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Nursing and You

Vol. 1, No. 2, March 1999 - Cancer Care

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Cancer Prevention in Ontario's Young People: the Role of the Public Health Nurse

"I think teaching is one of my strengths," says RN Heather Tucker, a public health nurse with the Durham Region health department, "but the one-shot classroom presentation just doesn't work any more, if it ever did. Motivating kids to stop smoking, or never start, is a pretty complex task, and you have to involve the whole community - parents, the school, the business community and particularly kids themselves ."

Heather Tucker on Quality Assurance:

"The competencies for a nurse involved in community development are a little different. I depend a lot on peer and client assessment to tell me I'm doing a good job."

Heather is one of five nurses in Durham Region exclusively dedicated to youth-oriented cancer prevention. She works mostly in the northern part of the region, in rural areas like Scugog and Uxbridge, where the proportion of young smokers is even higher than in cities like Oshawa or Whitby. "It's estimated that perhaps 40% of the student population at Brock High (in Cannington) smoke, and that's an alarming statistic," says Heather. "But most of them started a lot younger, so the senior elementary grades are where we concentrate our efforts."

It was peer pressure that got most of these young people smoking to begin with, so the nurses feel that the same influence may get them to quit. That's why the Durham prevention and cessation programs recruit heavily among high school students to spread the messages about the effects of smoking.

"The messages that will motivate teens to give up on tobacco - money, athletic ability, relationships - are best delivered by teens themselves," Heather says. "But there needs to be a multi-pronged approach, so we involve everyone - parents, students and staff - in planning the campaign in a particular school. We encourage teachers to incorporate the anti-smoking message throughout the curriculum, in areas like science, social studies or communications, and we use parent volunteers extensively."

"I almost wish I could say I had once smoked," says Heather, "it would give me a bit more credibility when I'm talking to these kids. But my husband is an ex-smoker, and I've watched hundreds of kids go through it, so I've got a pretty good idea how difficult tobacco is to resist."

The nurses realize that the easiest way to quit is never to start, so they take a broader approach to health promotion for teens. "Eat better, stay fit and avoid tobacco, " she says. "If they try to do the first two things, their chances of achieving the third will be that much greater."

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Youth Smoking in Ontario

For those in Grades 7 through 13*:

26.4% of males and 28.7% of females smoke, for an average of 27.6%.
This percentage represents a total of about 258,600 students.

Rates of smoking increase to a peak in Grade 11*:

10.2% in Grade 7
26.0% in Grade 9
43.4% in Grade 11
30.9% in Grade 13

*Source: Addiction Research Foundation, 1997

55.4% of teens who smoke have attempted to quit smoking, 83% have thought about it.**

**Source: Survey of Smoking in Canada, Health Canada

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A Dramatic Approach

Public health nurse Sandra Murphy, RN, of the Halton Region Health Department reports a very successful youth-to-youth anti-smoking campaign that took place during the 1995-96 school year. Fifty drama students from two Milton high schools (many of them smokers) developed an interactive play called Straight Talk on Smoking, and presented it to over 1,300 senior elementary students in eight schools. Surveys afterward revealed that the play significantly discouraged the elementary students from starting to smoke, and a few of the actors even stopped smoking themselves!

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What is a Nurse?

In Ontario, the nursing profession comprises two groups: Registered Nurses (RNs) and Registered Practical Nurses (RPNs). In most ways, the two categories are subject to the same regulatory requirements; the general standards of practice, the complaints and discipline process, the registration process, all are the same. The two main areas of difference are educational requirements and scope of practice. Although all nursing students learn from the same body of nursing knowledge, RNs study it in greater depth and breadth over a longer period of time, and accordingly are able to provide care in more complex situations.

RNs and RPNs are the only categories of nurse we regulate (although there are sub-groups like nurse practitioners or rehabilitation nurses); indeed, they are the only categories of health care provider entitled to call themselves "nurses". Patients should never be afraid to enquire about the credentials of the person providing them with care.

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Editorial: Keeping Current: Qualifications

Every day, we encounter people in whom we must put our trust, everyone from a bus driver to a teacher to a nurse. We find ourselves thinking: What does this person need to know in order to do what they do? Who decides whether their qualifications are sufficient to justify our trust?

For the nursing profession in Ontario, the organization responsible for answering these questions is the College of Nurses of Ontario (CNO). We are responsible for examining an individual's education and experience, and determining if they meet the standard for becoming a nurse in Ontario.

