Community-Based Care: A Summary PDF

BOX 5.1  Community-Based Care: A Summary An approach to health care that integrates the elements of primary and community care as well as home care Care and services that are delivered in a variety of community settings: providers' offices or clinics, hospices, patients' homes, public health u...

BOX 5.1  Community-Based Care: A Summary An approach to health care that integrates the elements of primary and community care as well as home care Care and services that are delivered in a variety of community settings: providers' offices or clinics, hospices, patients' homes, public health units, workplace settings, and schools (e.g., immunizations, educational programs) Care and services that are responsive to economic, social, language, cultural, and gender differences within a community Care and services that respond to the needs of each community (e.g., within an urban or rural setting or in remote communities in northern regions of the country, where community needs vary greatly) Community-based primary care provides community members with a full spectrum of services, including patient education, disease prevention and health promotion strategies, counselling, curative and rehabilitative services Addresses the social determinants of health as required in each region or community; primary care providers collaborate with community agencies and other stakeholders to promote a healthy environment. This may include food security, safe water, proper sanitation, maternal-child health, mental health support (e.g., drug and alcohol use and addiction), and immunization protocols. Shift to Patient-Centred Care Typical of Western medicine, physicians assess a patient's needs, form a health care plan, and advise the patient what to do. Patient-centred care involves the skills of a variety of health care practitioners (as seen in primary care organizations) to maximize health outcomes for the patient. In addition, over the past several years, patients have played an active part in their own health and health care, assuming responsibility for healthy lifestyles and managing their own risk behaviours. Treatment options are discussed with the patient, who is an active participant in the decisions made regarding their treatment plans. Conventional, Complementary, and Alternative Practitioners Health care providers have traditionally been divided into three categories: conventional, core, or mainstream (e.g., physicians, nurse practitioners, midwives, nurses, dentists); complementary health professionals (e.g., dental hygienist, dietitians, optometrists, psychologists, social workers); and complementary and alternative practitioners (e.g., Indigenous healers, naturopathic doctors, homeopathic practitioners, massage therapists). Some sources simply refer to health professionals as either regulated or nonregulated, others refer to health professionals as physician and non-physician practitioners, dispensing with the previously discussed categories. See Table 5.1 for one categorization of some of Canada's many health care providers. How health care providers are grouped remains controversial, especially since managing the care of patients has taken on a team approach, with numerous health professionals participating in and contributing to the patient's diagnosis, treatment, and ongoing care. Interdisciplinary team members are regarded as partners with respect to rendering patient care, contributing differently but equally, relative to their professional expertise and scope of practice. Conventional Medicine Conventional medicine is frequently referred to as orthodox, mainstream, traditional, allopathic medicine, biomedicine, or Western medicine. Conventional medicine typically encompasses all those modalities not performed by alternative practitioners. "Conventional" practitioners typically diagnose and treat prediagnosed health problems and render technical, therapeutic, or supportive care with scientifically proven therapies, medication, surgery, or a combination of these modalities. Complementary and Alternative Care Complementary and alternative medicine (CAM) is practised by all health care providers not generally considered mainstream. The terms are sometimes used interchangeably but, strictly speaking, there is a difference. As the names suggests, complementary medicine, meaning "in addition to" supports, or complements, conventional medical treatments and services. Alternative medicine usually involves an option, an alternative treatment modality that can be used in conjunction with or in place of conventional treatments. These treatments may or may not be to the exclusion of conventional medicine. What is considered alternative and what is considered complementary is somewhat fluid and very subjective. There is often no one "right" category to place a particular modality in. Is chiropractic mainstream, complimentary, or alternative? What about holistic medicine? Are doctors of holistic medicine considered complimentary or alternative because they focus more on natural treatments? What category would you put therapeutic touch or ear candling in? Ask 10 different people and you are likely to get a variety of answers. The term complimentary has gained some prevalence over alternative as the latter can be interpreted as having negative connotations despite the fact that, for many people, modalities that traditionally come under that umbrella are both therapeutic and effective, with most founded deep in one's culture or traditions. Moreover, what is considered standard treatment in one country, or even in one province or territory, may not be in another. Indigenous healers, for example, are well recognized in most jurisdictions and are free to treat individuals within their communities (with variable oversight). Acupuncture is standard and mainstream medical care in China and considered by many in Canada to be either mainstream medical care or complementary. Acupuncture Canada offers a range of courses for regulated health professionals ranging from introductory to advanced courses, including some that teach traditional Chinese medicine assessment and treatment, resulting in certification to perform acupuncture. For example, physiotherapists often offer acupuncture as part of a treatment program. Traditional acupuncturists are regulated in British Columbia, Alberta, Québec, Ontario, and Newfoundland and Labrador. Critics of alternative medicine believe that for treatments to be considered conventional, they should be scientifically proven before they can be claimed as effective treatments (also called an evidence-informed or evidence-based approach). Practitioners of therapeutic touch, for example, claim to use balance and energy, coupled with the healing force of the practitioner's hands, to facilitate a patient's recovery; however, no scientific evidence exists to prove it alters the course of a disease. That is not to say that therapeutic touch does not benefit the patient by reducing stress and promoting relaxation. For many, this in turn can certainly have an effect on the mind--body connection. For example, we know that stress reduction and feeling calm reduces a person's heart rate and blood pressure. Mindfulness is another modality that has gained popularity in recent years and has been shown to be very effective in reducing anxiety and stress and promoting a sense of well-being (see Chapter 7). In Canada, the uptake in popularity of CAM is driven in part by Canadians themselves, as a significant number of people use CAM at some point in their lives. This may be due to several factors, including disillusionment with conventional treatment, difficulty getting appointments with their primary care provider, cultural influences and belief systems that contradict mainstream medicine, as well as information available on the Internet. In addition, many more people are actively participating in their own health care and treatment options. This includes, for most people, the desire to integrate all components of the care they seek and a move toward collaborative care by interprofessional health care teams. According to the most recent survey commissioned by the Fraser Institute, in 2016, Canadians spent \$8.5 billion on providers on complementary and alternative health services, and an additional \$2.3 billion on natural health products, including herbs, vitamins, and classes, between 2015 and 2016 (Esmail, 2017). In 2016, nearly 56% of Canadians used at least one CAM health care service (Esmail, 2017). Highest usage was in British Columbia and Alberta, followed by the Atlantic provinces and Québec (Table 5.2). Almost all medical practitioners are aligned with complementary medical services, but some have reservations about modalities not supported by evidenced-informed criteria. That said, as long as an alternative therapy is safe and results in some benefits for the patient, many medical practitioners have no objection to their use. Often individuals will seek alternative modalities when they feel conventional medicine is no longer effective, or if they do not want to endure the recommended treatment (such as chemotherapy for cancer), particularly when their prognosis is guarded at best. Chiropractors (doctors of chiropractic medicine) form the largest group of CAM practitioners. To obtain a degree to qualify for clinical practice, chiropractors complete 4 to 5 years of postsecondary education. Working in individual or group practices, they diagnose and treat a wide range of conditions that deal primarily with disorders of the spine, pelvis, extremities, and joints, and the resulting effects on the central nervous system. Taking a holistic approach to patient care, chiropractors use various types of noninvasive therapies, such as exercise routines and spinal adjustments (treatments used by individual chiropractors may differ). Chiropractors are not licensed to prescribe medicine in the same manner as a medical doctor or to do surgery. Chiropractic care is not covered by most provincial or territorial plans, but most private insurance plans (extended health benefits) will pay for a specified number of visits and treatments. Chiropractic medicine is still considered by many to be on the cusp of alternative and complementary medicine, but that is a subjective view. Increasingly, chiropractors are moving into the complementary and conventional stream, as primary care providers. The relationship between chiropractors and physicians is variable, some sharing a mutual respect, others preferring to keep their professional distance. Regulation of Health Care Professions The majority of health care professions are self-regulated, meaning that a professional body enters into an agreement with the government to exercise control over and set standards for its members. Some professions are entirely self-regulated while others are regulated under the umbrella of another professional organization. There are also professions regulated by the government, meaning that legislation controls the conduct and practice of the profession and its members. Regulatory authority is granted through legislation, such as an act or statute that outlines the framework for behavior and values for a given profession. In Canada, provincial and territorial legislation (e.g., British Columbia's and Alberta's Health Professions Act, Ontario's Regulated Health Professions Act) provides the legal framework for regulating most health care professions. Regulated professions have self-governing bodies called colleges (e.g., College of Registered Nurses of Nova Scotia, College of Massage Therapists of Newfoundland and Labrador), which regulate the conduct and practice of their members. Each province and territory has 20 to 30 regulated health care professions; professions regulated in some provinces and territories may not be regulated in all (Table 5.3). For example, registered psychiatric nurses in British Columbia are regulated by a college unique to their specialty---the College of Registered Psychiatric Nurses of British Columbia---while in Ontario, psychiatric nurses are under the umbrella of the College of Nurses of Ontario. Although regulated professions provide support for its members, the overriding objective of regulated professions is to protect the public, ensuring that safe care is rendered by health professionals who are properly educated and working within their