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= Doris Grinspun =

Doris Grinspun RN MSN PhD LLD(hon) Dr(hc) FAAN FCAN OONT (born 29 October 1952) is a nurse leader, author and speaker on health and nursing policy, as well as a policy advocate and public figure in the province of Ontario, Canada. She has served since 1996 as the head of the Registered Nurses' Association of Ontario (RNAO), and has led the growing influence of this professional association both nationally and internationally. An advocate for nursing and health for all, and a proponent of social and environmental determinants of health, she has influenced policy change in Ontario. She founded and has led since 2001 RNAO’s Best Practice Guidelines program, currently implemented in more than 1,000 health organizations in 15 countries. Recently she has played a prominent public role in Ontario's response to the COVID-19 pandemic.

Early and family life
Grinspun was born as Dorita Rappaport in Santiago, Chile to Jewish parents. Her father, Leib Rappaport, arrived in Chile in 1939 escaping from Czechoslovakia but her grandparents and aunt, last seen at the Terezin concentration camp, perished at the hands of the Nazis. She completed elementary and high school studies at the Hebrew Institute in Santiago. She is the youngest of four sisters.

From childhood she wanted to become a nurse and demonstrated concern for social conditions. After graduating from high school she moved to Israel with a group of classmates and enrolled at the Hadassah School of Nursing in Jerusalem. When she was a second year nursing student the Yom Kippur War broke and Grinspun was asked to open an interim unit for soldiers with minor injuries, later working on a unit with burnt soldiers, which left a lasting impression on her.

In Israel she married her Chilean high school friend, Ricardo Grinspun. They were both active in the Israeli peace movement, moved by the experience of two wars (1973 and 1982). They have two married sons and four grandchildren.

Education and early career
Grinspun received her Registered Nurse Diploma from the Hadassah School of Nursing in Jerusalem in 1974. She completed a post baccalaureate degree in nursing, magna cum laude, at Tel Aviv University in 1983, while working as a staff nurse in a surgical unit at Meir General Hospital, Kfar Saba, followed by several staff nurse roles at Loewenstein Rehabilitation Hospital, Raanana. Later she became the assistant head nurse of the cranio cerebral injury unit at Loewenstein. In 1983, the family of four moved to Ann Arbor, Michigan for graduate studies, and she completed her third degree in nursing, a master of science in nursing at the University of Michigan.

She also worked as a registered nurse in the rehabilitation department at the University of Michigan Medical Centre and became assistant head nurse. She was impressed both with the quality of health services and highly professional nursing care provided at a top US hospital, but also shocked with the reality that many of these services were rationed by people’s insurance scheme and their ability to pay. After she and her husband completed their graduate studies the family migrated to Canada, attracted by its publicly-funded healthcare system.

In Canada she started work as a clinical nurse specialist in rehabilitation at Queen Elizabeth Hospital in Toronto (now the Toronto Rehabilitation Institute). Soon thereafter she was invited by then vice-president of nursing Judith Shamian to apply as a director of nursing at Mount Sinai Hospital. During the six years (1990-96) she served in that position she led the planning, implementation and evaluation of professional nursing practice across the hospital.

Grinspun completed a PhD degree in sociology at York University in Toronto in 2010. Her dissertation focused on the social construction of nursing caring in a tertiary hospital in Toronto.

Registered Nurses’ Association of Ontario
The Registered Nurses’ Association of Ontario (RNAO) is the professional association representing registered nurses, nurse practitioners and nursing students in Ontario. Grinspun became the executive director of RNAO in 1996, serving since then as head of the association, with a change of title to chief executive officer in 2011. She has been the longest serving executive leader in RNAO’s history, and has led transformation, growth and impact that have been publicly recognized by nurses, universities, politicians and the public. RNAO’s voluntary membership grew from 11,000 when Grinspun took the helm to 45,000 today.[REF] Grinspun envisioned a nursing social movement[REF] with strong grassroots across Ontario utilizing RNAO's network of XX chapters, regions and 31 interest groups. Grinspun's financially robust management of RNAO included the purchase of a home office building in downtown Toronto in 2006, opened in the presence of political leaders.