Fortunately or unfortunately, we live in a time of rapid change, particularly in scientific fields like nursing, and qualifications that were adequate yesterday may be insufficient tomorrow. Recently, CNO has consulted extensively with Ontario nurses, nurse educators, nurse employers and the general public, and asked whether the current requirements were realistic. What we learned is that there are many aspects of their practice which today's RNs learned through ongoing education and experience, but which new graduates will have to know from the outset.

As a result, the College has recently approved a new set of competencies for Registered Nurses (RNs). CNO recommendeded to the province that, beginning in 2005, a bachelor's degree in nursing become the minimum basic education requirement for RNs entering the profession. A new entry standard for our other category of nurses, Registered Practical Nurses (RPNs), is currently being developed, and is expected to be approved by our governing Council later this year.

The new entry requirements will not affect the status of those nurses already registered with the College prior to January 1, 2005.

The College's next step is to have these changes approved by the provincial government. Our hope is that this will occur before the end of the current academic year, allowing a good amount of time for everyone to accommodate the changes.

With these changes, Ontario joins five other Canadian provinces in requiring the bachelor's degree for new nurses. Support for the move has been wide-ranging, from nursing students just beginning to learn what the profession is all about, to nursing managers in the profession for decades.

The new entry requirements are our promise to you that Ontarians will continue to receive the best nursing care in the world.

Petra Cooke, RN
Council President, College of Nurses of Ontario

Margaret Risk, RN
Executive Director, College of Nurses of Ontario


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Encircled by Love: Home-based Palliative Care

When a patient knows that his or her days are drawing to a close, it's natural to want to be in the midst of loving friends and family, encircled by a comfortable, familiar environment. That's why more and more palliative (terminal) patients, many of them suffering from cancer, are choosing to die at home, says Registered Practical Nurse Pat Stuart.

"Sometimes it's difficult to give up the immediate care available in the hospital or nursing home," she says. "But the benefits are usually worth it, and with our home care service, we're on call 24 hours a day anyway, so a nurse is never very far away if you really need her."

Pat works for Saint Elizabeth Health Care, a long-established visiting nurse agency that cares for home-based cancer patients throughout Ontario. Once Saint Elizabeth is assigned a client by the local Community Care Access Centre, a nursing case manager is designated (who may be either an RN or RPN, depending on the type of care required), and other nurses are assigned to the team. Currently, Pat is manager for some 25 home-based palliative clients in Etobicoke, and part of the team for many others.

Pat has been an RPN for over 20 years, but has focused on palliative care since 1986. "Working with these patients and their families is very rewarding," she says. "Mostly I try to control their symptoms, ease their pain, to make their time comfortable and peaceful. I do a lot of teaching with patients' family and friends who provide care, and I build a strong relationship with them. They're so appreciative of what we can do for them. When bereavement finally comes, it's less painful, because the family or friends know they've done all they can."

Pat also prefers the home setting because it allows her to practise independently. "I'm able to use more of my skills here in the community," she says. "I like to solve my own problems, and here I get to do a lot of that."

Nevertheless, if a patient's condition destabilizes, an RN, trained in dealing with more complex situations, will usually become involved in the case. "At Saint Elizabeth, we don't hesitate to share care with other types of nurses if the situation calls for it," Pat says. "I do what I do best, and other nurses have other strengths. We use whatever the patient needs."

Pat Stuart on Quality Assurance - "As a nurse, you never stop learning. The St. Elizabeth organization is very helpful in arranging for the self-assessment or peer assessment required by the College. There are a lot of courses for keeping current, and I have never found it difficult to keep on top of my career here."

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Who Are Ontario Nurses?

In December of 1998, there were almost 141,000 nurses in Ontario. The College of Nurses knows this because all practising nurses must be registered with the College. Understandably, amongst that large a group, there is considerable diversity. Here are just a few interesting statistics on the nurses of Ontario.

MEMBERS BY CATEGORY
RNs
107,000
RPNs
34,000

 

 

 

 

WHERE NURSES WORK
 
RNs
RPNs
Hospital
59.2%
52.9%
Long-term Care
8.3%
24.1%
Community
13.1%
8.7%
Other (education, research, physician's office, etc.)
19.4%
14.3%


 

 

 

 

 

 

 

GENDER
 
RNs
RPNs
Female
96.7%
94.1%
Male
3.3%
(2.5% five years ago)
5.9%
(5% five years ago)

 

 

 

 

 

 

PLACE OF BASIC EDUCATION
Ontario
83.3%
Rest of Canada
72.2%
United States
0.8%
Other Major Nations
(Britain, Philippines, Hong Kong, Jamaica)
8.7%

 

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What is the College of Nurses of Ontario?

