Nursing Midterm Notes

Development of Self as A Practical Nurse: Leadership
Leadership Defined:
o Definition: the ability to influence other people
o A leader is someone who sets direction and influences people to follow that direction
o A process which involves both the leader and the follower(s)
o Leaders are nothing without followers
Followership:
o Followership and leadership are separate but have common or shared roles.
o Without followers, there cannot be a leader.
o Without leaders, there are no followers.
o We all play the role of follower much of the time--regardless of our position.
Followership Defined:
o Followership is not a passive, unthinking role.
o The most valuable follower is a skilled, self-directed employee.
Qualities of Followership:
o A good follower:
 Participates actively
 Invests his/her time and energy in the work of the group
 Thinks critically and advocates for new ideas
Good Followership:

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Informs the team leader or manager about problems right away. Even better, includes a suggestion for
solving the problem in the report.
Freely invests interest and energy in their work.
Is supportive of new ideas suggested by others.
If you disagree, explain why you do not support an idea or suggestion.
Listen carefully, and reflect on what your leader or manager says
Continue to learn as much as you can about your specialty area.
Share what you learn with others (steps from a follower to a leader)

Primary Tasks of a Leader:
o Sets the direction: mission, goals, vision, purpose
o Builds commitment: motivation, spirit, teamwork, development of self and others
o Confront challenges: innovation, change, turbulence, problem solving
Management:
o Management is a process used to achieve organizational goals. It involves planning, leading,
organizing, and controlling. (Kelly, 2008)
o “The manager’s function is to do whatever is necessary to make sure that employees do their work
and do it well.” (Tappen, 2004)
o 2/3 of their time is spent on people management
o Remainder: budget work, meetings, preparing reports, and other “administrivia” (Lombardi, 2001)
Management:
o Potter & Perry (4th edition) – “Whereas leadership refers to a shared vision, values, organizational
strategy and relationships, management most often refers to the competencies required to ensure that
day-to-day delivery of nursing care according to available resources and standards of practice.”
o More pressure on managers in recent years to learn new skills related to business – financial and
marketing (Kelly, 2008,p162). There has been a move towards more business management styles in
health care.
Leadership vs. Management:

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Leadership:
 Visionary
 Inspirational
 Innovative
 Committed to challenging status quo
 Proactive
 “Does the right thing”
Management:
 Bureaucratic
 Rigid
 Resistant to change
 Static
 “Does things right”

Leadership vs. Management:
o Can you be a manager and not a leader?
o Can you be a leader and not a manager?
o Management refers to the actions used to achieve goals, whereas leadership is the effort to envision,
inspire, and facilitate change.
What Do Leaders Do?
o Individual Level:
 Mentor
 Motivate
o Group Level:
 Build teams
 Resolve conflict
o Organizational Level:
 Build culture
Leadership Characteristics:

Able to see the ‘big picture’ Listener
Excellent communicator
Confidence and trust in team members
Seeks consensus
Dependable
Flexible
Visible
Integrity
Good judgment
Respect for others
Imaginative
Professionalism
Energetic
Knowledgeable
Supportive
Personal development
Development of others
‘Emotional Intelligence’
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Self-confidence
Ability to influence significant people
Initiative
Visionary
Critical thinker
Charismatic
Courageous
Inquisitive
Approachable
Problem-solver
Open-minded
Humour
Passion
Goal-setter
Positive thinker
Challenges the status quo
Creates and shapes change
Detail-oriented

Emotional Intelligence:
o The most effective leaders demonstrate these 5 qualities:
 Self-awareness
 Self-regulation
 Motivation
 Empathy
 Social skills
Emotional Intelligence:
o Emotional Intelligence is “the ability to recognize the meaning of emotions and their relationships
AND to solve problems on the basis of emotions.” - the emotionally intelligent nurse can identify,
use and regulate emotions to maximize critical thinking resulting in sound decisions that support both
positive outcomes and inter-professional collaboration.
o “Characteristics of a leader are less important than what a leader chooses to do.”
Leadership Behaviour:
o Initiating Structure:
 Organizes and defines work to be done
 Establishes work patterns
 Establishes channels of communication
o Consideration:
 Behaviour that conveys mutual:
 Trust
 Respect
 Warmth
 Rapport
Leadership Styles:
o Autocratic leadership
o Democratic leadership
o Laissez-Faire leadership
o Situational leadership
Autocratic Leadership:
o Leader retains authority
o Primary concern is task accomplishment
o Assigns clearly defined tasks
o One-way communication
o Decisions made by leader alone
o Stress prompt, orderly performance
o Uses power to pressure those who fail to follow expectations
Appropriate Use of Autocratic Leadership Style:
o Where most work group members are novices
o In situations in which immediate action is required
o No time for group decisions

Democratic Leadership:
o People-centred approach
o Primary concern human relations and teamwork
o Employees given more control and participation in decision-making
o Facilitates goal accomplishment while stressing the self-worth of each employee
Appropriate use of Democratic Leadership Style:
o Works best with mature employees
o Groups that work well together
Laissez-Faire Leadership Style:
o Permissive
o Leader gives up control
o Avoids responsibility by delegating decision-making to group
o No establishment of goals, policies
o Abstains from leading
o Provides little or no direction
Appropriate use of Laissez-Faire Leadership Style:
o Effective with mature groups who are:
 Confident, capable and highly motivated
 Skilled people, who have produced excellent work in the past
Situational Leadership:
o The most flexible style
o Combines four styles in one
o Leader adapts style to:
 Work situation
 Needs and abilities of staff
o Four styles: Directing, Coaching, Supporting and Delegating
Directing:
o Leader provides specific, detailed instructions
o Supervises the accomplishment of the task
o Enforces rules and policies
Coaching:
o Monitors accomplishment of task while explaining decisions
o Asks for feedback or suggestions
o Recognizes good performance
Supporting:
o Supports efforts of others
o Facilitates goal accomplishment
o Shares responsibility for decision-making
o Willing to try new ideas
o Values growth not perfection; collaboration not competition

Transformational Leadership Approach:
o A more recent and popular approach to the theory of leadership in nursing.
o An exchange process between individuals and leaders – relationship is valued
o Motivates both parties to achieve more
o Leader is a visionary and inspires people to follow
o Reference RNAO 2006 BPG for Leadership
CNO—Leadership:
o “Each nurse demonstrates her/his leadership by providing, facilitating and promoting the best
possible care/service to the public.” CNO Professional Standard, 2002

Power – A Definition:
o Power is the ability to create, acquire and use resources to achieve one`s goals. It comes from the
ability to influence others or to affect their thinking or behaviour (Kelly, 2013).
o Power can be:
 Personal – how the individual perceives power
 Professional (Experts) - authority
 Organizational - utilize all the mandatory resources in favor of organization development
o Power, regardless of level, comes from the ability to influence others or affect others’ thinking or
behaviour
o Effective nurses view their ability to understand and use power as a significant part of their
responsibilities to clients, their coworkers, the nursing profession, and themselves (Kelly, 2013)
Sources of Power:
o Expert power: derived from knowledge & skills ie expert nurses vs novice nurses
o Legitimate power: derived from the position of authority a person holds ie managers, CEO of an
organization
o Referent (charismatic) power: derived from how much others respect & like a person
o Reward power: derived from a person’s ability to bestow rewards on people ie offering incentives
which greatly motivates employees
o Coercive (Forced) power: is the opposite of reward power. It is the ability of the power holder to
remove something from a person or to punish them for not conforming with a request
o Connection power: derived from a person’s connection to others with power ie networking for a job
position with “who you know”
o Information power: derived from a person’s ability to provide information
Power – CNO, 2009:
o Power. The nurse-client relationship is one of unequal power. Although the nurse may not
immediately perceive it, the nurse has more power than the client. The nurse has more authority and
influence in the health care system, specialized knowledge, access to privileged information, and the
ability to advocate for the client and the client’s significant others. The appropriate use of power, in a
caring manner, enables the nurse to partner with the client to meet the client’s needs. A misuse of
power is considered abuse.
Empowerment:
o “The process by which we facilitate the participation of others in decision-making and taking action
within an environment where there is an equal distribution of power”. (Kelly, 2009, p 289)
o There are many reasons to empower nurses –ineffective nurses are those who lack power - they lack
job satisfaction and experience more burnout
o Empowerment for nurses should be exercised at all levels – they are more engaged and involved in
the decision making process in both their clients and their organization thus finding more fulfillment
within their profession
o In order to be empowered individuals need to recognize the power that exists in their experience,
knowledge, and internal motivation – self awareness
Empowerment and Leadership:
o Leaders empower themselves and others by:
o Demonstrating high values for individuals and their opinions
o Encouraging critical thinking

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Viewed as important contributors
Honoring and recognizing excellent workers
Encouraging autonomy
Viewed as valued team members
Allow employee skills and abilities to benefit both the organization and themselves

Advocacy:
o A voice
o “Advocacy in nursing means taking the part of another, speaking for persons who cannot speak for
themselves, or intervening to ensure that their views are heard.” (Oberle & Bouchal, 2009)
o Requires good awareness of the context and the power relations involved
o Example – Cathy Crowe, Street nurse- nurse that helps Toronto homeless and their health needs
Advocacy:
o Nurses pose great knowledge and expertise and are key informants when it comes to health and health
care issues
o Nurses have a valuable role in advocating not only for their patients but also for their profession
o The voice of nurses was heard in the 1990’s when cutbacks in health care led to the layoffs of nurses
throughout the country with impact on patient care and nursing morale
Advocacy:
o The lobbying efforts by nurses for a nursing voice in the federal government during this time led to
the creation in 1999 of the Office of Nursing Policy – part of Health Canada which advises on health
policy issues from a nursing perspective. (Kelly, 2009)
o Nurses have gained respect and a place in the political views where their voices have been heard
advocating for change – better work environments, decreased patient load leading to safe nursing care
and recognition for the services nurses provide
Communication:
o The style of communication a person uses can greatly influence the outcome of an interaction with
others
o Passive Communication is when a person speaks quietly, avoids eye contact or slumps their posture.
They may agree to something they don’t feel comfortable doing or back down from confrontation
Communication:
o Passive-Aggressive Communication is when a person is passive and agreeable in face-to-face
situations, but aggressive when the other person is no longer present
o Assertive Communication is clear, direct and shows respect for self and others. An assertive
communicator makes eye contact, appears relaxed, and speaks firmly from their own viewpoint. Use
“I”
o Aggressive Communication is when a person yells at others, clenches his jaw or fists, and points at
the flaws in others. This sometimes escalates into violence. Blame others use “you”
Tips for Assertive Communication:
o Start small
o Start with strangers
o Be persistent
o Use “I” messages – I feel... I expect....I want...I choose....I decide...I plan....I believe... I am (angry,
confused, delighted, disappointed)