scope of practice. Title Protection Regulated professionals---those who belong to a professional body---are licensed to practise their profession and are legally entitled to use a specific designation, such as registered massage therapist (RMT). These professions receive title protection, meaning only properly trained persons registered and in good standing with their regulatory body can legally use that title. For example, people who have cared for loved ones at home but have no formal training cannot call themselves licensed or registered practical nurses. Likewise, someone who dropped out of college halfway through a respiratory therapy program cannot call themselves a respiratory therapist. Nor can health care aides call themselves nurses. Conversely, someone trained on the job can call themselves a health care aid or a personal support worker equivalent as there is no regulatory body legally protecting this title, although regulation of some type for health care aids (and the equivalent) is under review in some jurisdictions. Fully trained nurses registered in other countries cannot call themselves registered nurses here until they have met the standards set by and have been accredited by the college of nurses in the province or territory they want to practise in. Along with title protection, regulated professions share other collective elements (Box 5.3). Any health care profession can apply to the government to become regulated, but it must meet strict criteria. The Minister of Health and some type of advisory body within the province or territory usually oversee the lengthy and often arduous application process. Just as the possession of a legitimate driver's licence indicates that a person knows how to drive and has passed a driving test, regulation proves a person has undergone training and gained a predetermined level of knowledge, skill, or ability. Possession of a driver's licence, however, does not guarantee driving excellence; even in regulated professions, some individuals working in health care professions render substandard services. All regulated professionals must practise within a framework of skills and services defined by their governing body (their scope of practice). Nurses have certain skills and acts they have been educated to carry out; physicians have a range of skills and services they have been educated to offer; and respiratory therapists, medical, and other health care practitioners, likewise, have a defined scope of practice. Even within a single profession, different levels of practice exist. For example, registered nurses with special education (e.g., advanced practice) may perform acts that those without this education cannot legally perform. Nurses usually have to take specialized courses to acquire the skills to start an intravenous line or manage wound care. Similarly, a medical doctor in family practice is not qualified to remove a gallbladder or do a hip replacement; a licensed practical nurse is not qualified to do a complete physical, but a nurse practitioner is; and a massage therapist is not qualified to deliver a baby, but a midwife, nurse practitioner (depending on their education), or obstetrician is. In health care, many of these skilled procedures, some specific to certain professions, are called controlled acts.  Regulated Professions: Common Elements Educational standards Provincial and territorial examinations Practitioner's scope of practice, which outlines skills, acts, and services the practitioner is able to perform competently and safely Curbing of individual's practice if standards are not met Formal complaints process for the public Complaints investigation and follow-up Title protection Competence and quality assurance Performing Controlled Acts Controlled acts (called reserved acts in British Columbia), if not performed by a qualified practitioner, may result in harm to a patient. Examples of controlled acts include giving an injection, setting or casting a fracture, passing a nasogastric tube, and prescribing a medication. Controlled acts are identified by the Regulated Health Professions Act (RHA) or the equivalent in each jurisdiction. For example, the RHA in Ontario has identified 14 controlled acts that a registered nurse may perform; these are similar across the country. Acts related to each profession further define which controlled act(s) mebers of that profession can perform---for example, respiratory therapists and regulated radiation technologists can perform 5 of the 14 acts, physicians can perform 13, thus there is some overlap. Controlled acts may only be performed in response to an order (either direct or indirect) given by a physician or nurse practitioner, for example. Exceptions Most provinces and territories allow controlled acts to be performed in certain situations by competent yet nonregulated individuals, including the following: A person with appropriate training providing first aid or assistance in an emergency Students learning to perform an act under the supervision of a qualified person, as long as that act is within the scope of practice of graduates of the student's professional program (e.g., a respiratory therapist student intubating a patient under the direct supervision of their clinical supervisor, who must be a registered respiratory therapist in good standing with their regulatory body). A person, such as a caregiver, trained to perform an act (e.g., giving injections to a person with diabetes) An appropriate person designated to perform an act in accordance with a religion---for example, a rabbi may circumcise a baby with a penis Exclusions also apply in the case of body piercing for the purpose of jewellery, electrolysis, tattooing, and ear piercing. Thinking it Through Performing Controlled Acts A personal support worker is looking after an older woman. The woman has been unable to urinate for several hours and is very uncomfortable because her bladder is full. The woman's visiting RN occasionally has to catheterize her; however, the nurse is unavailable for a few hours. The personal support worker, who is a fully qualified nurse from England, easily catheterizes the woman, making her comfortable. Clearly, the personal support worker is performing a controlled act that they are not qualified to do in Canada. 1\. In your opinion, was making the patient comfortable more important than the legal implications of performing a skill not legally within the personal support worker's scope of practice? Explain your answer. 2\. What might the legal implications be for the personal support worker for performing the procedure? 3\. What other courses of action could the personal support worker have taken? Delegated Acts As our health care system continues to evolve, health care providers' scopes of practice are also changing. Reforms in the health care system, in methods of delivery, and in health care providers' responsibilities, have affected the traditional roles of health care providers. The needs of patients also continue to change---more complex care is required more frequently. For patient needs to be met, occasionally the acts, procedures, and treatments rendered by health care providers must go beyond standard boundaries. A delegated act by definition is the means by which a regulated health professional (authorized to perform the delegated act) transfers legal authority or permits another person to carry out a controlled act they are otherwise unauthorized to do (procedures that are not controlled acts do not require delegation). The person to whom the act is being delegated must be provided with education and observed performing the act to ensure understanding and competency to perform the act. A delegated act may include a specific procedure, treatment, or intervention that is not within the scope of practice of the person to whom the act is delegated. For instance, a registered nurse working in the community can delegate the act of giving an injection to a nonregulated provider (personal support worker), or to a daughter caring for her father at home. Physicians can delegate the act of obtaining a Pap smear to a qualified nurse. Not all controlled acts can be delegated. Those that can, are defined by provincial and territorial regulations (under the jurisdictions of the Regulated Health Professions Act). For example, a nurse practitioner cannot delegate the act of prescribing a medication to a registered nurse or an occupational therapist. Acts in most jurisdictions cannot be subdelegated. This means that a person accepting the responsibility of performing a delegated act cannot assign someone else to carry out that act. Guidelines and protocols for delegation of medical acts vary across Canada. In some jurisdictions, controlled acts can be delegated only to a person who is a member of a regulated profession, but in others, certain acts may be delegated by a regulated health professional to a nonregulated health care provider. Generally, the delegated act must be clearly defined and supervised accordingly. Supervision can be direct (i.e., the delegating health care provider is physically present) or indirect (i.e., the delegating provider is available for consultation). In most health care organizations, authorities such as a board of directors or a medical advisory committee or their equivalents must agree to the rules and procedures for delegated acts. Delegated acts must also be approved by the health care agencies that specific people can take on the task. This may be agency specific, for example, identifying acts a registered nurse may delegate to a nonregulated care provider to perform. The health care provider with expert knowledge has a commitment to their patient to ensure that the person performing the act---called the delegate---is properly trained and demonstrates competence in completing the act. The delegating health care professional, the delegate, and the facility or environment in which the act is performed share responsibility for the act. The health care professional who teaches or assesses the delegate's initial performance of the delegated act (and determines the delegate is competent) is accountable for ensuring the act is, in fact, carried out competently. The person carrying out the act is liable if they perform the act ineffectively. Usually the patient or patient's power of attorney for personal care must give informed consent to allow someone other than the regulated health care professional (for whom the act is within their scope of practice) to perform a procedure. For acts typically performed by physicians, delegation will occur only with the patient's consent and only after the physician has assessed the patient, discussed the procedure, and answered any outstanding questions. Details outlining regulations for delegated acts are available on provincial or territorial websites for related nursing and medical associations. It is worth noting that many colleges offer courses to nonregulated individuals on carrying out certain interventions. Complaint Process Regulated professions have a system in place whereby the public can launch complaints against a health care provider. A designated committee investigates all complaints, protecting both the public, who can rest assured that legitimate complaints will be looked into and appropriate action taken, and health care providers, who will have illegitimate or unfounded complaints against them dismissed. Health care providers found to be at fault may face suspension, an order for additional training, the loss of their licence to practise, or even legal proceedings, such as a criminal investigation. Educational Standards A regulator of a profession has the authority to set educational standards for the training of its professional members, including theoretical and practical components of their education as well as examinations for entry to practise. The educational process both prepares professional members and provides assurance to the public that the health care provider is competent to practise. Professional bodies often use competency-based assessment programs to ensure the continued maintenance of practice standards, protecting both the health care provider and the public. The requirements may include the use of self-assessment tools, participating in continuing education programs, keeping a record of professional activities, or a combination of these. Often proof that these