15

Education is a human right with immense power to transform. On its foundation rest the cornerstones of freedom, democracy and sustainable human development.

—Kofi Annan, former UN Secretary–General (1999)

Introduction

As you complete a four-year baccalaureate degree in nursing and enter the profession of registered nursing, there are several organizations that will play a significant role in supporting your practice. Provincially, these include the professional regulatory body and the nursing union. Nationally, there is the Canadian Nurses Association (CNA), the Canadian Federation of Nurses Unions (CFNU), and the Canadian Nurses Protective Society (CNPS). In addition, the Canadian Indigenous Nurses Association (CINA) works to improve the health of Indigenous people through support of Indigenous nurses. The mandates and initiatives of these organizations are all focused on supporting and engaging registered nurses in the development of a strong profession.

This chapter will discuss the role of each organization and the role you possess in being an informed, participating member in these organizations that have a direct impact on your profession and your ability to deliver safe, quality nursing care.

 

15.1 Entry into the Profession of Registered Nursing

In order to practise as an RN, you must complete a program of study, and write and pass a national exam, both of which must be recognized by the regulatory body for RNs in your province. Currently, in most provinces and territories in Canada, this requires completing a four-year degree program at the university level and passing the National Council Licensure Examination for RNs (NCLEX-RN). Following this, you must register to be licensed with a provincial regulatory body before you can call yourself an RN and proceed to work within the role.

15.2 Regulation

Professional Self-Regulation

In Canada, registered nursing is a self-regulated profession. It is through the framework of professional self-regulation that RNs in Canada have long enjoyed the ability to inform and influence the creation and implementation of health policies, thus ensuring the provision of quality patient care. Self-regulation is generally understood to mean that the profession regulates itself through creation of a regulatory body, rather than being managed by government (CNA, 2007) and “is based on the belief that the profession has the specialized knowledge necessary to set standards of practice and to evaluate the conduct of its members through peer review” (Storch, 2010, p. 201).

Legislation governing registered nursing is found in provincial and territorial statutes that may be specific to nursing, such as an RN Act, or encompassed within “umbrella” legislation that applies to several different health care providers (CNA, 2007). It is this legislation that gives RNs the authority to practise, and provides the framework for governance of the profession. In professional self-regulation agreements, governments delegate the responsibility for appropriate and effective enactment of this legislation to the regulatory body, thus transferring the legal authority to regulate members in the public interest based on the legislative requirements. One important aspect of professional self-regulation is to ensure title protection for its members—this caveat is usually contained in profession-specific legislation. The protection of title is important in ensuring the public is able to identify which professions possess which skills.

The main responsibility of any professional self-regulatory body is always to ensure protection of the public. Therefore, the professional regulatory body must carry out activities and govern regulated members in an effective manner to protect and serve the public interest; otherwise, it risks having the privilege of self-regulation revoked. Protection of the public is achieved through the principles of promoting good practice, preventing poor practice, and intervening in unacceptable practice (CNA, 2007). Regulatory bodies achieve this mandate by ensuring that RNs are safe, competent, and ethical practitioners through a variety of regulatory activities. This requires the regulatory body to “define the practice and boundaries of the nursing profession, including the requirements and qualifications to practise” (CNA, 2007).

The main functions of a regulatory body include: (1) setting requirements for individuals to enter the profession; (2) setting requirements for the practice of the profession; (3) setting up an investigation and disciplinary process; and (4) setting up a process to evaluate the continuing competence of members (Randall, 2000).

Another important aspect of establishing standards for a profession is the recognition of the unique and defined body of knowledge possessed by its members. This is achieved through specified and specialized education and cannot overlap significantly with another occupational group. If a large part of the body of knowledge of the profession is already possessed by other occupational groups, it becomes impractical to set standards of practice for the profession (Randall, 2000).

 

 

It is important to understand that professional self-regulation is beneficial to both parties. In this relationship, the government still has some control over the practice of the profession through its ministerial accountability and approval of professional bylaws, but does not have to maintain the expense and specialized expertise required to safely govern a profession of which they have little knowledge. For the professions, self-regulation is an exceptional privilege, showing that government trusts the profession to safely provide the services in the best interest of the public (Human Resources Professionals Association, 2016).

 

Trends in Nursing Regulation

Traditionally, regulatory bodies encompassed both the college role (regulation of the profession) and the association role (advocacy for supporting RNs to inform and influence health care), balancing the administrative management of the profession with the need to advocate for environments, policies, and practices that allow members to meet their required accountabilities and responsibilities. Generally speaking, the difference in the purpose and function of each regulatory body lies largely in whether or not legislation combines the self-regulatory arm of nursing (the college function) and the professional advocacy arm of nursing (the association function), or if these functions are maintained separately (Schiller, 2014).

