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The Final Chapter

Reflections of the Critical Foundations in Health Disciplines Course


Embarking on a master’s degree is no small task but the rewards far outweigh the work involved. When I was deciding on what path I wanted to take in my career it was easy to say that I wanted to complete a master’s degree; choosing one that fit my interests and professional identity was a bit more of a challenge. In my research, I came across the Master of Health Studies program at Athabasca University. The online learning modality and flexibility that the program offered was something that resonated with my personal and professional life. The courses offered within the program also fit within my learning needs and goals.


The first course within the program is entitled Critical Foundations in Health Disciplines. This course is designed to foster an environment of collaboration with peers in your class, analyze research, and have meaningful dialogue through discussion posts about factors that influence the health of Canadians. (Athabasca University, 2019). The weekly topics, research and content curation, weekly forum posts, and blog posts allowed me to explore information that is relevant to my profession and my current role within the healthcare system.


Throughout the course, we have examined concepts such as how we fit within the healthcare system, social determinants of health, levels of influence on health, chronic disease management, vulnerable populations and innovations in health. In researching these subjects, themes began to emerge that I was able to link together as well as consider how these health issues presented themselves in my daily work as a Clinical Manger of an acute medical unit.


A recurrent healthcare issue that I commonly see in my practice is related to chronic disease management. For a significant portion of the patient population admitted to an acute medicine unit, chronic disease(s) represent a proportion of the admitting diagnoses and also present some of the greatest discharge challenges. Throughout this post I will be reflecting on how the Critical Foundations in Health Disciplines course supported my growth as a professional by broadening my understanding of the different populations that present themselves to acute care hospitals and how I can assist in their transitions.


Understanding Professional Identity & Where I Fit within the Healthcare System

One of the first steps in the course was to complete a social media and professional audit. We were asked to reflect on how our current online persona reflects who we are as professionals and if we would feel enticed to speak up on social media about current events. In exploring who I am as a professional, I also had the opportunity to reflect on where I fit within the healthcare system.


As a regulated healthcare professional, the Regulated Health Professions Act (RHPA); 1991 requires that health regulatory colleges “are responsible for ensuring that regulated health professionals provide health services in a safe, professional and ethical manner” (Ministry of Health and Long Term Care, 2018). Under the RHPA, as a Registered Nurse (RN), I belong to the College of Nurses of Ontario (CNO). The CNO is responsible for ensuring that its members are adhering to a set of professional and practice standards in order to safeguard and protect the public. Professional standards include accountability, continuing competence, ethics, knowledge, knowledge application, leadership, relationships and professional relationships (College of Nurses of Ontario, 2002). As a member of CNO I am required to renew my nursing license annually. Part of annual registration is completing the Quality Assurance (QA) program. The QA program requires that nurses complete a self-reflection questionnaire as well as an Action Plan (formerly a Learning Plan). Nurses may randomly be selected to present their Action Plan to the CNO where they are either satisfactory in their submission or may be required to submit further evidence of continued competence.


Nursing is a rewarding career and it has taken me a while to see where I am the most valuable. Advocacy and mentoring are the two areas of healthcare that are important to me. Advocating for high quality, evidence based patient care and ensuring the next generation is equipped to deal with the changes that the healthcare world is facing is where I feel the most impactful within our healthcare system. Canadian Nurses Association (2020) defines advocacy as “engaging others, exercising your voice and mobilizing evidence to influence policy and practice. It means speaking out against inequity and inequality. It entails participating directly and indirectly in political processes and acknowledging the importance of evidence, power and politics in advancing policy options.”


Focusing on Health & Social Determinants of Health

A part of understanding populations or groups of people is understanding what factors produce health outcomes. The definition of health and a call for its revision has been debated by philosophers, researchers, and scholars alike. It is felt that the World Health Organization (WHO) definition of health does not meet the current standard of what health encompasses. The definition of health, as explained in the Constitution of the WHO, has been upheld since 1948 with no changes. Researchers find the definition, that encompasses the wording “complete well-being” (WHO, 2020), problematic; a nearly impossible target in modern society. In the years since the definition was disseminated globally, life expectancy has risen, child mortality has decreased, and more people are living with chronic disease (Huber, 2011; Kierhan Fallon & Karlawish, 2019; Leonardi, 2018). WHO defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 2020).


But what actually contributes to and shapes our health? Our health is determined by several factors that we may not even realize influence it. It is partly influenced by access to social and economic opportunities, the quality of our schooling, the resources available to us and the cleanliness of our water, food and air (Office of Disease Prevention and Health Promotion, 2020). The WHO (2018) defines the social determinants of health (SDH) as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”


Part of my role as Clinical Manager is to review patient’s plan of care and goals including discharge planning. The health care team is repeatedly faced with obstacles that limit their ability to effectively plan for a safe transition to their discharge destination. For a lot of patients, the social determinants of health play an integral part in these challenges. Reviewing and having a better appreciation of what the social determinants are and how they impact the health of these individuals, I can assist the team in reviewing all aspects and taking a different approach to care and goal planning.


