Ministry Reports

Good Nursing, Good Health : An Investment for the 21st Century

Report of the Nursing Task Force, January 1999


Table of Contents

Letter of Presentation
Introduction: About this Report
Summary and Recommendations

Issues and Implementation
Key Findings : Our Research and Stakeholder Discussions Appendices

Letter of Presentation

Dear Minister:

We are pleased to present you with the report of the Nursing Task Force -
"Good Nursing, Good Health: An Investment for the 21st Century."

The primary focus of the nursing profession (both registered nurses and registered practical nurses) in this province is the quality of health care for Ontarians. To this end, we believe that the comprehensive recommendations developed by the Task Force will ensure that Ontario has a solid foundation of nursing services to meet our health needs in the 21st century.

Although the impact of nursing on health consumer outcomes is a relatively new field of study in Canada, research is emerging that establishes a relationship between an appropriate level of nursing resources and better health outcomes. Indeed, nursing staff shortages have been linked to increases in patient complications which can lead to longer lengths of stay in hospitals. In addition, health care consumers and providers of health care services point to a shortage of nursing resources and the detrimental effects this has on the health and well-being of patients and their families.

Nurses reported two specific concerns to the Task Force - fear of not being able to provide adequate care, and fear of an impending shortage of nurses in Ontario. The evidence reviewed by the Task Force supports both these concerns.

There are approximately 140,000 nurses in Ontario, making them the largest single group within the health care workforce. As the key front line professionals, they have been the group most affected by system restructuring. Nurses are working harder, caring for more individuals, and spending less time with each person. What has been squeezed out in this changing environment is the critical time nurses need to spend assessing clients, monitoring their condition, and providing necessary interventions in a timely manner as well as educating, caring for and coordinating care for health care consumers and their families.

There are not enough young, graduate nurses in full-time positions today to ensure there will be an experienced nursing workforce to care for Ontarians as both the nursing workforce and the Ontario population grows older. Experienced nurses are reporting reduced job satisfaction and high levels of stress as workloads increase.

There are fewer permanent and full-time nursing positions available, and many nurses are working several casual jobs to make ends meet - often without the benefits that a permanent position offers. Nursing enrollments and graduations have decreased and nurses are leaving Ontario to go to other jurisdictions or to jobs outside of health care.

The Nursing Task Force recommends that there be an immediate investment, on a permanent basis, of $375 million in nursing services before the year 2000. The Task Force is of the view that $125 million of this permanent investment must be made no later than March 31, 1999 to create permanent, front line nursing positions across all sectors of the health care system. This action is essential to stabilize the existing nursing workforce and to prevent further erosion of our current pool of skilled and knowledgeable nursing professionals.

While the Task Force is aware that there may be areas of urgent need in the short term, we strongly recommend that a comprehensive investment in the nursing sector be made across the spectrum of the health care delivery system to enhance the quality and continuity of health care. This investment must be guided by a method of funding nursing services that ensures health care consumers receive appropriate nursing care, regardless of the setting in which care is received.

Specifically, the returns on this investment for health care consumers will include reduced hospital admissions, less frequent emergency room visits, reduced stress for those caring for family members at home as well as enhanced accessibility to nursing services. In other words, this investment will result in better health for Ontarians both today and in the future.

Minister, the Nursing Task Force believes it is imperative that action be taken now, before the nursing crisis worsens. We also believe that your positive response to this report will be the critical factor in retaining our existing resource of qualified and skilled professional nurses and in recruiting young and talented nurses for the future.

As you review our key findings and recommendations, we strongly advocate that a process be established to monitor the implementation, effectiveness and outcomes of the recommendations and we recommend that the Joint Provincial Nursing Committee (JPNC) be charged with this responsibility.

We could not have completed our work in the time available to us without the participation of many dedicated individuals and groups, and to them we extend our sincere appreciation. All of them were passionate about the importance of nurses in the health care system and impatient for the changes recommended in this report.

Nurses, employers of nurses and health care consumers shared their experiences and concerns, and proposed solutions. The Nursing Effectiveness, Utilization and Outcomes Research Unit (NRU) at the University of Toronto and McMaster University contributed a significant body of work and related analysis that provided essential evidence for many of our recommendations. Some 75 organizations and individuals took the time to prepare written submissions to the Task Force outlining issues and proposing solutions. These submissions were of tremendous value to our report and in the development of our recommendations.

In addition, representatives of more than 60 health care organizations, including the JPNC, reviewed our draft recommendations and implementation strategies. Each of them provided us with wise and practical advice. We also wish to acknowledge the excellent logistical support and pertinent information received from staff in your Ministry.

Minister, we are pleased that you had the foresight to establish the Nursing Task Force. We believe that our recommendations, when implemented in their entirety, will form the basis of a strategy to ensure that the people of Ontario have access to high quality professional nursing services now and in the future. It is our belief that this strategy will serve as the foundation for on-going investments in health care through nursing services to ensure that we keep pace with the needs of the Ontario population as we move into the next millennium.

Susan J. Strelioff
Chair
Nursing Task Force


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Introduction: About this Report

"As we proceed with health reform, our challenge ... is to move forward together and build on the strengths of our present system.... We must ensure that we address the health needs of all Ontarians at every stage of their life and provide them with the best possible quality of care."
--(Elizabeth Witmer, Ontario Minister of Health, Registered Nurses Association of Ontario, 1998 Annual General Meeting.)

On September 15, 1998, Ontario's Minister of Health, the Honorable Elizabeth Witmer, established the Nursing Task Force to examine nursing services in Ontario, to identify how changes in the profession have affected the delivery of health care services, and to recommend how the province's health system can be improved through nursing services.

The Task Force was directed to examine the level of access to quality nursing services and to identify changes in nursing related to health care reform. The Task Force was also asked to assess how these changes may affect both health care professionals and health care consumers.

The Task Force was established in direct response to the requests and concerns of the nursing profession, and its recommendations are designed to ensure and enhance the quality of patient care through the effective use of nursing resources today and in the future.

Members of the Task Force - who include staff nurses (1 Registered Nurse and 1 Registered Practical Nurse), representatives from nursing organizations, community-care services, long-term care, hospital services, and the academic community - met with approximately 150 nurses, nursing students, nursing employers, educators, health care providers and health care consumers in five Ontario centres.

The Task Force reviewed a large amount of relevant data and information to support its findings and recommendations. The Nursing Effectiveness, Utilization and Outcomes Research Unit (NRU) at the University of Toronto and McMaster University contributed a significant body of work, including a statistical overview and environmental analysis for nursing services.

In addition, the Task Force received written submissions from a wide range of approximately 75 groups and individuals, all of which were invaluable to the conclusions and recommendations contained in this report.

To assist readers in understanding this report, the following explains how various terms have been defined and used throughout this document :

  • The term "nurses" refers to Registered Nurses (RNs) and Registered Practical Nurses (RPNs).
  • "Nursing services" are those professional services performed by RNs and RPNs - and defined by their scope of practice - in a variety of health care settings.
  • "Health care consumer" denotes those who have contact with the health care system in the widest sense. It includes patients receiving treatment or care in health care facilities and at home, and those who have interaction with public health professionals in the community. The term encompasses individuals and their families and loved ones.