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Just Say No
 Example: The telephone rings and you are asked to cover a shift due to illness. You know
that your colleagues will be working short if you do not agree to pick up the shift. You have
no interest in working extra tonight as you have already made plans with a friend. You have 3
choices for a response: passive, aggressive, or assertive.
Try to be specific, state the facts
Keep practicing

Critical Thinking:
o Pew Health Professions Commission asserted that nurses must “demonstrate critical thinking,
reflection, and problem-solving skills” to thrive as effective practitioners in the 21st century (Bellack
& O’Neil, 2000)
o Rapid changes in the health care environment not only have expanded the decision-making role of
the nurse but also have demanded that the results of decisions be effective
o Critical thinking is essential when making decisions & solving problems
Critical Thinking:
o National Council for Excellence in Critical Thinking Instruction, define critical thinking as “a mode
of thinking—about any subject, content, or problem—in which the thinker improves the quality of
their thinking by skilfully taking charge of the structures inherent in thinking and imposing
intellectual standards upon them.”
Critical Thinking:
o Two components:
1. A set of information and beliefs generating and processing skills
2. The habit, based on intellectual commitment, of using those skills to guide behaviour
o Is subject to the context of situations.
o Should be viewed from 3 perspectives
1. Thinking ahead (ability to be proactive)
2. Thinking in action (thinking on your feet)
3. Thinking back (reflective thinking)
Critical Thinking:
o A good critical thinker:
 Examines decisions from all sides and takes into account varying points of view
 Generates new ideas & alternatives when making decisions
 Asks “why” questions about a situation in order to arrive at the best decision
o Scriven and Paul (2004) conclude that “no one is a critical thinker through-and-through, and for this
reason the development of critical thinking skills and dispositions is a life-long endeavour.”
Reflective Thinking:
o Reflective thinking is watching or observing oneself as one performs a task or makes a decision about
a certain situation
o The reflective self watches the active self as it engages in activities, acting as an observer and offering
suggestions about the activities engaged in
o Reflection upon a situation or problem after a decision has been made allows the individual to
evaluate the decision
o Regulatory colleges in Canada have implemented continuing competence programs

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Reflective thinking mainstream in all domains of practice including, direct administration, education
& research

Reflective Thinking:
o Reflective thinking is based on the fundamental assumption that learning from one’s experience is
critical in developing and maintaining competence because what was learned from a particular
situation may be used as a guide for future situations, or be incorporated into one’s existing
knowledge (Mann, Gordon, & MacLeod, 2009).
Problem Solving:
o Problem solving is an active process that starts with a problem & ends with a solution
o The problem-solving process consists of 5 steps:
1. Identify the problem (assessment, diagnosis)
2. Gather and analyze data (outcome identification)
3. Generate alternatives & select an action (planning)
4. Implement the selected action (implementation)
5. Evaluate the action (evaluation)
Decision Making:
o Decision making is the cognitive process leading to the selection of a course of action among
alternatives
o Clinical decision making occurs with the context of a health care environment
o Decision making is a core competency for all nurses because of rapid changes in the health care
environment
o Nature of decision making in nursing (2 types of decisions):
1. In the context of a therapeutic relationships with clients
2. In the context of their own professional development
Decision Making:
o Nursing & Decision Making:
 Nurses have opportunity to make decisions choosing maintenance versus greatness, caution
versus courage or dependency versus autonomy
o Nurse autonomy—key indicator of quality work environments
o Autonomy is an interactive, relational process that occurs with in the context of one’s being & work
o 3 types of autonomy—structural & work, attitudinal, & aggregate
o Autonomous decision making helps us to understand that we are the cause & not the effect
o Choosing autonomous decision making over dependency puts us in charge
o Nurse autonomy is a key indicator of quality work environments, yet definition, measurement, and
interpretation of research findings have complicated the effective integration and promotion of this
key indicator into nursing work environments
Decision Making:
o Numerous factors influence decision making including:
 Individual variables (experience & knowledge)
 Creative thinking ability
 Education
 Self concept
 Environmental & situational stressors

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Intrinsic factors can be controlled
Extrinsic factors include organizational climate & culture, client rights & choices, legal legislative
frameworks
Perception can help with decision making
Objective perception — characterized by seeing problem objectively (logically)
Subjective perception — done with feelings (empathy)
Incorporating both objective & subjective important

Decision Making:
o Knowledge & experience important to decision making
 Intuitive (understanding without rationale) is hallmark of expert nursing judgment
o Knowledge & experience are influenced by past experience (education & decision making
experience)
o Competence — The specific knowledge, skills, judgment and personal attributes required for a
registered nurse to practise safely and ethically in a designated role and setting (Canadian Nurses
Association, 2007)
o To be effective decision-makers, nurses must have a solid anchoring in the core competencies related
to entry to practice and must possess knowledge and abilities related to problem solving and decision
making, which have been integrated into professional practice
o Self-confidence is a term used to describe how secure people are in their own decisions and actions
o Self-confidence is learned through repeated successful application of the decision-making process
o Nurses who possess a high degree of confidence believe they have the competence to perform an
action correctly or achieve some specific goal
o Stress — arises when individuals perceive the environment to be demanding, because it exceeds their
resources and threatens their personal well-being
o Nurses with an internal focus of control in a clinical setting perceive opportunities to influence
outcomes for their clients, other nurses, and the organization
o Moderate amounts of stress are required for optimal thinking
o Stress that is a constant results in higher rates of job strain, lack of job satisfaction, and higher illness
rates among nurses
Decision Making:
o External Factors
 Organizational Climate and Culture
 Client Choice and Rights
 Legislation and Regulation
Steps in Decision Making:
1. Identify the need for a decision.
2. Determine the goal or outcome.
3. Identify the alternatives or actions along with the benefits and consequences of each action.
4. Decide which action to implement.
5. Evaluate the action.
Group Decision Making:
o Group decision making may be necessary in some situations
o People affected by a decision often will be involved in the decision
o People with information or resources that contribute to the decision may be involved

Group Decision Making:
o Advantages:
 A group can generate more ideas, thus allowing for more choices & an increased chance of
higher quality outcomes
 When members participate in the decision-making process, the decision is more likely to be
accepted
 Groups may be used as a medium for communication
o Disadvantages:
 Time-consuming
 Can be wasteful & unproductive if not managed effectively
 Can be costly
 Can generate conflict
Group Decision Making:
o Techniques of Group Decision Making
 Nominal Group Technique
o Group members write ideas, without discussion
o Each idea is presented with advantages & disadvantages
o Group discusses, clarifies, & evaluates ideas
o Group votes privately on ideas
 Delphi Group Technique
o There is no face-to-face meeting
o Questionnaires are distributed to groups
o Responses are summarized & disseminated to group members
o The process is repeated until the group reaches consensus
 Consensus Strategy
o Consensus means that everyone in the group can live with & fully support the
decision regardless of whether they totally agree
o This strategy should be reserved for important decisions that require strong support
from participants who will implement them
 Consensus decision making is best used under these conditions:
o All members of the team are affected by the decision
o Implementation of the solution requires coordination among team members
o The decision is critical, requiring full commitment by team members
 Group Think
o In groupthink, the goal is for everyone to be in 100% agreement
o Groupthink hinders creativity, & usually leads to inferior decisions
 To avoid groupthink:
o Appoint group members to roles that evaluate how the group decision making occurs
o Encourage all group members to think independently & verbalize their individual
ideas
o Allow the group time to gather further data & reflect on data already collected
Limitations to Effective Decision Making:
o Pitfalls to effective decision making include:
 Making decisions based on 1st available information

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Comfort with status quo
Bias & preconceived ideas
Inflexible values
Making decisions to justify previous decisions
Ignoring evidence that does not support predetermined ideas
Presenting the issue in a biased manner
Inaccurately presenting alternatives

Use of Technology in Decision Making:
o Technology can support, but not take over, the decision-making process
o Clinical practitioners should evaluate technology before adopting it
o Other staff on which technology will have an impact should have input into decisions on its adoption
The Nurse’s Role in Patient Decision Making:
o Patients are increasingly knowledgeable about health care & involved in treatment decisions
o Nurses must be aware of patients’ rights in making decisions about their treatments and must assist
patients in their decision making
o Comfort with decision making usually comes with experience
Strategies to Improve Decision Making:
o Make only those decisions that are yours to make
o Write notes & keep ideas visible about decisions to utilize all relevant info
o Write down pros & cons of an issue to help clarify your thinking
o Make decisions as you go along rather than letting them accumulate
o Consider those affected by your decision
o Trust yourself
What is Evidence-Based Care??
o Evidence-based Care:
 A blend of the beliefs, values & attitudes of clients, families, & practitioners, with the most
current knowledge of incidence & prevalence of the health care problem at hand & an
understanding of the organization & delivery of health care
Importance of EBC:
o Best Research Evidence refers to methodologically sound, clinically relevant research on
effectiveness and safety of nursing interventions, the accuracy & precision of nursing assessment
measures, the power of prognostic markers, the strength of causal relationships, the cost effectiveness
of nursing interventions, and the meaning of illness & client experiences
o EBC does not guarantee good decisions but it is key to improving outcomes that affect health
o EBC should be viewed as the highest standard of care (supported by critical thinking & sound clinical
judgement)
How do Organization Create Supportive Environment for Evidence Based Practices?
o Compensate managers & front-line nurses for participation in academic activities
o Provide easy access to library resources & computers
o Include clinical nurse specialists in staffing mixes
o Use evidence in management decision making
o Adopt evidence-based corporate goals

