This letter is a response to the article by Marie-Ève Cousineau entitled “The nurse as the doctor’s right arm”. First, the team formed by the Dr Rivard and Nurse Charest looks excellent and noteworthy. While it is clear (and much appreciated) that the article seeks recognition for our profession, it also raises broader social considerations about the reality of nurses, which we wish to discuss.
First, it is important to mention that the Dr Rivard is here the employer of Mme Charest. In Quebec, although they benefit from public funds, the majority of FMGs are private […] allowing physicians to incorporate as self-employed workers. The Dr Rivard, like many of our colleagues on the front line, can manage his clinic independently, for example by hiring staff himself. The private management of clinics also makes it possible to put constraints on the field of practice of the professionals hired. It is the privilege of the employer in this context. On the other hand, for the vast majority of doctors and nurses, the relationship is professional, not employer-employee.
As for the rest of the article, the main point of tension is the title: the nurse as the doctor’s “right arm”. Why does this expression upset so many nurses? It goes to the heart of our professional autonomy. Little Robert defines someone’s right-hand man as “their main enforcement agent”. The expression of course expresses a bond of trust between the performer and the person who leads, but all the same comes under a relationship of subordination. In an employer-employee relationship, this expression makes sense, but be careful not to apply it to the whole of a profession whose members are at the same time autonomous, independent and accountable.
For most of our fellow citizens in Quebec, the role and reserved activities of the nursing profession are still nebulous. Since the “modernization” of our profession more than 150 years ago, the nurse has been considered subordinate to the doctor. The professionalization of nursing work happened gradually, at a time when women had few political and economic rights. […] Decades of feminist struggles have allowed enormous progress for the status of women and for the nursing profession, considering the place that women occupy within it. For example, we are no longer “prisoners” of hospital schools during our training and we have access to university studies. On the other hand, our social position within the health network does not seem to have changed at the same rate as the evolution of women’s rights.
Get involved equally
The “subordination” of nursing work to medicine is never really questioned. It is often taken for granted that the hierarchy in health is reflected in skills and knowledge, a form of “meritocracy”, if you will. But is this really the case? […]
In Quebec, the Office des professions, under the aegis of the Ministry of Higher Education, oversees all 55 professional orders in Quebec. To be considered a profession, a profession must obtain a law which authorizes it to regulate itself through a professional order and which gives it a reserved or exclusive field of activities. The nursing profession, for example, is regulated by the Order of Nurses of Quebec, the OIIQ, founded in 1974 at the same time as the Office des professions was created. […] The professional orders themselves establish the standards that determine who has the right to use the professional title they represent. Professionalization is first and foremost a political act to obtain practice privileges.
In the healthcare field, many professional orders have formalized overlapping scopes of practice. For example, a nurse, a respiratory therapist or a doctor all have the right to administer a prescribed medication by nebulizer, such as an asthma pump. […] But in a hospital setting, for example, a nutritionist, even if she knows how to administer this kind of medication because she herself suffers from asthma, is not allowed to do so.
For nurses, many skills learned in school, mainly at university, are not formally recognized by the professional system. Probably the most glaring example is that of specialist nurse practitioners (SNPs). For years, they have been asking for their achievements to be recognized; they have the training and experience to work independently, but they are still subject to a supervisory relationship with their so-called partner physicians.
Many studies show that Quebec SNPs have one of the most advanced training in Canada, but they are among those with the least autonomy. Why ? If we only considered skills and training, and therefore our “meritocracy” previously raised to discuss the medical profession, Quebec NPs would be much more autonomous. The same goes for other healthcare professionals; we could have all kinds of clinics in Quebec, run by different professionals. Nurses, social workers, pharmacists, physiotherapists and others could all be equally involved in the organization of the front line, to the maximum of their skills.
The reasons why this is not the case have everything to do with politics and absolutely nothing to do with the skills of the professionals in question. Without going into the details of the bureaucratic juggernaut that is the health and social services network in Quebec, it is important to note that the exclusivity of certain acts, which include economic and social privileges, can act as a barrier to autonomy and use of the full scope of professional practice.
To each his own skills
So, is the nurse a physical appendage of a doctor, like his right arm or his eyes? Sometimes yes, but certainly not by choice. The subordination of our field of professional practice has nothing to do with our skills and everything to do with political prerogatives determined by governments which often have no idea of the nature of nursing work.
We remember well the words of Mr. Legault at the start of the pandemic when he said that we “needed arms” in CHSLDs and that if medical specialists agreed to volunteer, we would make them do the work of nurses to spare them the work of beneficiary attendants. This kind of talk had irritated the nurses as well as the doctors and attendants, because it placed us in a hierarchy from another era, which gave an erroneous portrait of the work we do.
A radiologist does not have the training and skills to give medication to a CHSLD resident who suffers from dysphagia (difficulty swallowing), for example. To claim that doctors have the skills to do the work of all other caregivers is absurd and reductive for all of us. This speech by Mr. Legault reminded us of the way that remains to be done to have nursing work recognized, just like the title of the article by Mr.me Cousineau.
Ultimately, each health and social care professional is entirely responsible for their own arms. Most of our work could not be done by any other professional. Like all of our colleagues, the perspective we bring to care is unique and necessary for safe, quality care.
Neither nurses nor any other health profession is an appendix or extension of another profession. The hierarchy that exists in health does not reflect the skills or value of each profession, but rather its position on the political spectrum. It is mainly laws and political regulations in the health network that limit the autonomy of nurses, not our skills and our knowledge.
*Also signed this text: Audrey Bujold (nurse), Caroline Dufour (nurse), Marie-Claude Jacques (nurse), Kenza Rahmi (practical nurse and representative of the Quebec Association of Nurses) and Alexandre Magdzinski (nurse)