Levels of Influence & Chronic Disease

When reviewing chronic disease data, it was important that I review data that was not only at a national level but broken down to a provincial and local level. To fully understand the population that I serve would mean to educate myself about all levels of data.


Chronic disease(s), or non-communicable disease (NCD), progress slowly over time, tend to have a long duration impacting a person’s quality of life and often require ongoing medical supervision and care (CCO, 2019). In Canada, 67% of deaths are attributed to one of the four most commons NCD’s; cancer, diabetes, cardiovascular disease, and chronic respiratory disease (Public Health Agency of Canada, 2013). The Public Health Agency of Canada (2013) reports that there are more Canadians (age 34-64) living with chronic disease than ever before. Modifiable risk factors are the driving factor for this increase (Figure 1).


Figure 1: Common Risk Factors for Chronic Disease

(Public Health Agency of Canada, 2013).


Local data of the Hamilton Niagara Haldimand Brant (HNHB) LHIN suggests that approximately 18.9% of the population has been diagnosed with 1 or more chronic condition. The most commonly reported NCD’s are congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM). Unfortunately, this number is set to increase as the area’s population continues to age (HNHB LHIN, 2014).

Chronic disease and chronic disease management is a national problem that requires strategies, policies and delivery models in order to improve patient outcomes. COPD is a NCD that requires an integrated health care framework in order to improve health outcomes. The prevalence of COPD in the HNHB LHIN is 1.5% higher than the provincial average (5.3% to 3.8%) (HNHB LHIN, 2014).


When reviewing chronic disease, specifically COPD, frameworks that aid in the prevention, assessment, and treatment are imperative in the facilitation of positive health outcomes for this group. The Chronic Care Model (CCM) (Figure 2) “identifies the essential elements of a health care system that encourage high-quality chronic disease care” (Improving Chronic Illness Care, 2011). The model essentially shifted primary cares’ focus to one that supports a proactive management of NCD with a framework that encourages productive interactions between informed, activated patients and the prepared, proactive healthcare provider(s).


Utilizing frameworks such as the CCM assist with guiding care and promote robust health teaching so patients can be informed, activated in their health care and self-motivated.


Figure 2: The Chronic Care Model (Improving Chronic Illness Care, 2011).



What the CCM provided was a pathway for modern models of chronic disease management. A service that I utilize in the management of COPD is the Integrated Coordinated Care (ICC) Program. A team at St. Joseph’s Health System pioneered the ICC model as a way to integrate care across the health continuum, specifically hospital care transitioning to home care. The ICC Program centred on providing care to patients with specific diagnoses by providing a single team and care management model in hospital and collaborated with home care providers in the community (Guertin et al., 2017) (Figure 3).

Figure 3: Standard model versus ICC model (Guertin et al., 2017).


The ICC Program allows for patients to be more in control of their chronic disease(s) by providing them with increased resources, either in person or virtually, increased health teaching, increased access to the healthcare team, and a pathway to meet individual goals. As a community that sees a higher than average incidence of COPD, consulting with the ICC Program lead is an imperative part of the discharge planning process for patients with a diagnosis of COPD on an acute medical unit.


Vulnerable Populations

Adding another layer to understanding the social determinants of health and their impact on chronic disease management is recognizing vulnerable populations. There are many groups of people that make up a vulnerable population classification. For the purposes of the course, I focused primarily on the Indigenous community and seasonal agricultural workers. Both of these groups are in relative close proximity to me and utilize the services of the acute care hospital that I work.


Both groups have also been increasingly vulnerable this year with respect to the COVID-19 pandemic. Both groups have had to deal with the repercussions of this pandemic in different ways. The seasonal agricultural workers have been primarily secluded from the outside world and calls for reform to the Seasonal Agricultural Worker Program (SAWP) have been widespread. As Haley et al. (2020) details, the National Farmers Union “publicized some of the key problems faced by temporary migrant agricultural workers amid the COVID-19 pandemic. In particular, they noted that the COVID-19 health crisis expose “deeper problems” in the seasonal worker program, and exposes the vulnerabilities of migrant farmworkers” (p. 36). You can read more about the SAWP on my blog post “From Farm to Table –The Seasonal Agricultural Worker Program.”


Six Nations of the Grand (2020) took an aggressive, yet necessary, approach to curtailing the spread of COVID-19 in the territory by restricting access, allowing only residents in. This was done in response to the large amounts non-residents entering the territory to buy gas and cigarettes. The rationale is unfortunately straightforward, according to the United Nations (2020) “Indigenous peoples experience a high degree of socio-economic marginalization and are at disproportionate risk in public health emergencies, becoming even more vulnerable during this global pandemic, owing to factors such as their lack of access to effective monitoring and early-warning systems, and adequate health and social services.” An example can be found during the 2009 H1N1 pandemic. Indigenous Canadians make up approximately 16% of hospital admissions yet make up only 3.4% of the population (Hansen, 2020).