What are the Behaviors and Factors that Facilitate the Use of Evidence Based Practices:
o Behaviors:
 On going and supportive leadership
 Continuing education
 An organizational culture supportive of evidence-informed practice
 Integration of guideline recommendations into organizational policies and procedures
o Factors:
 On going leadership by champions
 Management support
 On going staff education
 The integration of the guidelines into policies and procedures
 Staff buy-in and ownership
 Synergy with partners
 Multidisciplinary involvement
Health Outcomes for Better Information and Care (HOBIC):
o Ontario Ministry of Health & Long Term Care created Ontario Nursing Task Force in 1998—now
known as Health Outcomes for Better Information and Care (HOBIC)
o Goals HOBIC:
1. Identify nursing-sensitive client outcomes
2. Determine appropriate ways of measuring these outcomes
3. Identify databases on which these outcomes could be housed
HOBIC Outcomes…
o End result for HOBIC to inform health policy and guide nursing practice
 Evidence-based guidelines
 Care plans
 Other decision-aid tools
o Results will be source of evidence to inform nursing policy and practice,
development of evidence-based guidelines
o Input from end users will improve likelihood that tools will be used
Attributes of Evidence Based Practice:
o 2011 review of literature focusing on factors affecting nurses’ use of research to inform practice:
 Having a positive attitude towards research
 Attending conferences and/or in-services
 Having a graduate degree (compared to a bachelors degree or diploma)
 Current roles (i.e., leadership and/or advanced practice compared to staff nurse)
 Clinical specialty (working in critical care areas compared to general hospital units)
 Job satisfaction
o Able to serve as role models for evidence-based practice
o Able to create opportunities for staff to develop networks to facilitate the
development of important skills needed in an evidence-based environment
o Able to share leadership and decision making among the team and provide
psychosocial support to help sustain new behaviours

Resources Influencing Decisions:
o Nurse administrators make decisions based on research and evidence:
1. Organization evidence (information about the organization’s capacity to execute tasks-information from financial reports, program evaluations, utilization data, and report cards)
2. Political evidence (gives a sense of how the various stakeholders may respond to policies—
information from stakeholder groups, environmental scans)
o Online Journals provide access of information to practitioners (i.e. Internet Journal of Advanced
Nursing Practice, Canadian Journal of Nursing Research)
o Systematic Reviews (i.e. Cochrane Collaboration)
Evidence-Based Practice Process Steps:
1. Define the clinical question
2. Search the literature
3. Select and critically appraise the most relevant reports
4. Decide whether and how to use the information
5. Evaluate the effects of your decision
Knowledge Transfer and Exchange:
o Knowledge Transfer & Exchange (KT & E)–refers to responsibility of creating and disseminating
research so that it can be readily used by decision-makers at all levels
o Examples of KT & E
 Canadian Health Services Research Foundation (CHSRF)
 Canadian Population Health Initiative (CPHI)
 Canadian Institutes of Health Research (CIHR)
 CHSRF & CIHR fund nursing research chairs to examine nursing practice, resources and
strategies to transfer knowledge into policy & practice
o i.e. Nursing Health Services Research Unit (NHSRU)
o NHSRU goals are to:
1. Conduct research & other forms of inquiry
2. Provide info necessary for evidence-based policy
3. Develop a joint mechanism for knowledge transfer between Ontario Ministry of Health &
Long-term Care (MOHLTC) to ensure best & most recent evidence to guide policy &
management decision making
Knowledge Transfer and Exchange:
o Principles:
 What? (Key messages must be clear, compelling "ideas" backed by a body of rigorous
research)
 To Whom? (The interaction should be specific to the audience)
 By Whom? (The messenger must be considered credible by the audience)
 How? (Interactive engagement between the messenger and the audience)
 With What Effect? (Performance measures must be audience specific and appropriate to the
context)
Let’s Review the Articles….
o Consider a client that you recently cared for. What clinical questions do you have about their care?
How would you try to answer them? Are any clinical pathways or standards in use to help you care
for this patient?

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There are five steps in evidence-based practice:
 Define the clinical question
 Search the literature
 Critically appraise the literature
 Decide whether and how to use the information
 Evaluate the effects of your decision

Try to Follow the Five Steps in Evidence-Based Practice:
o Clinical example:
 The client was an 82-year-old woman admitted to a medical unit with a decubitous ulcer.
o Define the clinical question – Is the type of dressing currently being used on the client’s decubitous
ulcer the appropriate choice?
o Search the literature – I would use electronic data bases such as Academic Search Complete,
Proquest Nursing and Allied Health Source, CINAHL Plus with Full Text, or PubMed to locate the
most recent research studies comparing the effectiveness of different types of dressings on decubitous
ulcers. If I did not have access to electronic databases I would go to the hospital library and look at
appropriate journals such as the Journal of Wound Care to locate relevant studies. I could also consult
with hospital based wound care specialists or clinical educators to see if any clinical pathways or
standards related to the nursing care of decubitous ulcer are available.
o Critically appraise the literature – If the decubitous ulcer nursing care information was received
from the wound care specialists or clinical educators I would ask if the information they provided was
evidence-based. If I was appraising literature I located myself from electronic sources or from the
library I would try to determine the quality of the data giving more weight to randomized controlled
studies recently published in peer-reviewed journals.
o Decide whether and how to use the information – I would consider how closely my client’s
situation fit with clients who were part of the published studies, whether the recommended treatment
was feasible in my setting, and if the anticipated benefits of following the recommendations of the
study were greater than the risks. I would consult with other team members including any wound care
or educational consultants available, share with them what I had discovered, and seek their input
before implementing a change in nursing intervention.
o Evaluate the effects of your decision – If the literature search and critical appraisal of the literature
resulted in a change in dressing protocol for the client I would monitor the effects of the new dressing
protocol and continue to seek up-to-date information on treatment of decubitous ulcers adjusting my
nursing interventions appropriately.
World Health Organization (WHO):
o WHO is the directing and coordinating authority for health within the United Nations system
o Diplomats at United Nations in 1948 established the constitution (World Health Day April 7 th 1948)
o GOAL:
 To achieve the highest level of health for all people
o “A state of complete physical, mental and social well-being, and not merely the absence of infirmity.”
Tasks for WHO:
o Combat disease
o Conducts health research in communicable diseases
o Combat infectious diseases (ie. SARS, H1N1, AIDS, TB, Malaria etc)
o For 3 decades WHO fought smallpox – eradicated in 1980
o Actively involved in treating such diseases
o Distribution of safe vaccinations and drugs

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Promotes health related campaigns (smoking, heart disease, healthy eating, exercise etc)
Responsible for: Providing leadership on matters critical to health and engaging in partnerships
where joint action is needed;
 Shaping the research agenda and stimulating the generation, translation and dissemination of
valuable knowledge;
 Setting norms and standards and promoting and monitoring their implementation;
 Articulating ethical and evidence-based policy options;
 Providing technical support, catalysing(channel) change, and building sustainable
institutional capacity;
 Monitoring the health situation and assessing health trends

National Health Care Systems:
Governance of Health Care:
o Federal Jurisdiction
 Establishes and delivers national principles for health care through the Canadian Health Act
(CHA)
 Provides financial assistance for provincial and territorial health care services (done by
transferring tax money to share costs of health care services)
 Deliver health care to First Nations, Inuit people, military veterans, federal inmates and
RCMP
 Promotion of health and prevention of disease (public health programs and consumer safety)
Provincial and Territorial Jurisdiction:
o Implementation of insurable health care in accordance with the principles of the Canada Health Act
o Allocation of hospitals and long-term care facilities
o Determines employment of health care professionals for hospitals and long-term care facilities
(determines the health care mix)
o Distributes money to various health care services
o Reimburses physicians and hospital expenses
o Unique plan coverage i.e. drug coverage, ambulance services, home care etc.
Private Health Insurance:
o Canadians can buy private insurance coverage or can participate in an employee benefit plan offered
by the employer
o Dental plans
o Vision care
o Pharmaceuticals
o Therapies (physio, speech, massage)

Federal Health Care Systems
Canadian National Health Care System:
o Designed to ensure Canadians have a reasonable access to medical treatment, hospital &physician
services on a uniform prepaid basis (Health Canada, 2006)
o 1947: Saskatchewan initiates provincial universal public hospital insurance plan (known today as
OHIP)

o
o
o

1962: Saskatchewan introduced a universal, provincial medical insurance plan to provide doctors'
services to all its residents
Tommy Douglas is the ‘Father’ of medicare in Canada
In subsequent years the remaining provinces and territories follow suit

Canadian National Health Care System: Canada Health Act:
o 1984: Canada Health Act, Federal Government combines both hospital and medical acts; to establish
5 basic principles for health care:
 Universality available to all eligible residents of Canada
 Comprehensive coverage for hospital and physician services
 Accessible without financial and other barriers; available to all Canadians on the basis of
need
 Portable within the country and during travel abroad
 Publicly Administered public authority administers and operates the plan on a non-profit
basis
o The Canada Health Act establishes principles & criteria:
 Provincial & territories health insurance in order to receive full federal cash transfers in
support of health
o Federal government provides cash & tax transfers to provinces & territories in support of health
through the Canada Health Transfer (CHT)
o Support costs of publicly funded services, including health care, the federal government also provides
equalization payments to less prosperous provinces and financing to the territories
Canadian National Health Care System: Canada Health Transfer (CHT)
o The CHA establishes criteria and conditions related to insured health services and extended health
care services that the provinces and territories must fulfill to receive the full federal cash contribution
under the Canada Health Transfer (CHT).
o CHT cash levels are set in legislation up to 2013-14 and grow by 6 % annually as a result of the
automatic escalator.
o HT cash transfer will reach $25.4 billion in 2010-11 & will reach over $30 billion in 2013-14.
o Provinces & territories also receive CHT support through a tax transfer CHT tax transfers amount to
$13.1 billion in 2010-11, & will continue to grow in line with the economy.
o Canada Health and Social Transfer (CHST) is block funding that combines health
care/postsecondary education/social services/social assistance
 Effort to allow provinces to provide reasonably comparable levels of service at reasonably
comparable levels of taxation
Canadian National Health Care System: Canada Health Transfer (CHT)
o Canada Health Act imposes:
 Financial penalties that prevent physicians from charging more than provincial schedule of
fees.
 Bans user fees and extra billing
 Establishes a provincial/territorial reciprocal billing agreement for out-patient hospital
services provided out-of province/ territory
o Nurses & CNA were instrumental in ensuring the passage of the bill that resulted in CHA
Canadian National Health Care System: CIHI
o 1991





