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3. Why NPs Need to Be Involved in Policy with Claudia Mariano

Updated: Jul 15, 2022

Hello and welcome back to Ubiquitous Evolution. I'm your host, Roberta Heale. Wow, I learned so much from our guest today, Claudia Mariano. She chatted about her experience as the Manager of Policy and Practice at the Nurse Practitioners' Association of Ontario. Now, before you think...this has nothing to do with me, let me tell you...Claudia describes policy issues. OK, the policy issues are for the province of Ontario and related to the Nurse Practitioners' Association of Ontario, but I've been around long enough to know that these are issues that affect all NPs across the world...and the strategies can be implemented anywhere. So don't miss this episode!

Today our guest is Claudia Mariano and we're going to be talking a little bit about opportunities to participate in professional organizations. But to start, Claudia, welcome! and can you tell the listeners a little bit about yourself?

Hey, Hi, Roberta. Thanks so much for inviting me. This is really exciting. So yeah, I have been a nurse practitioner since 1999. I was an RN For 13 years before that. There was no NP Program at the time, so when I became an RN, I had actually done a Masters in Nursing already beforehand, because I knew I wanted to go back to school, continue my education and further my career. So, I already had a master's degree, and then the nurse practitioner program came out again, and sort of the mid 90's. I think I was in the second class of students starting that program, and then second year they offered it. So. yeah, I've been around for a bit I spent my time of those 20 plus years I was working in a Community Health Center for 10 years and then I worked in a Family Health Team for just over 10 years, and I do consider myself now sort of semi-retired. I'm doing a little bit of teaching, and a little bit of policy work. For the last 3 years, up until last year, I was the Manager of Practice and Policy at Nurse Practitioners' Association of Ontario. So, I've done done a little bit little bit of everything, mostly my clinical work, but had the good privilege of being heavily involved in other policy and advocacy work during that time as well, mostly on a volunteer basis.

Oh, you have been busy. My goodness and you know it's the policy stuff that we're interested in in learning more about, and I think a lot of it has to do with the fact that I think a lot of nurse

practitioners who were NPs back in the day if they weren't involved they didn't really understand how much work, and the kind of work that was involved. And now, nurse practitioners coming through in Ontario and actually across Canada, because the legislation and regulation have sort of evolved to the point where it's not quite as it's not, the focus

isn't quite the same, but they might not even understand what have happened in the past,

or maybe, the importance of it so that's what we're, hoping to talk to you about today a little bit about. First of all, what was your role like as the Policy Director?

So it was. It was really it was a really good role, and I really quite enjoyed it. My title was Manager of Practice and Policy within NPAO and I always joked that, you know, I finally got paid as a staff person for doing work I've been doing as a volunteer for 20 plus years, because I've been involved with some capacity since I was an NP student. You know I'd be

on the conference planning team, maybe I was a regional rep. I was President, Past President, I sort of held various roles in NPAO over the many years, and so doing the work that I did as Manager, perhaps policy just sort of seem to be continuation of all that role.

Oh, I did a number of things when I was involved there. One of my big roles was actually speaking individually with members who would call with practice or policy, related questions. They had a question about something going on in their place of employment. They had question about, you know, a position that they were thinking that applying for. They had concerns about something going on in their community, lack of access. And you know how NPs could or could not be accessed by members of their community. So, I spoke with members regularly. I also would receive calls and requests from members of community or members of a of organizations. I often spoke with employers who hadn't had an NP, as an employee yet, and we're just wondering how to best integrate what they were thinking it would be a good fit and what did they have to think about, and, you know, to make the role successful.

So, I spoke to employers as well. A lot of the work was liaising, of course, with government and policy folks and other stakeholders. So, lots of conversations with different people in the Ministry of Health, Chief of Staff, their strategic policy people on issues related to healthcare responses about what NPAO does as an organization, for example, to the Long-Term Care Commission. We did a you know I was able to participate with NPAO, I was able to participate with NPAO in a presentation to the Long -Term Care Commission Inquiry and then responding to their final recommendations, and having follow up meetings with the Ministry of Long- Term Care around their recommendations for integrating NPs, and so on. So there was. It was a bit of everything. Social media was involved. Trying to post on social media around work that NPAO was doing, how NPs could be better integrated, and so on. So, it was, it was a It was a little bit of everything and I really quite enjoyed it.