Grinspun leads the strong media presence of the association. During a one year fiscal period, 2012-2013, there were 863 media hits, 663 RNAO members were quoted in media, and on 93 occasions stories quoted RNAO executive members, most of these featuring Grinspun. Website traffic reached almost 3 million page views during that year. Social media influence continues to grow at a steady pace, as Twitter numbers grow. A search for "Doris Grinspun" in the Toronto Star since 1996 shows 343 results.[REF]

In her role, Grinspun has supervised the publication of RNAO's award winning bimonthly journal, Registered Nurse Journal since 1996, and she has used her column to educate, guide and mobilize nurses.

Nursing policy and nursing human resources
Grinspun has been influential in Ontario health and nursing policy since the late 1990's, working with Ontario governments of different political stripes.

During 1996-1997 there was widespread disruption in the Ontario hospital system as a result of restructuring and layoffs of nurses under Premier Mike Harris. Grinspun's activism soon became evident, as she called in November 1996 for a candlelight vigil at Queen's Park with 600 nurses, other health providers, and politicians in attendance. In an open letter to Ontario citizens, RNAO decried the downsizing of hospitals, firing of nurses, impoverished community health services, the deskilling and de-professionalization of nurses' work, and the promotion of privatized health services.

Grinspun's work with then Minister of Health and Long-Term Care (MOHLTC), Elizabeth Witmer, led to positive engagement with government. In 1998, the legislature passed Bill 127, Expanded Nursing Services for Patients Act. Bill 127 was proclaimed at the RNAO home office with Minister Witmer in attendance, making Ontario the first Canadian jurisdiction to legally recognize the role of nurse practitioner. That same year, following a RNAO report authored by Grinspun, the government established the Ontario Nursing Task Force, with then RNAO president Judith Shamian as a member. The purpose of the Task Force was to enhance the quality of patient care through the effective use of nursing resources. Its 1999 report, Good Nursing, Good Health: An Investment for the 21st Century, focused on helping Ontario retain and attract nurses, improve working conditions for nurses, and ensure nurses have the skills they need. MOHLTC requested a second report from RNAO and the Registered Practical Nurses Association of Ontario. This Grinspun-led report, Ensuring the Care Will Be There, set out a comprehensive nursing recruitment and retention strategy following province-wide consultation. The Ontario government based its nursing strategy on these two documents and proceeded to implementation. Grinspun co-chaired the implementation for the ministry's Joint Provincial Nursing Committee (JNPC), and issued two follow-up reports in 2001 and 2003. She continued to play a central role in JPNC, which she co-chaired from 2009 till 2012 and again from XX to 2020.

RNAO, under Grinspun's leadership, was central to several milestones in nursing policy in Ontario:

Baccalaureate entry to practice. RNAO advocated for legislation to make the BScN the entry to practice requirement for RN practice in Ontario. On April 2000 the government announced the regulation amending the Nursing Act, 1991, with the requirement becoming effective on January 2005. It also announced funding to enable the start-up and expansion of collaborative university-college BScN programs.

Enhanced role of nurses. Premier Dalton McGuinty announced at the 2011 RNAO annual general meeting (AGM): a) changes to the Public Hospitals Act that require chief nurse executives to be a member of a hospital’s board and their quality committees; as well as b) mandating all 37 public health units in the province to appoint a chief nursing officer; and c) that nurse practitioners (NPs) will have their powers extended to admit and discharge patients in hospitals. Grinspun has championed an expanded scope of practice, for example allowing RNs to prescribe medicines. Premier Kathleen Wynne announced at the 2014 RNAO AGM that the government wants registered nurses to be able to prescribe medications in some circumstances.

Expanding scope of practice and utilization of NPs. Grinspun, working with the Nurse Practitioners’ Association of Ontario (NPAO), then an interest group of RNAO, continued to push government to make changes to the nurse practitioner role and open NP-led clinics. Since 2012, NPs in Ontario are working autonomously, prescribing without “a list,” and are authorized to admit, treat, transfer and discharge inpatients in hospital. The Primary Care Nurse Task Force, a multi-stakeholder effort co-chaired by Grinspun, called in its 2012 report for full scope utilization of NPs in primary care. The advocacy for increased numbers of NPs continued, and government responded,  bringing them into new sectors. Grinspun argued that expanded scope and larger utilization will provide better health outcomes. Going forward, the RNAO has continued to call for improved compensation, scope of practice and expanded utilization. Canada’s first NP-led clinic opened in Sudbury, Ontario, in 2007, following years of advocacy. One year later, the provincial government promised to open 25 clinics in communities across Ontario. These clinics resulted in improved access to primary care for thousands of families. Ontario minister of health Deb Matthews recognized in the Ontario legislature RNAO's role in these advances.

