Nursing
The entry-to-practice exam for registered nurses has also recently changed. In January 2015, the first National Council Licensure Examination (NCLEX-RN) in Alberta was administered. Replacing the pencil and paper exam that was used before, this exam uses computerized adaptive testing, which assesses competency based on the difficulty of questions answered, rather than the number of questions. Based on how a writer answers one question, the computer follows with a harder or easier question, continuing its adjustments to determine the writer’s level of knowledge more specifically. This type of testing is becoming more common in many fields and is also used for the Licentiate of the Medical Council of Canada (LMCC) exam that medical graduates write and a number of standardized admissions tests like the Graduate Management Admission Test (GMAT) for business students.
The current era has continued to face a chronic shortage of registered nurses and other health professionals. The health-care system has been strained and Albertans have had to deal with long wait times and trouble accessing care. One strategy to address these issues has been to move towards a community-based primary health-care system. Not unlike the travelling clinics from the era of district nursing, this model takes advantage of the skills of different health professionals working collaboratively to treat patients and to provide support around other socioeconomic factors by focusing on health promotion, screening and chronic disease management. This model has been long-supported by Albertan RNs who began campaigning for direct access in the 1990s.
As the demand for, and interest in, primary health-care grew in the mid 1990s, so did the interest by Alberta Health in nurse practitioners (NPs). NPs are registered nurses with graduate education and advanced clinical training. Well-suited for work in primary health-care, In Alberta, all NPs are authorized to assess, diagnose and treat a wide variety of illnesses and injuries. They can also prescribe medication, perform treatments and interventions. By December 2015, all NPs in Alberta will also be authorized to prescribe controlled drugs and substances. This long sought milestone required changes to federal legislation followed by extensive consultations between CARNA and stakeholders. In 2014, CARNA to introduced new educational requirements for NP registration and processes to include NPs in the Alberta Triplicate Prescription Program to track the use of certain drugs with potential for misuse or abuse.
So it’s not necessarily that I was spectacular, or I was diagnostically brilliant, I was human.”
Charissa Elton-Lacasse, NP
In 2001, the Taber Health Project was launched as a pilot project to improve health-care services in the region. It relied on an expanded role for RNs and alternative methods of organization, delivery and physician payment. After the model was introduced, emergency room visits decreased and hospital stays became shorter for those patients who were admitted. Nurse practitioner Mary Nugent developed the Well Woman Clinic to help foster women’s health and created learning packages to help patients get informed on a wide range of areas including breast cancer and smoking cessation. The diverse team of health-care providers worked collaboratively and shared their knowledge in pursuit of change.
At the St. Albert and Sturgeon Primary Care Network in Central Alberta for example, RNs currently provide direct patient care, chronic disease management and patient education as well as serve as case managers who coordinate interdisciplinary team efforts. By working together, nurses and physicians are able to see more patients each day and the proactive approach to chronic disease management can help to reduce complications and resulting patient visits.
Have a question about your baby’s fever at 2 a.m.? Who are you going to call? Every day, thousands of Albertans access the expertise of registered nurses from the comfort of their own homes for health information from babies to seniors and everything in between. Thanks to the lead role played by registered nurse Marianne Stewart and retired member Shaunne Letourneau, Health Link Alberta received its first call in Edmonton in September 2000.
Today, Health Link includes nurse tele-triage, tobacco-cessation counseling, pharmacist and dietitian access, and information and referral to programs. This service is available toll-free, 24/7 to all Albertans. Nurses ask questions to assess symptoms to provide reliable health advice that is focused on the needs of the caller. By 2010, Health Link had received over 10 million calls and helped an average of 300 Albertans avoid a trip to an emergency department daily. In 2014–2015, Health Link responded to more than 800,000 calls.
In 2015, Health Link introduced specialized dementia advice so that callers can be referred to a nurse specialized in dementia care for additional support when needed.
Stewart and Letourneau worked with numerous stakeholders to implement the project in the eight months prior to launch. Today, Stewart continues to provide nursing leadership and direction in Alberta’s Provincial Primary Health-Care Program. Letourneau was director at Health Link Alberta when she retired from registered nursing in 2013.
In 2000, the Edmonton area was hit with an outbreak of meningitis. The regional health authority launched a campaign to vaccinate 168,000 children between ages 2–19 in just two weeks. At its peak, this unprecedented campaign employed about 500 nurses, including some who came in from other regions to help. Health professionals in the health region west of Edmonton also set up a vaccination program that reached a total of 14,107 people with RNs on hand, not only to vaccinate participants, but to provide them with follow-up information and help with site coordination.