In recent years, governments, stakeholders, and the public have begun to question the benefit of one body holding responsibility for both regulatory administration and advocacy. Some believe separation of these functions is a positive change, removing any perceptions of bias, self-promotion, or impropriety; others see it as a move to weaken the voice of the profession and enable the passing of poor policies without challenge.

While membership in a college is mandatory, involvement in an association is voluntary. In this regard associations rely on RNs to understand the importance of the advocacy role and choose to be involved through paid membership. Thus, the separation of the regulatory process from the advocacy role results in a mandatory college model where the regulatory aspects are administered, while the advocacy role is fulfilled by RNs willing to form an association. If RNs are not willing to form such an association, advocacy, an important aspect of the profession, is unfulfilled.

 

 

Similarly, the Association of Registered Nurses of British Columbia (ARNBC) identifies the significant detrimental effect RNs experienced during the transition from an association to a college. With the dissolution of The Registered Nurses Association of British Columbia, “the profession no longer had mechanisms through which to engage with government on issues of concern to nurses or advocate for health and public policy matters affecting British Columbians during a time of significant health care system restructuring” (Duncan, Thorne, & Rodney, 2012, p. 5). As a result the creation of an association was embarked on, with the purpose to rebuild BC nursing’s public policy voice in order to (1) represent the professional perspective of nursing in current health policy debates; (2) ensure that the talents of nursing are effectively deployed in the solution of major challenges, such as primary care reform and continuing care expansion; and (3) regain a meaningful place for their profession at government and other public policy processes, provincially, nationally, and internationally (Duncan et al., 2012, p. 8).

While the literature is scarce on which model is most beneficial in protecting the public and ensuring the development of effective health policies, it is clear that registered nursing requires a strong, united voice in order to effectively participate in health care debates and contribute to decisions. With the separation of regulatory functions from advocacy roles, there is an overwhelming feeling by RNs that their voice has been lost and silenced. With the loss of that united voice, three questions have emerged:

1. How will RNs utilize their leadership to have the courageous conversations that will inform key decisions on the future of their profession?
2. How will RNs develop and continue to contribute to the organizational structures that best serve the profession’s current and future mandates?
3. How will RNs know if current and future organizational transitions are contributing to the advancement of the profession, in the public interest? (Duncan et al., 2012)

Regardless of which model registered nursing ascribes to, or is mandated to function under, it is clear that a mechanism to ensure the voices of RNs are heard is essential to the delivery of quality patient care. According to the ARNBC,

We take as a fundamental premise that nursing will thrive as a profession in the public interest if it is well supported by effective regulatory college, professional association and union functions, and we are convinced that the demise of one will ultimately lead to the weakening of the others. (Duncan et al., 2012, p. 3)

A profession is more than an occupation; it is a career with specialized knowledge and functioning. It is through the knowledge and service of a profession that the public has come to trust that members of a profession will be competent and ethical. It is through this trust that professional self-regulation is granted. RNs must therefore recognize the tremendous benefits that self-regulation brings but also the responsibilities expected of each and every one of us in upholding standards and providing quality care.

 

15.3 Unions

Unionization of Registered Nurses

Labour unions are organizations that represent workers in their negotiations with employers. Unions are based on a simple concept: working women and men joining together to gain strength in numbers and presenting a united voice to address issues of concern and create safe work environments. Unions provide their members with many benefits and supports. The primary purpose of a union is to engage in collective bargaining with the employer to determine issues related to wages, terms and conditions of work, and worker security, and to support workers during conflict.

Collective bargaining is a process whereby members of a profession, supported by their union, meet with representatives for the employer and discuss and negotiate agreements on key issues and concerns. This collective bargaining culminates in a product called a collective bargaining agreement (CBA). The overall goal of a CBA is to ensure that mutual agreement on issues of employee safety and fair treatment on the job are defined and enacted. In short, a union works to ensure overall better working conditions for its members, thus contributing to care environments where safe, quality nursing care can be provided.