National Task Force on Health Information, federal, reports; leads to creation of Canadian
Institute of Health Information (CIHI)
Independent, not-for-profit organization that provides essential data and analysis on Canada’s
health system and the health of Canadians
CIHI’s data and reports focus on:
o Health care services
o Health spending
o Health human resources
o Population health

Canadian National Health Care System: Canadian Health Services Research Foundation:
o Canadian Health Services Research Foundation (CHSRF)
 Independent non profit corporation
 Funded by federal government
o Promotes and funds management and policy research in health services and nursing
 Collaborates with health system decision makers to support and enhance the use of research
evidence
o Example:
 Research in the 1970s indicated that patient outcomes and costs varied significantly in
different parts of the country
 Studies related to unnecessary surgeries and outcomes for patients impacted on physician
practice
Canadian National Health Care System: Canadian Health Services Research Foundation:
o CHSRF research priorities 2004
 Managing for quality and safety
 Management of the healthcare workplace
 Primary healthcare
 Nursing leadership, organization and policy

Provincial Health Care Systems
Federal, Provincial & Territorial Collaboration:
o Canada's federal, provincial, & territorial governments collaborate on various health care policy &
programming issues
o Key vehicle for strengthening partnership and collaboration:
 Annual Conference of Ministers of Health discuss a broad range of issues.
o Advisory Committee on Governance and Accountability
o Advisory Committee on Health Delivery and Human Resources
o Advisory Committee on Information and Emerging Technologies
o Advisory Committee on Population Health and Health Security
Provincial Health Care Systems:
o Provinces & territories administer and delivery health care services guided by the Canada Health Act
o Primary Health Care is the foundation of the health care system: first point of contact people have
with the health care system



o

o
o
o

o

o

o
o

Canadian Federal Government (2000) --Invested $800 million in Primary Health Care
Transition Fund (support provinces/territories to improve and expand primary health care
delivery in Canada)
Health care services include:
 Insured primary health care (ie: physicians and other health professionals services)
 Care in hospitals (account for the majority of provincial and territorial health expenditures)
Services publicly funded from general tax revenues without direct charges to the patient.
7/10 dollars government (fed/prov); 3/10 private ins/individuals
Pan Canadian Public Health Network created in 2005 by federal, provincial and territorial ministers
with mandate to:
 Facilitate information sharing across Canada
 Provide policy and advice to deputy ministers of health
 Support public health challenges
Primary Health Care
 The first encounter with a health care provider (nurse/ doctor/pharmacist/telephone advice
line)
Primary Health Care has five guiding principles
 Equitable access (health and health services)
 Public participation
 Appropriate technology
 Intersectoral collaboration
 Reorient health system to promote health and prevent disease and injury
World Health Organization (WHO) 1978
 First international declaration underlining the importance of primary health care
Canadian Federal Government (2000)
 Invested $800 million in Primary Health Care Transition Fund (support provinces/territories
to improve and expand primary health care delivery in Canada)

Provincial & Territorial Role in Health Care Delivery:
o Canada’s health care system is public but not nationalized
o Each province/territory manages its own insurance system includes own healthcare identification
cards
o Once care moves beyond the services required by the Canada Health Act - inconsistency from
province to province in the extent of publicly-funded coverage
 Out-patient drug coverage
 Rehabilitation
 Dental
 Eye care, as well as vision care
 Mental health
 Long-term care
o Substantial portion of such services being paid for privately, either through private insurance, or outof-pocket
o Many treatments & services covered in hospital no longer covered in the community
o Some provinces charge health care premiums (taxes)
o Mix of public and private deliver health care
o Some provinces eliminated individual hospital boards and have Regional Health Authorities instead

o

Doctors bill on a fee for service basis except in some hospitals and interprofessional clinics where
they have a blended funding model

Services Not Covered by OHIP:
o Ambulance services.
o Routine eye examinations for people aged 19-64;
o Some Physiotherapy )may be partially covered or not at all.
o Regular dental exams; only some dental surgery that is done in a hospital will be covered.
o Podiatrists are only partially covered by OHIP.
o Chiropractors.
o Necessary emergency medical tx obtained outside of Canada is only covered on a very limited basis
Ontario Ministry of Health and Long Term Care (MOHLTC):
o In 2006, the MOHLTC divided the province into 14 regions or Local Health Integration Networks
(more succinctly known as LHINs)
o Thought was… people living locally were better able to plan, fund and integrate health services in
their own communities than people in Toronto
o By April 1, 2007, LHINs took on full responsibility for health services in their communities.
LHINs:
o Main roles of the LHINs:
 Plan, fund and integrate health care services locally in communities
 Development Integration of Health Service Plans
o Each LHIN consulted the people in their communities – the general public, patients,
advocates, health services. The plan was tailored to local needs and priorities and met
provincial strategic directions.
o LHINs Funds:
 The health service providers
 Allocates local health dollars based on community priorities.
o LHINs helps to integrate health services --better coordinated and more efficient
Public Health:
o Over 50 years in Ontario
o Currently 36 Health Units in Ontario
o Legislated by the Health Protection and Promotion Act
o Mandate: “To provide for the organization and delivery of public health programs and services, to
prevent the spread of disease, to promote and protect the health of the people of Ontario.”
 Education, community action, and advocacy
o Decision makers: board of health and a medical health officer --Members are municipal officials and
community representatives.
Public Health Activities – Current:
o Immunization
o Alcohol Policy network
o Chronic Disease Prevention Projects
o Heart Health Resource Centre
o Injury Prevention Initiative
o Nutrition Resource Centre

o

Youth Engagement Project

Community Care Access Centres (CCACs):
o Vision: Outstanding care – every person, every day.
o Mission: To deliver a seamless experience through the health system for people in our diverse
communities, providing equitable access, individualized care coordination and quality health care.
o Community Care Access Centres (CCACs) are local agencies that provide information about care
options in your area.
o CCAC helps people to:
 Live independently at home
 Apply for admission to a day program, supportive housing or assisted living program, or
certain chronic care or rehabilitation facilities
 Apply for admission to a long-term care home
 Coordinate services for seniors, people with disabilities and people who need health care
services to help them live independently in the community.
 Explore the options best suited to your needs and personal situation
 Determine your eligibility for government-funded services and settings
 Find out how services are delivered
 Determine the availability of financial subsidies for particular service options
Community Care Access Centres (CCACs):
o Anyone can make a referral to a CCAC — an individual requiring service, a family member,
caregiver, friend, physician or other health care professional.
o 14 CCACs operating across Ontario.
 CCAC boundaries align with the geographic boundaries of Ontario’s 14 Local Health
Integration Networks. Community Care Access Centre.
o Funded & legislated by the Ontario Ministry of Health and Long-Term Care.
o Connectors to home care, long-term care destinations, and other services in your community.
Community Health Centers- CHCs:
o 120 Primary health care centres in Ontario
o Serve members of community
o CHC are governed by a board of clients, community members, health providers and community
leaders
 Enables health services to be more easily oriented towards what community members
identify as their most important needs.
o I.e. NP Clinics and Telehealth Ontario
Accord on Health Care Renewal — 2003:
o Prime Minister, provincial and territorial premiers agreed on Health Care Renewal
o Accord provided direction for changes to access, quality and long-term sustainability of health care
system
o Accord targeted reforms to primary health care, short-term acute home care, prescription drugs for
catastrophic levels, improved access to diagnostic and medical equipment and better government
accountability
o Federal government transfers increased
o CHST split into Canada Health Transfer for health and the Canada Social Transfer for postsecondary
education, social services and social assistance

Additional Reforms — 2004:
o 10 Year Plan to Strengthen Health Care
 Focus on improved access to quality care and reductions in wait times
 Additional reforms targeted
 Federal government increased healthcare cash transfers again and applied escalator (to
provide predictable growth in funding) — expected to continue until 2014
Types of Health Care Services:
o Health can be categorized into four levels:
1. Health Promotion
2. Disease and Injury Prevention (Protection)
3. Diagnosis and Treatment of Existing Health Problems (Primary, Secondary, Tertiary)
4. Rehabilitation
Health Care Professionals in Canada:
o Statistics Canada (2004) reported total# of registered nursing workforce 78% were RNs and 20%
were RPNs (LPN)
o Most of these registered professionals work in hospitals
o Physicians make up the second largest group in the workforce
o Nursing and physician workforce aging (average age 40’s)
o Professions have subcultures that affect their working together (impact on care delivered to clients)
Health Care Spending:
o Canadian health care spending has increased three times amount since 1975
o Canada has one of the highest ratios of health expenditures to GDP
o 2010
 Spent almost $200 billion
 Federal (3.5%)
 Provincial (65%)
 Municipal (.5%)
 Private sector (30%) — paid by private patients or insurance companies
Approaches to Health Care in Canada:
o Newer developments for approach to health care in Canada
 Population Health
 Integrated Health Care Delivery
 Disease Management
Population Health:
o Population Health is:
 An approach to health care that focuses on health determinants
 Aims to reduce inequities among different groups of population (the vulnerable)
o Goal: to improve the health of the entire population
o Focus: on strengthening health determinants through health care system
 Determinants of health (i.e. education level/ income level) contribute to health

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Determinants of health determine ability to possess physical, social and personal resources to
identify and achieve personal aspirations, satisfy needs and cope with the environment
Populations become healthier when we invest in preventing illness