My goodness as you're explaining this it just occurred to me the massive amount of expertise that you required in a variety of areas in order to respond to the individual requests and that sort of thing and I'm just wondering if you can comment on that piece.

But yeah, thanks for that question. I have to say I think most, a lot of it, was just something that comes with experience after you've been working for a while, become more familiar with the role. But it is really information that we don't receive in our training, in our education, right?

We go to school and whether we're RNs or NPs, we're going to school to learn how to do the work of the role, right? How not to harm a patient, and you know things to think about you know you're in the NP Program you just worried about not messing up the first prescription you write and ordering the right test or not missing something on a patient. We don't really you know, we're not really aware of a broader context, in which we practice. And so, as part of my work with NPAO right from the beginning, I really had the privilege of being in a position where I was participating in conversations with other groups, other stakeholders, who, for the most part, are not working in healthcare. They do not have a healthcare background.

But these are people who often make the decisions and the policies, and then came to understand that the way we as nurses, as NPs perceive a problem and a solution is not the way others perceive it, because they have a different perspective, a different background, a different lens and it's so important for us to appreciate the lens that that comes from.

So, I learned so much over the years, just by having conversations with people who did not work in healthcare, but who were responsible for healthcare, for healthcare policy, delivery, and being able to hear from them their perspective, their concerns, and things that had never occurred to me, because my only experience was in healthcare as a nurse, as a nurse practitioner. So, it would get really became important for me to understand those other roles, and why those decisions were being made. And I really do wish it was something we could pay more attention to in our NP education programs because I think, understanding the context of the role in which we work is critical. I mean, how many times do we all just sort of shake our heads and say, I like I don't understand why would they do this why would they make this decision? Why? can't they just let us do ask Why? Why? Why? And it becomes so frustrating for us. I think if we understand, perhaps the background and some of the ways that those decisions are made, it can lessen a bit of our frustration and discomfort, because, at least it gives us a bit more of an understanding, and then it helps us to be able to target our message, perhaps more appropriately, because if you don't understand the perspective of your audience and what information they are required to make their decision, you're much less likely to get the open that you want.

Oh, my goodness, and you've tapped on so many things. One thing that came to mind when you were when you were chatting with the concern about not having a good understanding about what people know about the nurse practitioner role and why decisions are made is not only policy related, and I see you nodding. I think you spoke about the NPs who emailed you about practice positions. So, the concerns that are raised about what do NPs do? What is our role? it's still filters into every part of our healthcare system. So even the fact that employers don't understand what nurse practitioners do, or they choose to create roles that aren't maybe as appropriate, don't allow the nurse practitioner to work to their full scope of practice that sort of thing, and those things have to be addressed systemically at times. And I think that's where you really, really came into play, your role was really very important in that respect. And is there any more that you wanted to add to that piece?

I mean, you touched on, you know, some is something really important there is that even as NP.. So, I think and I've just thought about this recently when we graduate as RNs and working as RNs, we don't generally go into a position and receive, you know, some kind of barriers to our practice by our employer, we don't usually have somebody say you know you're not allowed to do this, or we don't want you doing that... like, as everybody knows what an RN does. We go into our role and we do our thing. Then, you know, you do the NP program, and you come out to work as an NP and start, perhaps in your first position, and now you're faced with an employer who says, "No, you're not, you're not going do that. We're not going to let you do that. That's what we want you to do here even though it's part of your role, even though it makes sense." And so, we're's never occurred to us that somebody might actually arbitrarily restrict our role as nurse practitioners, because we didn't have that experience as RNs and I think we need to be really aware and, maybe, prepare our new grads better for the fact that you know there, that will likely happen. There are different reasons for that, as to what you know, why that didn't occur when you were in RN, but it's quite likely to happen in an NP position because employers don't necessarily understand the role, as you said, but are also looking for something different than perhaps what we envision we graduate from the NP program.