The College of Nurses (CNO) is the regulatory body for nursing in this province. Established by, but at arm's length from, the provincial government, CNO derives its revenues from annual membership fees; it receives no funding from the province. The College decides the criteria for becoming a nurse in Ontario, and the standards of practice to be met to maintain that designation and privilege. No one can practice as a nurse in Ontario, or use the titles "nurse", "registered nurse", or "registered practical nurse", without a valid certificate of registration from the College.

CNO is governed by a 39-member Council, 21 of whom are nurses elected by their peers from across Ontario (14 RNs and 7 RPNs). The other 18 are public members appointed by the provincial government.

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What Do Nurses Need to Know?

When pollsters from time to time survey the general public as to what profession most inspires their confidence and respect, nurses invariably place at or very near the top. The public's admiration is something nursing can be very proud of, but it also gives the profession high expectations to live up to. Just how have nurses achieved this status in the public mind, and how can they hold on to it?

One of the keys, of course, is nursing education. While it is true that a "caring" person is more likely to go into nursing, one cannot assume that a student naturally possesses the gifts that translate a "caring" attitude into high quality nursing.

Comprehensive scientific knowledge - how the human body works, and how to treat it when it doesn't work - comprises an important component of a nurse's basic education. But there are other core elements as well, including: how to apply nursing knowledge in various situations and practice settings; how to deal effectively and caringly with the public; how to behave professionally and ethically; and how to assure continued competence in nursing. Learning requirements in each of these areas can be found in the new entry competencies currently being adopted by the College of Nurses of Ontario (see the editorial on page two), and in our professional standards of practice, which establish benchmarks for everything from footcare to ethics to telephone practice.

Nursing educators use these tools when designing their programs. As a result, nurses actually learn in the classroom not only how to administer medication, but how to decide whether to accept a gift from a patient; not only what to do in case of a heart attack, but also what constitutes verbal abuse of a patient. Nursing education equips its graduates not just to meet a patient's health needs, but to meet them in a caring and professional manner.

In Ontario today, Registered Practical Nurses (RPNs) receive their basic education in community colleges, Registered Nurses (RNs) at either a college or university, or a combination of both. If an RN has received a Bachelor's Degree, she or he may continue in university to obtain a Master's Degree or even a Ph.D. Any nurse may also pursue specialized education, leading to a certificate in areas ranging from community nursing to intensive care. In short, all nurses learn from the same body of nursing knowledge; individual nurses, however, may have studied in greater depth or for a longer period of time, and can contribute their resulting expertise to the health care team.

What a nurse can or cannot do depends on her or his education and experience, with each nurse being accountable for knowing her or his abilities and for maintaining competence in them. The public esteem that nursing enjoys is a reflection of both the quality of nurses' educational preparation, and their individual accountability for every professional act they perform.

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Quality Assurance in Nursing

The College of Nurses' mission is "to protect the public's right to quality nursing services by providing leadership to the nursing profession in self-regulation". What does this really mean?

First of all, "self-regulation". Although it was a provincial law that created the College of Nurses of Ontario and gave us our mandate for protecting the public, how we carry out our job is in many ways up to us. Almost all of our budget comes from annual registration fees, paid by practising nurses. Our governing Council has a majority of nurses. Most of our professional staff are also nurses. In large part. then, the College is a case of nurses regulating nurses.

But the term "self-regulation" also means that each of our 140,000 members is responsible for practising in accordance with the standards of the profession, and for keeping themselves current and competent throughout their nursing careers.

The College provides "leadership by establishing professional standards of practice that all nurses are expected to follow. In addition, we help nurses maintain their competence from year to year through our Quality Assurance Program (QAP).

One element of the QAP is reflective practice, whereby with the assistance of colleagues, employers, or the self-assessment tool developed by the College, a nurse can identify the strengths of her practice, and put together a learning plan to address areas that need development. Participation in reflective practice is required by law for all nurses practising in Ontario.

Another element of the QAP is voluntary, and focuses on the places where nurses work (what we call practice settings). The ground-breaking Practice Setting Consultation Program involves both employers and nurses in a joint effort to identify elements of the workplace which support quality nursing care, and those which could use improvement. After a successful pilot phase, this program was officially launched in February of 1999, and has a waiting list of employers eager to participate.

