 Hi there, I'm Sheena Wildman, Associate Director of the Health Law Institute, and welcome to the final installment of this academic year's Health Law and Policy Seminar Series. Today's seminar is co-sponsored by the Faculty of Health Professions, that's a partner faculty in the Health Law Institute that has actively and generously supported the seminar series along with other institute initiatives over the years. Today's lecture promises to offer some insights into regulation of the health professional, so it's an occasion for the Faculty of Health Professions to share the spotlight. More directly, in the spotlight is our lecturer today, Professor Peter Tuhit. Very lucky to have him with us today, he's a faculty member with the Atlantic Canada Studies Program and Department of History at St. Mary's. He's a sought-after teacher and graduate supervisor, and also serves as adjunct faculty with Dalhousie's Faculty of Medicine and Faculty of Graduate Studies. From 2003 to 2013 he held the Canada Research Chair in Atlantic Canadian Studies. Much of Professor Tuhit's interdisciplinary scholarship has engaged the history of public health and health professions in Canada, with much of that focused on Atlantic Canada. He's the author of two books, in addition to having co-edited a series of books, taking an interdisciplinary approach to health, illness and disease, and his work includes community-based and qualitative health research. This past September, Professor Tuhit was honored with admission into the inaugural cohort of the Royal Society of Canada's College of New Scholars, Artists and Scientists, and we're going to have him with us today. You know, the best thing about being elected to the Royal College was I was still considered a new scholar, so I thought I was deeply appreciative of that honor. And I should say just before I begin that I spent the formative part of my career here at Dalhousie, I was fortunate to be a member of the Department of History here. I wrote a book about the Dalhousie School of Nursing, you see hope in the back. While I was a PhD student and I was very fortunate to work in the Dalhousie Faculty of Medicine for seven years before leaving to take up Lake Canada Research Chair, so feels good to be back in some sense. And honestly, this is the first lecture I've given at Dalhousie since I left. So it's good to be back and I'm really grateful to be here today. I move around a lot, I hope that's not going to be an issue. There were widespread reports in Canada in the 1950s and 60s that there was a profound shortage of healthcare workers. So what I want to do today is to address a seemingly very simple question. How did Canada respond to this shortage? In a period when the healthcare system was rapidly expanding. I'm a historian, some of you are historians, historically-minded legal scholars, historically-minded health professionals. So the important thing to know in a very short way is that the 1950s and 60s were the period in which Canada's Medicare system was constructed. Two key pieces of legislation, the first that ensured hospital services, the second ensured physician services on a national scale. So that's all I'm going to say about that. So I could ask a slightly different question by asking what strategies did Canada use to meet its health human resource needs in different jurisdictions and in different periods? So that would be a slightly different question, and I think everyone in this audience would readily see the applicability of this question to Canada's contemporary healthcare system. After all, current strategies to meet shortages of healthcare workers include such things as international recruitment, expanding the educational or training capacity, or introducing new kinds of healthcare providers. And I feel that's necessary to add that this last point could be viewed as altering the scope of practice. Of course, a very hot question, a very good report just issued this week, looking at the scopes of practice of existing providers, or what I might describe in the safety of an academic setting as altering the division of labor. But projects that talk about the division of labor are not terribly sexy in this neoliberal age, so we don't do that anymore. Let me start because I'm a person of Irish descent with a story. In 1966, the Toronto Daily Star columnist, a guy named Jim Liederman, wrote an article about a giant hospital and its giant tragedy. It was about the Ontario Hospital at Smith Falls. This was a mental health facility, part of a network of hospitals that provided mental healthcare in the province of Ontario. It was a large institution housed more than 2,400 individuals with a variety of intellectual disabilities. This sprawling facility had been in the news often. Stephen Lewis, the Minister of the Provincial Parliament, had publicly criticized the state of affairs at the hospital the year before, but it was the more recent drowning of one of the hospital residents while trying to escape the facility that prompted the newspaper article by Jim Liederman. The hospital was described as hopelessly overtaxed, understaffed and overcrowded, and I'm sure those words resonate with health professionals in the audience. But despite these difficulties, the administrator, Morley Ferguson, stated it used to be a whole lot worse. The staff shortages were acute, they were profound, and the complement of professional staff was only about half of what it needed to be. Some of the residents had been transferred to nursing homes and even to unused wings of tuberculosis