Securing full-time employment and changing work arrangements. Grinspun publicly raised concerns about casualization of the nursing workforce, about fragmentation of nursing care and the increasing use of casual and agency work, part of cost-driven hospital restructuring in Canada during the 1990s. Patient care suffers when employment arrangements undermine the ability to ensure patients have continuity of care and caregiver (the same nurse taking care of the same patient using the same treatment plan as much as possible). RN full-time employment helps improve patient outcomes, ensuring system cost-effectiveness, improving recruitment and retention, and ensuring sustainability of the nursing profession. Given a low rate of full-time RN employment in Ontario and in Canada, she advocated for what she coined “the 70% solution” – make sure at least 70% of the nurses in each work setting are permanent full-time. RNAO's mobilization was effective and politicians paid attention,  implementing policy changes.

Recruitment and retention of nurses. Grinspun argued that cost-cutting, restructuring and casualisation backfired and created a nursing shortage, with many Canadian nurses seeking jobs in the US. In a RNAO survey of expatriate nurses, most wanted to come back to full-time employment in Ontario.

New graduate employment guarantee. As part of her "70% solution," Grinspun identified that young nursing school graduates had difficulty finding full time employment. She led RNAO to successfully lobby government. In 2007 the Nursing Graduate Guarantee program in Ontario was established, guaranteeing full employment to new graduates as they begin their careers. The program remains in place.

RN effectiveness and securing appropriate RN-to-population ratios. Grinspun has made the case that RNs can make a difference in the life of their clients and patients. Armed with evidence about RN effectiveness on patients’ health and clinical outcomes, as well as organizational and system cost-effectiveness, Grinspun has positioned this issue at the forefront of RNAO’s work. Grinspun has been a tenacious advocate for securing an appropriate number of RNs providing direct care to patients, clients and residents; for expanding the RN scope of practice; and addressing the shortfall in Ontario's RN-to-population ratios.

Healthcare system transformation
With Grinspun’s arrival at RNAO the organization expanded its focus to embrace a healthcare system-wide perspective and engaged in Canadian public policy discussions:

Enhancing Medicare. Grinspun noticed the limitations of tiered healthcare in her birth country, Chile, and in the United States, and her move to Canada in 1989 was influenced by appreciation of Canadian Medicare. She views Medicare as work in progress and led mobilization to support the Romanow Commission. She identified the single focus on hospital services as a weakness, and called during federal-provincial Health Accord discussions for expanding primary care, stopping privatization and expanding Medicare with national programs such as Pharmacare.

Primary care. Grinspun works with RNAO staff to help shape Ontario’s primary care system with influential policy reports that provide evidence to the value of nurses practising to their full scope and contributing to positive clinical and health outcomes as well as system efficiency and cost effectiveness. The report on Primary Solutions for Primary Care (2012) laid out a plan to maximize the role of Ontario’s primary care nurses and to eliminate the care gaps that prevent patients from accessing timely and coordinated care.

Grinspun's brainchild, the impactful Enhancing Community Care for Ontarians (ECCO) report calls on the government and health system partners to strengthen community care and anchor the health system in primary care to better meet the health needs of all Ontarians. First published in 2012, updated in 2014 as ECCO 2.0 and updated in 2020 as ECCO 3.0 , the latter version aligns with health system transformation that responds to the COVID-19 pandemic. ECCO proposes an accessible, equitable, person-centred integrated and publicly-funded health system, delivered primarily on a not-for-profit basis, realized through a robust community sector anchored in primary care. This influential report has resonated with politicians and been featured in the media. Some aspects of the Ontario government plans for health system restructuring announced in February 2019 are consistent with RNAO's ECCO report. The changes introduce local Ontario Health Teams to coordinate and deliver a variety of health services for patients.

Envisioning healthcare transformation. A long term visioning exercise that Grinspun led with the RNAO board of directors culminated with the 2014 release of Visionary Leadership 2030 – Charting a Course for the Health System and Nursing in Ontario. The report portrays scenarios for transformation in a number of health system areas. It proposes a health system anchored in the communities where people live, work and play, and that helps people stay healthy from birth - physically, emotionally, socially, and cognitively. It does so with health professionals working to their full scope of practice in interprofessional teams.