Not too long after the meningitis outbreak, the worldwide Severe Acute Respiratory Syndrome (SARS) epidemic prompted emergency preparations across the country. In Alberta, the idea of setting up alternative treatment spaces emerged. While the idea of curbing staffing shortages by having registered nurses prescribe medications was brought forward, it wasn’t fully developed at the time.
When the first wave H1N1 pandemic hit Canada in March of 2009, Alberta Health Services (AHS) opened up an influenza assessment centre in a remote area. By October, the number of patients had increased and more treatment spaces were to be opened in remote parts of the province and in communities with high numbers of patients. In order to improve efficiency, AHS decided to seek an emergency ministerial order to authorize RNs to independently prescribe the antiviral oseltamivir. To enact this special authorization, key stakeholders were called together. CARNA’s role as the RN regulatory body was to provide the parameters around RN prescribing that would ensure public protection through safe, competent RN practice. The focused partnership of the ministry, CARNA and AHS resulted in establishing the RN prescriber role over a few days including a clinical decision-making tool and patient assessment and documentation tools. By the third day after the first influenze assessment center (IAC) opened, RN prescribers selected for the program had completed the orientation and had a protocol needed to use their assessment and intervention skills to deal with a variety of health issues. Often, patients were found to have risk factors that required additional nursing care related to primary conditions such as asthma or diabetes. The IACs were closed after a month, and a survey sent to IAC staff suggested that the addition of RN prescribers had improved patient flow, allowed physicians and NPs to focus their time on the sicker patients and enabled Albertans to have prompt access to antiviral medications.
It was a bit of a surreal experience.”
Nurses connect with many people in their work and help fill in gaps in the provision of health care. In their interactions, they are able to get a broader, more complete sense of a patient’s health and circumstances.
According to Statistics Canada, one-in-five Canadians report that they are or have been in an abusive relationship. Domestic violence can have life-long health implications for victims and is an often-silent issue that nurses have a unique opportunity to raise proactively in their assessment of patients. Emergency department and urgent care centre nurses in Calgary participated in domestic violence intervention training on how to bring up the topic, provide patients with a safe space for disclosure and educate them about the impact abuse can have on their overall health.
Our scope of practice as registered nurses is really amazing.”
Mia Torres BN, RN, 2014 Graduate of the University of Calgary Faculty of Nursing
Public health nurses are also able to make connections with families and communities. They can gain insight into where support is needed, and facilitate collaboration among stakeholders to address a broader range of health and community issues. For example, one school nurse in Calgary noticed more and more high school students were attending school hungry. The issue was too great for the school to address on its own, so the nurse brought in local human services agencies to work together to find a way to provide nutritious food to high school students in need city-wide.
Nurse navigators also provide a unique kind of support to patients. Still a relatively new role in Alberta, a nurse navigator guides patients through the health-care system. The program at Edmonton’s Misercordia Community Hospital supports patients who are newly diagnosed with breast cancer. Whether referred by a physician or self-referred, patients and their nurse navigator review their treatment plan and address questions and concerns. Nurse navigators provide resources as well as contact information for other support networks. Patients can decide what level of continuing contact they’d like after their initial meeting, and the program operates with an open-door policy and the opportunity for in-person appointments or regular phone calls.
Alberta’s population is aging. The Government of Alberta projects that by 2031, one in five Albertans – over 923,000 people – will be seniors. CARNA recognizes the unique perspective that RNs bring to advocating for the care of the aging population. A review undertaken in 2012 identified strategies and potential actions to optimize and support the health and well-being of older adults in Alberta.
Recently, some tactics for improved care of older adults were put in place at the Killam Health Centre’s continuing care facility. RNs led the change from task-oriented care to resident-focused care as they took on the role of case managers for groups of residents that facing similar health issues like dementia, chronic lung disease and congestive heart failure. Each case manager pursued extra training in specialized areas so they could implement best practices of care. The RNs follow the care and treatment of the residents assigned to them, which allows for a more proactive approach for solving problems. They also connect with families regularly to address concerns.
Building on the momentum of changes in education that have occurred over the years, collaborative and specialized programs have continued to expand. There are currently many more options available to students interested in studying nursing than ever before.