sanatorium, but the reality was that at Smith Falls, overcrowding still pushes patients into wars like cattle pens, road leadermen. The hospital served the entire province from the St. Lawrence River to the Lakehead. I love that description. There were more than 350 children on the waiting list, while some waited upwards of two years to be admitted to Smith Falls. The facility's residents had considerable needs, and this made the work challenging for the staff. Workers had to provide personal care, keep the rooms, keep bedding in good order, prepare food, feed the residents, and give medication. One pavilion housed two wards, with 101 bed-ridden residents and only one attendant to meet their needs. The infant ward was designed for 24 children, but it housed 37. The staff complement was supposed to be six, but it was reduced to only three, because three of the workers had been drawn off to other services where the need was even more dire, if you can imagine. I like to start here, because it's an important reminder that the kinds of issues that I'm talking about had a very real and material impact on the quality of life of those receiving healthcare services. Patients, clients, however we want to conceptualize those, shortages of staff matter in a material way to the people in these facilities. The shortages of staff ran across all of the services. When a pharmacist was absent, the duties fell to the pharmacy assistant. The director of nurses training would sometimes fill in. The two psychiatrists working at the facility spent most of their time doing, guess what? Administration, rather than care. There were three full-time, hopelessly overburdened physicians. These were assisted by five part-time general practitioners who would come to the facility from time to time, but what they actually needed were three more full-time practitioners. There were insufficient numbers of psychologists, there was no physiotherapist, and as Jim Liederman Riley noted, the institution, quote, is probably the only children's hospital anywhere with no staff pediatrician. Ontario's health minister, Dr. McKinnon Phillips, suggested that close to 20% of the people in mental health hospitals were over the age of 70. So there's an age thing going on here. Phillips suggested that this figure, which had tripled in a decade, was the result of the, quote, inability and unwillingness of young couples to take care of elderly parents with mental trouble, end quote. The increasing population of the elderly in these institutions had been an issue in Ontario for some time. Ontario Premier Leslie Frost had suggested that provincial hospitals were, quote, parking places for senile and infirm aged persons, and that mental hospitals in particular were, quote, cluttered up with old persons who should be in other institutions. A decade later, Matthew Diamond, the Ontario Health Minister, described how nearly 5,000 patients in mental hospitals were forgotten, never receiving visitors nor inquiries about their care. Diamond thought that this situation was a disgrace and one of the great tragedies of 20th Century Canada. The shortage of staff profoundly affected residents, workers, families. I like to start with the story of Smith Falls because it's important to me. I think we need to remember that in these kinds of analyses. Professional journals, mainstream media, they all addressed the issue of shortage on a regular basis, and it touched every area of Canada and different occupational groups. So I'm going to talk today about nursing assistants. I've done other work on occupational therapy assistants. I'm going to focus largely on Ontario, but I've just completed a study on maritime provinces and there's one coming for British Columbia. So the point is that in Canada is complex, labour intensive healthcare system. There's a range of occupational groups. They work in an interrelationship and a shortage in one area has profound impacts all through the system. I point this out because until very recently the historiography of Canada's healthcare system has largely ignored most of these healthcare workers. We have a good historiography of the profession of nursing. We have reasonably good studies of some aspects of medicine and we have virtually no studies of what we would often describe as allied healthcare professions or of all the subsidiary workers who populate the healthcare system. Virtually none. So my work is something of an intervention into this absence. Let me offer as an illustration my example of nursing assistants. I'm hoping to go quickly and to leave lots of time for questions because this is still work and development. I love coming to the seminar series and having the opportunity to rethink some of my ideas on testing some of those ideas here today. I'm using the term nursing assistant precisely to mean a category of regulated healthcare workers. They work in nursing practice and they are regulated by statute. And following the First World War, Ontario hospitals grappling with this shortage of nurses really embarked on a process of renegotiation. Looking at nursing practice and saying what needs to be done by registered nurses and what tasks could be assigned to other kinds of workers. This renegotiation included practical nurses who had been part of nursing almost from the beginning of nursing. It included some trained nursing assistants. It included ward aids, orderlies, clerks. They were all being assigned nursing tasks. Nurses were concerned for registered nurses. This renegotiation posed a significant threat from