In addition to the role it plays in negotiating an agreement and ensuring the day-to-day administrative requirements of the CBA are upheld, the union has two other relevant functions. Unions lobby and work with governments to improve labour and occupational health and safety legislation (as safe working conditions contribute to the safety of patients and workers). Unions also assist in ensuring standards are upheld. For instance, some people believe that workers’ rights are already protected by the employment standards legislation. Although there is legislation in place to provide minimum standards in the workplace, violations of these standards are very difficult to enforce. In situations of a worker challenge (e.g., when standards are not being met), employers have a financial advantage in that they are able to hire lawyers to represent their organization through the process of investigation. Employees, on the other hand, are often left to represent themselves. Unions help to level the playing field by assisting employees through processes negotiated between the workers and the employer. Employees are often entitled to paid time to attend meetings and hearings pertaining to their concern and are afforded representation throughout their dealings with the employer.

In-Scope and Out-of-Scope Positions

Upon graduation most RNs will enter into roles that are categorized as in-scope positions. An in-scope designation refers to positions that are unionized. These roles usually apply to all direct care providers including registered nurse educators, resource nurses, etc. This is in contrast to out-of-scope positions, which usually apply to management and senior administrative roles and do not fall within the category of unionization. Therefore, they are not part of the CBA and are not afforded the benefits and protections of such an agreement. In determining if a position should be out-of-scope, one considers the responsibilities of the work. Traditionally positions that are responsible for hiring, firing, and disciplining workers are classified as out-of-scope.

Collective Bargaining Agreement

The collective bargaining agreement (CBA) essentially contains the “rules” that direct the workplace. Often a CBA is thought to be a document belonging solely to the members and its representative union. This is not so—in fact, the CBA is a joint agreement between the members of the union and the employer. In this regard, the agreement affects all members of the union, as well as having an equal effect on the employer. Therefore, enforcement of the CBA is essential to upholding the terms of the agreement and resolving issues in a standardized, agreed-upon approach. Allowing the employer or members to violate any of the terms and conditions erodes application and utilization of the agreement for all involved and jeopardizes the cohesiveness and administration of the workplace.

Collective Bargaining Accomplishments

Prior to the unionization of nursing, RNs were paid very low wages and worked extremely long hours in unsafe environments. Some of the advances unions have made for RNs include:

• a set, predictable work week;
• limitations on being required to work more than a set number of shifts or hours in a row;
• recognition that hours or shifts worked in excess of the set agreement must be paid at overtime rates;
• premiums for in-charge responsibilities, weekend shifts, etc.;
• the right to scheduled breaks;
• vacation, statutory holidays, and leaves of absence;
• the right to representation in disputes with employers;
• wage parity with comparator male-dominated groups (e.g., police officers, firefighters);
• parental leaves; and
• pension and benefits.

In addition, CBAs often include language to assist in addressing:

• grievances and arbitrations;
• professional practice support and nursing advisory;
• health and safety of members; and
• continuing education, orientation, mentorship, and professional development.

Saskatchewan Context

The Saskatchewan Union of Nurses (SUN) was created in 1974 and represents registered nurses, registered nurse (nurse practitioners), and registered psychiatric nurses. SUN’s mission is to enhance the social, economic, and general well-being of its members, and to protect high-quality publicly funded and delivered health services. Members of a union also have a role—that being solidarity and active engagement, as a union is only as strong as the membership who engage in it.

 

Inclusion of Professional Practice Supports

In addition to the foundational role of collective bargaining, SUN has been innovative in developing additional ways to support its members. This includes acknowledging that many of the issues facing RNs were beyond the terms of the CBA. Concerns around workload, staffing, and the inability to uphold professional standards as developed by the professional regulatory body were not directly identified in the CBA. In this regard, the need for professional practice support was recognized. SUN created a professional practice arm of its union to work in conjunction and collaboration with the labour relations side of the organization. This includes utilization of RNs to assist members in meeting their professional standards. The professional practice team often meets with members and employers to discuss the requirements of the professional regulatory body and works to find ways to support professional practice, once again focusing on patient safety and quality outcomes.

SUN has also developed collaborative partnerships with many stakeholders including government, regional health authorities, and educational institutions in order to influence policy and health care decisions, implement best practice guidelines, and work on innovations to more effectively provide health care services. Some of the successes include implementation of patient care acuity assessment tools, nursing models of care, patient flow and utilization models, and initiatives aimed at reducing overtime utilization of RNs.

Impact of Unions

It is a common myth that unions and their members are solely interested in increasing salaries. Research shows that wages are often not within the top three priorities of collective bargaining (Akyeampong, 2005). This is also true of RNs in Saskatchewan. Over the last number of collective bargaining sessions, items such as safe staffing, manageable workloads, and ability to uphold professional standards have been the main priorities of members.