Integrated Health Care Delivery Systems:
o A network of health care organizations that provides or arranges to provide a coordinated continuum
of services to a defined population an is willing to be held clinically and fiscally accountable for the
outcomes and the health status of the population served.
o Care provided on a continuum includes:
 Prevention
 Wellness
 Health promotion
 Acute, restorative and maintenance care
o Coordinated Services can be provided through a network of systems:
 Hospitals
 Nursing homes
 Schools
 Public Health Departments
 Social and Community Health Organizations
Regionalization (9 provinces) Main Features:
o Regions defined by geography
o Authority consolidated at regional level
o Regions responsible for full range of health services
o Provincial governments transfer health care responsibility to regional authorities
Disease Management:
o Disease Management is a cost effect approach to improving service quality and integration and
promoting consumer empowerment and quality of life
Canadian Health Services Research Foundation:
o Canadian Health Services Research Foundation (CHSRF)
 Independent non profit corporation
 Funded by federal government
 Promotes and funds management and policy research in health services and nursing
 Collaborates with health system decision makers to support and enhance the use of research
evidence
o Example:
 Research in the 1970s indicated that patient outcomes and costs varied significantly in
different parts of the country
 Studies related to unnecessary surgeries and outcomes for patients impacted on physician
practice
Accreditation:
o Accreditation Canada (AC) national organization:
 Assists health service organizations across Canada to examine and improve quality of care
they provide



Qmentum (2009) new programme — looks at health system performance, client safety, risk
prevention planning, performance measurement and governance

Patient Safety:
o Accreditation (AC) has focused on patient safety:
1. Culture
2. Communication
3. Medication Use
4. Work life/workforce
5. Infection Control
6. Falls prevention
7. Risk Assessment
Institute of Medicine Committee on Health Care Quality Reports:
o Institute of Medicine (IOM) committee report 2001 identified six major areas.
o Health care should be:
 Effective
 Patient-centered
 Timely
 Efficient
 Safe
 Equitable
o Identified four major areas to target for change:
 Information technology
 Payment
 Clinical knowledge
 Professional workforce
Adverse Events:
o Are occurring in health care at alarming rates and are resulting in increases in morbidity and mortality
o Canadian Patient Safety Institute established and funded by federal government focuses on
1. Education
2. Research
3. Interventions and Programs
4. Tools and Resources
Quality Health Care:
o Process to manage the health care
 Using clinical practice guidelines
 Identify & implement best nursing and health care interventions
o Outcome:
 Reflects the effectiveness of structure and process
 End product of quality care
 Indicates patient status as result of care provided
o What structures must be in place to deliver quality health care?
 Uses the elements structure, process, and outcome.



Quality patient care standards, environmental standards,

Privacy Legislation:
o Two main acts govern privacy issues and must be considered in the context of health care delivery
 Privacy Act
 The Personal Information Protection and Electronic Documents Act
Other Forces Currently Influencing Health Care:
o Capitation: payment arrangement for health care service providers such as physicians or nurse
practitioners. It pays a physician or group of physicians a set amount for each enrolled person
assigned to them, per period of time, whether or not that person seeks care
o Payment of clinicians based on performance, using clinical guidelines
o New technology
o Aging population
o Genetic engineering
o Increasing cultural diversity
o New diseases
o Information management
o Globalization of the world economy
Trends in Canadian Health Care:
o Need to work with interprofessional teams
o Required to ensure seamless process with an integrated approach to health care delivery
o Future demands will include interdisciplinary education
o Focus health care will be outcome-focused, evidence-based, wellness-oriented, population-based,
technology intensive and highly cost aware
Budget Overview:
o Budgets
 Help define services (costs)
 Require forward thinking (planning)
 Serve as benchmarks
 Typically are monitored monthly
 Foster collaboration between departments
Types of Budgets:
o Operating Budgets
 Account for income & expenses associated with day-to-day activity within a department or
organization
o Capital budgets
 Account for the purchase of major new or replacement equipment
o Construction budgets
 Are developed when renovation or new structures are planned
o Operational budgets
 Financial tools that outline anticipated revenue & expenses over a specified period.
o Accounting
 An activity that managers engage in to record & report financial transactions and data.

Accounts for purchasing and replacing larger pieces of equipment e.g. greater than $2000 with life
expectancy greater than 5yrs.
o E.g. CT scanner (computed tomography) costs about $100,000—last about 7yrs
o Many involved in the purchasing of equipment and the allocation of funds before any final
decisions are made lawyers, directors clinical specialties, engineering, finance, technologists,
staff members etc.
o Financial tool outlining anticipated revenue and expense in a time period
o Account for income generated and expenses needed to deliver services
o Connects operating plan and allocation of resources
o One of the indicators that reflect organizational success
o Managers ‘account’ and record financial transactions
Nurse’s Roles in a Cost-Controlled Environment:
o Nurses….
 Ensure the caliber of care is not compromised
 Manage care costs as it relates to their own clinical practice
 Accountable for distribution and consumptions of resources
 Partner with management team to implement cost-effective practices
o

Budget Overview:
o Balanced Scorecards
 A documentation tool providing a snapshot of pertinent information & activity at a specific
time
 Identifies four perspectives about an organization
o Finances
o Customer satisfaction
o Internal operation efficiency
o Learning & growth
Budget Preparation:
o Budgets are generally developed for a 12-month period, or yearly cycle
o Fiscal year is determined by the organization
o Shorter- or longer-term budgets also may be developed
o Fundamental information gathered to prepare a budget:
 Demographics (volume increases or decreases) —determine client characteristics & health
care needs
 Regulatory influences—Accreditation Canada (AC) accredits health facilities to ensure they
meet standards — their recommendations can affect operating budgets
 Strategic plans—map out the direction for the organization over several years
 Consumer willingness to pay—some items no longer covered and are out of pocket expenses
for patients
o Strategic Plans
 Map out the direction for the organization over several years
 Guide the staff at all levels so that the entire organization can have a shared mission and
vision with clearly defined steps to meet the goals
 Each department develops unit-specific plans to help the organization follow its overall
strategic plan

Scope of Service, Goals and History:
o Hospital systems are frequently divided into subsections or units, commonly called cost centers
 Each cost center defines its own scope of service
 Departmental goals may include the introduction of new technology, facilities, or services,
which may result in additional expenses for staff, equipment, & supplies
 The manager is responsible for identifying the expenses associated with patient care up front
so they will be covered by the charges
o Scope of service: usually identified by cost center which is related to the type of service provided,
treatments, procedures, hours of operation, types of clients, and customer groups
o Departmental goal: includes, new technology or goal, client education, special client care
environments ie best practices implemented
o Manager responsible to identify the expenses associated with client care for the budget.
Budget Development:
o Organizations look at past budget information to:
 Establish a baseline for a department or unit
 Establish patterns of a department’s growth or decline over time (information may predict
future demand & capacity)
o Establish projections of services, patients, & revenue
o Revenue is income generated through a variety of means, e.g., billable patient services, &
investments in & donations to the organization
o Third-party payer affects revenue & can change from year to year (e.g. accommodation rates semi or
private)
Revenue:
o Billable client services
o Investments, donations
o Unit-based revenue includes:
o Billing for services and procedures (volume of activity)
o Anticipated # of pts admitted
o Average length of stay
o Projected occupancy rate
o Expenses: Cost associated with the delivery of services e.g. medical supplies, drugs, paper supplies
labour, equipment, utilities etc.
o Supplies: List of items and quantity used—includes both bulk plus the individual cost of items
 Stock piling is bad, because it takes away supplies that another nurse can use for their patient
Expenses:
o Expenses - the cost associated with the delivery of service
o Expenditures- resources used by an organization to deliver services --include labour, supplies,
equipment, space, utilities, & miscellaneous items
o Human Resources
 Salaries & benefits account for 80% health care budgets
 Calculations are made according to amount staff time required to complete a service
o Staffing- staffing models outline the number of staff required (based on the procedures or clients)
most cost effective combination of staff important to consider
o Supplies



Zero-based budgeting is a process used to drilldown into expenses by detailing every supply
item & quantity of items used

Budget Approval & Monitoring:
o Budgets are completed at unit levels & final approval happens with senior administration
o Budgets are monitored monthly for variance
 Flexible budgets allow for adjustments
 Unit staff should be involved in discussion of variances
Human Resource:
o Health care is labor intensive and expensive
o Estimate 80% of operating cost is salary and benefits
o
Models of Care Delivery:
o Care delivery models organize the work of caring for patients
o Models of Care based on the needs of clients & availability of competent staff skill levels
o Collaborative practice: “an interdisciplinary process for communication and decision-making that
enables the separate and shared knowledge and skill of the care providers to synergistically influence
the client/patient care provided”
o Advantages
 Achieve optimal utilization of workforce
 Strengthen the provision of safe & high quality care
 Improves retention
 Enhances client & staff satisfaction
o Disadvantages
 Role confusion
 Providers perceive as excessive duplication of effort
Total Patient Care:
o Nurse is responsible for the total care for a client assignment for a worked shift
o Advantage
 Client receives consistency in care
o Disadvantage
 Nurse may not have same clients from day to day
 This model uses high level of profession nursing hours (therefore more costly)
Functional Nursing:
o Divides work into functional units assigned to one team members
o Each care provider is responsible for specific duties or tasks
o Advantages
 Care can be delivered to large numbers of clients
o Disadvantages
 Care seems disjointed to clients --care delivered by a number of staff
 Continuity of care compromised
Models of Care Delivery:

o
o

Modular nursing is team nursing that divides a geographic space into modules of patients with each
module having a team of staff led by an RN to care for them or team nursing divided by geographic
space into modules of patients with a team led by an RN to care for them
Team nursing
 Assigns staff to teams responsible for a group of patients
 Units divided into two (or more) teams each led registered nurse (team leader)
 Team leaders supervise & coordinate all of the care provided
 Care is divided into the simplest components & assigned to care provider with the appropriate
skill level