below. After all, the question of who gets to nurse while seemingly straightforward is very much a matter of ongoing debate and reconfiguration. So nursing leaders like Katherine Gerard, long-time administrator of the Halifax Infirmary talked about bringing practical nurses under a system of licensing as early as 1945. This was part of a widespread effort across North America to license and regulate all kinds of individuals. Legislation was achieved in the mid-1950s in many jurisdictions and this established regulations for training, for sitting exams, and for registration, all the things that the law students in the room can relate to right now. Kathleen Russell, the formidable Dean of Nursing at the University of Toronto, an absolute force in 20th century nursing in Canada, pointed out in 1956 that what was different was the official approval, the regulation, the restricted title given to nursing assistants. That's what was new, not the category of labor. And according to Kathleen Russell, that there was a need to ensure and safeguard standards of nursing services through such things as approving nursing standards, creating standards of nursing care, standards for preparing auxiliary nursing groups, personnel policies for both groups that would allow a rational division of labor, or at least to know what that division of labor ought to be, and then standards for registration and control. Following the Second World War, nursing assistants were the fastest growing segment of nursing labor. So they grew exponentially faster than registered nurses. They're one of a number of regulated occupations introduced into healthcare in this period, or if they weren't introduced who had enabling legislation passed in this period. And Tracey Adams in the article that I shared with those who read it has done a lot of work on professional regulation in Canada, and she looked at just five provinces across Canada, found more than a thousand pieces of legislation regulating 35 groups in five provinces. So it's an enormous piece of work, a great contribution for those who are interested. And for me, one of the interesting things that Tracey Adams discovered was how much regulation varies by province and by profession. Considerable variation. We were out to lunch a couple weeks ago and we were talking about land surveyors, and why aren't land surveyors registered in many provinces, but why are they in Nova Scotia? Why are land surveyors regulated in Nova Scotia? So we were kicking that question around. So the point for us today is that we need to be sensitive to this. We need to be paying attention to the historical conditions that lead to regulation in some settings and not others. And we have to pay attention to the details. I told Tracey I was going to take her to task on this. She told me that was okay because she in the same article points out that British Columbia passed legislation to regulate nursing assistance in 1951, and she's absolutely correct that legislation was passed, but the government never dropped an order in council. So between 1951 and the early 1960s, nursing assistance were unregulated. Not only were they unregulated, but the British Columbia government was actively training, educating these nursing assistants. So on the one hand they had passed this legislation to give registered nurses some control over this new category of legislation, but they hedged their bet, they held it back, they didn't give the order in council, and then they embarked on this massive training program to allow nursing assistants to enter into practice in hospitals throughout British Columbia. The Canadian Nursing Association acknowledged that there was a need to reconfigure nursing labor. They knew that the educational capacity of diploma schools or university schools simply could not meet the demand in Canada for nurses. But they also wanted to ensure that any auxiliaries entering into nursing practice were properly qualified. The CNA was also worried about unfair economic competition posed by the rise of this new group. So they were concerned that a growing pool of nursing assistants if not properly regulated could displace registered nurses. In their submission to the Federal Department of National Health and Welfare the CNA wrote that occasionally there has been a tendency on the part of these workers to assume a professional status and to exact a fee which their degree of preparation and competence does not justify. So the Canadian Nursing Association is identifying that nursing assistants were being hired and were functioning as our ends, and they were deeply concerned by that. It's not unique in nursing, the same thing is happening in occupational therapy. Occupational therapy assistants are being hired by hospitals, by mental health facilities, by all kinds of settings, and the idea is that they would work under the supervision of an occupational therapist, but there are no occupational therapists. So occupational therapy assistants are ending up in leadership positions running OT programs in the absence of any university-educated occupational therapist. So this is the great fear from nurses. With this in mind, the professional organizations begin to turn their attention to getting involved in the education of nursing assistants. So the Registered Nurses Association of Ontario responds to the nursing shortage by sponsoring short courses to prepare RNAs. If they're going to acknowledge that these RNAs are going to be present, at least they're going to be involved in the education of them. This was originally