One such specialized program is the Support Program for Aboriginal Nursing Students (SPANS) in Lethbridge. Launched in 2007, SPANS aims to help address the shortage of registered nurses on reserves by supporting students as they prepare for and participate in the Nursing Education in Southwest Alberta program in Lethbridge. It includes a pre-nursing program to help students complete prerequisites and engages aboriginal elders, who lead a Blackfoot culture orientation for faculty. Students can take part in a mentorship program throughout their degree and can access tutoring and a social network of peers. They also have the option of completing their practicum placements in their home communities and can receive financial support for travel and lodging.
In 2003, Grande Prairie Regional College began to offer a post-RN degree program. Through distance learning and evening or weekend classes it allows RNs who hold a diploma to earn their baccalaureate degree in nursing while continuing to work full time. The program uses context-based learning courses in which students investigate, research and discuss situations in a way that allows them to integrate what they’re learning with knowledge they already have from years of working.
There have also been a number of collaborative education programs available in the province. In the early 2000s, the East Central Health region partnered with Grant MacEwan College to provide rural program delivery. They used video conferencing and found qualified faculty from rural areas. The program helped to increase the number of RNs working in rural communities – a role that is often difficult to fill. Currently, the University of Alberta partners with Grande Prairie Regional, Keyano and Red Deer Colleges to allow students in those communities to study locally while earning a degree from the University of Alberta.
We were never afraid to try new things, and I think that's a characteristic of nurses in this province.”
Dr. Pauline Paul
One government strategy to address the ongoing nursing shortage has been to recruit nurses from other parts of the world. With an increasingly mobile, and global workforce, regulators are challenged to assess the equivalence of the qualifications of applicants educated outside of Canada. During the 2005-2006 practice year, CARNA only received 222 applications from internationally-educated nurses (IENs), but by the next year, 1,012 IENs applied – a number that more than doubled in the 2007–2008 practice year, with 2,339 applications from IENs.
In 2010, a slowdown of hiring led to a decrease in the rate of applications, providing an important opportunity for CARNA to review and reflect on assessment practices. In 2012, CARNA initiated a comprehensive analysis of past IEN application data and registration outcomes gathered over the previous five years. The goal of the five-year project is to improve the efficiency and quality of the assessment of IEN applications.
The increase in IENs is not unique to Alberta, and applications for registration have increased Canada-wide. Over a period of eight years, CARNA collaborated with nursing regulators across the country as a member of the National Nursing Assessment Service (NNAS) to coordinate a consistent national approach providing a single point of entry for IENs to be assessed for professional nursing in Canada. The online portal was launched in August 2014 and within a week nearly 800 applicants had signed up.
The nursing practice in Canada has really interested me. It’s more focused on the patients and more time is given to take care of them.”
The influx of IENs has contributed to a more multicultural and global workforce, but that isn’t the only change to nursing demographics. Gender diversity among Alberta RNs has steadily been increasing over the past two decades. While still a predominantly-female workforce, the percentage of male RNs prasticing in Alberta has increased from just over two per cent in 1998 to seven per cent in 2014. There have also been changes to the age of nurses working in Alberta: over half of all registered nurses who are working are over the age of 41 – a stark contrast to earlier eras when many nurses left the workforce upon getting married.
When I first started, I was more nervous about how I would be perceived in school, and as a student you’re not super confident in the way you carry yourself as a nurse in general.”
Tyler Hume, RN, Founder of the Nursing Guys Club at the University of Calgary
One hundred years ago, six nurses created a vision of nursing excellence that has endured and continues to guide the profession of registered nursing in Alberta and CARNA. Advances in technology, new clinical evidence, increases in chronic disease prevalence, and different public expectations are already changing our approach to health and the pace of change will only increase in the decades ahead.
History has demonstrated that RNs possess the knowledge and skills to adapt to local and global trends that influence the delivery of expert care. RNs have been, and continue to be, trusted health partners who work towards a health system that puts the patient first.
In the future, health-care research will continue to confirm the positive impact RNs have on the quality of care patients receive. RNs will continue to play a critical role as members of an inter-professional team in hospital-based care while also taking on a more visible role to support Albertans in their own communities to manage their health-care needs. CARNA looks forward to continuing to support the leadership, innovation and success of RNs in the century ahead in finding solutions that provide expert, compassionate care for all Albertans.
I applied to get into nursing and it turns out I was accepted, and it ended up being the best choice I ever made in my life. Here I am today, loving exactly what I'm doing with my career.”
Mia Torres, RN