Long-term care. Grinspun has led RNAO's advocacy for changes in the long-term care sector for over two decades, with the goal of enhancing outcomes for residents, families and staff. A number of reports and briefing papers prepared by RNAO alone or in collaboration with other organizations have been released. Many of RNAO’s recommendations relate to staffing and the funding models required, ensuring safe, evidence-based resident care. They emphasize the need for a skill mix of health providers that reflects the increasing acuity of the residents that currently live in Ontario’s long-term care homes, as well as funding models that address their needs. During the COVID-19 pandemic she led the demand for a Nursing Home Basic Care Guarantee to shore up staffing levels based on these principles. Grinspun was cited dozens of times by the media in reaction to the hundreds of COVID-19 outbreaks in Ontario nursing homes.

Social and environmental determinants of health
Before Grinspun’s tenure as the head of RNAO, the traditional approach of the professional association was to address matters related to the “profession” (nursing) and the healthcare system. RNAO's policy staff, under Grinspun's leadership, worked to bring a broader definition of health and wellbeing that included the social determinants of health (SDOH) -- such as poverty, social exclusion , shelter , racism , nutrition and education --, as well as environmental determinants -- such as clean air and water, protection from toxics and climate change.

Her approach is to devise evidence-based policy, and then working with her team to mobilize nurses and the public calling for action from politicians and governments, utilizing submissions to government, open letters, “action alerts,” presentations, and directly appealing to politicians. For Grinspun, “this is a perfect example of the power of working together to mobilize people towards progressive change.” She devised the “action alert”, now a mainstay of RNAO’s advocacy process, as a way to inform RNAO members of critical nursing, health and social issues, and to mobilize their advocacy efforts,  and worked with grassroots organizations to advance common causes (i.e., organizing a community consultation, joining with a group of nurses for an affordable housing rally, or activating members to pen letters to their local media).

Social determinants. "We believe in the social determinants of health as paramount to the well-being of people," says Grinspun. She identified poverty as the largest preventable source of ill-health in Canada, dedicating a 2005 issue of Registered Nurse Journal to the topic of child poverty. An anti-poverty coalition in which Grinspun played a personal role advocated successfully for the government to announce in 2008 Ontario’s Poverty Reduction Strategy. Grinspun approach was to celebrate the announcement but insist that “actions speak louder than words,” pushing government to demonstrate action through policy and budgets. RNAO has called, working with civil society coalitions, to provide access to healthcare services for refugee claimants, and for an affordable housing strategy.

Environmental determinants of health. Emphasizing evidence linking environmental factors to health, Grinspun prioritized advocacy for a cleaner, greener environment, arguing fewer pollutants and toxics means lower morbidity and mortality (from asthma, lung cancer, cardiovascular disease, allergies, etc.). She led the writing of Creating Vibrant Communities, the association’s platform for the 2011 provincial election, outlining recommendations related to greenhouse gas emissions, coal and nuclear power, toxics, pesticides, clean wate r and public transportation.

Grinspun worked with the RNAO board of directors starting in 2000 to support a campaign to ban the cosmetic use of pesticides in Ontario, working with a Partnership for Pesticide Bylaws, a group of 14 community organizations. The association also joined a coalition of health and environmental organizations, led by the Canadian Association of Physicians for the Environment (CAPE), to launch an anti-pesticide ad campaign in 2005. Responding to the pressure, in 2008 the Ontario legislature passed Bill 64: An Act to amend the Pesticides Act to prohibit the use and sale of pesticides that may be used for cosmetic purposes. An editorial in Alternatives Journal says: "Doris Grinspun, CEO of the Registered Nurses' Association of Ontario, played a central role in pressing her province to pass a cosmetic-pesticide ban, the most health-protective legislation of its kind in North America." RNAO also collaborated with CAPE and the Ontario Clean Air Alliance to advocate for the closure of all coal-fired generating units, a successful campaign leading to complete coal phase-out in 2014.

Best Practice Guidelines program
An area of vast accomplishment for Grinspun and the team she has assembled at RNAO is in the enhancement of nursing and health evidence-based practice. The RNAO Best Practice Guidelines (BPG) program is the embodiment of that achievement and one that Grinspun considers the most impactful initiative she has been engaged professionally in her career.