In my experience, anecdotally, it's almost been worse, if an employer thinks they understand what the role of nurse practitioner is and try to manage the role without really realizing that the nurse practitioner is responsible and accountable for their practice, not the employer, and it's created all kinds of strange situations over the years. But I guess now I'm thinking back and you are in the policy role for quite some time and before that, as you mentioned part of the Nurse Practitioners' Association, Ontario, involved in various levels. How do you see that that maybe evolved over time?

Well, I think the one of the things that I realized, in some ways, I have to say there wasn't a whole lot of evolution in that conversations, because every few years you're having a conversation with somebody new. There's either a new government, or even a new person within the government. So generally, you're not meeting with the Minister of Health, or the minister of whatever. You meet with a senior policy advisor, or their Director of Stakeholder Relations, or something. Those people tend to cycle through fairly regularly. They don't necessarily stay in the same position very long. So, you'll have a conversation, establish a relationship get, a good rapport, you know, feel like there's good understanding now on the other end about the NP role, and you know what we bring to an issue, and how we can help the government solve a particular issue, then that person is gone, and there's someone new who has no idea, or the government changes. So, you know we have a we have this thing, you know, having just had our election here Ontario. We still have the conservative government. There probably isn't a lot of change, perhaps going happen. But if we get a new Minister of Health or new that Minister of Long -term care, you know, if there's a cabinet shuffle, or if there's you know, some of their own staffers, policy people now change or leave you again. You're all starting from square one every few years. It does feel like the last 20 some years I've sort of been saying the same thing over and over but just saying it to different people. I think that's part of the challenge is that we provide our input and our expertise and our advocacy. But we have to keep in mind that those the relationships that we build. We build those over long -term, and sometimes the people are building them with don't stay around for a very long time that's that can be quite a challenge.

Oh, no kidding and particularly if there is turnover during the middle, or during the transition of legislation, or a real lobby for our advocacy for a particular piece, and then it's lost and you have to start at the beginning.

It happened with Minister Fullerton was Minister of Long-Term Care and they had some great conversations. I've actually met her personally we were able to arrange one -on- one meetings with her, which is very rare, to actually meet directly with Minister and have great conversations about Long-Term Care about the impact of the COVID pandemic and so on. We were making some great strides with her and with her senior policy people and then she was shuffled out, and somebody new came in and there. You know the relationships, and the conversations became very different and not so open anymore, because the you know, the Minister of Long-Term Care now had a different focus, or was being directed to focus on other things. So, we sort of had lost that. But that is the nature of politics and advocacy, continuing to say the same thing but it's to different people all the time, and your message may be received differently, depending on who's there.

You mentioned social media earlier, and boy that has been something that's changed our whole lives, and I wondered if you could comment on how it changed the role in as a Policy Director.

So, when I started with NPAO social media wasn't something I had sort of on our on the radar. But through, you know, conversations and discussions, particularly with other stakeholders, other groups, and with policy people and media people, I became aware that really, if you're not on social media you don't you don't exist. You have. We have to, you know, as in piece we have to have a presence there. As associations we have to have a presence there, particularly on Twitter, because Twitter is where all the media people and all the political people live. And so, you have to have a presence on there and it wasn't something I knew a lot about. I mean, I'm 60 what do I know about social media and Twitter? I still can't figure out Instagram, right? So, I was laugh. I am not the person who should be should be doing this, and there is somebody at NPAO now whose job is purely to do social media, which has made a huge difference. I think it's NPs it's also really important for us to understand that when we say you know we need to do something, or why isn't x happening, and why doesn't our association do x, even as individual NPs we also have, I think, a responsibility to add and make sure that the message is amplified by going on social media ourselves. So many of us are just not comfortable putting ourselves out there with the statement, with you know, with our perspective on a certain issue. We don't like being in front of the camera or in the lime light, that's not usually what we do as nurses. But I would challenge that and say it's absolutely critical to continue to get our message out. It is so important that those who make policy decisions, but even also you know not healthcare people, just patients and people in general, hear over and over from NPs as frontline healthcare providers about our experience. It's critical that it those messages not just come from the associations. But we have to be comfortable with the discomfort of standing up and speaking the truth. I can tell you it was very difficult on so many levels. Sometimes we were looking for an NP to respond to something, or had media requesting, I know that they wanted to interview an NP in a certain clinical area with a certain level of expertise. It was very difficult, almost impossible, to find someone who was going to do that. People just didn't feel comfortable standing up and doing that, and that's something we really sort of just we just have to get over that discomfort. You just have to be okay, standing up and owning what we do and sharing that with others through social media.