Team Nursing:
o Advantages
 Maximizes the role of the registered nurse
 Nurse is able to get work done through others
o Disadvantages
 Patients often receive fragmented, depersonalized care
 Communication is complex
 Shared responsibility & accountability can cause confusion & lack of accountability
Primary Nursing:
o Defines the responsibility & accountability of the nurse
o Nurse the primary provider of care
o Advantages
 Clients & families develop a trusting relationship with the nurse
 Accountability & responsibility for developing plan of care with client & family
 Holistic approach to care, rather than a shift-to-shift focus, facilitates continuity of care
 Authority for decision making is given to the nurse at the bedside
o Disadvantages
 High cost nurse skill mix
 Needs knowledge about all the patients & staff to match nurse to patient.
 Lack of geographical boundaries on unit-travel long distances to care for patient
 Nursing time is often used tasks that could be completed by other staff
 Nurse-to-patient ratios must be realistic
Emerging Models of Care – Client-Centred Collaborative Practice:
o Goal: to ensure delivery right care, by the right provider, in the right setting, requires a clear
understanding of providers roles
o Client-centred or Client-focused care
 Focus on client needs rather than staff needs
 Necessary care & services are decentralized & brought to clients
 Staff close to patients in decentralized workstations
 Care teams are established for a group of clients
 Disciplines collaborate to ensure appropriate care is received
Client-Centered Care:
o Advantages

o

 Convenient for clients
 Expedites services to clients
Disadvantages
 Can be extremely costly to decentralize major services in an organization
 Some perceive model as a way of reducing RNs & cutting costs in hospitals

Care Delivery Management Tools:
o Length of Stay (LOS) are opportunities to reduce costs & two strategies to accomplish decreased
LOS include:
 Clinical pathways
 Case management
o Clinical pathways
 used to enhance outcomes & contain costs
 outline expected clinical course & outcomes for a specific client type
 Pathways by days-- each day expected outcomes are articulated
 client progress is measured against the expected outcomes
Clinical Pathways:
o Advantages
 Very instructive to new staff
 Save time in the process of care
 improve care & shorten length of stay
 Allows for data collection of variances to the pathway
o Disadvantages
 Some physicians perceive pathways to be cookbook medicine & are reluctant to participate in
their development
 Development requires a significant amount of work to gain consensus from the various
disciplines on the expected plan of care
 Pathways are less effective for patient populations that are nonstandard, since they are
constantly being modified to reflect individual patient needs
Clinical Practice Guidelines:
o Evidence based best practice in prevention, diagnosis or management of a symptom, disease or
condition for a client or group of clients
o Canadian Medical Association (CMA) integrated in quality care program
Case Management:
o Strategy to improve patient care & reduce hospital costs through coordination of care
Case Manager:
o Responsible for coordinating care & establishing goals from preadmission through discharge
o Evaluates the patient’s outcomes daily & compares them to the predicted outcomes articulated in the
clinical pathway
o Works with all the disciplines to facilitate care
o Has a data function to improve care
o Collects aggregate data on client variances from clinical pathways

o

Shared with members of health care team in effort to explore opportunities for improvement in
pathway or in system

Organizational Purpose, Mission, Philosophy, Values:
o Mission statement: formal expression of the purpose or reason for existence of the organization
o Philosophy: value statement of principles & beliefs that direct the organization’s behaviour
o Vision: provides a clear picture of what the future will look like, it defines the key results achieved
& goals that are to be accomplished
o Values: may be formally stated & explicit, or may be implicit & part of the organizational culture
Organizational Structures:
o Facilitate the execution of the mission statement, strategic plan, reporting lines and communications
with in the organization
 Board of Trustees
 Chief Executive officer
 Vice Presidential Officer
 Department Directors
 Managers
 Charge Nurses/Clinical Leaders/Nurse Educators
 Staff Nurse
Strategic Planning:
o Planning Goals & Objectives
o Goals & objectives must be prioritized after identification (according to strategic importance/
required resources & time & effort involved)
o Timelines for completion along with evaluative measures for each goal
o Communication of all goals & objectives to all stakeholders is key (marketing)
Structure of Professional Practice:
o Shared governance:
 Framework grounded in the decentralization of leadership that fosters autonomous decision
making and professional nursing practice
 Allocation of control, power, authority among mutually invested participants
 Example: management relinquishes control over clinical practice issues
o Nurses accept responsibility and accountability for their practice
 Clinical practice council
 Quality council
 Education council
 Research council
 Management council
 Coordinating council
Benner’s Novice to Expert:
o Benner’s clinical or career-laddering model acknowledges that practitioners can be expected to have
acquired tasks, competencies, and outcomes that are based on five levels of experience.
 Novice – task oriented, focused
 Advanced beginner – somewhat independent





Competent – 2/3 years
Proficient – plan of care
Expert - ++ experience

Quality Assurance and Quality Improvement: Understanding ‘Quality’ and ‘Customer’:
o Quality is …
 Being better, doing things right the first time
 Health care professionals seeing themselves as having customers or clients
 Directing health professionals to give more than the basics
o Every problem as an opportunity for improvement
o Customer is… (our client/patient)
 Anyone who receives the output of your efforts
 Can be internal, within the organization
 Can be external, outside the organization
General Principles of QI:
o Quality Improvement is a structured system aimed at understanding & meeting (exceeding) customer
needs & expectations
o Quality principles include:
 Priority is to benefit clients & families
 Achieved through participation of all organizational members
 Improvements developed by focusing on the work process
 Decisions to change or improve a system or process are made based on data
 Improvement of the quality of service is a continuous process
 Committed leadership is necessary to make it happen
 Both education & long-term commitment are required
Difference Between QA and AI:
o Quality Assurance QA
 Assessing/measuring performance
 Determining whether performance conforms to standards
 Improving performance when standards are not met
o Continuous Quality Improvement CQI
 Meeting needs of customer
 Building quality performance into the work process
 Assessing the work process to identify opportunities for improved performance
 Employing a scientific approach to assessment and problem solving
 Improving performance continuously as a management strategy (not just when standards are
not met)
Unit-Based Performance Improvement:
o Comprehensive unit-based continuous quality improvement program consists of four outcomes from
four domains:
 Access
 Service
 Cost



Clinical quality

Primary Benefits of QI:
o Ability to discover performance issues quickly and efficiently
o Improve staff satisfaction by involving staff in the developing and implementing the work process
o Empowering staff to identify and implement change
o Demonstrate to clients that you care about meeting their clients needs
o Decrease unnecessary costs from waste and rework, lost time and meeting provincial standards
Participation of Everyone in the Organization:
o Each employee:
 Must feel they can participate
 Take responsibility for success or failure
 Actively develop new ways of doing business
 Trust their efforts are valued
o All staff should be encouraged to participate
o All involved with or affected by a goal or process should participate
o Staff can participate on individual, unit, or organizational levels
How is ‘Improvement’ Implemented??
o Improvement Based on Data
 Decisions to change or improve a system or process are made based on data
o Quality improvement measured by the overall value of care
o Value is determined by outcomes & cost
o Outcomes can be clinical/functional (did the patient live?) or related to patient satisfaction
o Cost can be direct or indirect
o Goal: increase quality outcomes, reduce cost
Methodologies for Quality Improvement:
o PDSA (Plan Do Study Act)
o FOCUS Methodology
 F — focus on an improvement job
 O — organize a team that understands the process
 C — clarify what is happening in the current process
 U — understand the degree of change needed
 S — select a solution for improvement
o Benchmarking
o Balanced Scorecard
 How do clients see us?
 What must we excel at?
 Can we continue to improve?
 How do we look to funders?
Methodology for Quality Improvement:
o Regulatory Requirements
 Accreditation Canada (AC) assists health organizations across the country to examine &
improve the quality of care & service they provide



o

New accreditation program in 2008 called Qmentum, which emphasizes health system
performance, risk prevention planning, client safety, performance measurement, and
governance
Sentinel Events/ Critical Incident
 Is an unexpected incident (related to a system or process deficiency) that results in a major &
enduring loss to the client
 Sentinel events require immediate investigation & response

Principles in Action:
o Using data collected to support change, needs, setting goals, outcomes
o Organizational structure—identifies people responsible
 Encourage accountability
 Maximize communication
 Communicate & focus priorities at all levels
o Communication key, mission, vision & value statements help organizations articulate their directions
with quality
What is Organizational Culture?
o Organizational culture -- basic pattern of shared assumptions, values, & beliefs that govern
behaviour within a organization
 Shared value system guiding members as they solve problems, adapt to external environment,
and manage relationships
o Culture is “how & why you do what you do”.
3 Functions of Organizational Culture:
o 1. Deeply embedded form of social control
o 2. The “social glue” bonds people together & makes them feel part of the organizational experience
o 3. Corporate culture helps employees make sense of the workplace
Subcultures:
o Is an important source of emerging organizational values
 Relationship between strong unified cultures and commercial success
 Coexistence due to occupational groupings
 Common orientation and similar espoused values
 May clash with the dominant culture and maintain an uneasy relationship
 Support, oppose or coexist alongside the dominant culture
Characteristics of Strong Organizational Cultures:
o Most employees across all units hold the dominant values
o Well established artifacts make it difficult for the values to change
o Strong cultures are long-lasting
o BUT…
 Must fit the organization’s environment
 Too strong may blind employees to alternate viewpoints
Adaptive Cultures:

o
o
o
o
o

Have employees focus on the changing needs of clients and other stakeholders and support initiatives
to keep pace with change
Have an external focus
Have employees that focus on continuous improvement of processes
Have employees with a strong sense of ownership who assume responsibility for the org’s
performance
Are proactive and quick to respond to change

Chapter 9-Effective Team Building:
Defining Teams & Committees:
o Team
 Something that exists any time two or more people are working together with a shared
purpose…team members have particular responsibilities that relate to their own specific skills
and knowledge.”
o Interdisciplinary Team
 Composed of members with a variety of clinical expertise
o Committee
 Is a work group with a specific task or goal to accomplish
o Adhoc (short term goal) bed utilization flu season
 Standing (may be mandated by organizational bylaws) eg. Quality committee
 Advisory Committee (reports back to a council or executive)
Stages of Team Process:
o Five stages that groups progress through
 Forming
 Storming
 Norming
 Performing
 Adjourning
Group Roles Functional Versus Dysfunctional:
o Functional roles
 Initiator
 Coordinator
 Mobilizer
 Questioner
 Antagonist
 Recorder
o Dysfunctional roles **Table 9-2: Strategies for Coping with Difficult Personalities**
 Criticizer
 Passive observer
 Detailer
 Controller