standards have been met is a requirement for renewal of a professional's license to practise. License to Practise In each province and territory regulators of professions, in conjunction with educational facilities and in keeping with provincial and territorial requirements, oversee the licensing of their members. Regulated professions almost always require licence renewal annually. Many now have other criteria that must be met, such as peer reviews or other proof of ongoing education. Moving from one province or territory to another can cause issues for some professionals since not all regulated professions have agreements and standards in place for members to practise in other jurisdictions (Case Example 5.1). Nonregulated Professions and Occupations Table 5.2 illustrates the current professions that are regulated in the provinces and territories across Canada. All others work in the many professions and occupations that remain nonregulated, ranging from jobs that require university degrees and in-depth, specialized training, to those requiring less formal education. People who work within nonregulated occupations do not have federal or provincial legislation governing their occupations. Like regulated professions, however, many nonregulated occupations have professional organizations or bodies that award certification when a person completes a set of written or practical examinations or both---for example, dental assistants are currently unregulated in Ontario, but dental assistants must complete a formal education and write certification examinations to practise. When a profession is unregulated or a job applicant has not met the educational requirements of their regulatory body, the person or organization doing the hiring sets the requirements (Case Example 5.2). For example, to work as a medical secretary, an administrator in a doctor's office, or a clinical secretary (ward clerk) in a hospital, a person requires a specialized knowledge base; however, an employer may hire someone with or without a certificate or diploma. A doctor, for example, can choose to hire a person with related experience as a medical secretary and provide additional on-the-job training, or they can hire someone who has graduated from a 1-year certificate or 2-year diploma program in medical office administration. A hospital may require a clinical secretary to have a Grade 12 diploma with some administrative experience or, alternatively, a diploma from a 2-year health administration program (or the equivalent). Physician Moving Their Practice From One Jurisdiction to Another Because physicians write a national examination, they are qualified to practise anywhere in Canada, but each jurisdiction must license physicians to practise. Dr. H., a licensed general surgeon in Newfoundland and Labrador, wants to practise medicine in British Columbia; therefore they must apply to the College of Physicians and Surgeons of British Columbia and follow provincial protocol before working in the province. Although the standards of practice for doctors are the same across the country, medical and legal issues are often different, and every physician practising in a particular jurisdiction must be aware of jurisdictional and legal guidelines that pertain to that region. Once licensed in British Columbia, Dr. H. will be assigned a billing number, which they must use to bill the provincial plan for services rendered. Hiring and Educational Requirements The CEO of a primary care organization in Alberta has decided that they want to hire a nurse to work with the health care team. The nurse must be a registered nurse (as opposed to a graduate nurse). An applicant, P.H., graduated 2 years previously from a university nursing program in the province but did not pass the national examinations. Therefore, P.H. is a graduate nurse and not a registered nurse. Another applicant, M.S., also a graduate from a university nursing program, successfully completed their national registration examinations (NCLEX-RN) a month earlier and met all requirements to become a member of the College and Association of Registered Nurses of Alberta. M.S. is a registered nurse, and because M.S. has this designation, they meet the criterion for the job. Many nonregulated disciplines have no specific standards to meet. For example, anyone can learn how to do ear candling or aromatherapy and put out a sign inviting the public to seek treatment. Primary Health Care and Interprofessional Team Members Health care traditionally has been dominated by physicians---from family doctors to specialists. However, a shift toward a team approach to health care continues to evolve across Canada, maximizing the skills and expertise of a variety of health care providers, particularly in the primary care setting (see Chapter 3). The following descriptions of individuals working in health care is organized, for the most part, alphabetically and includes specialists, primary care practitioners, and collaborative health professionals who typically work as interprofessional teams. Dentists Applicants usually complete a 4-year undergraduate degree (often in science) before applying to dental school at a recognized university where they must complete another 4 years to become a dentist. In Canada, a dental program must be accredited by the Commission on Dental Accreditation of Canada. The first 2 years are primarily spent in the classroom and laboratory while the second 2 years focus, in part, on applying theory to practice in the clinical setting. To become a licensed dentist, a graduate must pass an examination overseen by the National Dental Examination Board of Canada. Dentistry is a regulated profession in all jurisdictions. Dental Hygienists There are both diploma and degree programs for dental hygienists in Canada. Diploma programs range from 2 to 3 years in length and can be completed at a community college. Universities offering degree programs include the University of British Columbia, University of Alberta, University of Manitoba, and Dalhousie University. Dental hygienists assess patients' oral health, carry out preventive and therapeutic dental hygiene treatments, as well as provide information about achieving and maintaining optimal oral health. Dental hygienists work collaboratively with other health care providers within the interprofessional health care team. Workplace settings include dental hygiene practices, dental offices, public health agencies, dental industries, and educational and research institutions. Dental Assistants Most dental assisting programs are 1 year in length and obtained at a community college. Programs offer two levels of competence, each resulting in more responsibilities that the student can assume in the workplace setting. After completing the necessary educational requirements, a student can graduate and practise as a level 1 dental assistant or go on to achieve level 2 competencies. Responsibilities are diverse, from patient education, preparing and setting up dental instruments, processing X-rays and assisting with dental procedures, to chair-side assisting. Dental assistants in Canada are governed by different regulations in each jurisdiction, and the profession is either regulated by their own body or under the umbrella of an external organization (Canadian Dental Assistants Association, 2017). For example, in Saskatchewan dental assistants are self-regulated and licensed by the Saskatchewan Dental Assistants\' Association, but in British Columbia the profession is regulated by the College of Dental Surgeons of British Columbia. The profession remains unregulated in Ontario and Québec. To become certified, dental assistants must pass the National Dental Assisting Examination Board examination(s). Family Physicians Family doctors are also called general practitioners or primary care physicians. With a wide knowledge base not limited to any specific disease or system or to any particular gender or age group, the family doctor provides ongoing care to individuals of all ages and to families that includes the diagnosis and treatment of conditions and diseases not requiring the care of a specialist. That said, family physicians are considered "generalists"; although they do not come to mind with the term "specialist," they are now regarded as specialists in their field. Family physicians complete a residency in family medicine (Box 5.4). Increasingly, family doctors are working in primary care groups with interprofessional teams, collaborating with other primary care providers to render seamless, comprehensive, patient-centered care. A few remain in solo practice, and some in various types of clinics or health centres, especially in more remote regions of the country. Many family doctors also oversee the medical care of patients in health care facilities such as long-term care facilities. Some still make house calls, most of which are covered by public health insurance if deemed medically necessary. More recently, many family doctors are choosing to give up their hospital privileges, temporarily turning over the care of their hospitalized patients to a hospitalist or other specialist (Box 5.5). Overview of Educational Requirements for Physicians Entrance requirements for medical school vary across Canada, but most universities require the applicant to complete 2 to 4 years of undergraduate work, usually obtaining a bachelor's degree, and then write an entrance examination, called the Medical College Admission Test (MCAT), before applying for placement in one of Canada's medical schools. Medical school consists of 3 to 4 years of study, followed by a residency in the person's area of specialty (e.g., family medicine, internal medicine, pediatrics, or general surgery). Many specialists work in solo practice; others work in private or public organizations or are employed by hospitals. All physician specialists must first complete their undergraduate degree in medicine. Following undergraduate training, residency training in an accredited program must be undertaken. General surgeons will have 5 years of additional training before they can write the Royal College Exams to be certified as a specialist. The Royal College of Physicians and Surgeons of Canada is the national professional association that oversees the medical education of specialists in Canada. They accredit the university programs that train resident physicians for their specialty practices and write and administer the demanding examinations that residents must pass to become certified as specialists. The Royal College also oversees postgraduate medical education. A physician's credentials must be assessed by the Royal College before they are eligible to write an exam to be certified as a specialist. Shortage of Family Physicians There is currently a shortage of family doctors across Canada for a number of reasons. Fewer physicians are choosing family medicine as a specialty, to avoid the increasing expectations placed on family doctors without the proper resources and what they feel are "stagnant" payment models. Many leave family medicine (e.g., to become hospitalists or emergentologists) for more appealing work hours, less overhead, and better remuneration. Many of those who stay in the profession tend to accept fewer patients and work fewer hours in pursuit of a reasonable work--life balance. Other family physicians diversify, practising part-time family medicine and part-time in another area, such as sports medicine or general practitioner (GP) anaesthesia. Since the COVID-19 pandemic, a significant number of family doctors are retiring early because of increased stress and exhaustion after working though the pandemic (not unlike what other care providers have experienced). The result? Thousands of Canadians still do not have a primary care provider. Or, for those that do, even getting an appointment in a timely manner can be difficult, although that situation is improving. A shortage of family doctors is more acute in rural and northern regions across the country. Medical Laboratory Technologist Medical laboratory technologists work in both private and public facilities as well as in provincial laboratories. In order to become a laboratory technologist in Canada, a person must be certified by the Canadian Society for Medical Sciences (CSMLS). To prepare for this certification, a person must complete an accredited program such as the one offered