 

Nursing unions have significant impact on members, patients, and society as a whole and the benefits of unionization extend well beyond those of perceived simple self-interest. In fact, research has shown that the higher the number of unionized employees in a workplace, the better the overall health of workers and the lower the poverty rates, for both union and non-unionized workers (Mishel, 2012; Raphael, 2006). Nursing unions ensure safe practice environments; this translates into better care for patients (Twarog, 2005). Standards established in CBAs result in increased productivity for the employer through better training, less turnover, and longer tenure of the workforce (Yetwin, 2016).

One of the greatest benefits for patients is that registered nursing unions provide a consistent collective voice for RNs in the workplace. They empower RNs to actively participate in shaping health care reform and care delivery, affording them the protected right to stand up and speak out for their patients, their practice, and their profession. There is no greater patient advocate than a unionized registered nurse. Ultimately the work of the union is aimed at giving RNs a collective voice to advocate for themselves and for their patients, thus benefitting society as a whole.

 

15.4 Similarities and Differences between Professional Self-Regulation and Unionization

Mandates

As previously discussed, the mandate of the professional regulatory body and that of the union are vastly different and yet they have one common goal: the delivery of safe patient care through supporting registered nurse practice. Nursing standards cannot be met if environments do not have the appropriate leadership, policies, staffing, and workloads to allow RNs to enact their legislated, professional role. Therefore, the mandates of the regulatory body and the union cannot be realized if such issues are not addressed.

For the regulatory body, protection of the public is not possible if their members are faced with unsafe and unsupportive work environments that do not use research and best practice guidelines as the foundation of care provided. For the union, CBAs alone cannot resolve issues of professional practice. Unions also vigorously promote the use of best practice research as this not only establishes quality workplaces for members, but also ensures a safe environment in which patients are provided care. In this regard, individual RNs need to be keenly aware of the initiatives of these two important organizations and become active and engaged.

This engagement can be achieved through running for council and board positions, becoming involved in organizational committees, and attending annual general meetings, where items directly impacting practice, and of interest to members, are raised, discussed, voted on, and enacted. In addition, members must keep up to date on organization news, correspondence, and projects. Members must also be willing to communicate directly with the professional body and the union regarding concerns and obstacles to meeting professional standards; this communication is an important and effective way of raising and working to resolve issues. This participation cannot be left to others, as the profession cannot support itself without the empowerment and voice of individual RNs.

15.5 Other Organizations

Canadian Nurses Association

The Canadian Nurses Association (CNA) is the national professional voice for registered nurses, representing almost 139,000 RNs. Membership in CNA varies according to provincial and territorial requirements. Members include provincial and territorial nursing associations and colleges, independent RNs from Ontario and Quebec, retired nurses, Canadian Nursing Students’ Association, and Canadian Network of Nursing Specialties.

CNA works to advance nursing excellence in order to (1) achieve positive health outcomes in the public interest;(2) promote profession-led regulation in the public interest; (3) act in the public interest for Canadian RNs, providing national and international leadership in nursing and health; and (4) advocate in the public interest for a publicly funded, not-for-profit health system.

 

In Saskatchewan, RNs are members of CNA through registration with the SRNA. A portion of your annual membership fee is directed to CNA on your behalf. One of the benefits of being a member of CNA is representation in CNA’s national advocacy and policy advancements. See the CNA’s webpage CNA on the Hill for more information on the advocacy and policy initiatives CNA is pursuing.

 

Canadian Federation of Nurses Unions

The Canadian Federation of Nurses Unions (CFNU) is another organization representing nurses, with the mandate to protect nurses and speak on behalf of the profession. It is made up of provincial unions and includes almost 200,000 nurses. Through membership with your provincial union, you are represented by the CFNU. CFNU provides a national voice for issues and concerns of Canadian nurses and supports provincial union activities. CFNU works hard to advance solutions to improve patient care and working conditions and advocates for the maintenance of a strong publicly funded health care system. The organization also engages in the development, utilization, and dissemination of evidence to inform policy decisions. It also works as an information resource, keeping nurses aware of current issues and advocating for viable solutions.

 

Canadian Nurses Protective Society

The Canadian Nurses Protective Society (CNPS) is a not-for-profit society that offers legal advice, risk management services, legal assistance, and liability protection to eligible RN members. In Saskatchewan, membership with CNPS is facilitated through your SRNA license.