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Ontario Nurses in the News: Nursing Research in Cancer Care

Margaret Fitch wears many hats. She is Head of Oncology Nursing at the Toronto Sunnybrook Regional Cancer Centre, Coordinator of Supportive Care for Cancer Care Ontario, and Co-Director of the Cancer Centre's Psycho-Social and Behavioural Research Unit. But actually all of her hats should have "researcher" emblazoned on the brim, because it is the researcher's commitment to asking questions and finding better answers that this high profile nurse brings to all her roles.

"In all my work," she says, "I try to base my decisions on scientific evidence for what is the best approach." Margaret is one of only a few nurse Ph.D.s in Ontario engaged in research on the care of cancer patients. It is not the kind of research that brings to mind images of test tubes and hushed laboratories.

"Medical research, conducted by physicians often with the collaboration of nurses, is usually concerned with the disease, finding a cure or new treatment. But increasingly nurses are engaging in their own research," says Margaret, "and it is concerned more with the cancer patient, with how to recognize and relieve his symptoms, and to ensure we are doing all we can to ease his suffering and to assist his care-givers in meeting his needs."

An example is a recent wide-ranging study on ovarian cancer, a disease that afflicts over 2,000 Canadian women yearly. When she spoke with a number of ovarian cancer patients in preparation for a national conference on the disease, Margaret was disturbed - but not really surprised - by what she heard.

"It became evident these women had a number of frustrations with the cancer care system and cancer care providers. We began to wonder how we could capture the perspectives of other women, and get to the cause of some of these problems."

The result was a wide-ranging study, funded by Health Canada, which surveyed not only the experiences of ovarian cancer patients, but the knowledge and practices relating to the disease of three major groups of care providers: family physicians; gynecologists; and complementary practitioners, such as herbalists or naturopaths (many cancer patients turn to this latter group for help at some point). Most of the research was carried out by nurses, and the results produced a number of implications for both nursing and medical practice, and education.

Margaret's research unit employs a number of nurses full-time, including RN Karen Deane of Waterloo. "I've worked in many areas of nursing, from the operating room to the ER," she says, "but I find research very challenging and satisfying, knowing that what I'm doing could have a long-term effect on nursing practice."

"I think all nurses are inherently curious people," says Margaret. "By applying that curiosity to our practice, by asking questions about what we do and how we do it, we can integrate research into every nurse's practice."

Margaret Fitch on Quality Assurance: "If we were honest with ourselves, we would have to admit that a number of practices in nursing have roots in ritual or tradition, and have not been tested with scientific research. A research-based practice is more likely to produce the highest quality of nursing care." Editorial Note: In our new entry competencies (see the editorial on page two), having research skills, and the ability to use research, figure prominently. As a result, future nursing education will place an increased emphasis on research-based practice.

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Diary: A Week in the Life of a Paediatric Community Cancer Nurse

Interlink is a non-profit agency which helps cancer patients and their families in many parts of Ontario with home visits by specialized cancer nurses. Some nurses like Marilyn Cassidy, RN, of Ottawa care mostly for children. This is her account of a typical week.

It's Sunday night and time to get ready for another work week. I have a school presentation in the morning for the classmates of a boy in Grade 3 with a brain tumour. I will also speak to his brother's Grade 6 class.

Monday

I meet the mother of the patient at the school office and with the principal we go to the classroom. I explain to the students what has been happening to their friend. They want to know how they can help him. I suggest not only sending notes and get-well cards, but also perhaps making a video with his classmates. Together we watch Why, Charlie Brown, Why?, a cartoon video about cancer.

I notice that his mom is a little teary; it's still all very new and tough. We tell the class he is doing well after his surgery and has begun radiation. We then head off to the brother's class, where I gear the presentation to this older group's level. Prior to leaving the school we meet with the principal. We plan to stay in touch regularly, and I will provide ongoing support to the school as needed.

Back to the hospital and it's lunchtime. I use a break with a colleague as a chance to catch up on what is new at the hospital.

Next I call the community palliative physician to review the status of a 17-year-old teenager, also with a brain tumour, who is dying. He has deteriorated but is comfortable with very little pain. I touch base by phone with Mom, planning a visit for the following day to help with funeral plans at her request.