at the Michener Institute in Ontario. Individuals who have received education outside of Canada and have successfully completed the CSMS Prior Learning Assessment process are eligible to write the certification examinations. CSMLS certification is accepted anywhere in Canada. This certification is the entry-level requirement for medical laboratory technologists in provinces where the profession is regulated. As well, most employers in jurisdictions where the profession is not regulated also require this certification. Midwives Depending on the jurisdiction, pregnant persons experiencing normal pregnancies may choose to see a midwife. Midwives provide prenatal care (before the baby's birth) and intrapartum care, deliver the baby (either at the patient's home, in a birthing centre, or in the hospital), and provide postpartum (after the delivery) and newborn care for up to 6 weeks after the birth. Midwives, in accordance with jurisdictional guidelines, will refer a mother to a physician, usually an obstetrician, if their pregnancy becomes high risk or shows signs of other problems during any phase of the pregnancy, labour, or delivery. Pregnancy-induced hypertension, gestational diabetes, placenta previa (low-lying placenta), or a multiple pregnancy, for example, would be considered high risk. In most jurisdictions, a midwife can still provide prenatal care and work collaboratively with a physician (usually an obstetrician) until the time of and after delivery. Midwifery, which has been practised by Indigenous people for years (Box 5.6), is now licensed in all jurisdictions in Canada. Prince Edward Island and Yukon territory are the last jurisdictions in Canada moving to regulate and fund this profession. New regulations regarding licensing midwifes in the Yukon territory came into effect in August 2021. Prior to the new legislation, a person could choose to have a home birth with a midwife, but they had to pay out-of-pocket for the service. Doula A doula (sometimes referred to as a labour coach) assists a pregnant person and their family through the process of having a baby. A doula can be a "birth" doula, or a "postpartum" doula (or both), providing the birthing parent and their family with informational, emotional, and physical support throughout the antepartum, intrapartum, and postpartum phases of childbirth. Doulas work independently for the most part, but they may also provide collaborative care with a midwife. No formal education is required to be a doula, but there are certificate courses that can be taken. These range from 7 to 12 months in duration with a practical component at the end before certification is earned. Naturopathic Doctors Naturopathic doctors are primary care practitioners who use a holistic approach to patient assessment, treatment, and care and are experts in natural medicine. Their focus of treatment is on health promotion and disease prevention considering the whole patient and is not symptom driven. British Columbia and Ontario have granted naturopathic doctors the authority to prescribe medications with the exception of controlled drugs under the Controlled Drugs and Substances Act (Canadian Association of Naturopathic Doctors, n.d.). Indigenous Midwives in Canada For generations, prior to colonization, Indigenous midwives provided their communities with safe, competent maternal--child health care services. In the nineteenth century, colonization and the medicalization of the birthing process led to a decrease in midwifery in Canada---almost to the point where there were no practising midwives among both the Indigenous and non-Indigenous population. The effect on the Indigenous population was striking, resulting in birthing parents having to leave their communities and support systems to give birth. Today, the number of Indigenous midwives (along with other Indigenous healers) is slowly increasing, which is congruent with Call to Action 23 of the Truth and Reconciliation Commission of Canada, which states: "We call upon those who can effect change within the Canadian health-care system to recognize the value of Aboriginal healing practices and use them in the treatment of Aboriginal patients in collaboration with Aboriginal healers and Elders where requested by Aboriginal patients" (Truth and Reconciliation Commission of Canada, 2015). Currently, the National Aboriginal Council of Midwives is attempting to expand educational opportunities for those living in Indigenous communities wishing to pursue a career in midwifery and to improve access to midwifery programs. The Council's vision is to (1) outline core competencies specific to Indigenous midwifery as a major component necessary to broaden educational pathways---this will ensure the cultural and traditional practices of Indigenous people are addressed in the educational process; and (2) remove financial and funding barriers to midwifery programs. Indigenous midwives offer their patients a unique set of competencies specific to the reproductive and sexual health of Indigenous people, respecting Indigenous culture, oral language, and traditions (Fig. 5.1). Their presence allows birthing parent to have uncomplicated deliveries within their own communities, surrounded and supported by loved ones. Birthing parents are encouraged to write their own birthing plan, which includes how they would like their birth experience managed and where they would like the birth to take place (e.g., home, birthing centre if available, or the hospital). Midwives also provide the birthing parent and the family with ongoing support in addition to facilitating parent--infant bonding, encouraging breastfeeding (promoting the related nutritional value to the infant), and infant care. Nurse Practitioners Nurse practitioners (NPs) are registered nurses with advanced training and skills (RN Extended Class), authorizing them to practise in an expanded role with many of the skills and responsibilities formerly relegated to physicians. NPs can autonomously diagnose and treat health conditions, order and interpret some laboratory and diagnostic tests, and prescribe a wide range of medications, including certain controlled substances. As with other providers, NPs incorporate health education, disease prevention, and health promotion in their treatment plans. In addition, NPs can carry out specified controlled acts and activities that other nurses, by law, cannot. NPs can oversee medical aid in dying procedures in many jurisdictions. There are numerous graduate and postgraduate nurse practitioner programs available in Canada, the majority at the master's and post-master's levels. Many of these programs are funded by their respective provincial/territorial governments. NPs need at least a master of science in nursing (MSN) degree, in addition to advanced clinical training, or completion of a nursing program with additional advanced or extended primary health care nursing education, and may require several years of practice as a registered nurse. Licensure of NPs in Canada is dependent on the legislation and regulations established in each province and territory (personal correspondence with Dr. Stan Marchuk, DNP, MN, NP(F), CNeph(c), FAANP, President of the Nurse Practitioner Association of Canada). Each province and territory sets out the requirements for licensure, including what examination(s) an NP must successfully complete to become an NP. Some provinces utilize the Canadian Nurse Practitioner Family/All Ages exam for their Primary Care/Family Nurse Practitioner registrant, while others use the American Academy of Nurse Practitioners Exam or the American Nurses Credentialing Center Exam. There is currently no standardization of examination among provinces. All NPs must complete a written exam for licensure; however, British Columbia and Québec also require an oral exam. Registration examinations in most jurisdictions are overseen by the provincial/territorial College of Nurses. NPs, like other regulated nurses, must renew their licence yearly. This usually involves completing a minimum number of practice hours and participation in designated quality-assurance programs, ongoing education, or both. Note that each province or territory endorses different streams of specialization (family, adult, pediatric, neonatal). Practice settings include primary care and community settings, hospitals under specialty designations (e.g., pediatrics, cardiology), and emergency departments (Case Example 5.3). Optometrists Most optometrists obtain an undergraduate degree, often in mathematics or science, before completing a 4-year university program in optometry at one of Canada's two schools of optometry (in Waterloo, Ontario, and Montreal, Québec). The minimum requirement for entry to these programs is 3 years of undergraduate preparation, preferably in science. Graduates of a school of optometry are awarded a doctor of optometry degree. To practise, optometrists must be licensed by their province or territory. Skilled in assessing eye function and conditions, they may prescribe selected medications (topical and oral) to treat a variety of eye conditions (e.g., bacterial or viral eye infections, allergic conjunctivitis, glaucoma, and eye drops to dilate the eyes for examination). Optometrists also prescribe glasses and contact lenses to patients who need them. Most optometrists work in group or solo practices. Like all health care professionals in Canada, optometrists are regulated by their provincial regulatory authorities. The exceptions are Yukon, Northwest Territories, and Nunavut, where the Optometry Act is administered by the Government of Yukon, the Department of Health and Social Services, and the Department of Health, respectively (personal correspondence with Rhona Lahey, Director of Communications and Marketing, Canadian Association of Optometrists). Nurse Practitioners' Practice Settings N.R. is applying for a nurse practitioner's licence in British Columbia. After completion of the nurse practitioner program, N.R. applies for, writes, and passes the College of Registered Nurses of British Columbia (CRNBC) examination, the province's clinical examination (OSCE) for adults, families, or pediatrics, and one of the written exams in their chosen specialty that is recognized by CRNBC. N.R. chose the family stream, or primary care stream. A person can choose from recognized examinations, including the Canadian Nurse Practitioner examination, the American Nurses Credentialing Center examination, or the American Academy of Nurse Practitioners in family examination. Opticians An optician completes a 2- or 3-year college program, sometimes followed by a practical component. Opticians can fill prescriptions for eyeglasses or contact lenses, fit glasses, help patients select frames, organize the grinding and polishing of lenses, and cut and edge lenses so they fit selected frames. They also do a considerable amount of health instruction related to contact lenses and glasses, including providing information about options such as lens coating and bifocal lenses. They may work independently or in a larger centre with other eye-care specialists. Opticians are regulated in nine jurisdictions across Canada. Pharmacists To practise pharmacy, a person must earn a bachelor's degree or master's degree in pharmacy (or a doctorate), complete an internship, and successfully pass a national board examination through the Pharmacy Examining Board of Canada. A licensed pharmacist, among other responsibilities, dispenses medications in response to prescriptions. Experts in their field, pharmacists provide other members of the health care team with valuable information about medications and medication interactions. The physician looks to the pharmacist for advice about current prescription medications and their interactions. The patient may look to the pharmacist for direction and advice about taking medications, their risks, and adverse effects. In most jurisdictions, the provincial or territorial plan will pay pharmacists to periodically review a person's medication profile, offer advice and counselling, or refer the person to their physician if needed. Increasingly, pharmacists are assuming expanded roles, from giving vaccinations to prescribing certain medications. Their scope of practice differs among jurisdictions. In January 2023 pharmacists in Ontario were authorized to assess and prescribe medication for 13 more conditions ranging from urinary tract infections to skin irritations and fever. See Table 5.3 for a detailed account of the responsibilities pharmacists assumed across Canada in 2021. The goal of adding new responsibilities to the scope of practice for the pharmacist is to reduce the volume of work for doctors, clinics, and emergency departments, and to provide Canadians with more options and more convenient access to front-line services (Khaira et al., 2020). Pharmacists are playing a significant role in providing vaccinations to Canadians. When vaccinations first became available, pharmacists were one of the most visible and accessible health care providers. Many felt safer visiting their pharmacy for their COVID-19 vaccination than they did going to larger vaccination centres, and the local pharmacy for many was closer to where they lived. Pharmacists have continued with this service, offering the third and fourth vaccinations for the COVID-19 series. The expanded responsibilities of pharmacists across Canada are summarized in Table. 