 Pleaser
Key Concepts of Effective Teams:
o “The whole is greater than the sum of the parts”
o Purpose
o Composition
o Communication
o Participation
o Progress
o Evaluation
Creating an Environment Conducive to Team Building:
o Supportive Organizational Cultures
o Supportive Policies & Procedures
o Strong Leadership
o Resources
Team Work on a Nursing Unit:
o The role of the RN/RPN team leader works directly with a wide variety of people:
 Physician orders done, documentation complete
 Treatments & procedures done
 d/c planning coordinated with Social Worker, Community case manager, pharmacist
 Family teaching re: discharge care
 Client teaching re: discharge care
o COMMUNICATION, COMMUNICATION, COMMUNICATION
Profession:
o Specialized knowledge base
o Regulation/legislation
o Continuing competence
o "A profession is a disciplined group of individuals who adhere to ethical standards and who hold
themselves out as, and are accepted by the public as possessing special knowledge and skills in a
widely recognised body of learning derived from research, education and training at a high level, and
who are prepared to apply this knowledge and exercise these skills in the interest of others.
o It is inherent in the definition of a profession that a code of ethics governs the activities of each
profession. Such codes require behaviour and practice beyond the personal moral obligations of an
individual. They define and demand high standards of behaviour in respect to the services provided to
the public and in dealing with professional colleagues
Guiding Principles:
o The first guiding principle:
 Nursing is one profession with two categories:
o Registered Nurse (RN) and Registered Practical Nurse (RPN)
o Nurse is used for both categories unless specifically stated
o The second guiding principle:
 Foundational knowledge base of RNs and RPNs is different.
 Areas that overlap (performance of client care and academic courses that have similar titles.)
 RNs four-year baccalaureate degree; RPNs two-year practical nursing diploma.

o

o

o
o

o
o

 RNs study in greater depth and breadth over a longer period of time.
 The clinical performance expectation for each nurse is different.
The third guiding principle: builds on the foundational knowledge base
 Enhance knowledge through formal and informal education, experience and reflective
practice. Both can become experts within their own category and area of practice.
The fourth guiding principle:
 RNs and RPNs are accountable for their own decisions and actions.
o Not accountable for what someone else does, or for what they are not informed
about.
 RNs are not accountable for the actions or decisions made by an RPN.
 All nurses are responsible for taking action to ensure client safety.
The fifth guiding principle:
 Client central focus & full partner in the decision-making process.
The sixth guiding principle:
 The overall goal is best possible outcome for the client with no unnecessary exposure to risk
of harm.
This may include intervening with client care and/or informing the employer of concerns related to
the conduct or actions of another health care professional. In addition, nurses are accountable for
maintaining competence throughout their entire career.
A client is defined as an individual, family, group, community or population.

Professional Standards:
o Accountability
o Continuing Competency
o Ethics
o Knowledge
o Knowledge Application
o Leadership
o Relationship
o The seven broad standards in the Professional Standards document provide the framework for nursing
practice and are imbedded in all practice standards, guidelines and RN and RPN competencies.
Professional Standards is the foundation for all other documents, such as the Documentation and
Medication practice standards.
Regulated Health Professions Act 1991:
o All 23 self-regulating health colleges in Ontario must do the following for their respective
professions:
 Decide what education and other qualifications are necessary to become a member;
 Establish the standards of practice with which members must comply;
 All regulated health professions have a profession-specific act with related regulations that
govern the profession
 Administer quality assurance required participation to maintain competence
 Provide a complaint and investigation process
 Scope of practice is not exclusive or protected
 Acknowledges the scopes of practice may overlap with various professionals performing
identical duties

RHPA: What’s New as of June 4, 2009?
o Increased openness, accountability, public safety and confidence are the key points of the
amendments to the legislation that governs nursing practice in Ontario.
o Suspension of registration for non-payment of annual fees decreased to 30 days. Non-payment is part
of the permanent online register
o Members self-report any court findings of professional negligence or malpractice, and any findings of
guilt for offences (this is added to the register as well)
o Organizations must report if they believe that a health professional is incompetent or incapacitated
o New Inquiries, Complaints and Reports (ICR) Committee
o ICR will be required to consider all prior decisions regarding a member, except if no action because
complaint was incomplete or invalid
o ICR Committee may order regulated health professional to complete specified continuing education
or remedial program.
o Promote interprofessional collaboration with the other health profession colleges
Online Register to include:
o Name/previous name, work address & phone number, class, registration number, and status of
registration with all findings of professional misconduct, incompetence or incapacity
o Documentation of past and current suspensions, if their licence has been revoked for any reason
which will include the start and end dates
o Notations of all Discipline Committee referrals that have not yet been decided
o A notation when a regulated health professional is under investigation, and the member and his or her
college reach an agreement that the member will permanently resign
Quality Assurance for CNO:
o The Quality Assurance (QA) Program is based on the principle that lifelong learning is essential to
continuing competence. The program measures a member’s knowledge and application of the
College’s practice standards and guidelines.
o The QA Program includes three components: Self-Assessment; Practice Assessment; and Peer
Assessment.
RHPA: Quality Assurance 3 Components:
o All members will be required to participate
1. Self-Assessment
 A three-step process that involves
 Creating a learning plan relevant to the member’s practice
 Seeking peer input into the plan and
 Documenting the plan
2. Practice Assessment
 An assessment knowledge, skill and judgment.
 Based on two practice standards that the College announces each year.
3. Peer Assessment
 Reviewers will review the results of the members’ tests and learning plans for completeness,
 Recommend next steps for improving practice as necessary.
The Nursing Act 1991:
o Contains a scope of practice statement that describes in a general way what the profession does and
the methods that it uses

o

Contains provisions and regulations specific to the nursing profession:
 Definitions of the classes of nurse registration
 Entry-to-practice and title protection regulations
 Regulations on initiating controlled acts
 Defines Professional misconduct

College of Nurses:
o Regulates nursing to protect the public interest
o Sets requirements to enter the profession
o Establishes and enforces standards of nursing practice
o Assures the quality of practice of the profession and the continuing competence of nurses
o Ensures individual members are responsible for following the standards of practice, remaining current
and maintaining competency
Professional Misconduct:
o Relevant to nurse’s decision to accept delegation and perform procedures
o 1. Disobey a standard of practice of the profession or failing to meet the standard of practice of the
profession (break the rules)
o 2. Directing a member, student or other health care team member to perform nursing functions for
which she/he is not adequately trained or competent to perform
o 3. Failing to inform the member’s employer of her/his inability to accept specific responsibility in
areas in which specific training is required or for which the member is not competent to function
without supervision
Controlled Acts:
o The RHPA established 13 controlled acts
 Controlled acts are considered potentially harmful if performed by unqualified persons
 The Nursing Act authorizes nurses to perform 3 of the controlled acts
o An RN or RPN is authorized to perform a procedure within the controlled acts authorized to nursing:
 If initiated in accordance with conditions identified in the regulation; or
 If the procedure is ordered by a physician, dentist, chiropodist or NP
o Controlled acts are not the only procedures that may cause harm
o Having the authority to perform a procedure does not automatically mean it is appropriate to do so
o Each nurse is accountable for her/his decisions and actions.
o Just because you can doesn’t mean you should and doesn’t mean it’s right!
3 Controlled Acts Authorized to Nursing:
o 1. Performing a prescribed procedure below the dermis or a mucous membrane
o 2. Administering a substance by injection or inhalation
o 3. Putting an instrument, hand or finger
 Beyond the external ear canal,
 Beyond the point in the nasal passages
 Where they normally narrow,
 Beyond the larynx,
 Beyond the opening of the urethra,
 Beyond the labia majora,
 Beyond the anal verge, or




Into an artificial opening into the body.
RN EC (Extended Class) role has additional authorization

Exceptions to the Need for Authorization:
o The Regulated Health Professions Act, 1991, provides several exceptions allowing unauthorized
members of regulated profession to perform controlled acts.
o 1. When providing first aid or temporary assistance in an emergency
o 2. Under the supervision or direction of a member of the profession, a student is learning to become a
member of that profession and the performance of the procedure is within the scope of the
professional’s practice;
o 3. Treating a member of a person’s household and the procedure is within the second or third
controlled act authorized to nursing;
o 4. When assisting a person with his/her routine activities of living and the procedure is within the
second or third controlled act authorized to nursing;
o 5. When treating a person by prayer or spiritual means in accordance with the religion of the person
giving the treatment.
o 6. Others: ear-piercing or body piercing for the purpose of accommodating a piece of jewellery,
electrolysis and tattooing, male circumcision as part of a religious tradition or ceremony, and taking a
blood sample by a person employed by a laboratory licensed under the Laboratory and Specimen
Collection Centre Licensing Act.
Categories of Registration and Classes of Certificates:
o General Class
 Received by most RNs and RPNs upon initial registration with the College.
o Temporary Class
 For recent graduates or applicants from outside the province who meet all entry requirements
except for having passed the registration exam. Some restrictions and conditions apply to
those in the Temporary Class.
o Special Assignment Class
 For experienced nurses who come to Ontario for a limited period on exchange or for a special
assignment. This class can also be used for nurses who come from outside Ontario to assist
during large-scale emergencies.
o Extended Class
 RNs in this class are Nurse Practitioners (NPs) and have met additional competency
requirements beyond those required in the General Class. There are four specialty certificates
in the Extended Class: NP-Primary Health Care, NP-Adult, NP-Paediatrics and NPAnaesthesia.
o Retired Class
 This class is available to current and previous members of the College who are age 65 or
older and have retired from active nursing.
Title Protection:
o Many titles used by nurses are protected under the Nursing Act.
o In Ontario, only members of the College can use the titles of nurse, Registered Nurse, Registered
Practical Nurse, or any variation, abbreviation or equivalent in another language.
o Only nurses in the Extended Class can use the title of Nurse Practitioner.

o

Individuals who refer to themselves as nurses or attempt to obtain employment as nurses in Ontario
without being registered with the College are illegal practitioners and can be prosecuted under the
Nursing Act and RHPA.