The mother of an 11-year-old boy with Acute Myelogenous Leukemia, a rare type of blood cancer, drops by my office. He has completed three months of chemotherapy and is ready for a bone marrow transplant next month. He has four siblings and thankfully he has two identical matches. His 10-year-old brother will be the donor. We review the potential needs of the family, both at home and when they will be in Toronto, and I alert the Cancer Society to the increased needs. They have a special transplant fund (Little Angels), which assists families in need.

At 2:00 p.m. I set off to visit a newly-diagnosed 13-year-old with a bone tumour, Osteogenic Sarcoma, in her femur. I have planned my visit for when the primary visiting nurse is going to be giving a medication, as I have prepared an information package for the nurse about this illness and the treatment protocol.

The patient's mother and I discuss the needs of the family, and what other community supports may be of assistance. I will make a referral to the Cancer Society which regularly assists families with Ronald McDonald House and transportation costs, parental attendance (which helps pay for food while at the hospital), and care for siblings. During my visit, the younger sibling (age nine) joins us, and I talk with her about her older sister and how things have changed in the family in the past few weeks.

Our patient is up in bed, two days post-chemo. She is in good spirits, drinking well, eating little. I talk to Mom about seeing a dietician. Her hair is coming out, as expected, she says. She has already picked out two baseball caps she likes. She will try to attend school when she is feeling better, but right now we will focus on obtaining home instruction for her. My visit ends after two hours, time well-spent as we completed a comprehensive assessment and established a good relationship.

I head back to my home-based office, where I return calls, then leave a report of each of my visits of the day on the voice mail of the respective Nursing Care Manager.

Tuesday

I start my day with a visit to the palliative patient I discussed yesterday, the 17-year-old boy with a brain tumour. His care is well-coordinated by shift nurses almost around the clock. I speak with the nurse and find that all is going as well as possible with good pain control via a morphine pump. I spend time with his mother, discussing plans for the funeral, and just listening. Over a game of Scrabble, I talk with his 12-year old sister about her feelings and I ask her if she would like to be linked up to one of our volunteers to spend time weekly with her. She thinks that would be a good idea.

Next I visit a family whose seven-year-old daughter has a Rhabdomy Sarcoma, a soft tissue tumour, in her jaw. She is doing well on chemotherapy, but Mom needs additional help in giving care at home. Together we complete the necessary forms. The little patient shows me how well she can now walk, having suffered weakness in her hands, legs and feet from the chemotherapy drug. On my way home, I use my cell phone to update the family's home care coordinator.

Wednesday

I head to the hospital (Children's Hospital of Eastern Ontario) early, as we have a team meeting where we share ideas and case reports with one another. I follow this with a 45-minute teleconference with my Toronto, Sudbury and Hamilton Interlink colleagues.

Next on my agenda is attending a one-hour parent drop-in on the hospital oncology unit. This is an opportunity for parents to come by informally, for support and to discuss whatever is on their minds. Following this, after reading the chart, I introduce myself to a new family. In the afternoon, team rounds at the hospital provide me with updated patient information.

Thursday

I have planned a case conference at the home of a 12-year-old patient with Acute Lymphoblastomic Leukemia, diagnosed last month. This family lives two hours away from the main treatment centre, so it is very helpful to have a meeting with the local care team. I bring plenty of information on both the illness and the treatment. I drop in to the local hospital with information about this patient, should he require urgent care. After a bite to eat down by the river, I visit the boy's school, and talk with all the Grade 6, 7 and 8 students. It's a full day.

Friday

This is usually a day that I try to reserve for administrative activity. There are many links and referrals to be made. This is a fascinating but difficult job, with different professional and personal challenges every day.

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Nurse and Client

Marilyn Cassidy's diary provides a close-up look at the many facets of the nurse-patient relationship. Especially because of the intricate nature of this relationship, it is essential for the nurse to establish and maintain professional "boundaries". The College of Nurses has a new standard on The Therapeutic Nurse-Client Relationship that provides nurses with comprehensive guidance on this aspect of their practice. Like our other professional standards of practice, it sets out practice expectations which Ontario nurses are obliged to follow.

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Contact Us

For further information about any aspect of nursing regulation in Ontario, including how to express a concern about a nurse's conduct or practice, please contact:

College of Nurses of Ontario
101 Davenport Road
Toronto, Ontario, M5R 3P1
cno@cnomail.org
Telephone: 416-928-0900 or Toll Free 1-800-387-5526
Fax: 416-928-9841

 

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