Innovations in Healthcare

As we look forward to the future, innovations in healthcare can take on many forms; a novel idea that changes a care pathway improving patient outcomes, a new product or technology. Kelly and Young (2017) reports that “successful innovations often possess two key qualities: they are both useable and desirable” (p. 121).


One innovation in healthcare that been assisting healthcare providers and patients is telemedicine. The Ontario Telehealth Network (OTN) has been providing patients with virtual access to healthcare providers since 1998. The goal of OTN is providing the ability to allow every Ontarian with access to health care where and when they need it. OTN offers different modalities for patients to connect with their primary healthcare provider; either via text, audio or video. This allows for less time spent traveling to physician offices and provides better outcomes for those living with chronic diseases (Ontario Telehealth Network, 2020).


Telemedicine is only going to continue to expand in its possibilities. The COVID-19 pandemic proved there was an increased need for telemedicine as many healthcare providers were not seeing many patients in person but opting for virtual visits. Virtual healthcare allows for more timely access and assists in decreasing emergency department visits. Currently in practice, I have seen virtual care used to access specialists such as neurologists and psychiatrists as well, the ICC Program uses virtual follow up care to COPD patients. As more people become comfortable with this technology and form of care, we are apt to see more services adopt this care method.


Next Steps

The Critical Foundations in Health Disciplines course has provided me with the foundational teachings that I will be able to utilize, not only as I move through the Master of Health Studies program but, as I continue on my career. I previously stated that I felt my role in healthcare was that of an advocate. By completing this course, it awarded me with the tools to be more forward thinking and open to situations concerning the concepts of health, health determinants and chronic disease frameworks thus allowing me the opportunity to impact patient outcomes and advocate on their behalf.


References:

Athabasca University. (2019). Master of health studies (MHST) 601 Critical Foundations in Health Disciplines. https://www.athabascau.ca/syllabi/mhst/mhst601.php


Canadian Nurses Association. (2020). Policy and advocacy. https://www.cna-aiic.ca/en/policy-advocacy


CCO. (2019). The burden of chronic diseases in Ontario: Key estimates to support efforts in prevention. https://www.publichealthontario.ca/-/media/documents/c/2019/cdburden-report.pdf?la=en


College of Nurses of Ontario. (2002). Practice Standard: Professional Standards. www.cno.org


Guertin, J.R., Bowen, J.M., Gosse, C., Blackhouse, G., O’Reilly, D.J., Baltaga, E., Cox, G., Johnson, D., LeBlanc, B., Joncke, J., Pugsley, S., Sivakumaran, R., Wheatley, L., Smith, K., & Tarride, J-E. (2017). Preliminary results of the adoption and application of the integrated comprehensive care bundle care program when treating patients with chronic obstructive pulmonary disease. Canadian Respiratory Journal, 2017. https://doi.org/10.1155/2017/7049483


Haley, E., Caxaj, S., George, G., Hennebry, J.L., Martell, E., & McLaughlin, J. (2020). Migrant farmworkers face heightened vulnerabilities during COVID-19. Journal of Agriculture, Food Systems, and Community Development, 9(3), 35-39. https://doi.org/10.5304/jafscd.2020.093.016


Hamilton Niagara Haldimand Brant LHIN. (2014). Complex and chronic conditions. http://www.hnhblhin.on.ca/goalsandachievements/integrationpopulationbased/complexandchronicconditions.aspx


Hansen, T. (2020). How COVID-19 could destroy Indigenous communities. BBC News. https://www.bbc.com/future/article/20200727-how-covid-19-could-destroy-indigenous-communities


Huber, M. (2011). Health: How should we define it? BMJ: British Medical Journal, 343(7817), 235-237. https://www.jstor.org/stable/23051314


Improving Chronic Illness Care. (2011). The chronic care model. http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2


Kelly, C.J., & Young, A.J. (2017). Promoting innovation in healthcare. Future Healthcare Journal, 4(2), 121-125. https://doi.org/10.7861/futurehosp.4-2-121


Kiernan Fallon, C. & Karlawish, J. (2019). Is the WHO definition of health aging well? Frameworks for ‘health’ after three score and ten. American Journal of Public Health, 109(8), 1104-1106. https://doi.org/10.2105/AJPH.2019.305177


Leonardi, F. (2018). The definition of health: Towards new perspectives. International Journal of Health Services, 48(4), 735-748. https://doi.org/10.1177/0020731418782653


Ministry of Health and Long Term Care. (2018). Regulated Health Professions. www.health.gov.on.ca


Office of Disease Prevention and Health Promotion. (2020). Social determinants of health. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health


Ontario Telehealth Network. (2020). About OTN. https://otn.ca/about/



Six Nations of the Grand. (2020). New timeline to begin restricting access to the Six Nations Community. http://www.sixnations.ca/PressRelease_NewTimelinetoBeginRestrictingAccesstotheSixNationsCommunity.pdf



World Health Organization. (2018). Social determinants of health. https://www.who.int/social_determinants/en/


World Health Organization. (2020). Basic Documents: 49th edition. https://apps.who.int/gb/bd/



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