While this report focuses on nurses, the Task Force recognizes the highly integrated nature of Ontario's health care system, and the key roles performed by other professionals including, but not limited to, doctors, physical and occupational therapists, pharmacists, technologists, and social workers. While the recommendations contained herein focus on RNs and RPNs, we recognize that nursing services must continue to be provided in conjunction with services delivered by other health care providers to ensure optimal health outcomes.

The report's structure is designed to make it easy for readers to pinpoint those areas of greatest interest to them :

  • Recommendations are contained in the Summary and Recommendations;
  • An overview of the issues together with the strategies and implementation plans to address the issues are found in Issues and Implementation;
  • Key findings based on the research the Task Force considered, and the groups and individuals from whom it heard' are outlined in the section, Key Findings: Our Research and Stakeholder Discussions; and
  • The Appendices contain greater detail on whom the Task Force specifically consulted and/or heard from, and the sources for its research.

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Summary and Recommendations

"... The last five years have seen a tremendous change in health care delivery in this province. Patient care has been affected in a number of ways. Patients in the hospital are sicker and seem to require greater nursing resource (and) ... are staying in the hospital for shorter periods of time... Patients discharged to home may need access to more sophisticated nursing and allied health treatments... At the same time, the nursing workforce reports serious concerns about inadequate staffing, workload and concerns of quality of care."
(Linda O'Brien-Pallas and Andrea Baumann; The State of Nursing Practice in Ontario: The Issues, Challenges and Needs Nursing Effectiveness Utilization and Outcomes Research Unit, November 1998.)

The Healthcare Environment

Throughout the 1990s, the health care system in Ontario - indeed across Canada - has undergone dramatic change as federal transfer payments have been reduced, as provincial governments have restructured their health care systems, and as the focus of health care has moved increasingly to the community.

Patients who receive nursing care today are often sicker, with an increasing amount of care being provided in the home. This has placed an added pressure on nursing services at a time when the nursing workforce is experiencing significant staffing and workload impacts.

I go home at night exhausted and wondering if I did everything right today
- staff nurse

I have learned through the health care system that I have to be a very patient patient
- health care consumer

Managing my health care is my full-time job now
- health care consumer

Ontario's approximately 140,000 nurses are the largest single group within the health care workforce. As key front line professionals, they have also been the group most affected by system restructuring.

Nurses are working harder, caring for more individuals, and spending less time with each person. What has shrunk in this changing environment, they told us, is the amount of time they have to assess, monitor and provide appropriate nursing care as well as be teachers, comforters and communicators. In short, the time required to fulfill their traditional role of health care coordinator.

Coupled with these workplace changes is a diminishing supply of registered nurses and registered practical nurses employed in the health system. There are not enough young, graduate nurses in full-time positions today to ensure there will be an experienced nursing workforce to care for Ontarians as the population ages and requires more care into the next millennium. Moreover, experienced nurses are reporting reduced job satisfaction and high levels of stress as workloads increase.

Nursing enrollments and graduations have decreased, and nurses report that they are leaving nursing in Ontario to go to other jurisdictions or to jobs outside of health care.

The quality and continuity of patient care is also being affected in many health care settings by a move to more casual and part-time nursing staff in an attempt to manage costs. Many nurses are working two or three casual jobs to make ends meet - often without the benefits that a permanent position offers.

These issues disproportionately affect Ontario women - both because the vast proportion of nurses are women and because traditionally women are the ones who care for family members who are ill or aged. This is exacerbated by the increased participation of women in the paid work force. Working women are often required to care for sick children or spouses or aged parents while trying to maintain a job that provides essential family income.

I didn't get into nursing to "bar code" people
- staff nurse

When I first came in (to the hospital) with a heart attack, I didn't know I was having a heart attack. The nurse came in, sat down on my bed, ... held my hand and said "no-one dies on my shift". She was great.
- health care consumer and a volunteer for heart attack survivor groups

Because of task-oriented nursing and the change in the acuity of patients, we are losing basic skills and not gaining the ones we require.
- staff nurse

Employers both inside and outside the health care sector see increases in absenteeism and requests for stress leave when work environments become too demanding or when insufficient nursing support for families stretch female care givers beyond their capacity.

As well, in an environment of significant advances in medical technology and treatments, nurses find themselves working in an increasingly "high-tech" world, while at the same time the need for their "high-touch" skills of assessment, monitoring, intervention, co-ordination, communication and compassion is more acute than ever before.

There are also issues about the level of education nurses need in today's changing health environment. Currently, RNs can receive either a three-year college diploma or a four-year baccalaureate in order to qualify for registration in Ontario. The College of Nurses of Ontario recently recommended that, in future, registered nurses will need a four-year baccalaureate degree as the standard for entry to practice.

Continuous learning and professional development opportunities for RNs and RPNs have been diminished as employers and nurses have had to focus primarily on the delivery of care with inadequate resources and very little time for continuing education.

It is within the context of this changing health care environment that The Honorable Elizabeth Witmer, Ontario's Minister of Health, established the Nursing Task Force to analyze a number of issues and to recommend solutions to address them.

These issues include :

  • finding ways to improve patient care through nursing services;
  • maintaining and enhancing a strong and continuing base of skilled nurses;
  • defining the role for nurses in a restructured health system; and
  • determining the educational qualifications nurses need in this changing environment.

Based on a thorough analysis of the existing research and wide-ranging discussions with, and submissions from, nurses, consumers, employers and other key stakeholders within the health care community, the Task Force has developed the following recommendations and established the following proposed timelines for their implementation.

Recommendations

A. Short-term: Six Months or Less

Recommendation 1:

To immediately enhance health care delivery through nursing services by stabilizing the nursing workforce and improving the retention of the existing nursing workforce, it is recommended that the Minister of Health :

Ensure that no further losses to aggregate professional nursing positions take place across all spectrums of health care delivery and immediately invest, on a permanent basis, $375 million to create additional permanent front line nursing positions before the Year 2000. The first $125 million of this investment should be made, no later than March 31,1999, to create additional permanent front line nursing positions across all sectors of the health care system.

It is further recommended that a specific portion of the $375 million be directed to the employment of trained and qualified nurse practitioners.

While there may be areas of urgent need for nursing services in the short term, the remainder of the investment ($250 million) will be determined by a method of funding nursing services that ensures health care consumers receive appropriate nursing care regardless of the setting in which it is received.
(See Recommendation 5)

Recommendation 2:

In order to improve patient outcomes and the level of nursing services provided to consumers, it is recommended that on-going structured opportunities be provided for RNs and RPNs to participate in a meaningful way in decisions that affect patient care on both a corporate and an operational level. In addition, health care delivery organizations must ensure that there is specific responsibility and accountability, at a senior management level, for professional nursing resources. It is recommended that this be achieved through amendments to relevant legislation.

It is also recommended that the Ministry of Health work with health care facilities and educational institutions to ensure nurses are prepared for their ongoing leadership roles.

Recommendation 3:

To ensure that nursing resources are available to health care consumers and are based on reliable, relevant and timely evidence, it is recommended that the Ministry of Health invest an additional $1 million annually for research to support a comprehensive nursing resource database. This database can be used to determine the appropriate number and skill mix of professional nurses and non-professional providers for optimal client outcomes.

Recommendation 4:

Continuity and quality of care are highly dependent on the retention of experienced and knowledgeable nurses and require not only a sufficient number of permanent positions for RNs and RPNs but also a working environment that offers flexibility and professional satisfaction. It is therefore recommended that employers of nurses mount pilot projects to test alternative models of nursing care (e.g. flexible hours, environments that enable nurses to develop clinical skills, etc.) and that these models be evaluated to assess the impact on client outcomes and the working environment for nurses.