Origin of the BPG program
The 1999 Good Nursing, Good Health: An Investment for the 21st Century report (see above) recommended establishing clinical models in practice environments to allow nurses to gain expertise in clinical areas. Grinspun wrote a proposal to the Ontario Ministry of Health to fund RNAO to create nursing clinical guidelines (dubbed "best practice guidelines", or BPGs) based on the best available evidence, analyzed and rated by nurse experts, and distributed widely to nurses in Ontario. Health minister Elizabeth Witmer allocated in 1999 multiyear funding to RNAO to create a dedicated program for BPG development and implementation. The funding to the BPG program has been extended and increased by successive governments in Ontario, to the present day.

Evolution of the BPG program
The BPG Program was officially launched in 1999 by RNAO in partnership with the Ontario Ministry of Health and Long-Term Care (MOHLTC) [5]. The purpose of the Program from its inception has been to support Ontario nurses—registered nurses (RNs), nurse practitioners (NPs), and registered practical nurses (RPNs/LPNs)—by providing them with Best Practice Guidelines for client care. It envisioned this would advance nurses’ ability to assert their clinical, health, and relational competence and expertise based on the most relevant evidence. So, for example, the widely used BPG on Preventing Falls and Reducing Injury from Falls, originally published in 2002 and currently in its fourth edition [6], has helped avoid many thousands of injuries from falls in elderly and other at-risk individuals. This emboldened capacity would inspire action at the individual level of each nurse and nursing student, and extend to the collective levels of service and academic organizations, as well as the broad foray of health policy. In doing so, nurses would optimize their contribution to patients, impacting individual patient, organizational and health system outcomes.

Grinspun recognized early on that the traditional tightly planned, and often top-down, approach used by health managers for this type of programs would not produce the type of social engagement needed to deliver substantive and sustained clinical, organizational, and system change through the BPG Program. RNAO’s approach needed to be multifaceted and include dynamic processes that would attract nurses to mobilize their internal commitment and energy to become the drivers for change. In a manner consistent with RNAO’s overall approach to working with its own members, Grinspun envisioned from the outset that the BPG Program should emulate a grassroots movement, one that both creates and delivers the changes proposed by the clinical guidelines. The end goal of this movement led by Grinspun and her team at RNAO has been, by design, consistent and clear: to advance evidence-based practice and improve patient, organization, and health system outcomes. A secondary goal of the Program, and one Grinspun has not shied away from, is to position nursing and nurses as knowledge professionals and robust contributors to health outcomes.

In its infancy, the program focused specifically on health-care issues the government viewed as vital, including elder care, primary health care, mental health, home care and emergency care. The first four Best Practice Guidelines (BPGs) were developed by the end of 2000, pilot tested in 2001, and publicly launched and published in 2002 [4]. In 2003 the government of Premier Dalton McGuinty doubled the program’s annual funding. Since the BPG program began, its growth has been astounding. By 2008 there were 31 clinical guidelines and six healthy workplace BPGs that were in use all over Ontario, across Canada and around the world. Today, there are 54 clinical and healthy work environment BPGs, and thanks to continued support from the provincial government with some added support from the federal government, more are on the way. The association maintains a rigorous guideline review and revision cycle, so that the BPGs remain current and capture the latest evidence.

A number of the earlier BPGs have gone through several editions. Among the most popular BPGs implemented across various sectors are: Preventing Falls and Reducing Injury from Falls (fourth edition) [6]; Person- and Family-Centred Care (2nd edition) [7]; Promoting and Supporting the Initiation, Exclusivity, and Continuation of Breastfeeding for Newborns, Infants and Young Children (3rd edition) [8]; Assessment and Management of Pain (3rd edition) [9]; and Integrating Tobacco Interventions into Daily Practice (3rd edition) [10]. The program is expanding every year and has grown to include top leadership and about 50 expert full time staff as well as thousands of expert nurses and others in health care who have volunteered their time and knowledge to contribute to the development of BPGs. In addition, there are more than 100,000 volunteer champions around the world who, as part of their daily clinical work, support guideline implementation globally, and utilize a data system that is helping track key indicators to evaluate improvements in patient care, organizational and system performance. The guidelines are also integral to nursing education at the undergraduate and graduate levels.