conceptualized as a demonstration project. It trained 125 individuals, but it was so successful that the Ontario government moved quickly to normalize this training program. So they amended the Nurses Act. They accommodated the regulation of nursing assistants within the 1947 Nursing Act. They extended a protected title of certified nursing assistant to those who went to approved training programs and registered nurses provided for their training and supervised examination. So they're complicit in creating this new category of labor. And of course I'm talking about nursing assistants and I'm talking about the 1950s, but we can all sit and imagine stories from 2015. We might think about physician assistants. We might think about recreational therapists. We might think about a whole host of workers who are going through exactly these same steps and battles. It's the ongoing renegotiation of healthcare that fascinates me. So in the early 1950s, Ontario training programs were graduating about 200 nursing assistants each year. About 85% of them are working in hospitals. How am I doing on time? Not well. I'll speed up. I'll add it as I go. I won't speed up. I won't talk any more quickly. So we have this shift toward creating nursing assistants. It had a positive impact. McKinnon Phillips says, well, there was about 38% less nurses than we need, fewer nurses than we needed. In 1950, that need had been reduced to about 20% by March 1954 because of the success of this training program. 1,200 certified nursing assistants registered in the first five years and this grew to about 2,600 by 1956. So the Department of Health is making a concerted effort to grow nursing assistants. And this is the number I'm going to spend virtually no time on this. But just look, from 1953 to 1965, about 4,500 nursing assistants are educated through these approved programs. The regulation of registered nurses and nursing assistants would ultimately pass to the College of Nurses when it was finally created in Ontario in 1962. And this effectively transferred all that power to the new college, including responsibility for registering nurses and nursing assistants, matters pertaining to education standards, approval of schools, all of the things that matter for a profession. Nursing assistants, you might be interested to know, also try to organize. They tried to resist the effort of registered nurses to control their occupation and their work. So they organized their own associations. They even fought against having registered nurses chair their education committees, administer their exams and do all the things that registered nurses wanted to do. So in Nova Scotia, nursing assistants were organized into an association in the 60s. In New Brunswick, 1965. And New Brunswick is a fascinating story because they actually go to court in the 1980s to fight with the registered nurses in New Brunswick to liberate themselves of the yokes of RN colonialism. It's a great story. I hope maybe there's somebody here that will help me write that story. By the end of 1966, there's about 13,000 nursing assistants in Ontario, but only about 15% of them are members of the association. There's a change from certified to registered nursing assistants. I throw that in because I'm a stickler for details. And eventually, the responsibility passes to the Department of Education. But the training doesn't slow down any. In the late 1960s, you can see the number of RNAs is going up very quickly from 8,100 to 14,000. Our ends also increasing, but the pace is not as quick. So more and more registered nurses are entering into nursing practice. Of course, this prompts another really interesting shift with the idea of the team. So when did this idea of the nursing team begin to emerge? I think it's a really interesting historical question. And I hope somebody does it, and hopefully not me. But as a member of the nursing team, nursing assistants earned about 70% of our ends. So this was actually pegged in many of the associations, in many of the enabling acts. So 70% of a registered nurse's salary. The idea of team becomes a crucial organizing principle. I think it's one that really is just waiting for a good historical analysis. Jenny Ives, the Toronto Nursing Consultant, focused on the use of teams to meet nursing needs. She said, we believe the quality and quantity of nursing care given by the nurse may be increased by assigning some tasks to auxiliary personnel. 1962, 30 years before, no registered nurse would have said such a thing. But by 1962, nursing assistants are part of nursing labour. And they're acknowledged to be part of that labour. And now we get this idea of the team. Ives went on. The nursing team, consisting of both professional and auxiliary personnel, has been found a desirable way of utilizing effectively the skills and abilities of each group. It allows patient care to be planned so that the various needs may be met by the most suitable worker. Helen Missalem, another of Canada's great nursing leaders, considered the team approach with different qualifications and a coordinated effort to be an essential component of the modern hospital. There will be no modern hospital without a team. And Missalem highlighted that scope of practice for healthcare workers was malleable, was contextual, and subject to renegotiation. Which makes me sound like I'm just repeating a finding of a really smart nurse 40 years ago. But that's okay. Registered nurses and nursing assistants were really unsure of their relationship to one another. And they were wary of an