In order to ensure ongoing access to continuity and quality of care by nurses in the community, and the recruitment and retention of nurses in this sector, it is recommended that the Ministry of Health, employers and nurses work together to address inequities remuneration of nurses for home nursing services.

To heighten awareness of the nursing profession and to encourage young women and men to choose a career in nursing, it is recommended that the professional nursing associations, with the support of the Ministry of Health, mount a comprehensive marketing and communications plan.

B. Medium-term: 6 to 18 Months

Recommendation 5:

To ensure that health care consumers have access to appropriate nursing services, regardless of the setting in which they receive them, the Ministry of Health must develop a comprehensive method of funding nursing services by November 1999. This funding method should be :

  • Responsive to the changing needs of the health care consumer;
  • Based on performance standards for nursing services that promote quality outcomes; and
  • Based on health information systems that provide comprehensive and reliable data on nursing services, workload and productivity.
Recommendation 6:

To ensure that decisions about nurse staffing and patient care are based upon the best information available, the Ministry of Health must ensure that information systems used for health care planning, delivery of services and funding provide comprehensive data on health care consumer status, nursing interventions and client outcomes. These information systems must include comprehensive and realistic information on nursing workload and productivity and should support client outcomes identified above.

Recommendation 7:

In order to ensure continued access to quality health care services, we must support our existing educated and experienced RN and RPN workforce and ensure that health care consumers continue to receive quality nursing services from professional nurses. In the future, to ensure professional nurses have the right mix of knowledge, skills and experience, the following is recommended :

a) Make the BScN the College of Nurses of Ontario (CNO's) minimum entry-to-practice requirement for new RNs beginning in the year 2005, consistent with the CNO's recent recommendation on RN entry to practice competencies, and confirm that all RNs registered with the CNO before that time continue to be eligible under the new system. 1

1 The College of Nurses of Ontario is the regulatory body for both registered nurses and registered practical nurses and is responsible for issuing certificates of registration for practice in Ontario.

b) Lengthen the college program for future RPNs from three to four semesters (pending completion of the CNO's work on competencies and education requirements for RPNs) and confirm that all RPNs registered with the COO before that time continue to be eligible under the new system.

c) Remove barriers and add financial incentives for partnering between community colleges and universities to provide relevant, accessible and portable education programs for RNs and RPNs.

d) Provide a flexible environment through financial incentives for nurses and their employers, to ensure timely and affordable access to continuing and advanced education. This flexible environment should include designated funds to support and facilitate continuing and advanced education for nurses, including sabbaticals, job exchanges, etc.

e) Establish clinical models in practice environments to allow nurses to gain expertise in clinical areas and be recognized for these additional skills.

f) Provide sufficient financial resources to employers to provide time and opportunities for experienced nurses to teach new nurses.

Recommendation 8:

To ensure that these recommendations are continuously reviewed, evaluated and adjusted, as required, to meet changing needs, we recommend that a process be established to monitor their implementation, effectiveness and outcomes. We further recommend that the Joint Provincial Nursing Committee be charged with this responsibility.


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Issues and Implementation

"It is timely for the Ministry to take stock of the effects that the changing conditions of health care delivery have had on nursing services and on the "health" of the profession as a whole. From the standpoint of CNO's central concern for protection of the public interest, it is a crucial undertaking.... In order to realize the full potential of its objectives, the work of the Nursing Task Force needs to be seen as an important first step in a renewed government commitment to the enhancement of quality client care through the effective use of nursing resources."
(College of Nurses of Ontario: Submission to the Nursing Task Force, November 1998.)

In developing its recommendations, the Task Force did a thorough analysis of the issues that gave rise to each recommendation; the mechanisms and resources required; the responsibilities that need to be assigned to ensure effective implementation; and the date by which each recommendation should be in place.

The Task Force arrived at its decisions based on evidence - from existing or commissioned research, and from what it heard from the key health care stakeholders, including nurses, employers and health care consumers.

Recommendation 1:

Issues:

Health care restructuring and fiscal pressures have reduced the permanent nursing workforce through the replacement of full-time nursing positions with part-time and casual positions and through the replacement of licensed nursing professionals with unregulated care providers.

There is an increasing body of research that links sufficient levels of nursing staff to improved patient outcomes. This is particularly evident among surgical patients who have shown a decrease in infections, pneumonia and other complications within settings where nurse staffing levels were above the average.

In addition, health care consumers have identified that a reduced nursing workforce with more casual and part-time nurses diminishes continuity of care and limits the amount of nursing care available.

It is the Task Force's view - based on the research and what it has heard from its stakeholder discussions that insufficient resources have been directed to the development of comprehensive primary health care in Ontario during the restructuring process. To help address this concern, there needs to be greater emphasis on health promotion and illness prevention and an increased reliance on professional nursing services, such as primary care nurse practitioners.

The Task Force has used a very broad measure (number of RNs per thousand population) to gauge the approximate investment needed to increase the critical mass of professional nurses in this province. Using the 1997 national average of RNs per 1000 population as a proxy, the overall investment required in nursing services (both RNs and RPNs) in Ontario is approximately $375 million. This is very close to the amount identified by the Registered Nurses Association of Ontario ($325 million) in its submission to the Premier in March of 1998.

The Task Force believes that there is a need to make a significant investment early in 1999, with the remainder of the funding to be provided before the Year 2000. As a result, the Task Force has determined that approximately one third of this overall investment needs to be made immediately, while a more thorough analysis of human resource needs, funding and information systems will guide the distribution of the remaining $250 million and longer term investments.

In addition, the Task Force believes that the system of primary health care in Ontario will be enhanced when Nurse Practitioners (NPs) are able to practice to their full extent. This has not been the case because of the lack of an appropriate funding mechanism; the lack of incentives for employers to include NPs in existing health care organizations; and the lack of flexible policies and regulations (e.g. the ability to admit patients to hospitals) to permit their full integration into the system.

Recommendation:

To immediately enhance health care delivery through nursing services by stabilizing the nursing workforce and improving retention of existing nurses, it is recommended that the Minister of Health :

  • Ensure that no further losses to aggregate professional nursing positions take place across all spectrums of health care delivery, and
  • Immediately invest, on a permanent basis, $375 million before the Year 2000 to create additional permanent front line nursing positions. The first $125 million of this investment should be made by March 31,1999 to create permanent and sustainable front line nursing positions across all sectors of the health care system. 2

    2 Approximately 7,700 RN positions required to bring Ontario up to 1997 national average of RNs per 1000 population.

    Assume 50/50 split between FT/PT
    = 3,850 FT positions @ $50,000 each = $192.5M
    = 3,850 PT positions @ $30,000 each = $115M
    Total (RN) = $307.5 million. Approximately :
    2,541 RPN positions (30% of RNs) @ 50/50 FT/PT
    = 1,270 FT @ 29,000 = $36.8M
    = 1,270 PT @ 20,000 = $25.4M
    Total (RPN) = $62.2M Grand Total (RN+RPN = $369.7M
    or approximately $375 million, with one third ($125 million) invested by March 1999.
  • It is further recommended that a specific portion of the $375 million be directed to the employment of trained and qualified nurse practitioners.
  • While there may be areas of urgent need for nursing services in the short term, the remainder of the investment in nursing services ($250 million will be determined by a method of funding nursing services that ensures health care consumers receive appropriate nursing care regardless of the setting in which it is received (see Recommendation 5).