In 2003, after seeing that uptake of the clinical guidelines was facilitated by key elements in the work environment, Grinspun and her team envisioned that in addition to evidence-based guidelines that advance the clinical practice of nurses, there was also an urgent need for evidence-based guidelines to enrich work environments. The Healthy Work Environments (HWE) BPGs were born, designed to support health care organizations in creating and sustaining positive work environments. This program was initiated with funding from the Ontario Ministry of Health and Long-Term Care and support from Health Canada, Office of Nursing Policy. The initial goal of the program was the development of six guidelines and systematic literature reviews related to healthy work environments. The six areas included leadership, collaborative practice, workload and staffing, professionalism, embracing diversity and workplace health, safety, and well-being. For the project, a healthy work environment was defined as “a practice setting that maximizes the health and well-being of nurses, quality patient outcomes and organizational and system performance”[11]. This leading edge work attracted much attention and interest across the health system, as these new guidelines were developed and published. For instance, the development panel for the Developing and Sustaining Interprofessional Health Care: Optimizing Patients / Clients, Organizational, and System Outcomes BPG [12] was co-chaired by Dr. Stewart Kennedy, then President of the Ontario Medical Association.

RNAO has also engaged in developing health system guidelines. That is the case with the Care Transitions BPG [13] to assist nurses and other health care professionals become more comfortable, confident and competent when caring for clients undergoing care transitions within and between healthcare sectors. This BPG is playing an important role, at the current time, in Premier Doug Ford’s plans to create Ontario Health Teams (OHTs) across the province of Ontario. At the current time, four of the proposed OHTs, each one composed of more than a dozen organizations, have adopted BPG implementation as part of their proposed plan of action, and several others have indicated interest. For example, all 13 organizations composing the North Western Toronto Ontario Health Team are training together to drive evidence-based practice, enhance health outcomes for patients and promote staff engagement [14].

RNAO’s plans from the outset included broad dissemination of the evidence-based guidelines and active support for their implementation. Today, RNAO leads what is likely the most robust and expansive implementation program for evidence-based practice for nurses anywhere in the world, and is amongst the strongest in any healthcare field [5]. Grinspun envisioned from the outset that social entrepreneurship would be the driving force expanding the program. This would work in three ways: 1) by scaling up, or expanding coverage; 2) scaling out, or altering the policies, laws, and standards; and 3) scaling deep, or changing the norms [15]. In the BPG Program, scaling up happens when BPGs are disseminated widely within an organization; scaling out, when they are disseminated to other organizations or to the health system; and scaling deep, when uptake and sustainability have occurred and an evidence-based culture has been achieved. Scaling deep can occur within an organization or across the health system, especially through policy impact and cultural change.

The focus of scaling up is on wide dissemination and uptake of BPGs within an organization. The first broad dissemination initiative was the development of ‘champions’ in the organizations adopting the BPGs. It began in 2002 by training individual nurses as champions who are passionate about BPGs to facilitate BPG uptake in their workplaces. By 2003 there were 278 champions in all sectors of Ontario’s healthcare system (JPNC Implementation Monitoring Subcommittee, 2003). At first, all the champions were direct care RNs; over the years the role has evolved to include all nurses and other health professionals in all roles. These are individuals selected by their organizations (and in many organizations, selected by their peers) and/or who volunteer for this role. Such a bottom-up approach helps ensure role sustainability. Champions are committed to evidence-informed practice and improving people’s care and health. They raise awareness of BPGs, support understanding, and influence their uptake among workplace peers. In 2002, with already hundreds of Champions trained, RNAO launched the Champions Network to foster active engagement and knowledge exchange among champions and between them and RNAO. Through this program, over 100,000 volunteer champions worldwide access tools and strategies such as in-person workshops, teleconferences, webinars, institutes and online modules.

"When I looked at the RNAO best practice guidelines, which have been adopted not only elsewhere in Canada but across the world, I realized that nurses do instinctively what I aspire to do across the health care system: build a system that is of the highest quality, that is evidence-based, that is cost-effective and that puts the patient at the centre." Specify from whom the quote is.

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"It's a great debate about the future of health care in our province. I want to say that it's a debate made more pleasant by the opportunity to have it in front of someone whom I consider a health care hero. That's Doris Grinspun from the Registered Nurses Association of Ontario."