Entry to Practice
o Regulations under the Nursing Act establish the seven requirements that must be met for registration
as an RN or RPN in the General Class:
o 1. Completion of an approved nursing or practical nursing program
o 2. Evidence of recent safe nursing practice
o 3. Passing the national registration examination
o 4. Evidence of fluency in written and spoken English or French
o 5. Registration or eligibility for registration in the jurisdiction where nurses completed their nursing
program
o 6. Proof of Canadian citizenship, landed immigrant status, or authorization under the Immigration and
Refugee Protection Act (Canada) to engage in nursing practice
o 7. Good character and suitability to practice.
RN and RPN Practice: The Client, the Nurse and the Environment
Three Factor Framework
o Client Factor Three Components:
 Complexity
 Predictability
 Risk of negative outcomes
o Nurse Factors
 One profession
 Accountability
 Foundational knowledge
 Enhanced knowledge
 Autonomous practice
 Consultation
 Collaboration
o Environment Factor Three components:
 Practice supports
 Consultation resources
 Stability and predictability
Competency:
o The stages of development of competency in Benner’s model are:
 Stage 1: Novice
o Will usually ask to be shown or told what to do
o Beginners, because they have no experience with the situations in which they are
expected to perform, must depend on rules to guide their actions. Following rules
however has its limits. No rule can tell novices which tasks are most relevant in real
life situations. The novice will usually ask to be shown or told what to do.
 Stage 2: Advanced Beginner
o Cannot reliably sort out what is most important in complex situations and will need
help to prioritize.

An advanced beginner is one who has coped with enough real situations to note (or to
have them pointed out by a mentor) the recurrent meaningful aspects of situations.
An advanced beginner needs help setting priorities since she/he operates on general
guidelines and is only beginning to perceive recurrent meaningful patterns. The
advanced beginner cannot reliably sort out what is most important in complex
situations and will need help to prioritise.
 Stage 3: Competent
o Lacks the speed and flexibility but competence is characterized by a feeling of
mastery and the ability to cope with and manage contingencies of practice.
o Typically, the competent professional has been in practice two or three years. This
person can rely on long-range goals and plans to determine which aspects of a
situation are important and which can be ignored. The competent professional lacks
the speed and flexibility of someone who has reached the proficient level, but
competence is characterised by a feeling of mastery and the ability to cope with and
manage contingencies of practice.
 Stage 4: Proficient
o Considers fewer options and hones in on the accurate region of the problem.
o This is someone who perceives a situation as a whole rather than in terms of parts.
With holistic understanding, decision-making is less laboured since the professional
has a perspective on which of the many attributes and aspects present are the
important ones. The proficient performer considers fewer options and hones in on the
accurate region of the problem.
 Stage 5: Expert
o Has an intuitive grasp of the situation and focuses in on the accurate region of the
problem without wasteful consideration of a larger range of unfruitful possibilities.
o The expert professional is one who no longer relies on an analytical principle (rule,
guideline, maxim) to connect an understanding of the situation to an appropriate
action. With an extensive background of experience the expert has an intuitive grasp
of the situation and focuses in on the accurate region of the problem without wasteful
consideration of a larger range of unfruitful possibilities.
o
Environment and Health:
o Environmental factors
o Influence health in all countries
 Important: access to safe water, sanitation, indoor and outdoor pollution, climate
changes, global warming
o Account for 25% of diseases and 23% of deaths globally
o Vulnerable populations include marginalized populations, children, and older adults
o

Effects of Climate Change:
o Climate change- changes in weather patterns
o Global warming- greenhouse gases
o Air pollution- indoor and outdoor
o Water- safe clean drinking essential
o Sanitation- wastewater & solid waste disposal

o

Climate change occurs when long-term weather patterns change. Changes noted in weather patterns
over the last few decades include global warming, increased rainfall in some regions, prolonged
periods of no rainfall in others, extreme storm systems, and rising sea levels. Over time, changes in
temperature and weather patterns will change land use; rising seas levels will cause loss of coastal
plains and small islands; and populations will be displaced and forced to migrate. Forest clearance,
accompanied by changing weather patterns, will cause vectors of diseases , such as rats, ticks, flies,
and mosquitoes, to migrate, bringing old diseases to new areas and giving rise to new diseases. West
Nile virus infection is an example of a new disease in Canada

Solutions for Climate Change:
o Adaptation—actions to adjust to changes in climate à health care systems must be alert to early
identification of new diseases
o Mitigation—efforts made to reduce greenhouse gas emissions à using environmental friendly
cleaners, alternate energy sources like solar power
o REDD--[reducing emissions from deforestation and forest degradation] help maintain the earth’s
capacity to absorb greenhouse gases
o *Success will require intersectoral and intergovernmental collaboration
International vs. Global Health:
o International Health:
o Health status among nations
o Focused on control of epidemics
o Emphasizes differences rather than commonalities
o Global Health:
o Health status that transcends borders
o Research and practice focuses on improving and promoting health
o Recognizes the integration of economies, societies and cultures
Global Health Agencies:
o World Health Organization (WHO)—international agency for health
o United Nations Development Program (UNDP)
o World Bank
o United Nations Millennium Declaration—Millennium Development Goals
Definition of Epidemiological Transition:
o Omran (1971) postulated the theory that countries transitioning from third world to first world
countries experience reduced mortality, increased life expectancy—shifts in morbidity and mortality
from infectious diseases to chronic, degenerative diseases
Classification of Countries:
o By Income—World Bank classifies countries by Gross National Income (GNI) à high, middle, low
o Industrialized Countries—G8 and G20 [world’s top economies]
o By Geography
o By Religion
o By Language
8 Millennium Development Goals [MDGs]:
o Eradicate extreme poverty and hunger

o
o
o
o
o
o
o

Achieve universal primary education
Promote gender equality and empower women
Reduce morality
Improve maternal and child health
Combat HIV/AIDS, malaria and other diseases
Ensure environmental sustainability
Global partnership for development

Capacity Building:
o Long term ability to develop and implement health care strategies
o Involves all stakeholders in population
o Uses human, scientific, technological and organizational resources (capabilities)
o Advocates education that supports knowledge and skill important to health
o Needs to occur at individual, institutional and societal levels (at local and international levels)
Sustainability:
o Refers to long term maintenance of developed programs
o Needs to be consistent with future & present needs of the population [unfold over time]
o Indicators include à environment, economy, institutional and social progress
o Helps to reduce mortality, morbidity and disability
Social Justice:
o Based on principles of equity, equality and respect for human rights
o Focuses on the allocation of health resources, equitable access to health resources and determinants of
health
o Due to disparity among marginalized populations it becomes necessary to identify at risk groups and
intervene
Major Issues in Global Health:
o The major issues in global health are as follows:
o Migration
 Movement of people either voluntarily or due to duress
 Nurses may have different values, beliefs and expectations related to health and the
delivery of health services than migrants
o Indigenous Peoples
 Are often marginalized with implications for poorer health
 These populations and communities may be isolated with limited access to services,
water and sanitation, creating inequities
 Canadian Indigenous People include First Nations, Inuit and Métis
o Poverty and Inequality
 Indigenous People, immigrants, women, and single parent families are at highest risk
for poverty
 Poverty increases risk of homelessness, poor living conditions and poor health
o Food Security
 Exists when all people have access to sufficient, nutritious food that maintains health
 Based on food availability, food access, food use
 Poverty is the factor that most negatively affects food security
o Disasters

o

o

o

o

 Often occur as a result of changes to climate
 Can disrupt normal services to clean water, sanitation and health care services
 Increase risk to health
 Organizations do provide emergency care during crises [e.g. Red Cross]
Infectious Diseases and Surveillance
 Monitoring disease outbreaks and threats to public health is a priority for the global
community
 Surveillance (monitoring) rules were developed by the International Health
Regulations (IHRs)
 The Public Health Agency of Canada (PHAC) is responsible for the implementation
of the IHRs and leads the Emergency Preparedness Response in Canada
Gender
 Refers to more than biology; also is influenced by socially constructed roles,
behaviours, activities and attributes
 ♂ enjoy better health then ♀ but have shorter life expectancy
 Two measures used to measure gender inequalities are
 Gender Inequalities Index à score represents ♀s’ loss of potential for human
development compared to ♂
 Social Institutions and Gender Index à measures gender equality
(discrimination)
Women’s Health
 Low income countries have higher levels of mortality for ♀
 Reproductive health is the most significant factor in gender inequality
 Risk to women during their childbearing years has secondary negative consequences
for children, families and communities
Child Health
 Risks to newborn’s health highest during 1st month after birth
 Newborn deaths occur most often due to lack of access to health care
 Globally deaths under 5 years of age are caused by infections and malnutrition

Nurses and Global Health:
o Nurses have many roles to play in influencing global health.
1. Education [including global health in the nursing curriculae]
2. The Relevance of nursing and nursing organizations to global health
3. Collective nursing knowledge as practitioners, educators, researchers and nursing leaders in global
and international settings
Nursing Education:
o Undergraduate education should include theory about global health issues and factors affecting health
o Canada has highest per capita immigration rate in the world so it is vitally important for nurses to
understand diverse needs of people from different cultures
Global Health:
o Canadian Nurses Association [CNA] endorses principles of health promotion and illness prevention;
considers global health a fundamental right
o Cultural competence is key to a nurse’s ability to practice safely and ethically in a global health
context

Preparing to Work in Global Health:
o It is important for nurses to consider their own motivation(s) and assets that they can bring to a job
and share with others
o Nurses working globally must be able to prioritize, make decisions and work with limited
technologies
o Ability to speak different languages and have personal interest also important
o Roles are often flexible and require multitasking abilities