Implementation:

The Task Force recommends that the Ministry of Health make an investment of $125 million no later than March 31, 1999 in areas of highest need and a further $250 million by December 31, 1999. Key nursing groups and employer groups should be consulted on appropriate investment areas.

Lead:
Ministry of Health

Timeline:
Flow $125 million by March 31, 1999 and a further $250 million by December 31, 1999.

Recommendation 2:

Issues:

Nurses are essential to providing health care and assisting consumers to make informed choices. Nurses often function as advocates, helping health care consumers better understand and use the health care system.

As the health system has been restructured according to financial targets, and health care delivery organizations have eliminated administration and management positions, the ability of nurses to be fully integrated into the decision-making process on matters that affect health care consumers has been diminished. This is particularly evident in the hospital sector where positions ranging from the "chief nursing officer" to "unit nurse managers" have been eliminated or the responsibilities for resource allocation have been removed from their portfolio.

Regulation 518 of the Public Hospitals Act includes a requirement that nurses participate on fiscal advisory committees. However, nurses report that there is considerable ambiguity among hospitals about the role and function of fiscal advisory committees and that the committees often lack a clear mandate, direction and integration with the on-going operation of hospitals. (Hiscott, R.D., Sharratt, M.T., Ontario Nursing Human Resources Data Centre, October 1991.)

Recommendation:

In order to improve patient outcomes and the level of nursing services provided to consumers, it is recommended that ongoing structured opportunities be provided for RNs and RPNs to participate in a meaningful way in decisions that affect patient care on both a corporate and an operational level. In addition, health care delivery organizations must ensure that there is specific responsibility and accountability, at a senior management level, for professional nursing resources. It is recommended that this be achieved through amendments to relevant legislation. It is also recommended that the Ministry of Health work with health care facilities and educational institutions to ensure nurses are prepared for their on-going leadership roles.

Implementation:

  • Amend the Public Hospitals Act and other relevant legislation to require that health care delivery organizations in every sector of the system designate a nursing professional(s) with authority and accountability for professional nursing practice, resource utilization and for decisions that affect the health care consumer.
  • Direct health care facilities and educational institutions to implement programs to prepare nurses for this leadership role.

Lead:
Ministry of Health

Timeline:
Fall 1999.

Recommendation 3:

Issues:

Only in recent years have resources been available for research on nursing services. However, to date, relatively minimal resources have been directed toward nursing services research, even though nursing services often consume the single largest portion of the budgets of health care delivery organizations. There is a need to further examine the relationship between nursing services and quality of health care.

There is also a need to undertake research to determine what type of practicing nurse and what mix of nursing skills will be required for the changing health care system, based on standards and outcomes of nursing care and the settings in which nursing care will be delivered.

While the Task Force was able to use a body of recent and emerging research, and particularly the work undertaken by the NRU, the overall paucity of research on RN, RPN and non-professional provider staffing patterns and health care outcomes in Ontario, limits the ability for comprehensive and detailed analysis of the effect on client outcomes of nursing staffing patterns.

Recommendation:

To ensure that nursing resources are available to health care consumers based on reliable, relevant and timely evidence, it is recommended that the Ministry of Health invest an additional $1 million annually for research to support a comprehensive nursing resource database. This database can be used to determine the appropriate number and skill mix of professional nurses and non-professional providers for optimal client outcomes.

Implementation:

  • The Ministry of Health to enhance funding to researchers and experts in the field of nursing resource allocation and planning.
  • This investment should be structured to take advantage of the existing research capability and partnerships in this province such as the NRU, the Institute of Clinical Evaluative Sciences (ICES), the Canadian Institute for Health Information (CIHI), and the Centre for Health Economics and Policy Analysis (CHEPA), among others.
  • The investment should be conditional on effective dissemination and regular reporting of findings to key stakeholder groups, such as employers, labour organizations and professional associations.

Lead:
Ministry of Health

Timeline:
Funding to be made available by Spring 1999.

Recommendation 4:

Issues:

The demographic profile of practicing nurses (average age 44), together with a decline in the number of students entering professional nursing programs - at a time when the need for nursing services appears to be growing - points to a potential shortage of RNs and RPNs in the future.

Indeed, the Nursing Task Force was advised that a number of long-term care facilities have a professional nursing staff with an average age of 59 to 60.

The working environment for professional nurses has deteriorated and, as a result, it is becoming more and more difficult to recruit young people, who often have a multitude of career choices, to the profession of nursing.

Nursing must be viewed as a viable and rewarding career in order to regenerate the profession to meet the needs for nursing services into the 21st century.

Recommendation:

Continuity and quality of care is highly dependent on the retention of experienced and knowledgeable nurses and requires not only a sufficient number of permanent positions for RNs and RPNs but also a working environment that offers flexibility and professional satisfaction. It is therefore recommended that employers of nurses mount pilot projects to test alternative models of nursing care (e.g. flexible hours, environments that enable nurses to develop clinical skills, etc.) and that these models be evaluated to assess the impact on client outcomes and the working environment for nurses.

To ensure ongoing access to continuity and quality of care by nurses in the community, and the recruitment and retention of nurses in this sector, it is recommended that the Ministry of Health, employers and nurses work together to address inequities in the remuneration of nurses for home nursing services.

To heighten awareness of a career in nursing and to encourage young women and men to choose a career in Nursing, it is recommended that the professional nursing associations, with the support of the Ministry of Health, mount a comprehensive marketing and communications plan.

Implementation:

  • Provide employers with necessary resources and tools to enable them to undertake pilot projects to test alternative models of nursing environments for RNs and RPNs and evaluate the impact on client care outcomes, professional satisfaction for nurses, and financial viability.
  • Develop tool kits for high school guidance counsellors, outlining opportunities for professional nursing.
  • Develop a program for practicing nurses to visit high schools and inform students about opportunities in nursing. Ensure that male role models are included in this initiative in order to tap into the potential interests of young men.
  • Develop an advertising and marketing campaign to heighten public awareness of the value of professional nursing services.

Lead:
Registered Nurses Association of Ontario (RNAO), Registered Practical Nurses Association of Ontario (RPNAO), Ministry of Health (MOH), Council of Ontario University Programs in Nursing (COUPN), Colleges of Applied Arts and Technology (CAATs)

Timeline:
Fall 1999.

Recommendation 5:

Issues:

Current funding formulas and guidelines for health care organizations vary across sectors and are not always equitable for health care consumers. This results in differing levels of nursing care in different health care settings, despite the fact that the health care needs of the consumer may be the same.

This situation has been exacerbated by a shift in responsibility for public health funding from the province to municipalities and the introduction of managed competition in the home care sector.

In order to ensure quality patient care it is critical that health care consumers receive the level of nursing services they require, regardless of the setting in which the care is delivered. This seamless continuum of care is contingent on a rational method of funding, which is guided by the needs of the client, rather than by historical funding inequities among health care agencies.

Recommendation:

To ensure that health care consumers have access to appropriate nursing services, regardless of the setting in which they receive them, a comprehensive method of funding nursing services should be developed by November 1999. This funding method should be :

  • Responsive to the changing needs of the health care consumer;
  • Based on performance standards for nursing services that promote quality outcomes; and
  • Based on health information systems that provide comprehensive and reliable data on nursing services, workload and productivity.