uncertain future, particularly our ends. When the Hall Commission was doing its work, the work that would ultimately lead to the adoption of insured services for physicians, nurses and nursing assistants submitted briefs. And registered nurses took a bold stand. They said, enough of these nursing assistants. They should all be, all the programs should be shut down and we should educate no more nursing assistants. Instead, what our ends wanted was a two-tier profession of nursing. Those who were currently being streamed into nursing assistant work should become diploma RNs. So they should go to diploma schools and they should be upskilled to become diploma RNs. And all of those diploma RNs who would be doing the work on the wards and the work that I described early when I was talking about Jim Liederman's piece, all of that work would be supervised by university educated registered nurses. Two tiers abandoning the idea of nursing assistants. This, as you can imagine, didn't go over well among the growing mass of nursing assistants. And in September of 1969, Helen McCallum finally said, okay, that's not going to happen. So what we should do is we should have three levels of nursing personnel. We should have 20% of our nurses be university RNs, 50% be diploma RNs, and then 30% be registered nursing assistants. So there's a lot of debate and discussion in this period about what the right composition of the nursing team is. I hope that those of you who think about nursing in contemporary Canada can see immediately the relevance for today's discussions. I'm not particularly interested as an academic to be sort of speaking to contemporary concerns. It's not what I do. But I think in this project I can see how this project speaks to contemporary concerns. I'm almost done. By the end of the 1960s, every province in Canada had approved training programs for nursing assistants. There's a lot of variations. Some of them were longer, 35 weeks in Ontario, up to about 18 months in the province of Quebec. Most of the programs, more than half of them were located in the province of Ontario. And all provinces except Quebec and Newfoundland had legislation providing for the registration of nursing assistants. Nursing labor had been effectively reorganized in this period. RNs, in my view, had effectively managed the critical issue of encroachment at least for the time being. They had managed this threat from below. The system of registration that was created on Ontario effectively legitimated the participation of RNs in the regulation of nursing assistants and registered nurses also participated in important ways in the governance of nursing assistants. So they oversaw the education programs, supervised the clinical work, and they did everything else. So I think, and I didn't do that, the history of nursing assistants provides really interesting insight into the ways in which professional boundaries are subjected to a variety of pressures. I see Matthew up there, and this is a story that I've explored before. I'm interested in the malleability of professional boundaries, the ebb and flow, between kinds of work, legislative regimes, and other kinds of workers. The education, licensure, roles and responsibilities, all of these things that help to delineate boundaries among occupational groups are changeable. And if they change in the past, they can change in the present, they can change in the future. I think this is an idea that is both liberating and frightening. It creates possibilities, but also concerns. I think for me, fundamentally, it challenges any assumptions that we might have that the division of labor in healthcare that we live with is natural, makes sense. Or, to put another way, relying on the idea of Gerald Larkin, I think this kind of analysis challenges what he describes as the aura of inevitable permanence around professional scope of practice. They have changed, and they'll continue to change. And I'm done. Thanks for your attention. I'm happy to have questions. And I only use three pages of my notes. That's not bad, eh? Nice long time for questions, right up until, you know, 20 up in the hour, if you wish to. I would love it if you go back to the slide that you had with the picture that says, Oh yeah, that's great. Yeah, so obviously a gendered dementia to a critique that I take is, my quick read is being voiced in that slide around exploitation and discrimination. So I wonder if you could just comment a little bit about how the gendered dimension of the nursing sort of pushed back to government may or may not have been expressed. And then I just have a second part to that around the further divide between, you know, university educated upper class nurses, you might say, and then assistant. And were there other elements that might go to an analysis of discrimination at all at play there in terms of effects of whether racial or socioeconomic dimensions to that divide that you've noticed? Those are great questions and the gendered part of this analysis, gender is a huge thing in what I do and very clearly the fact that what we're talking about is an occupation that is virtually 100% female matters, right? In fact, when they set up the programs, they made no provisions, none whatsoever, for the education of men. So nursing assistants in the first few instances had to be women. Men were excluded, right? They did the same thing when they created occupational therapy assistants. They had to be women. They couldn't be men. And you might explain that away and say, well, this is just simply because of the