You're right and not only is a response for the big things, but I think one of the biggest advantages of social media has been, it's created some transparency about what nurse practitioners do, and that we're actually here because nurse practitioners can easily be lost in the discussions. We are a small group we don't have as loud a voice, perhaps, as physician groups, or even nursing groups other nursing groups, and I think that our ability to continually present ourselves, positive messaging, new insights, practice successes everything on social media platforms will create an awareness of nurse practitioners in the world, and with the general public and with the decision makers. So hopefully, if that is the foundation, if we can create a foundation like that, then when the issues arise, we have their attention a little bit more, and I think that's what you are alluding to a little bit.

Absolutely and I mean you are a perfect example of someone who's very active on social media, particularly on Twitter. I see your posts, you're posting research that you're doing. You're highlighting the expertise of NPs in other areas, and where NPs make a difference. This this is what we need more of this and exactly what you're doing now.

So, I just I'm just so thrilled that you are that you're doing this that you're stepping up into this space and opening it for other nurse practitioners to be able to share what they do so that we can put that out into the role, because we have to use our own voice as individuals. We cannot simply rely on our associations to do that. The message is received very differently by media, and by government, and stakeholders and policy people as well. The same message is received differently if it comes from a professional association versus the messages coming from individual NPs saying the same thing and giving their perspective. That is received much more favorably. So, we again, as individual NPs can't be afraid to step up and also just say our piece as individuals.

I thank you for that, and I have to say that you know it is a little daunting at times, too, to Tweet and to do stuff. But I try to remember that you don't be all controversial. You don't have to be controversial you can post the good stuff, and just try to just increase the profile, and that is a huge win, regardless, but absolutely so. we talked we talked into this a little bit already, but can you give some little bit more insight into why the role that you had at the Nurse Practitioners' Association Ontario was so important. why was the role important?

Because, really, this talking about policy and the people will make the decisions, this is how decisions are made that impact our practice. I don't think I had a really good appreciation of that for many, many years. When we go to nursing and we really don't understand that the biggest impact on how do we interact with patients, what we able to do, the context in which we do it, that is all decided by people who are generally not in healthcare and work in some you know government office building somewhere. That's where that decision was made, and it filters down to our individual interactions with patients. I don't think I had a really good understanding of that for many, many years. I think it's really important for us to be aware that those who are not in nursing, those who are not seeing patients, those who are not directly involved, are making decisions that impact what we do. So, if we do not have a role in advocacy, in advising people in policy, in presenting our case and showing what we do at those opportune times, we are, we are going to be lost. We really are going to be lost in the shuffle. Nobody will be thinking about us until there's a crisis. So, having a position like Manager of Practice and Policy, somebody who is liaising with those decision makers, I think it's critical that when we do that we also have, we can also speak from our clinical experience our own personal experience, which is where I think the NP role becomes so critical because we are required by the college to have to maintain the clinical practice. So, I think that gives us a lot of credibility as well. it's very common for physicians, for example, to you know, they will have a clinical practice while they direct this, and you know run a hospital, or do something else. I think it brings a lot of credibility when you can be in a meeting with a stakeholder, someone from government, or someone else, and be able to speak about an experience he had recently with the patient that's relevant to the conversation. You're not speaking esoterically. It's not sort of, the macro level philosophy. It's real. Front line. Those direct patient experiences, those shared those stories about exactly what happened with the patient, with an individual, are probably the most powerful tool that we have, sharing those stories. Those make a huge difference when you're when we're trying to advocate and meet with policy people and advocate for change. Associations can do that on some level, because, as you know, when you're running association, you receive that information from members, but I don't think anybody tells a story better than us this individual NPs, which is why it's again so critical, not simply to rely on a professional association or an individual in a particular role association, but to share those stories as individual individuals.

