It takes six to nine months of work from a dedicated group of experts who consult nurses from across the country in various disciplines and settings to develop a CNA document like the recently released National Nursing Framework on Medical Assistance in Dying in Canada.
Because so much effort is required to produce a landmark resource, CNA is careful to choose priority projects that align with CNA’s strategic plan to advance the principles of primary health care and are highly relevant to members, explains Carolyn Pullen, director of Policy, Advocacy and Strategy.
Routine in-depth environmental scans are part of the CNA process for monitoring emerging trends and issues, such as changes in the Canadian health-care system or in legislation. CNA’s jurisdictional members and external partners play an essential role in contributing to the scans.
When identifying key themes or issues, an important filter is the extent to which they align with the strategic plan. “On issues where CNA can make a significant contribution to influence change, we recommend to the board that we wade in,” Pullen says.
Medical assistance in dying is one such issue. It was clear that early drafts of the legislation did not support equitable access for all Canadians. Physician-assisted death (the term initially used) would not be readily accessible to those living in rural and remote locations in which most primary care is provided by RNs and NPs. As well, the early drafts included no protection from prosecution for nurses who might participate in some way in assisted dying. “These were critical gaps in the proposed legislation,” Pullen says. The board agreed these issues were important for CNA to spotlight through advocacy.
“If we identify an important opportunity where CNA can offer rigorous and credible insight, then we recommend to the board that CNA get involved. In addition, we suggest what we think the right policy and advocacy approach would be,” Pullen says. It could be a framework, position statement, fact sheet, press conference or media release, to list a few possibilities.
To ensure RNs and NPs are protected from prosecution, that they can conscientiously object to taking part in MAID, that they have appropriate information to share with patients and that all Canadians have equitable access, CNA brought its voice to the debate during each step of the process.
Once the legislation was finalized, a key strategy to support nurses was to develop educational resources, Pullen says. “We released the framework in January and now we are finalizing other resources, including online learning modules.”
With the framework, CNA wanted a document that would raise awareness of the details in the legislation and help nurses reflect on ethical issues that could arise as they care for individuals considering end-of-life health-care choices. As well as outlining the roles of NPs, RNs, licensed practical nurses and registered psychiatric nurses in MAID, the framework is meant to support nursing regulators, leaders, administrators, employers and interprofessional health-care teams in developing policies, guidelines and processes. It provides practice guidance and case studies for NPs providing MAID and for nurses aiding in MAID.
Contributions of task force members
To develop the framework, CNA created a task force, which included representatives from CNA’s jurisdictional members, four of the Canadian Network of Nursing Specialties’ groups, the Canadian Federation of Nurses Unions and the Canadian Association of Schools of Nursing along with other individuals.
Elaine Borg, legal counsel at the Canadian Nurses Protective Society, was one of the invited task force members. MAID is an area the nurse and lawyer has been actively involved in. “I’ve presented on medical assistance in dying a lot over the last year and a half and I found that it is most helpful to just start with the basics of what the law is and how we got to this point, because if you only go by media accounts, the precision may not be there,” Borg says.
Another member, Patty McQuinn, president of the Canadian Hospice Palliative Care Nurses Group (CHPCNG), provided examples of the questions and concerns from palliative care nurses. She says she appreciated the pan-Canadian consultation, which included a face-to-face meeting, multiple teleconferences and online review. She also gained a deeper understanding of how CNA establishes practice-related documents.
The CHPCNG board of directors was “involved in seeking out questions and insight from our members into the planning for feedback on the document. Membership was involved through invitations on our message board, and provincial palliative care associations were included,” McQuinn says, which increased the knowledge base of the task force.
CHPCNG has a unique perspective on MAID, which is not a palliative care issue directly, she says. “Palliative care affirms life and regards dying as a normal process and neither hastens nor prolongs death. CHPCNG recognizes that patients may have questions about MAID and want more information and to have discussions. Explaining the role of palliative care, providing information, being open to discussions and providing directions for care are a big component of the palliative care approach.”
With its long-standing relationship with Health Canada, CNA invited Leila Gillis, a director at First Nations and Inuit Health Branch (FNIHB), to join the task force to represent the major employer of nurses working in remote and isolated communities. Gillis says she learned so much about this issue, allowing her to more fully update the FNIHB Nursing Leadership Council and advise colleagues in the Home and Community Care program. “There were also several meetings within the department to discuss and plan around the issue, such as further discussion of end-of-life options, including the need for enhancements to palliative care and the option of medical assistance in dying, should a client request it.”
Among CNA’s 10 member representatives was Zak Matieschyn, president of the Association of Registered Nurses of British Columbia. He solicited feedback from some of the ARNBC members, particularly those working in home care and palliative care settings. “I thought the engagement for this national nursing framework was very robust,” he says. “I was impressed as I looked around the table and saw such diverse representation from all over our country, and from all aspects of nursing.”
Once the task force drafted the framework, CNA circulated it within the nursing community to get feedback that could be incorporated into a final document. “That’s an important part of the process too,” Pullen says. “We aim to have an open and thorough consultation process, with as much member engagement as possible. After all, these are the documents of our membership.”
Following the right approach
Position statements, including the ones on NPs and CNSs highlighted in this issue, follow a similar process but usually take less time to develop.
“Whether you are talking about developing position statements or seminal documents like the framework, best practice is to do that through a committee of experts, to ensure high-quality, balanced input,” Pullen says. This approach helps manage bias and conflict of interest. With variations in health care across provinces and territories, having each of the jurisdictions involved in the development helps ensure relevance to as many nurses as possible.
“CNA is a unique national organization, so they certainly have a long history of [cooperation],” Borg says. “They gathered a group of people who were truly, truly interested in the subject and had no difficulty putting forward their own views, which were not all similar. CNA had to take all of that and craft a framework that was suitable in light of the law and in light of the change in practice for health-care professionals.”
CHPCNG has also collaborated on CNA position statements and contributed to environmental scans. “The input CHPCNG has given and shared with CNA is well received and, I feel, helps to make the final documents and position statements by CNA stronger,” McQuinn says.
Via the Canadian Network of Nursing Specialties, her group has received requests from others to review and provide input into other position statements and policy statements, she adds.