words they work on, because of the kind of work that they do. I think there's a deeper meaning there that these forms of auxiliary labor are conceptualized from the outset as women's work, right? That they are women helping other women, right? So I think that matters huge. This is from McLean's magazine, this headline, and it's there really as a reminder that the struggles of nursing assistants for things like wage parity or wage fairness are bound up in a larger struggle that's taking place in Canada in the 50s and 60s for better wages and working conditions for women. But gender also works in a really complicated way with nursing assistants because it's a place where lots of married women worked. In New Brunswick, in the 1950s and 60s, more than half of all the nursing assistants were married women. Now this is really interesting to me. You know, I read, I think I've read everything about gender in Atlantic Canada. And one of the things that I find really interesting is a lot of the conclusions of that work say, well, gender in Atlantic Canada works pretty much the same as it worked everywhere else. That never really made sense to me because men's work in Atlantic Canada has never looked like it worked. Men's work in Atlantic Canada was never the same as men's work in every other part of Canada. Men's work was seasonal. Men were on boats. Men were in the woods cutting pulp, right? So if you're doing that kind of work with the uncertainty of wages, the uncertainty of other things, did that alter the gender relationships in the household? I think, being an interesting analysis to do, that these nursing assistants, when I look at where they're coming from, where do nursing assistants in New Brunswick come from? The Acadian Peninsula, Mir Meshi. They come from the Acadian coast. They come from parts of New Brunswick where work is seasonal. I suspect these women aren't choosing to work so much as they have to work to support their families. And I think the fact that 56% of those nursing assistants are women really matters. And that's an analysis I want to get to. I think it's a fascinating story. So I think it's really complicated the way gender is working through this story of nursing assistants. And you had a second question, Sheila, and I can't remember what it is. So it was focused on the divide between registered nurses and the nursing assistants and what if any patterns you might see in terms of socioeconomic difference or racial difference, or any other paths you may have picked out. Yeah, and I think, again, you know, if I'm speaking to the Atlantic Canadian experience, you know, nursing in the Atlantic region is largely a white profession. We're talking largely about white women. Yes, there are a few exceptions, right? But we're talking largely about a white profession. We're talking about university educated nurses. Registered nursing assistants, a little bit different. You start to see in the 1960s the recruitment of international nurses. They come to places like New Brunswick and they take their seats, their place on the wards in rural hospitals, and those women are coming from the Philippines. They're coming from other international settings. So nursing assistants are more diverse in their composition in this period than the profession of nursing. So I think, again, it's an interesting contrast. And I think that, you know, that does have an impact on sort of the way people view these professions, right? One is sort of bourgeois middle class, upper class, however, access to university education in the 1950s, all of those things. Whereas these women are linguistic minorities, sometimes from racialized groups. They're a more diverse cross-section of Canadian society. Again, I think that's interesting. I don't have a concrete answer in terms of how it shaped the interaction between the two groups, but what I will say is through the 1970s and 80s, this relationship between RNs and nursing assistants gets worked out in interesting ways. Nursing assistants largely receive more and more autonomy through the 1970s in New Brunswick. It's not until the 1980s that they launched their lawsuit and eventually freed themselves of the nurses association, the nurses union in New Brunswick, which again I think is a really interesting story. But they moved toward a path of having more autonomy in their professional group. What's really interesting, see I have long answers. That's why I had to leave lots of questions. What's really interesting is in the province of Prince Edward Island in the 1990s, nursing assistants face a threat from below. So Holland College, the community college on Prince Edward Island, begins to train another category of worker, residential care workers. We know the story we've had experiences with residential care workers. Long-term care facilities in Prince Edward Island begin to hire residential care workers and they displace nursing assistants from the work in nursing homes. Of course, this dries up opportunities for nursing assistants. PEI shuts down its education program and you have a lot of unemployed nursing assistants now in Prince Edward Island. So what the long-term care facilities begin to do? They begin to hire these nursing assistants but pay them as residential care workers. But still have the expectation that they will function as nursing assistants and use their full scope of practice even if they're not being paid that way. And this is a story in the 1990s that explodes in the PEI media. So I think it's a really interesting and again, it's like a dance of the