5.4. Podiatrists (Chiropodists) The term podiatrist is used internationally as the name for a foot specialist. In Canada, only Ontario uses the term chiropodist. Podiatrists specialize in the diagnosis, assessment, and treatment of foot disorders. They treat sports injuries, foot deformities (related to the aging process, as well as misalignments), infections, and general foot conditions, including calluses, corns, ingrown toenails, and warts. Included in their scope of practice is performing specified foot-related surgical procedures, administering injections to the feet, and prescribing medications (e.g., nonsteroidal anti-inflammatory medications and antibiotics, depending on the jurisdiction). Podiatrists refer patients to surgeons or other doctors when necessary. In Canada, the chiropody/podiatry program is offered only at the Michener Institute in Toronto. Although Québec offers a podiatry program for residents of the province, students are required to do 1 year of training in New York. Chiropody/podiatry is not regulated in all Canadian jurisdictions. Practice requirements and scope of practice vary from one jurisdiction to another. In jurisdictions with no regulatory body, there are no standards of practice; essentially anyone can call themselves a podiatrist and treat patients. Practice settings include health care facilities, clinics, the community, primary care organizations, and private practice. Some podiatrists specialize in such areas as biomechanics, diabetic foot care, or foot care in long-term care facilities. Personal Support Workers Most jurisdictions recognize this category of health care workers, who provide a wide variety of services to those in their care and that vary somewhat with the workplace setting. There are numerous titles for these health care workers: personal support worker (PSW), health care aide, health care assistant, continuing care assistant (used in Nova Scotia), health care support worker (commonly used in British Columbia), home care support worker, resident care aide, health care attendant, or patient service associate. This category of health care worker provides invaluable support for patients across the health care spectrum. In most jurisdictions, individuals in this classification of caregivers must have a certificate from a community or private college in order to work for community agencies and in most health care facilities. Individuals can take a course that enables them to administer medications to stable residents in residential care (which is one step below care in a long-term care facility), usually under the supervision of a registered nurse or registered practical nurse/licensed practical nurse. These health care providers work in long-term care facilities, home care organizations, adult day care programs, seniors' residences, and group homes under the direction of other members of the health care team. Other less common practice settings include hospitals, clinics, industry, interdisciplinary primary care practices, and private practice. This category of caregiver is currently not regulated in any jurisdiction in Canada. Disability Support Worker Saskatchewan offers formal education and clinical application of skills for the designation of disability support worker. Workplace settings for disability support workers are residential and vocational settings where they provide personal care for residents. Psychiatric Nursing Assistant In Manitoba, health care aids can further their education to become a psychiatric nursing assistant (PNA). PNAs are prepared at the college level, for they have not only the required college preparation for a health care aide but additional training specific to psychiatry. Psychologists Psychologists graduate from university programs at the bachelor's, master's, or doctoral level. To practise psychology in Canada, psychologists must be licensed by the regulatory body in the province or territory where they work. Psychologists work primarily as clinicians in hospitals, academic facilities, clinics, primary care facilities, correctional facilities, and private practice. Psychologists work with individuals and families to treat emotional and mental disorders, mainly through counselling. They administer noninvasive written and practical tests such as personality tests, intelligence tests, assessment tests for attention deficit disorder (ADD), and diagnostic tests for the early stages of Alzheimer's disease or dementia. Since psychologists are not medical doctors, they do not have the authority to prescribe medications, perform medical procedures, or order laboratory or diagnostic tests. Often, a psychiatrist and a psychologist will work as a team for more effective and ongoing patient treatment. Private insurance usually covers a specified number of visits to a psychologist, but usually only those with a PhD; for the most part, provincial and territorial plans do not cover these services. Physiotherapists Physiotherapists (PTs) are regulated health care providers who graduate from university at the master's level and must pass a national exam to enter professional practice. An essential part of the primary care team, PTs work with individual patients to limit and improve upon physical impairments and disabilities, and to prevent and manage pain related to acute and chronic diseases and injury. They work in a variety of settings, such as health care facilities and clinics, as part of a primary care team, in the community (home care), and in private practice, often in groups. Some PTs specialize in such areas as geriatrics, sports medicine, or pediatrics. Most jurisdictions cover physiotherapy services under specific conditions and for limited time frames. Many private insurance plans also offer some coverage. Occupational Therapists Occupational therapists (OTs) are members of a regulated profession who provide support, direction, and therapies to individuals in need of assistance in almost every aspect of everyday life, from recreation and work to the activities of daily living. For example, they help people learn or relearn to manage important everyday activities, including caring for themselves or others, maintaining their home, participating in paid and unpaid work, and engaging in leisure activities. OTs work with patients who have difficulties as the result of an accident, disability, disease, emotional or developmental problems, or aging. In most jurisdictions, individuals can visit OTs without a referral, although the decision to see an OT is usually made jointly with a primary care provider. OTs work in hospitals, private homes (usually through provincial or territorial home care programs), schools, long-term care facilities, mental health facilities, rehabilitation clinics, community agencies, public or private health care offices, and employment evaluation and training centres. To practise as an OT in Canada, the minimal educational requirement is a baccalaureate degree in occupational therapy. All OTs must be registered with their provincial or territorial college. Upon passing the national certification exam, OTs can practise anywhere in Canada. Physiotherapy Assistants and Occupational Therapy Assistants Physiotherapy assistant (PTA) and occupational therapy assistant (OTA) programs are offered at many community and private colleges in Canada. Most programs are 2 years in length and combine the two disciplines. A number of private colleges have single-discipline programs, usually for PTAs. Program names vary. For example, the Southern Alberta Institute of Technology offers a 2-year diploma program called Rehabilitation Therapy Assistant and graduates students with both OTA and PTA skills. All programs are in the process of becoming accredited through the Occupational Therapist Assistant and Physiotherapist Assistant Education Accreditation Program. OTAs and PTAs work collaboratively with and under the direction of PTs or OTs to administer rehabilitation treatments to individuals who are experiencing physical, emotional, or developmental problems. Work settings include rehabilitation centres, long-term care facilities, the community (e.g., home care), physiotherapy clinics, and sports and medical clinics. Some jurisdictions, such as Alberta, have a professional therapy assistant association for PTAs, OTAs, speech-language pathologist therapy assistants, and recreation therapy assistants. Registered Respiratory Therapists To become a registered respiratory therapist (RRT), one must successfully complete a respiratory therapy program from a college or university that has been accredited by Accreditation Canada. College programs are 3 years in length; university programs are 4 years long. The Canadian Society for Respiratory Therapists (CSRT) is the national professional association for respiratory therapists and the certifying body for RRTs who practise in nonregulated jurisdictions. In regulated provinces, provincial regulatory bodies provide the certification for RRTs. To obtain the RRT designation and be licensed to practise in Canada, graduates of accredited programs in respiratory therapy must write the national certification examination and meet designated registration criteria from CSRT and their respective regulatory bodies. RRTs have expertise in caring for individuals with acute and chronic cardiorespiratory disorders and perform health-related functions---both in and out of hospital settings. In the hospital setting, they are available to evaluate, treat, and support inpatients and outpatients throughout the facility; however, they are especially vital within critical care areas such as the emergency department and in Critical Care or Intensive Care Units, where they manage advanced life support for patients with cardiopulmonary problems (e.g., persons on ventilators). With their advanced skills, respiratory therapists respond to emergencies (such as cardiac and respiratory arrests) and are able to intubate patients (a complex procedure of inserting a tube into the airway to facilitate breathing and initiate the use of a ventilator). Respiratory therapists are often required in the transfer of critically ill patients from one facility to another (e.g., transferring critically ill patients with COVID-19) or from an accident scene to a hospital. They are also required in the delivery room when doctors suspect the baby has or may develop respiratory problems. Respiratory therapists perform diagnostic testing, including arterial blood gases, and pulmonary function tests. In the hospital setting, the respiratory therapist is often responsible for setting up oxygen therapy or inhalation treatments. Respiratory therapists also work in medical centres, clinics, complex continuing care and rehabilitation facilities, and in the community. Registered Nurses Many agree that the nurse, with skills across several disciplines, remains the backbone of the health care system, working in numerous settings, including hospitals, primary care settings, in the community, and in industry. Multiskilled and flexible, with a broad knowledge base, nurses frequently assume responsibilities typically assumed by other members of the health care team, particularly in the hospital setting. For example, when a respiratory therapist is not available, the nurse may do the inhalation treatments or set up oxygen for a patient; when a physiotherapist is unavailable, the