The mission of CNPS is to “exist so that Canadian nurses are enabled to effectively manage their professional legal risks, and are appropriately assisted when in professional legal jeopardy” (2018). CNPS provides advice on foundational and arising issues facing RN practice through various publications, webinars, workshops, and presentations. Resources are available to address general nursing topics as well as emerging trends that affect RN functioning, such as medical assistance in dying (MAID) and medical marihuana.

 

Canadian Indigenous Nurses Association

The Canadian Indigenous Nurses Association (CINA), formerly known as the Aboriginal Nurses Association of Canada, is the longest serving Canadian association for Indigenous health professionals. It is a non-profit organization dedicated to improving the health of Indigenous people in Canada. This is achieved through engagement activities related to recruitment, retention, and support of Indigenous nurses and Indigenous nursing knowledge, consultation, research, and education. Its mission is to improve the health of Indigenous people, by supporting Indigenous nurses and by promoting the development and practice of Indigenous health nursing.

Any individual interested in Indigenous nursing or Indigenous health care issues is welcome to become a member of CINA. Voting rights, however, are reserved for those RNs, RN(NP)s, RPNs, and LPNs of Indigenous ancestry.

 

Summary

A registered nurse’s practice is supported by several organizations at both the provincial and national level. Professional regulatory bodies ensure that only members who have met the specified criteria are eligible for registration as an RN, and therefore eligible to practice in this professional capacity. The Canadian Nurses Association acts as a national body representing issues important to registered nursing at the national level. The provincial unions, along with the CFNU, ensure that RNs have a voice and are able to speak about issues without fear of reprisal. The Canadian Nurses Protective Society also serves an important role in supporting registered nurse practice through provision of legal advice and liability coverage.

All combined, registered nurses have an abundance of organizations supporting them to practise within the expectations of their professional responsibilities. It is important that each RN stay informed as to what priority issues these organizations are working on. It is only through active, engaged participation of RNs at each level that professional RN standards and delivery of safe, quality care is possible.

 

References

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Annan, K. (1999). Foreword. In C. Bellamy, The state of the world’s children, 1999: Education (p. 4). United Nations Children’s Fund. Retrieved from https://www.unicef.org/sowc99/sowc99a.pdf

Canadian Nurses Association. (2007). Understanding self-regulation. Nursing Now: Issues and trends in Canadian Nursing, 21, 1–5.

Duncan, S., Thorne, S., & Rodney, P. (2012). Understanding the implications of the changing regulatory environment in nursing: Insights from the B.C. experience. Vancouver: Association of Registered Nurses of British Columbia.

Human Resources Professionals Association. (2016). What does it mean to be a regulated profession? Retrieved from https://www.hrpa.ca/Documents/Regulation/Series-on-Governance/What-it-means-to-be-a-regulated-profession-20160101.pdf

International Council of Nurses. (2013). Defining nurse regulation and regulatory body performance: A policy Delphi study. International Nursing Review, 60(3), 303–312.

Mishel, L. (2012). Unions, inequality, and faltering middle-class wages. Economic Policy Institute Issue Brief, 342, 1–12. Retrieved from http://www.epi.org/files/2012/ib342-unions-inequality-middle-class-wages.pdf

Randall, G. E. (2000). Understanding professional self–regulation [Unpublished manuscript]. Retrieved October 2016 from http://www.paramedicsofmanitoba.ca/uploaded/web/pdf/Understanding%20Professional%20Self-Regulation.pdf

Raphael, S. (2006). Social determinants of health: Present status, unanswered questions, and future directions. International Journal of Health Services, 36(4), 651–677.

Saskatchewan Registered Nurses’ Association. (2015). Our Role in the Public Interest. Regina, SK: Author. Retrieved from https://www.srna.org/wp-content/uploads/2017/12/DualRoleClarity2015_06.pdf

Schiller, C. J. (2014). Self-regulation of the nursing profession: Focus on four Canadian provinces. Journal of Nursing Education and Practice, 5(1), 95–106.

Storch, J. (2010). Professionalism and the role of the nurse leader: Ethical practice and knowledge utilization. In V .C. Pangman and C. Pangman, Nursing Leadership from a Canadian Perspective (pp. 193–225). Philadelphia, PA: Lippincott Williams & Wilkins.

Twarog, J. (2005 May). The benefits of union membership: Numerous and measurable. Massachusetts Nurses Association Newsletter. Retrieved from http://www.massnurses.org/labor-action/labor-education-resources/union-rights-and-benefits/p/openItem/1214

Yetwin, A. (2016). Labor lines: Nursing unions matter for the middle class. The Alaska Nurse, 67(5), 18–19.