Implementation:

  • Establish a working group on funding, which would include comprehensive representation from various nursing sectors, to oversee this task.
  • Conduct an inventory of existing funding mechanisms for nursing and other health services to determine appropriate measurements. Identify any gaps in measurement.
  • Manage this project in parallel with work on nursing information systems. (see Recommendation 6)
  • Develop a new method of funding nursing services that ensures that health care consumers receive the level of nursing care they require, regardless of the setting in which the care is delivered. (This should be done in conjunction with nursing information system work, outlined in recommendation 6).
  • Ensure consultation and linkage with other key stakeholders.

Lead:
Ministry of Health

Timeline:

  • Minister to establish working group by February 1999, with expert representation from across the health care sector.
  • Model for funding nursing services to be developed by November 1999.
Recommendation 6:

Issues:

An investment in nursing services should demonstrate tangible paybacks across the health care system in the form of improved health outcomes and healthy communities. In recent years, many of the decisions related to nursing services and the nursing workforce have been driven by financial benchmarks and fiscal pressures rather than by health care outcomes. This is due in part to an absence of comprehensive information systems that accurately capture the relationship between nursing services and patient outcomes.

The ability of nurses to provide sound advice on the impact of nursing services on health care consumers depends on the availability of comprehensive, consistent and reliable data. In some sectors, such as long-term care, considerable work has been done on linking the needs and acuity of residents to the resources available for nursing services. In other sectors, such as home care, the data on nursing workload and consumer outcomes is inconsistent, incomplete, and in some cases, non-existent.

Recommendation:

To ensure that decisions are based upon the best information available, information systems used for health care planning, delivery of services and funding must provide comprehensive data on health care consumer status, nursing interventions and client outcomes. These information systems must include comprehensive and realistic information on nursing workload and productivity and should support client outcomes identified above.

Implementation:

  • Identify in each key sector of health care, the current status of information systems that are used to inform decisions about funding, staffing for professional nursing services and consumer outcomes.
  • Establish a working group to build on systems that are relatively well developed, and determine suitability for application across the spectrum of health care facilities where nursing services are provided. The working group should include resources from Joint Provincial Planning Committee (JPPC), Canadian Institute of Health Information (CIHI), Nursing Effectiveness, Utilization and Outcomes Research Unit (NRU), and nursing organizations.
  • Make seed funding available to support on-going data development and establishment of pilot sites for data collection and information system development.

Lead:
Ministry of Health

Timelines:
Establish working group by February 1999, with a report on potential pilot sites by June 1999.

Recommendation 7:

Issues:

A majority of stakeholders support the need to make the BScN the basic educational preparation for RNs in Ontario, rather than the current system of both a three-year diploma and a four-year university baccalaureate. The College of Nurses of Ontario (CNO) recently recommended that in future registered nurses should have a four-year baccalaureate degree as the standard for entry to practice.

RPN education in Ontario must be based on a consistent model, which ensures that educational requirements are sufficient to meet the needs of health care consumers. COO will recommend on core competencies and required education for RPNs in the summer/fall of 1999.

Several barriers, but primarily funding, currently hinder collaborative baccalaureate nursing programs between colleges and universities. Due to differences in funding mechanisms, collaborative programs can result in reduced funding for infrastructure, teaching, faculty and clinical opportunities. Other barriers include governance and human resources issues.

As the health care environment continues to change, there needs to be greater emphasis on continued and advanced education. Nurses are caring for patients with more complex conditions and ailments. There is also a shift to more community-based treatment and independent practice, and new and emerging technologies are making a greater impact than ever before on health care.

At the same time, continuing education and professional development opportunities have been reduced' and' as a result of fiscal constraint, there are limited opportunities for employers to recognize special skills and training of nurses.

Recommendation:

In order to ensure continued access to quality health care services, we must support our existing educated and experienced RN and RPN workforce and ensure that health care consumers continue to receive quality nursing services from professional nurses. In the future, to ensure that professional nurses have the right mix of knowledge, skills and experience, the following is recommended :

  • Make the Bachelor of Science in Nursing (BScN) (or equivalent), the College of Nurses of Ontario (CNO) minimum entry-to-practice requirement for new RNs beginning in the year 2005, consistent with the CNO's recent recommendation on RN entry to practice competencies, and confirm that all RNs registered with the CNO before that time continue to be eligible under the new system.
  • Lengthen the college program for future RPNs from three to four semesters (pending completion of the CNO's work on competencies and education requirements for RPNs) and confirm that all RPNs registered with the CNO before that time continue to be eligible under the new system.
  • Remove barriers and add financial incentives for partnering between community colleges and universities to provide relevant, accessible and portable education programs for RNs and RPNs.
  • Provide a flexible environment through financial incentives for nurses and their employers, to ensure timely and affordable access to continuing and advanced education. This flexible environment should include designated funds to support and facilitate continuing and advanced education for nurses, including sabbaticals, job exchanges, etc.3

    3 Estimate of financial resources required on an annual basis - $100/per employed RN/RPN = $14 million

  • Establish clinical models in practice environments to allow nurses to gain expertise in clinical areas and be recognized for these additional skills.
  • Provide sufficient financial resources to employers to support the ability of experienced nurses to teach new nurses.

Implementation:

For subsection a):

  • Review CNO recommendation on competencies and education requirements.
  • Establish a working group with key stakeholders to develop an implementation plan, including changes to regulations, appropriate funding mechanisms, education program evaluation and assessment, and RN supply requirements.

For subsection b):

  • Await CNO recommendation on competencies and education requirements for RPNs.
  • Establish subcommittee of working group, identified in subsection a, to develop an implementation plan.

For subsection c):

  • Working group, identified in subsection a, to develop a model and implementation plan for collaboration on basic education for RNs and advanced and continuing education for RNs and RPNs. The model will identify funding, the regulatory and organizational barriers to be removed, and the resources required to implement it.

For subsection d):

  • Establish an incentive fund that both nurses and employers can access to support continuing and advanced education for nurses.

For subsection e):

  • Nurses and employers will collaborate on proposals to access resources based on established criteria to be developed by the working group, identified in subsection a, to work with RNAO, RPNAO, CNO and other professional associations, labour organizations and educational institutions to identify and implement potential clinical models that will enhance patient care and improve nursing work life.

For subsection f):

  • Availability of financial resources to be tied to investments made in Recommendation 1.

Lead:

For subsection a), b), and c):
MOH, Ministry of Education and Training (MET), College of Nurses of Ontario (CNO)

For subsection d):
MOH

For subsection e):
Employers , RNAO, RPNAO, lab our organizations

For subsection f):
MOH

Timeline:

For subsection a):

  • CNO recommendations delivered in December 1998.
  • Establish working group in February 1999 to plan for first intake of BScN-only students by 2002.

For subsection b):

  • CNO recommendations are expected June to October 1999.
  • Establish subcommittee of working group, referenced in subsection a, in the Fall of 1999.

For subsection c):

  • Establish a specific working group in February 1999 to report by Fall 1999.

For subsection d):

  • See Recommendation 5.

For subsection e):

  • Clinical models to be established by Fall 1999.