nurse ambulates a patient and supervises their related exercises; when the chaplain is not available, the nurse counsels and comforts the patient and loved ones. When the clinical secretary is ill, the nurse may also assume administrative responsibilities for the patient care unit. All Canadian jurisdictions except Québec require a bachelor's degree in nursing (BN or BScN) to enter the profession. In Québec, two pathways to becoming a nurse remain: one results in a college diploma (Diploma of College Studies) or a bachelor of science in nursing (Ordre des infirmieres et infirmiers du Québec, n.d.). Degrees in nursing can be completed in 2, 3, or 4 years. Accelerated (2-year) programs are available across Canada. The related regulatory body in each province or territory must ensure that the individuals seeking to practise as nurses meet designated levels of competence. To that end, program graduates in all jurisdictions except Québec must write a national examination. Introduced in 2015, the National Council Licensure Examination (NCLEX-RN) replaces the Canadian Registered Nurse Examination (CRNE) as Canada's national examination. Applicants for registration as a registered nurse (RN) are required to successfully complete the NCLEX-RN exam, administered by the National Council of State Boards of Nursing (NCSBN). Some jurisdictions require additional examinations. In Québec, in addition to a provincial examination, applicants must pass a Language Proficiency Licensure Examination administered by the Office Québécois de la Langue Française, in accordance with Article 35 of the Charter of the French Language. Those applying to practise in Ontario must also write a jurisprudence examination, which tests knowledge about provincial nursing and health care legislation. Postgraduate and ongoing educational opportunities for RNs vary among provinces and territories. Some specialties include critical care, emergency nursing, community health nursing, hospice and palliative care, as well as perinatal and obstetric's health. The RN usually assumes the most complex components of nursing care and also a variety of leadership roles both clinical and administrative. Many hospitals and other facilities employ RNs only in specific areas, such as Intensive or Critical Care Units, where their specific skill sets, particularly in assessment and decision making, are critical. In 2021, there were approximately 459,005 regulated nurses eligible to practice in Canada. This figure includes 312,382 registered nurses (up 2.5% from 2020) and 7,400 nurse practitioners (an increase of 10.7% from 2020), representing the largest increase of all the nursing designations. There were 132,886 licensed or registered practical nurses (an increase of 1.6% from 2020) and 6,337 registered psychiatric nurses (an increase of 3.6% from 2020) (Canadian Nurses Association, 2022). Of interest, the Canadian Institute of Health Information (CIHI) reports that in provinces where the information was available, 4,186 RNs who either retired or left the profession for other reasons returned to the workforce to provide support that was badly needed during the pandemic. Most of the returning nurses were from Quebec and Ontario (CIHI, 2021a). Most jurisdictions are offering various incentives to encourage individuals to apply to nursing programs in order to address the current national shortage of nurses. In addition, incentives are being offered to foreign-trained nurses. British Columbia, for example, in the fall of 2022, pledged \$12 million to recruit foreign-trained nurses by simplifying the recertification process and making it more financially viable (Immigration Canada, 2022). Advance Practice Nurses Advanced practice nurses are registered nurses with additional education. There are two categories of advanced practice nurses recognized in Canada: nurse practitioners (discussed earlier) and clinical nurse specialists. Clinical Nurse Specialists Clinical nurse specialists (CNSs) are registered nurses who have a master's or doctoral degree in nursing in addition to wide-ranging nursing knowledge and skills and clinical experience in a specialty area (e.g., cardiology, oncology, mental health, geriatrics, neonatology). Usually in leadership positions, CNSs work in a variety of roles---as clinicians, consultants, educators, and researchers. In any setting, CNSs contribute to evidence-informed practices, continuity of care, improved patient experiences, and enhanced treatment and health care outcomes. CNS is not a protected title. Registered/Licensed Practical Nurses To become a licensed practical nurse (LPN/RPN), called a registered practical nurse (RPN) in Ontario, a person must complete high school (or the equivalent) and a 2-year diploma program at a community or private college. All jurisdictions require graduates to write the Canadian Practical Nurse Registration Examination (CPNRE) for provincial or territorial registration and to use the professional designation (College of Licensed Practical Nurses of Manitoba, 2022). Some jurisdictions are replacing the CPNRE with the Regulatory Exam--Practical Nurses (REx-PN™) (College of Nurses of Ontario, 2022). This replacement took effect in Ontario and British Columbia in January 2022. There are no limits on how many times the writer takes this exam; it is computer based, and the system will automatically give the writer new questions each time they log in to rewrite it. The skill set and scope of practice of LPN/RPNs have expanded dramatically over the past few years, with practical nurses now assuming many of the skills and responsibilities formerly limited to registered nurses. Their skill set includes doing dressings, dispensing medications, and, in some facilities, taking charge of units. The practical nurse collaborates with registered nurses and other members of the health care team to render patient care. Practical nurses can be found in almost all practice settings and in the community. The CIHI reports that there were 130,710 LPNs incensed to practise in Canada in 2020 with more of them practising part-time than other categories of nurses (CIHI, 2021b). LPNs also make up the largest number of regulated nurses working in long-term care facilities across the country. As with registered nurses, a number of LPN/RPNs who had retired or left the profession for other reasons returned to the workforce in 2020 to provide support where needed during the pandemic. Ontario and Québec accounted for the majority of those returning. Registered Psychiatric Nurses Registered psychiatric nurses (RPNs)---not to be confused with registered practical nurses (RPNs) in Ontario---are recognized as a separate regulated health profession in Western Canada (Manitoba, Saskatchewan, Alberta, and British Columbia) and the Yukon. They form the largest body of mental health care professionals providing services in Western Canada. RPNs focus on the mental, developmental wellness (i.e., incorporating a holistic approach including mind, body, and spirit), mental illness, addictions and substance use, as well as the physical components of health of individuals within the context of their overall health and life situations. RPNs apply concepts from biopsychosocial and spiritual models of wellness, integrated with cultural norms, to maintain inclusion of a holistic approach to care and treatment. RPNs work with a variety of other health care providers and mental health and community organizations. Practice settings are diverse and can include crisis stabilization and forensic assessment units, hospitals, the community, and academic facilities. Unique and separate from BN or BScN programs, education for RPNs (available only in western Canada) is offered at the degree level (bachelor's or master's degrees) and incorporates medical and surgical nursing skills with those specific to the area of mental health. RPNs are regulated to practice only in four Canadian provinces: British Columbia, Alberta, Saskatchewan, and Manitoba, and in the Yukon Territory. The Registered Psychiatric Nurse Regulators of Canada (RPNRC) is the national umbrella organization for registered psychiatric nurses regulators in Canada. The provinces of British Columbia, Alberta, Saskatchewan, Manitoba, and the Yukon territory regulate psychiatric nursing as a distinct profession. Specialists and Consultants Cardiologists Cardiologists specialize in conditions and diseases of the heart, ranging from abnormal rhythms and heart attacks to related vascular problems. The cardiologist treats patients from a medical perspective, but does not do surgery. If surgery is required, the patient will be referred to a cardiac surgeon. Aside from seeing patients in the office setting, cardiologists with special training may carry out diagnostic procedures such as cardiac catheterizations in a hospital or private diagnostic facility. Emergentologists Some physicians, called emergentologists, have chosen careers practising full-time emergency medicine. This specialty has developed because most emergency departments (EDs), also often referred to as emergency rooms, are choosing to hire full-time physicians, rather than staffing the ED with on-call physicians as in the past. Trauma surgeons also work in the ED. Geriatricians Geriatrics focuses on the care of older people, typically those over 65. A geriatrician is usually an internist who has additional training in caring for older adults. Geriatrics does not attract a large number of physicians. The assessment and treatment of an individual with complex medical conditions is time consuming. Additionally, geriatricians are typically paid less than other specialists. Most work in private practice, team-oriented practices, or health care facilities. There were just over 300 geriatricians working in Canada in 2019 (Glauser, 2019). Gynecologists and Obstetricians Specializing in health of persons with a female reproductive system, gynecologists diagnose and treat disorders of the gynecological and reproductive systems. Obstetricians focus on the care of pregnant people and the delivery of their babies in both normal and high-risk situations. Closely related, these two specialties are usually undertaken together (resulting in the abbreviation OB/GYN). Midwives will refer a patient to an obstetrician if they determine that the patient is "high risk," meaning that the pregnant person needs specialized care and that there is a likelihood of a complicated delivery. The midwife will continue elements of care, collaborating with the obstetrician. Examples of a high-risk pregnancy include a history of a complicated delivery, diabetes, or pregnancy-induced hypertension (PIH). Internists and Hospitalists An internist typically diagnoses and renders nonsurgical treatment for diseases of a person's internal organs (e.g., problems of the digestive tract, liver, or kidneys). An internist often refers patients to other specialists who deal with specific organs. A hospitalist is a physician---usually an internist---who oversees the medical care of patients in the hospital, usually those who do not have a family doctor with admitting privileges to that hospital. Also, a hospitalist will collaborate with specialists as required. Usually employed by the hospital, a hospitalist may or may not have a private practice. Neurologists A neurologist treats conditions of the nervous system, including chronic and potentially fatal conditions such as Parkinson disease and multiple sclerosis, sleep disorders, headaches, peripheral vascular disease, brain tumours, and spinal cord injuries. Neurologists do not perform surgery. Patients requiring surgery would be referred to a neurosurgeon. Ophthalmologists Ophthalmologists, medical doctors who specialize in diseases of the eye, can carry out both medical and surgical procedures, such as cataract removal and ocular emergencies (e.g., glaucoma, eye trauma). Although ophthalmologists can perform refractions and prescribe glasses, these functions have largely been taken over by optometrists (who are doctors of optometry, different from medical doctors). Cataract surgery is done either in hospital or in free-standing medical facilities, such as Lasik MD clinics or the Canadian Centre for Advanced Eye Therapeutics Inc. Osteopathic Physicians Osteopathy incorporates a holistic, manual approach to the diagnosis and treatment of disease. It considers, in particular, the musculoskeletal