dialectic, right? And it goes on and on and on in these little moments. And in these little moments, I think they're really revealing. My next answer will not be that long, I promise. I don't know where to go. Fascinating. Since your topic is regulation, you've kind of implicitly woven it through what you're saying. But I do hear you explicitly addressing how regulation functioned in this way. Who was it helping? Who was it not helping? Where were the pressures coming from to bring in regulation? Where was the resistance? That's a great question. I probably bailed a little bit on the regulation question thinking, you know, there's an awful lot of people in this room that know a lot more about regulation than me. So maybe when I get to the drafting of the paper, I'll share it with folks and they'll address the regulation. But absolutely, so who is regulation benefiting? Well, it's partially benefiting the community of registered nursing assistants. But who it's really benefiting, I think, are the RNs. Because it's creating a bulwark between the unregulated masses, all those ward aids and orderlies and unlicensed nursing assistants, all of those individuals who are still doing lots of this work. So they move toward a restricted title, but anybody can do the work of a nursing assistant. Only the title is restricted, not the scope of practice. So it's a regulation, but it's not complete professional formation. It's imperfect professional closure. So ward aids and others are still able to do this work in virtually every jurisdiction in Canada. This will begin to change in the late 1960s and through the 70s when nursing assistants begin to lock down their scope of practice in law and begin to weed out those other kinds of individuals. So I think it's really our ends who are benefiting, because it's creating a very clear pattern. So you have our ends at the top of the hierarchy. You have this category of certified or registered nursing assistants LPNs today. You know, in that middle category, you have this unregulated mass below, but it's the RNAs who are serving as the buffer between that mass and the registered nurse. That would be my analysis. Other people might have a different opinion. I don't know what come of that. Matthew. I wanted to invite you to just elaborate on the importance of the frame that you sort of started with around shortages and the work that that did in terms of how scope of practice is regulated and divided the battles within. And the reason I'm curious about that is because I'm thinking about the regulation of pharmaceuticals and drugs and that sort of interprofessional contest between pharmacists and physicians previously to the period you're describing and how the frame in that case was really one of safety, although it could have been a part about access to shortages and physicians, pharmacists being more accessible sources of drugs and so on. But really the frame of safety, to my mind, over time actually necessitated federal intervention and took control away from both professionals to a large extent. And so that difference in frame, at least in hindsight, has a lot of salience for me. I'm curious if you can just sort of expand on the importance of shortages in this case. Yeah, and you know, it's a great question because, you know, I never really accepted the claims of hospital administrators about shortages. Like, I always, when I read those sources, I'm very skeptical. And there is competing evidence, right, about whether there is a national shortage of nurses or whether it's a localized shortage in only some places. Mental health facilities are certainly struggling. They can't recruit people to go to work in most mental health facilities in Ontario or elsewhere in the 1950s because there's other options. So, is it a national shortage? Is it dependent upon what aspect of the healthcare system we're talking about? Is it more localized? But what I would say, and where my analysis is sort of situated is, regardless of the sort of empirical truth of the shortage in any one jurisdiction, all policymakers were behaving as if there was a shortage. And that's what really mattered because they expanded training capacity, not just for RNAs but for nurses. They opened new programs. They create new university schools of nursing. So they build, you know, more and more nursing programs. Training capacity is expanded. So they behave as if there is a nursing shortage. They open up legislation or pass new legislation to facilitate the entry of these new groups into practice. So I think, you know, for me, the frame, right, of the shortage really matters here because that's the starting point for every jurisdiction in Canada, every province. They all make the assumption that there's a shortage and that that shortage is not going away anytime soon, right? Through the 50s and 60s, everybody is panicked about retaining nurses. There's a flight from British Columbia in the 1960s, sort of ironic, but everybody goes to Ontario because wages are better in Ontario. They spend the first part of the 1970s in Ontario and then they all go back to BC in the late 1970s and 80s to resume their nursing positions there. I don't know if that was a satisfactory answer, 100%, but, yeah. Oh, sorry. I have two questions, a short one first. In research, do you come across any of the other nursing programs where they were, like, nurses, psychiatric nurses and that kind of thing, and I'm just wondering if you can speak a bit about how that interplayed or if, in fact, it did at all. But I would assume it must have