For subsection f):

  • See recommendation 1.
Recommendation 8:

Issues:

An on-going monitoring process needs to be established to ensure that the Task Force's recommendations are properly resourced, are implemented in a timely fashion, and are continuously evaluated for their effectiveness and desired outcomes.

Recommendation:

To ensure that these recommendations are continuously reviewed' evaluated and adjusted' as required, to meet changing needs, we recommend that a process be established to monitor their implementation, effectiveness and outcomes. We further recommend that the Joint Provincial Nursing Committee be charged with this responsibility.

Implementation:

  • The Minister mandates the Joint Provincial Nursing Committee (JPNC) to be responsible for monitoring the implementation of the Task Force's recommendations and the evaluation of their effectiveness.
  • The JPNC reports regularly to the Minister on the progress of implementation and if the recommendations are achieving the desired outcomes. It also suggests adjustments and enhancements, as required.

Lead:
JPNC

Timeline:
On-going, with quarterly reports to the Minister.


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Key Findings : Our Research and Stakeholder Discussion

"Nursing services in Ontario are undergoing dramatic change as health care moves away from institutions and into the community, as medical and information technology continue to evolve, and as fiscal pressures force providers to redefine how they deliver health care. Much of this change has significantly diminished the quality of patient care that nurses can deliver, and the growing nursing shortage - quickly reaching crisis proportions - will only further erode the situation."
(Submission to the Nursing Task Force, November, 1998: George Brown College, The Change Foundation, The Ontario Hospital Foundation.)

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The Financial, Demographic and Research Context

Health Care Spending

Throughout much of the 1990s, the environment for nursing services has been buffeted by a multitude of pressures, including fiscal restraint measures by all levels of government, the reform and restructuring of the health care system, the aging of our population, and the increasing acuity of patients in care.

In the early 1990s, the provinces began to restructure their health care systems, reorder priorities, and focus on reinvesting savings in new and emerging priorities. These actions are reflected in Canada's total health care spending patterns over the five-year period, 1992-97.

The reduction in federal transfers to the provinces of about $6 billion in the early 1990s created significant challenges for Ontario. During that period total public sector spending on health care in Ontario - which includes spending by all levels of government, plus government agencies - was reduced significantly from the double-digit percentage increases that were commonplace in the 1980s.

The importance of the federal government's role in health care funding is recognized by the Canadian Nurses Association, which recently submitted a brief to the federal Minister of Finance. The proposal, entitled "The Quiet Crisis in Health Care," recommends that the federal government commit $40 million a year for five years for recruitment, retention and research in the nursing profession.

In recent years, the overall Ontario Ministry of Health budget has increased (from $17.6 billion in 95/96 to $18.7 billion forecast for 98/99) in response to increased needs for health care and population growth. However, when total public sector spending on health care in Ontario is analyzed on a per capita basis, the figures show a decline between 1992 and 1997 - $1,887.76 in 1992, compared to 1997's forecast figure of $1,766.52 (Canadian Institute of Health Information, 1998). While the 1998 forecast shows the first increase in per capita spending in five years, up 3.4 per cent to $1,826.82, it is unclear what proportion, if any, of this increased spending will be directed to professional nursing services.

Total Public Sector Health Spending per capita, Ontario, 1992 to 1998

Source: Canadian Institute for Health Information (CIHI)
Public Sector: includes all government spending
f: forecast

If per capita spending by the Ontario government alone is calculated, the CIHI figures show a similar level of decline between 1992 and 1997 - $1,764.37 in 1992, compared to the 1997 forecast of $1,651.77. Again, the 1998 forecast indicates an increase in per capita spending, up 3.8 per cent to $1,714.62

According to its 1998-99 business plan, the Ontario Ministry of Health spends approximately 50 per cent of its $18.68 billion operating budget on hospitals (including nurses) and 30 per cent on the services of physicians and other providers (excluding nurses).

The remaining 20 per cent is spent on community services, (including nurses) for such items as long-term care facilities and home care, as well as other diagnostic services, therapies, devices and drug programs.

Based on planned expansions in the long-term care sector, spending on community services will increase as more than 20,000 new long-term beds are added to the system. It's estimated that by the year 2006, 100,000 more people will receive care at home than do currently.

The fiscal pressures of the 1990s have had a significant impact on the nursing profession since the approximately 140,000 professional nurses make up the single largest group of front line health care providers in Ontario. Based on a recent report by the Canadian Institute of Health Information, in 1997 Ontario had the lowest ratio of employed RNs per 1,000 population of all Canadian provinces.

Our Aging Population

While Ontario's total population grew by almost 11 per cent between 1986 and 1991, and by almost seven per cent between 1991 and 1996, the comparative rates for residents 65 and older, and 75 and older, grew by almost twice as much.

Between 1986 and 1991 the percentage of people 65 and older grew by 19 per cent, and by 13.1 per cent between 1991 and 1996. When those figures are calculated for the very elderly - those 75 years and older the percentages were 20.1 per cent between 1986 and 1991 and 15.5 per cent between 1991 and 1996. These statistics highlight the aging of Ontario's population, and the impact this is having - and is projected to have - on Ontario's health care system over the coming years.

"The potential implications for the health care system of the current and future population distribution in Ontario are considerable," states a report prepared for the Nursing Task Force by the NRU at the University of Toronto and McMaster University in Hamilton.

"The 1994 per capita health expenditures for those more than 65 ... were more than four times those for the 45 to 64 year age group," the report adds

Population of Ontario by 5-Year Age Groups, 1996

Statistics Canada figures indicate that within the next 10 to 15 years approximately 1.5 million Ontarians currently between the ages of 50 and 65 will move into the elderly population group and become much greater consumers of our health care resources.

Health System Restructuring

Health system restructuring has had an impact in a number of areas, but it has been best documented in the use of hospital services.

For example, the number of days spent in Ontario hospitals declined by 19 per cent since 1990, while the number of beds declined by about 29 per cent over the same period.

Occupancy rates have remained stable at about 80 per cent for acute and psychiatric beds, and 95 per cent for chronic beds. In contrast, out-patient surgeries continued to increase.

An Ontario Hospital Association report released in October 1998 indicated the average length of stay in acute hospitals has decreased to 6.4 days in 1997/98 from 8.2 days in 1989/90. This is occurring at a time when it is generally recognized that patients in the hospital system are in greater need of acute care.

As the shift to community-based care has grown, home care admissions have risen substantially - up by 44 per cent between 1988/89 and 1995/96 - while nursing homes and homes for the aged are also seeing an increase in the complexity of the health care needs of their patients. This latter fact is evidenced in the growth in the number of residents requiring higher levels of care within both nursing homes and homes for the aged.

Changes to mandatory programs and guidelines and the shift of funding responsibility to municipal governments from the province have affected the public health sector.

In a submission to the Task Force from the Association of Nursing Directors and Supervisors of Official Health Agencies, a recent survey indicates that in some public health units, the number of public health nurses has decreased by approximately 50 per cent between 1988 and 1998.

While some of the changes in public health support population-focused health promotion activities, such as the Healthy Babies, Healthy Children initiative, there are concerns about the elimination of services, such as counseling, prevention and promotion, and education to the most vulnerable members of the community.

It is the Task Force's view - based on the research and what it has heard from its stakeholder discussions that insufficient resources have been directed to the development of comprehensive primary health care in Ontario during the restructuring process. To help address this concern, there needs to be greater emphasis on health promotion and illness prevention and an increased reliance on professional nursing services, such as primary care nurse practitioners.