system and its relationship with the rest of the body in terms of self-healing, self-regulating capabilities. In Canada there are osteopathic physicians and osteopathic manual practitioners or therapists. Osteopathic physicians are those individuals who have trained in the United States and who hold a medical degree from a university approved by the American Osteopathic Association. Their qualifications are the same as those for a medical doctor, and if they have completed the provincial/territorial requirements, may practise in Canada. There are numerous schools of osteopathy across Canada graduating students who can practise as osteopathic manual practitioners or therapists. These programs are typically 4 years in length with a mandatory clinical component. Graduates from these programs are not medical doctors. Manual osteopathy and related educational facilities are currently not regulated in Canada. Oncologists Oncology is the branch of medicine that deals with all forms and stages of cancer development, diagnosis, treatment, and prevention. Because cancer treatment has become so highly specialized, oncologists may specialize in only certain areas, such as radiation therapy, chemotherapy, gynecological oncology, or surgery. Oncologists usually practise in large hospitals or medical centres specializing in cancer treatment. They also provide ongoing treatment for patients in hospices and related facilities. Psychiatrists Psychiatrists specialize in mental illness and emotional disorders, including depression, bipolar disorder, schizophrenia, obsessive-compulsive disorder (OCD), borderline personality disorder, bulimia, anorexia nervosa, and personal stress issues. As medical doctors, psychiatrists can order laboratory and diagnostic tests and prescribe medications, unlike psychologists who are not medical doctors. Psychiatrists do not perform surgical procedures. Geriatric psychiatry is an emerging field. Surgeons General surgeons are qualified to perform a wide range of procedures, mostly involving the gastrointestinal tract. Many go on to further specialize in specific areas such as gynecology, neurosurgery, or cardiovascular surgery. A surgeon's scope of practice varies with experience, specialty training, and level of comfort with the type of surgery they are asked to perform (Case Example 5.4). Surgeons' Scope of Practice A patient presents in the emergency department complaining of chest pain. Investigation reveals they have a blockage in a major artery serious enough to require surgery. A general surgeon is on call. The general surgeon is qualified to assess the patient's condition but has no special training in cardiovascular surgery. The patient is referred to a cardiovascular surgeon, who completes all required examinations and tests and performs the surgery. Speech-Language Pathologists and Audiologists Speech-language pathologists are experts in disorders of human communication. They assess and manage persons with a wide variety of related conditions, including problems with swallowing and feeding, stuttering, and delays in speaking, and also social communication and literacy issues. Practice settings include hospitals, long-term care and mental health facilities, research and academic facilities (schools and universities), group homes, the community, and private practice. Audiologists work with patients with problems related to sound, hearing, deafness, and balance. They provide ongoing education and diagnostic services, as well as create and manage treatment plans for all age groups. In most jurisdictions, audiologists can prescribe and fit hearing aids and other hearing devices. Practice settings are similar to those of the speech-language pathologist, with the addition of industrial settings. In Canada, the minimal requirement to be a speech-language pathologist or an audiologist is a master's degree in the relevant course of study. Communications Disorders Assistant Communications disorders assistants (CDAs) work with, or under the direction of, both speech-language pathologists and audiologists. They assist clients in communicating effectively or using alternative forms of communication, among other things. Their scope of practice includes initiating and carrying out diagnostic tests (e.g., audiology screening), assisting with treatments, and health teaching. CDAs require a graduate certificate along with an undergraduate degree or diploma in a related field such as linguistics, early childhood education, social work, or educational assistants. Administrative Roles Health Information Management Health information management (HIM) professionals hold the designation of CHIM---Certified in Health Information Management. They provide leadership and expertise in the management of clinical, administrative, and financial health information in all formats and in a variety of settings (e.g., hospitals, community care, long-term care facilities, physician offices, clinics, research facilities, insurance companies, and pharmaceutical companies). The Canadian College of Health Information Management (CCHIM) administers the National Certification Examination (NCE) on behalf of the Canadian Health Information Management Association (CHIMA), the national body representing approximately 5000 HIM professionals. To become a CHIM, one must graduate from a CHIMA-accredited diploma or degree program, offered at colleges and universities across the country, and successfully pass the National Certification Examination, which is offered at one level countrywide. This examination assesses the entry-level competencies of qualified applicants. Membership is classified as professional, student, retired, or affiliate. Successful candidates receive a certificate of registration in the Canadian College of Health Information Management and are eligible to use the CHIM credential and the title Certified HIM Professional. Certified members of CHIMA are required to participate in earning continuing professional education (CPE) credits to maintain their certification. Conestoga College in Ontario offers a bachelor of health information sciences (BAHIS) degree and will also consider graduates of CHIMA-accredited HIM diploma programs for advanced-standing opportunities. Detailed contact information on current CHIMA-accredited programs, including those offered through distance education, can be found on the CHIMA website. The HIM profession has four domains of practice: data quality (the collection and analysis of health information, the coding of clinical information, and quality assurance); e-HIM---electronic health information management (the physical-to-digital conversion of health records, digital cloud storage and distribution of health information, and the management of complex communications systems); privacy (keeping health information confidential and secure, and enforcing privacy legislation as it pertains to the information for which they are responsible); and HIM standards (records management standards, documentation standards, terminology standards, etc.). Health information managers are involved with almost every aspect of health information throughout its life cycle, from data and information collection, analysis, and retrieval, to the destruction of information once it is no longer needed. For example, when working with health records, health information managers facilitate the collection of health information and oversee proper access to and use of the information. They ensure that data are stored properly and safely, and when no longer needed, are disseminated and destroyed according to facility and legal guidelines. Health information managers also conduct quantitative analysis of health records, ensuring they are accurate and complete, and statistical analysis used for identifying trends, such as births, deaths, diseases, and health care costs. In Canada, HIM professionals are trained in six core competency areas that include biomedical sciences; health care systems in Canada; health information, including the HIM life cycle; information systems and technology; management aspects; and ethics and professional practice. The HIM professional is playing a pivotal role as Canada continues to work toward the implementation of integrated electronic health information systems at local, provincial and territorial, and national levels. They will continue to be instrumental in directing and reshaping how health care is delivered. Health Office and Services Administration Every aspect of health care requires some level of administrative support. The responsibility for the day-to-day administrative management of a hospital unit, a clinic, primary care organization, or a physician's office requires skill, knowledge, patience, commitment, and a high level of professionalism. The name for individuals working in these roles varies (depending on the workplace setting) from medical secretary or medical office/administrative assistant (in hospitals), to unit clerk, clinical secretary, or administrative coordinator. People in these roles must have a sound knowledge base in several areas, including pharmacology, diagnostic and laboratory testing, medical terminology, anatomy and physiology, disease pathophysiology, and the principles of triage. Those working in primary care settings must have both clinical and administrative capabilities to manage electronic health records, schedule and triage patients, and be able to do provincial or territorial billing. In the hospital setting, administrative staff have to navigate complex computer software systems for data-entry responsibilities and understand hospital policies and procedures. All must have the ability to multitask and to work efficiently under pressure, and they must be ethical, highly professional, flexible, friendly, empathetic, supportive, and comfortable around individuals experiencing any type of physical, emotional, or mental health problems. Practice settings include doctors' offices and group practices, specialists' offices, all hospital units, and long-term care facilities. Health services or health office administrators are not regulated, so there are no provincial or territorial standards.. The International Association of Administrative Professionals (IAAP) welcomes members from any administrative discipline and has chapters across Canada. Other Non-physician Practitioners Alternative practitioners are valuable contributors to the health and wellness of Canadians. Some disciplines have provincial or national organizations with varying levels of oversight by their associated bodies. Most are unregulated. Educational requirements vary greatly within the discipline, and across provinces and territories. Volunteer Caregivers Friends, family, and volunteer caregivers (who work in partnership with professional caregivers) provide tremendous support to those who are ill, family members, and the general public when they interact with health care facilities. With current shortages in all categories of health care providers, many individuals depend on this group of people to fill in the gaps in their care that cannot otherwise be filled. The hours of care, direction, and support provided by these individuals are uncountable, the output unequalled, and the stress phenomenal. Many individuals interfacing with the health care system could not manage without this supportive network. The importance of the role of volunteers during the COVID-19 pandemic cannot be underestimated. Volunteers, for example, were essential in organizing and staffing vaccination clinics, providing information for people, as well as support. Many agencies are staffed, at least in part, with the assistance of volunteer caregivers. The exclusion of volunteers from long-term care facilities during the pandemic, justified with respect to infection prevention and control measures, was detrimental to residents in terms of their physical and mental well-being. Workplace Settings Workplace (or practice) settings described here provide a cross-section of where health care is delivered. Included in some detail are practice settings that interprofessional teams work in. Several types of clinic settings are also described. Community and Home Care You will recall from Chapter 3 that home and community care refers to the practice of effectively managing the health care needs of eligible Canadians in their homes or other community settings in which they reside. The