had some impact. Yeah, and, of course, registered psychiatric nurses, for those who aren't familiar, are a regulated category of nursing labour west of the Ontario border. So, you know, what I say in my, in the opening of my paper is that there are actually three communities that we need to understand when we're studying nursing practice. There are registered psychiatric nurses, there are RNs and there are nursing assistants, right? And if we're truly to understand nursing practice, we have to understand all those. Some people will say, well, what about nurse practitioners? I will say, well, all nurse practitioners are also RNs. So I think the category is broad enough to accommodate them. You know, we might get to a point where we would have to add a fourth. So, absolutely, registered psychiatric nurses are playing a critical role in supervising these RNAs in those psychiatric facilities. But I don't think it changes the analysis so much because you still have RNs sort of in that supervisory position, right? And that's what's really key, and that's where I think RNs won the day. They ensured that nursing assistants were always working under the supervision of RNs in a hospital setting. Because as Matthew pointed out, it could have been different. RNAs could have worked under the supervision of other kinds of healthcare providers, including physicians, right? But they don't. They work under the supervision of RNs. And I think that's a very important thing. Here? It's really interesting that in the 60s, registered psychiatric nurses, when they came to our exposure, could be registered. They didn't take additional education in order to become registered here. And I don't know if that was consistent across the country or not. Yeah. Chris Stuley has done some really important work on registered psychiatric, the history of registered psychiatric nurses. And yeah, I mean, as a separate category, right? It's west of the... And of course, nurses had these specializations in other provinces, but it's the separate category that's distinct in Manitoba, Saskatchewan, Alberta and British Columbia. The other thing that's really interesting is there were attempts to have private training commercial schools educating registered nursing assistants. And these schools were... They operated in Toronto. There was one in downtown Toronto, just off Yonge Street. And these schools were looked at rather dubiously by health administrators, but particularly by RNs. So they really attacked the private school issue. And Prince Edward Island passed legislation to ensure that no private school could be opened, that all registered nurses would be educated... Registered nurses assistants would be educated through a common central school. Yeah. Yes, please. So the division of labor within nursing practice I wouldn't say that it opened up opportunities for different gendered dimension, but what you start to see are debates about how men should enter into practice as a nursing assistant. So again, I'll go to New Brunswick. Several of the schools, the hotel due in Campbellton comes to mind. They were training both men and women to be nursing assistants. But they weren't giving the men courses in maternity and care of the child. And these were two critically important areas of labor for nursing assistants, right? That's where a lot of work gets done, caring for children, big thing in hospital settings. So the nurses, the RNAs and the registered nurses began to sanction these hospitals and say, look, you have to give men these courses too. They are the same registered nursing assistants. They have to follow the same curriculum and we expect them to be able to, if not practice in those areas, to at least provide coverage. So I think it's a very interesting, maybe something we wouldn't anticipate in terms of how gender would play out, but in this case men were being exempted from an area of care and they were being forced back into that area of care. The hospital administrators were being forced back into these areas of care too. There you go. Welcome to watch the director of the Health Law Institute. Nobody here sees many of you on a regular basis. Before I take the opportunity to have us extend a formal thanks to Professor Tui, I'd like to extend my own thanks from myself and all of us from the Health Law Institute to you, our audience. We feel very fortunate to be able to attract the diverse audience who regularly attends our series from scholars to students, healthcare professionals, policy makers. It's a great experience for all of us, as well as, of course, the engaged citizen. I want to take this moment just to extend our thanks to the Schulich School of Law, the CHR training program in Health Law Policy, which provides us with some funding support. And again, thanks to our other partners like the faculty of health professions who co-sponsored our talk today. So I hope that I will see all of you again next year for our next series series. It will be our 18th year of offering a seminar series. As always, we're very open and excited about receiving suggestions for topics and for speakers from members of our audience. And quite often our audience comes up with ideas that we would never have thought of on our own, which we're very happy to pursue. So please don't be shy in terms of bringing suggestions to our attention. We'll be sending out notice in the late summer as to our series next year, which everybody who's on our list. And I'll just close by saying thank you very much once again Professor Tuhig for speaking with us today.