Consumer Impacts

The subject of RN, RPN and unregulated care provider staffing patterns in Ontario, and the relationship to consumer outcomes is one, that to date, has not been well researched in Ontario. However, during the deliberations of the Task Force, more Canadian and U.S. research was starting to emerge that illustrates trends towards nursing staff shortages and negative outcomes for health care consumers. It should be noted that most of this research focuses on the relationship between RNs and consumer outcomes.

U.S. research points to negative health care consumer outcomes as a result of reductions in nursing staff. "The State of Nursing Practice in Ontario", produced for the Task Force by L. O'Brien-Pallas and A. Baumann of the NRU, identified several studies that relate patient outcomes to nurse staffing levels.

A study of four U.S. hospitals identified that an increase in absenteeism among registered nurses could be linked to an increase in the rate of infections contracted by patients while in hospital due to fragmented staffing that disrupted continuity of care and diffused accountability for patient care. (Taunton, Kleinbeck, Stafford et.al., 1994).

Another recent U.S. study examined 506 hospitals in 10 states and found that surgical patients in hospitals with more registered nurses were less likely to get infections, pneumonia and other complications. (Kovner, C. and Gergen, P., December 1998). Similarly, a 1988 study linked nurse-staffing shortages to longer hospitalizations and increased patient complications.

Most of the research focuses on RN staffing levels and the impacts of using personnel other than registered nurses to provide front line nursing care. In a number of institutions and organizations in Ontario, unregulated care providers are performing patient care responsibilities, which are appropriate for registered nurses or registered practical nurses. While it is recognized that unregulated workers can contribute to the maintenance of the health care environment and can contribute to the personal care of health care consumers, an enhanced skill mix - a greater proportion of nursing professionals - is required to provide direct nursing care in an increasingly complex environment.

The recent Ontario Hospital Association Report Card (Nov. 1998) reveals that 50 per cent of hospital patients perceive that staffing adequacy is "poor or fair". The College of Family Physicians of Canada recently published a survey that reveals almost 70 per cent of the family physicians who responded feel the health or well-being of their clients is adversely affected by inadequate or delayed access to home care and in particular nursing services.

Anecdotal evidence and information provided to the Nursing Task Force through discussion groups with consumers highlighted the stress and pressure being placed on the nursing profession today. Increasingly, consumers feel that they are responsible for managing their access to health care today where previously they could rely on a nurse, as the coordinator of their health care needs.

In addition, recent recommendations from several coroner's juries have pinpointed the need for an appropriate number or "safe ratio" of nurses in emergency wards and other hospital units, as well as the need for trained professionals (such as nurses) to assess and triage patients, and for nurses to receive on-going education and training. (Office of the Chief Coroner, September 1998 and December 1998.)

Impact on the Nursing Profession

Restructuring and fiscal restraint have focused largely on cost reduction and have involved downsizing of the nursing workforce, replacement of licensed professionals by unregulated health care workers and reductions in the number of permanent positions for nurses. In addition, there has clearly been a shift to casual positions from permanent positions in both the hospital and community sectors.

While there are some studies starting to emerge in Canada about the impact of health system reform on health care professionals, to date there has been little conclusive evidence. However, in other jurisdictions the impact is clear. A 1997 Finnish study established a link between downsizing and medically certified sick leave, with absentee rates for nurses and other health professionals two to three times greater after a major downsizing than after a minor one.

Emerging research from the U.S. suggests that downsizing of professional nursing staff end the hiring of unregulated workers lead to a reduced quality of work life for nursing personnel. Concerns included increased workload and stress, reduced morale, reduced job security and satisfaction, and lower professional and organizational commitment.

Between 1992 and 1997, there has clearly been a shift of RNs to casual positions from permanent positions in both the hospital and community sectors, while RPNs have experienced a significant decrease in full-time employment and a slight decrease in casual employment in the same period. There was, however, a marked increase in RPNs working part time during that period.

The competitive model, introduced into the community sector several years ago, has had profound effects on the delivery of nursing services to clients in their homes. This model allows both for-profit and not-for-profit providers of home care services to bid on contracts with regional Community Care Access Centres. Bids are intended to be based on a combination of quality and cost, although home care nurses have identified specific problems in home nursing services such as increased turnover among community nurses and considerable downward pressure on salaries.

This practice has created significant inequities in compensation for nurses in the community sector compared to the hospital sector. Hourly rates for RNs providing home nursing services range from approximately $16 to $23, versus a range of approximately $19 to $28 per hour in hospital settings (verbal communication with Ontario Nurses Association, January 1999). The prospect of significantly reduced compensation in the home care sector serves as a deterrent for experienced hospital nurses to seek work in the community. It also discourages recent nursing graduates from pursuing a career in the sector of the health system that will experience the most growth over the next decade.

Providers of home nursing services express concern about the lack of continuity of care, fragmentation of care as unregulated workers take on more nursing responsibilities, and reduced amount of time per visit. Moreover, the Task Force is concerned that nursing services are experiencing considerable pressure in a sector that is forecast to grow significantly over the next decade.

Since nurses constitute the largest group of front line health care workers, they are often most affected by fiscal constraint and downsizing. Nurses contend changes in the health care system have made nursing very task focused, resulting in lost continuity of care. In many cases, this task-focused approach is exacerbated by increasing nursing workloads, resulting from a lack of sufficient resources and having to care for patients who are sicker.

One of the major challenges of restructuring is redeployment or assignment of health care personnel to jobs for which they have not been adequately trained. This occurs when nurses are redeployed to settings where they have no clinical expertise or theoretical knowledge, or in those cases where unregulated workers are assigned functions previously performed by nurses.

Re-engineering and restructuring have reduced nursing positions that support the educational and clinical practice development of nurses. A number of agencies have eliminated the senior nurse executive position on their senior management team, along with nurse managers and other middle management positions. Consequently, nurses are experiencing heavier workloads, and more acute and complex problems with fewer educational opportunities and less supervisory support.


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The Nursing Profession

The Demographics of Nursing

A 1998 study by the Canadian Institute of Health information revealed Ontario has fewer RNs per capita than any other province - 6.9 per 1,000 people versus a national average of 7.6 per 1,000. In addition, more than half of all professional nurses are employed on a part-time or casual basis.

A recent study by the Canadian Nurses Association pointed to an impending shortage of as many as 113,000 RNs across Canada by the year 2011. These and other studies have raised concerns about the future supply of professional nurses in this province.

The vast majority of nurses in Ontario are female, with an average age among both RNs and RPNs of 44. The largest age group in the nursing workforce is between 45 and 49 and almost half of all working nurses are over 45.

Number of RNs and RPNs Working in Ontario by Age, 1998

Nurses under age 30 are also increasingly employed in part-time or casual positions, with the majority of both RNs and RPNs aged 20 to 24 seeking more work in nursing in Ontario. The following analysis presents a comprehensive overview of the supply of professional nursing resources - both RNs and RPNs - in Ontario. It is based primarily on registration statistics from the College of Nurses of Ontario.

Nursing Supply and Demand

While Ontario's population increased by almost 25 per cent between 1981 and 1997, the number of RNs registered with the CNO increased by about 12 per cent. The number of RPNs registered with the CNO rose by about 2.6 per cent. In more recent years the overall supply of both RNs and RPNs per 1000 population has been declining.

