Taking Off the Blinders

What emerges from a conversation with Carole Anne Orchard is that four statements define her personality: she analyzes; she takes risks; she seizes the day; and she is determined to make the people who are responsible for public healthcare in Canada operate the same way.

Those qualities have taken her to India as a volunteer nurse. They've propelled her through university degrees – a Bachelor's in nursing, a Master's in adult education, a Doctorate in education administration. They've pushed her into the world as a widow with an adolescent son, and led her to Saudi Arabia as a nursing administrator, to Pakistan as a nursing professor, and in and out of clinical nursing, academic nursing and political activism in Canada. Since 1998, she's been director of the School of Nursing at Newfoundland's Memorial University.

Sitting (barely – she frequently bounces forward to punctuate what she's saying) in an oversized leather chair in a Quebec City hotel, Orchard acknowledges that she's always known where she was going. She acknowledges it, actually, with an air of faint surprise, as if she has never before given it thought. Which is why, beneath her cool exterior, the state of Canada's C$69-billion-a-year public healthcare system must drive her up a wall.

The Long Road from A to B

She knows where it should be going. She's been thinking about it for years. She knows that, for the system to get from Point A to Point B – for it to survive, for it to meet Canadians' expectations (they've gone through the roof), for it to meet all the demands that are going to come tumbling down on top of it over the next few years – the politicians, bureaucrats, administrators and healthcare professionals have got to start thinking out of the box. Not tomorrow. Now. They've got to throw out what Orchard calls the old industrial model of healthcare – "You know, where women don't work; they take care of the children" – and replace it with something new, Point B. She knows what Point B should look like: a Canadian healthcare system dramatically different from what exists now. She knows the critical actors at Point B are going to be nurses. She knows the horrific statistics on nursing shortages (a deficit of 113,000 in Canada by the year 2016), statistics that in reality, she says, are worse than those published. "The reported shortages are for funded positions, not needed positions."

A reformed model, she says, has to factor in things like the health costs of industrial pollution. It has to factor in housing for poor people ("It's the pits"). It has to acknowledge Canada's dramatically aging population, and the nature and needs of the 21st-century Canadian family. It has to acknowledge that hospitals and other institutions aren't good places in which to get well. It has to shift the hospital from the center stage of public health to being just one resource of many. It might well have to redefine hospitals as places where patients (or their families) make their own beds and administer their own medications. It has to produce new kinds of interdisciplinary healthcare workers who attend to the total quality of people's lives as well as to their sickness. Indeed, she says, communities have to define their own health needs, identify what programs they want and don't want. And they must recognize that the major deliverers of those programs are going to be nurses – their roles broadened, and much of their education and training radically redesigned.

"Everything is moving so fast. There isn't time to go through orderly change. We have to take the blinders off. We've got to give up our comfort zones. We've got to change people all the way up to the top. We've got to take risks." That Orchard word. And it's not happening: "We can't seem to go forward, but we can't stay where we are" – a statement that's been echoed over the past decade by virtually every academic and hospital nursing executive in the country.

It has become a cliché to say Canadians value their public healthcare system somewhere between their right to vote and hockey. What they have trouble understanding, says Orchard, is how much the system they want is going to cost them. "The public has to understand what is going on. We're operating on a [funded] supply model; our projections are based on this model – X-number of doctors, X-number of nurses. It's not a demand model. We have no idea what the need is. I suspect that when we see the real demand for services, it will outstrip our ability to pay for them. And privatization isn't the answer; that would be a disaster."

A Chance to Try New Things

She left Canada in 1991 because she foresaw the calamity that was about to smack into the healthcare system. She had been director of nursing for critical care and surgical services at British Columbia's Children's Hospital in Vancouver; prior to that, she was the director of nursing for critical and ambulatory care at Vancouver's Shaughnessy Hospital. In 1979, at age 34 (practically a "teenybopper," she jokes), she'd been appointed head of British Columbia's largest nursing diploma program at the British Columbia Institute of Technology, where she ignited a political protest against government cuts to nursing education and was surprised by its effectiveness. Before that, she'd been an ER nurse, a nurse-instructor, and a volunteer nursing sister and nursing tutor with Canadian University Services Overseas in India's Punjab region.

In 1991, she was offered a job as a nursing administrator at Saudi Arabia's Al Hada Armed Forces Hospital in Taif. "I've always liked exotic places," she says. "And most of my friends were married." Her husband, Don, a physician, had died of rheumatoid arthritis three years earlier, leaving her and their son financially secure. She took the job. "I thought, if I go overseas, I can test some things and then I'll bring them back." Her son David enthusiastically went off to a boarding school in the French Alps (he's now doing a PhD in political science at the University of British Columbia; wherever the two of them are in the world, they talk on the telephone once a week). She convinced a colleague, Cheryl Plummer, to go with her.

"We redid care at that hospital," Orchard says. "We did very imaginative things, some very dramatic stuff. I worked for a general who kind of let me do what I wanted." What Orchard did was analyze the workload, bed-occupancy, and quality-of-care-standards and staff the hospital according to the monitoring data. She introduced nursing practice standards. "Our department was the only one allowed to continue [paying] overtime, because we had our costs down." She also expanded her knowledge of how to change systems, how to involve everyone in the institution from top to bottom in change.

From Saudi Arabia, in 1994, she went to the Aga Khan University in Pakistan as director of the Bachelor of Science in Nursing program, where she stayed for three years. She worked with the faculty to shape integrated interdisciplinary programs, to develop programs that went beyond rote learning and stimulated independent thinking. She created a management skills program for hospital medical and nursing superintendents, worked on a model for a national institute of child health, and helped to develop models for research into effective nursing.

Making Change Happen

Her experience abroad gave here skills and a thirst to effect change in Canada. At Memorial University, she's working with hospital administrators to change and broaden their thinking on community healthcare. She has tailored nursing education programs to fit in with individual communities. She's designing interdisciplinary instruction that blurs the boundaries between nursing, medicine and social work. She's developing new models for mentoring student and newly graduated nurses in clinical placements – critically important to nursing education.

She lobbies politicians and public servants. She writes newspaper articles to educate the public. She is in Quebec City on a Sunday afternoon, attending a conference as president-elect of the Canadian Association of Schools of Nursing. She sits on a national advisory committee on nursing roles. She helped found an organization to utilize research into nursing. She has written dozens of papers on the image of nursing, on patient outcomes from nursing, on nursing education, on education philosophy, on management philosophy, on how to change systems, on how to manage nurses so that they derive satisfaction from their work. She's doing research into community public health models in Canada's Atlantic provinces.

"Are we producing them [the new nurses]? Yes." She slumps back in her chair. "But the system has to accept them. With the budget restrictions, a lot of hospitals are still not hiring."

So many days to seize for Carole Anne Orchard. So little time. So many roadblocks.

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