objective is to reduce time in hospital or avoid hospital stays altogether, and delay or avoid admission to long-term care facilities. Strictly speaking, home and community care are different services, community care referring to the use of community resources and services to assist individuals being cared for at home; home care involving the services and support provided within the person's place of residence. More often than not, the services are interdependent. The need for home and community care is increasing for several reasons, ranging from an aging population and the shift away from institutionalized care by our provincial/territorial health care system to the growing preference on the part of most Canadians to be cared for within their communities. Home and community care services are not covered under the Canada Health Act. Selected home care services (but not all) are identified, implemented, and paid for by provincial and territorial public health plans (see Chapter 4). If services provided for a person do not meet their needs, additional services must be paid for privately. In January 2020, Statistics Canada released a report stating that approximately 3 million Canadians received some form of home care in 2018, with the majority of those being 65 years of age or older (Statistics Canada, 2020). In addition, one in six of those receiving home and community care services were between the ages of 15 and 24 (age is not a barrier to receiving home care). Collectively, the reasons for requiring home care services included individuals with acute or chronic illnesses; those recovering from surgery; those with physical disabilities, mental health issues, or complex health needs; those needing palliative care, respite, or rehabilitative care; and individuals with other matters related to aging. Requests for home care can originate with several sources, including the person wanting home care, a family member, friend, or primary care physician; in the case of a hospitalized patient, the request may come from the health professionals within the patient's circle of care (e.g., physician, social worker, nurses, physiotherapist). In most jurisdictions, the initial point of contact for requesting home care services is made through a related community organization. After a referral has been received, the individual is assessed for the type and amount of care that would best meet their needs. A hospitalized patient's needs may be short or long term in nature. If a patient's needs are considered to be long term, for example, if an older person with chronic medical conditions is assessed and home care services feel they cannot accommodate the patient's needs at home, other options must be considered, for example, long-term care. It can take days to weeks to find a long-term care bed, during which time the patient must remain in the hospital occupying either an acute care bed or be transferred to a bed considered an alternate level of care (ALC) bed, for example, in a step-down unit (Case Examples 5.5 and 5.6). A Short-Term Need for Home Care Services A 76-year-old patient who is paraplegic had an outpatient procedure done recently, and they require intravenous (IV) antibiotics and dressing changes. A referral for home care would result in a visiting nurse administering the IV antibiotics and changing the dressings. This would be considered a short-term need for home care services. If mobility was not an issue, an alternative would be for the patient to go to the hospital or other community facility for the required interventions. A Long-Term Need for Home Care Services An 84-year-old patient has heart disease and hypertension, chronic obstructive pulmonary disease (COPD), low vision, and some mobility issues related to arthritis. With family assistance they managed in their own home. The patient fell and broke their hip, requiring surgery and a period of rehabilitation. After the surgery, it became apparent that they could not manage at home without significant support. A home care assessment (part of the patient's discharge planning) determined they could go home with the proper home and community support, which involved several levels and types of interventions. An occupational therapist helped to make modifications to their home, addressing the patient's mobility issues. Meals on Wheels were engaged to provide them with seven meals a week. A community nursing agency was contacted to provide the patient with a personal support worker for 3 hours daily, helping with bathing, dressing, and some home management. An LPN was also made available to attend to the patient's medical needs. The support the patient requires is considered long term. In Canada there is a shortage of long-term care beds. It is estimated that the number of long-term care beds in Canada will need to double to accommodate the demographic needs by the year 2035. Shortfalls in this type of accommodation are due to increasing need, system organization (or lack thereof), a lack of health human resources, and insufficient funding. Home care services that are typically funded for a designated number of service hours per week are determined at the intake assessment (see Chapter 4). If a patient feels they need additional hours of care (e.g., housekeeping, general maintenance, and more supportive care), those services must be hired and paid for privately. In some regions it is difficult to find additional care, especially from nurses or personal support/care workers, because of the shortage of health human resources. Home Care Management in Saskatchewan Some jurisdictions have alternative funding models, such as individualized funding provided by the Saskatchewan Health Authority. This option is offered through the province's home care program and allows the patient or their family/guardian to accept the responsibility of managing and directing supportive services (e.g., personal care or home management services such as meal preparation, house cleaning, or grocery shopping). The level of funding provided for these services is based on the assessed need. Professional services (e.g., those provided by registered nurses or therapies) are excluded from individualized funding and are provided instead through the Saskatchewan Health Authority. People who choose individualized funding are responsible for hiring, training, and terminating workers, managing payroll under the Employment Act, and reporting to the Saskatchewan Health Authority at designated intervals. Clinics Urgent Care and Walk-in Clinics Canadian residents who do not have a family doctor, are away from home, or cannot get an appointment with their primary care physician can seek medical care from an urgent care or walk-in clinic. These clinics reduce the burden on emergency departments by providing nonemergency care to patients who would otherwise clog up the ED. Typically, clinic visits are less costly to the health care system than visits to the ED. Some urgent care clinics offer more immediate access to diagnostic testing, such as ultrasound, and to minor procedures, such as suturing, whereas walk-in clinics often refer the patient elsewhere for these procedures. Ambulatory Care Clinics In the most literal interpretation, ambulatory care clinics have traditionally encompassed any clinic---for example, a walk-in, urgent care, or private clinic---that offers services and discharges the patient when their health care issue has been addressed. Ambulatory care, therefore, may include day surgeries, cast changes, postsurgical assessments (perhaps after hip or knee surgery), and cancer treatment. Within the past 5 years, the term has referred more specifically to facilities that offer groups of services in one location---often, a hospital. Outpatient Clinics Outpatient clinics offer services that vary from hospital to hospital and community to community in an effort to meet the unique needs of a particular area. An outpatient clinic can operate under the umbrella of an ambulatory care clinic---a clinic within a clinic. Services may include family doctor care, minor surgery, screening procedures (e.g., vascular screening), laboratory and diagnostic procedures, and foot care. Outpatient clinics in large hospitals offer an even wider range of services. Some hospitals divide clinics into areas of specialty and related services; others offer many disciplines within one clinic. Mental Health Clinics Most jurisdictions have clinics that respond to the specific needs of individuals with mental health disorders, although services provided are rarely adequate. Some services focus on youth and young adults and include addiction support. For the most part, these clinics collaborate with other organizations and hospital outpatient services to provide short-term, problem-focused therapy, peer support, and system navigation to help individuals find the services they need. For example, a mental health counsellor can fast track a person to a psychiatrist. Almost all jurisdictions have adult mental health clinics (for individuals age 18 years and older). Some accept walk-in patients, others require referral from a primary care provider or have a self-referral option. For example, clinics in Saskatchewan offer a variety of services, from individualized to group sessions, which may or may not be problem specific. These clinics also provide access to wellness programs, support groups, counselling for victims of sexual violence and abuse, addiction services, and treatment for common conditions such as depression, acute anxiety, and eating disorders. Clinics in most regions also provide access to a mobile crisis team (also called a crisis response team) staffed by health care professionals with crisis response training (e.g., registered psychiatric nurses and counsellors) who will respond to mental health emergencies within a given geographic area. Nurse Practitioner--Led Clinics Nurse practitioners in some jurisdictions have taken the lead role in seeing patients in a clinic setting. The purpose of these nurse practitioner--led clinics is to provide care for individuals who do not have access to a primary care physician or primary health care team. Individuals register with a clinic (not with a specific provider) and are offered routine health and preventive educational services (e.g., prenatal or well-baby care, managing a chronic condition) similar to those received in any other primary care delivery model, theoretically over the course of a lifetime. Basic primary health care services are provided by the nurse practitioner, not a physician. Other team members are similar to any primary health care team model: registered nurses, registered psychiatric nurses (in the western provinces), social workers, pharmacists, dietitians, psychologists, occupational therapists, physiotherapists, and others. Teams can be designed to meet the needs of the community they serve. The nurse practitioner can refer patients to specialists and other community resources as required. Why Clinics Make Sense Clinics have gained prominence for a number of reasons, including the following: Cost effectiveness. New technologies have shortened surgeries and made them less invasive, allowing for earlier discharges and follow-up in clinics. It costs less to care for patients at home than to maintain them as inpatients. Many tests and procedures formerly done in a hospital are now done in a clinic on an outpatient basis. Having patients see a specialist or other health care provider in the clinic setting on a first-come, first-served basis usually costs less than having them make an appointment with a specialist or other health care provider. Organizations can staff clinics more efficiently according to perceived need. In addition, equipment booking, if handled centrally, can result in available equipment being maximized. Timely access, fewer patient visits, and convenience. With proper organization, patients can access more services faster, possibly in one clinic visit. The move toward interprofessional health care teams in clinics, similar to those found in primary care groups, has enabled clinics to readily provide the patient with a variety of services (Case Example 5.7). With centralized resources, the patient should have to make fewer visits, which is especially beneficial to patients with multiple health problems and those with mobility or transportation issues. Walk-in and similar clin