You know, I absolutely agree. My experience, just thinking back within the Nurse Practitioner Association of Canada, when we were working with Federal legislation changes met with, as you described, bureaucrats who were not healthcare providers and didn't understand. They

were very helpful, and they were trying very hard to understand how they could help us but, they didn't know how practice worked. But by giving some stories, you know, that they could easily relate to that they could see people in their own lives within those contexts. It made a huge difference, and I think we made some huge inroads with that just by being able to do that.

So, I absolutely agree with you for that. But okay, okay. So regardless of us, and I mean you're not the only one, other people have interviewed have often said that's important for nurse practitioners to get involved at a level beyond just basic practice, or their practice, and it's hard, it's overwhelming. So, I just don't know if there's any advice you can give NPs about getting involved in in policy or advocacy or leadership in some way.

It's a really great question thank you for that. Again, I think in some way we just have to be okay with the discomfort of it, because we don't get into nursing because we think there's going to be a lime light involved, or a spot light. That's not what we do, and we're not socialized that way. It isn't part of our education and our socialization. I was using the example that I you know I was a number of years ago. I was invited to a meeting of a group of NPs who worked in a facility. They were having their monthly meeting and they wanted me to come and speak about something. So, I had a privilege of being able to listen on a part of the, meeting, and just was so blown away by the expertise they had and how compassionately and effectively they provide a care and the impact that they had. And so, I said, "You know I would love ...this is the kind of story you need to share. Could I just get a quick 30 seconds from a few of you? Here's my phone. Could you do a quick 30 seconds, just tell me what you do in your role, and why it's important? And all of these stellar outstanding NPs said no, none of them wanted to. They felt very uncomfortable doing that. They didn't feel it was that important. They didn't let me feel that they you know it wasn't that big a deal, and they were just very uncomfortable.

So I said, Okay, but if I said if I were to walk down the hall and stick my phone and my you know camera in the face of any physician and say, could you just give me 30 seconds about what you do here and why it's important? They would say yes. There wouldn't be a chance in the world that they that they would say, Oh, no, I don't feel comfortable telling you that. They would just do it because they may just have a different you know a different perception of their role and their importance in the system. So, in some ways, I think our... the biggest message I can give is to just get over the discomfort. Just be comfortable with the fact that you're going to be a bit uncomfortable, because we didn't get into this role again to do that. But if we do not own, if we do not share our story and say, "Here's what I do, and here's why it's important" someone else is going to speak on our behalf, because they have, and they will continue to do so. If we do not share our story to someone else who is not in healthcare with no background as an NP

and our role, will be explaining what it is that we do. And we can have that.

That's a disaster that's a recipe for disaster.

It certainly is because it has been in the past. You're right. I think one thing to kind of encourage nurse practitioners to embrace their discomfort a little bit and move forward is the fact that when people come forward who don't have that polished, you know, elevator, pitch and they're just speaking about themselves and the work that they do, it's very authentic and believable, and you know people are quite trusting of it. They appreciate the message that comes forward much more so that the You know the polished. celebrity type of person. So as I stumble over my words I think maybe this is where/ why I'm thinking these things!

But, you're right. It's that authenticity, and maybe even that bit of discomfort that does make someone more believable because you're not reading from a script you're not coming across as artificial. You're a nurse practitioner working in your role, passionate about what you do and the impact you have on patients. And nobody can say that better then you as an NP. That passion and that commitment will come forth just because. And I think that is, that would make it a massive difference, as you said, that comes across as so authentic.

You know, as nurses, we already, have the privilege of having a very high level of trust among public and everybody in general. And so, when we can just speak authentically for 30 seconds, and say, "You know here's what I do. Here's the impact I have on patients. I love what I do and, you know, how I'm able to help patients that makes a huge difference." But if we don't say that someone else will say it on our behalf, and it will not be authentic, and it will not be accurate.

Oh, absolutely Okay. So now I, if I understand correctly, you are formally retired. But I was going say, I see you a lot on the Nurse Practitioners' Association of Ontario /NPAO social media outlets, and you contribute continuously. So, I just was wondering where you're at now with all of your work.

Oh, well, yeah, thank you for that question. I am teaching a course at UofT (University of Toronto) one of their courses for the NP program. I'm doing a still some work with the Joint Compensation study for the Midwives Tribunal. I started out when I was at NPAO and I'm still happy to continue that to provide input on the NP role, so they have a really good understanding when they're going to the tribunal around what exactly the NP role is about.

I haven't speaking to NPs here and there who contact me with questions about their role. A lot of sort of career coaching and counseling. They're not sure about a certain role, about a certain position. Many NPs now are taking roles with individual physicians or smaller groups of physicians who are posting for NPs. They're sort of outside of the funded models that's my speak to a lot of NPs about how that role might evolve, some things to think about so I've done a little bit of that, answer career counseling and coaching as well. So, you know little bits here and there and you know well. We'll like maybe still do a little bit of local work clinically.

This year. but my focus is sort of changing to more of that kind of policy background support.

Oh, so if there's anything you'd like to add at the just to wrap things up for new nurse practitioners or nurse practitioners who haven't really been engaged with the advocacy,

policy work. Is there anything in particular you'd want to say more so than sit with a discomfort and that sort of thing?

Yeah, so realize that you're more of an expert than you think. You know you can start small. There are lots of resources through NPAO, for example. They just had with the election. They did have the opportunities, for, they set up meetings between NPs and their ridings and their local candidates up to the election, to speak with them. You can start small that way, you can respond to something in that you see in your local media. So your local city town, local newspapers they're often really looking for stories or looking for input from people in the community who have a particular focus. You can start with perhaps a letter to the editor, suggesting a particular story, or responding to something that has been written in your local paper and saying, "Well, you know here's in my experience, my perspective as a nurse practitioner, someone living in this community. Here's my experience. Here's my thought, and you can just begin responding that way.

So it doesn't have to be big you don't have to start off thinking that you're going be meeting with the Minister of Health, or you know stakeholder, or something. But you know that's saying what's that saying "Think globally, at locally" I would say, start there. What's happening in your community that you can respond to, just on the small level, using your expertise and your experience, and just go from there. And the more you do it the more you realize that you actually know what you're doing, and what you're saying and people don't know...we assume that what the information we have is fairly well known. Like, we just think it's something that's sort of obvious and evident. And really, we're in a perfect position to just share that with people. And so just start small. I encourage everyone certainly to join the professional association, obviously to join the Nurse Practitioners' Association of Ontario.

There's so much information and support there, around advocating and, sort of speaking with others. Speaking with local, I said local counselors, local MPPs, whatever. So now that we've had our election and some people they've had a new MPP, or maybe you have this same one, book a meeting, right? Give them a couple of weeks to, you know, maybe get over the election.

But you know, as an MPP they are supposed to be in their constituency office every Friday to meet with their constituents. So, call, book a meeting, and say you're my MPP and you represent me. I'm in your riding. I'm a nurse practitioner, and I'd like to talk to you about some of the healthcare issues here in this area. So just start small. I can guarantee you they will look appreciate it. They very likely have no idea about what a nurse practitioner does, or even a really good understanding of some of the healthcare issues in their own riding. So just start small that way, and as you sort of build up your confidence, other doors and other avenues will open, there are a lot of resources and supports for sure.

So, I think. just to tell people to start really small and looking at how they can respond to things locally in their own communities. It's a really great place to start.

Hmm that's wonderful advice. So, you know, as we wrap up I just want to thank you for doing this podcast, but more so for all the work that you've done on behalf of nurse practitioners over the years. And I know you said that it was that it was a paid position for a part time position, I know for a fact that you but you work far harder than the remuneration you received and you were part of a group of nurse practitioners that really worked endlessly and tirelessly to move our profession forward. So many, many, many thanks to you.

Oh, thank you for that! And you were certainly part of that group as well. and you continue to be, because now you yourself are blazing ew trails, and, you know, going where no NP has gone before.

Oh you're welcome! It's been fun for's been great.

Thanks so much for this opportunity.

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