Number of RNs and RPNs per 1000 Population in Ontario 1992-1 997

Since 1994, there has been a four-per-cent decline in the supply of RNs, and a five-per-cent decrease in the supply of RPNs. This decline is occurring at a time when the demand for nursing services is on the increase, as evidenced by trends such as the 44-per-cent increase in home care admissions from 1988 to 1995. On average, about 81 per cent of RNs and RPNs eligible to work in Ontario currently do so, and this figure has been relatively stable since the early 1990s.

There has been an increase in the number of RNs moving to community-focused positions in home care, public health or community health centres since 1992. As well, others have moved to work in physicians' offices, education, government and occupational settings, or are self-employed.

This number still accounts for less than five per cent of the total number of RNs working. The same is true of RPNs who have made modest gains in the long-term care and community sectors.

At the present time, slightly less than half of the RNs and RPNs in Ontario report full-time employment, while the remainder work part-time or on a casual basis.

The Task Force heard frustration from both nurses and consumers about the lack of continuity caused by this greater reliance on casual workers. Patients have identified their concerns about seeing a "new face" each shift during the course of their nursing care.

While the 20 to 29 age group represents a small portion of the total nursing population, among RNs it is he most likely to be working outside of Ontario, and among both RNs and RPNs has the highest percentage of casual employment.

An October 1998 report by the C.D. Howe Institute notes that trends in emigration patterns of skilled professionals in the 1990s are cause for concern. The report noted that the number of RNs emigrating from Canada to the U.S. in 1993/94 represented the equivalent of 40 per cent of the 1991 nursing graduating class. While this rate is calculated by using only graduate baccalaureate nurses as a denominator, it nevertheless supports observed trends in the employment opportunities for nurses.

The C.D. Howe report points to the cost to the economy of this migration, both in terms of the value of educational investments and the "churning costs" of having to replace skilled emigrants. Although in-migration of nurses from other provinces and countries has added considerably to the supply of nurses each year, since 1992 there has been a gradual decline in the immigration of nurses to Ontario.

Since the early 1990s there has also been a steady and significant decrease in the number of students enrolled in both RN and RPN programs. First-year enrollment in community college RN programs declined by almost a third from 1993 to 1996, while first-year RPN enrollment declined by almost 17 per cent over the same time period.

In the same period, there was a decline of almost eight per cent in RN graduates and almost 13 per cent in RPN graduates from community college programs. Although the number of RN graduates from university programs increased by slightly more than 10 per cent over the same time period the combined number of RNs graduating from both college and university programs declined by five per cent between 1993 and 1996.

Based on an average age of retirement of 56, and not accounting for recruitment into the profession, approximately half of Ontario's current supply of nurses will retire by 2013.

In an October 1998 report analyzing nursing personnel in Ontario, the Nursing Effectiveness, Utilization and Outcomes Research Unit assessed the issue this way:

"In reviewing both the research-based and anecdotal information, it is apparent, given the present trends, that there is a complex issue of supply and demand for nursing personnel in the province of Ontario"

"...Without a doubt," the report added, "the distribution of the aged population of nurses in Ontario, the shrinking pool of registered nurses, the decreasing applicant pool, and shifting practice of employment and utilization are all changing the face of nursing in Ontario"

How Nursing Resources Are Used

The analysis of nursing utilization in the hospital sector is based on paid hours per patient day, since this is a variable that has been reported consistently to the Ministry of Health over the 1983-1996 period.

With the change in nursing information systems in 1994, it is no longer possible to differentiate paid hours by the type of caregiver. There is no breakdown, for example, among paid hours for RNs, RPNs or unregulated care providers.

From 1994 to 1996, while the number of paid nursing hours increased steadily, the number of paid hours for services such as housekeeping, patient transport and dietary services declined. Over the same time period there was also a reduction in the number of head nurse and administrative positions in nursing services.

Both these factors - plus an increase in the use of casual staff- may help account for increased workload and increased hours of patient care in hospitals. The home care sector has also seen significant growth over the same time period evidenced by the fact that the number of nursing visits to chronic care patients increased by 80 per cent between 1988 and 1996.

Despite this rapid and apparent increase in demand for nursing services, data from the College of Nurses of Ontario suggests that since 1992, there has only been a three-per-cent increase of RNs and RPNs reporting employment in the community sector.

"Future studies will examine the questions of what level of nursing personnel is currently meeting the (community-based) need and what level of provider should be meeting the need," the NRU stated in an October 1998 report analyzing nursing personnel in Ontario.

Between 1994 and 1997, the long-term care sector has seen an increase in the number of residents classified into higher intensity classification categories. Ontario Ministry of Health statistics indicate there have been overall increases in the intensity of needs related to aggressive and anxious behavior and ingestion of foreign substances.

While these and other conditions would seem to require a greater demand for skilled nursing services, since 1992 the growth in RNs working in this sector has been only about two per cent, and about five per cent for RPNs.

The majority of those working in the long-term care sector are still unregulated care providers - this is largely due to different methods of funding various health care agencies such as nursing homes, hospitals and Community Care Access Centres.

Nursing Workloads and Skill Mix

Employers in Ontario have used a variety of different workload and skill mix models. They range from employing all RNs to using a majority of unregulated care providers with minimal professional nursing staff. Typically, acute-care hospitals employ mostly regulated providers (RNs and RPNs), while the percentage is much less for the long-term care sector.

Research for the Task Force by the NRU found that a decrease in support services, such as housekeeping, has a cumulative effect on nursing workload and hours of care on any given day. As hospitals redesign work processes to reduce costs, the research continued, "models that decrease the support services to nursing in hospitals ... seem to be associated with increased hours of care for nursing services."

A recent home care study examined the factors that influence service utilization and client outcome in a sample of clients receiving home care. The study "demonstrated that a greater nursing skill level, as measured by registration status (RN/RPN) and education level (baccalaureate/no degree) was associated with fewer visits, a perception of adequate time for care, improvement in (patient) health status and improvement in patient knowledge and behaviour related to health condition." (O'Brien-Pallas, 1998)

Another contributing factor is that nurses are finding themselves dealing with patients - both in hospitals and home care - who seem to be sicker and have more complex conditions than in the past. Moreover, hospital stays are shorter, and patients, some of whom still require significant levels of care, are increasingly being looked after in the home.

An October 1998 report from the NRU said "anecdotal evidence suggests that in the last year and half, clients moving into the community are more complex than ever before. ...Increased complexity is anticipated as more clients, traditionally treated in hospital, are treated at home."

In the public health sector, a number of concerns have been raised about the changing role of nurses in the community, and they were categorized in a submission to the Task Force by the Community Health Nurses' Interest Group of the Registered Nurses Association of Ontario.

Chief among the group's concerns over the past decade were reductions in the number of public health nurses and a narrowing of their focus; substantial reductions in services to vulnerable groups such as school-age children, elderly people, and persons with mental illness; and elimination of nursing managers' positions.

As well, the group cited the need for change in the delivery of such community-based programs as home care, calling for changes to the current system "in order to promote quality care, client and nurse satisfaction, and the on-going viability of visiting nursing."

Basic and Continuing Education

Nurses, employers and patients all highlight the need for greater emphasis on continuing education, given the rapidly changing work environment. Although many nurses have knowledge that is relevant and can be transferred to a new position, learning needs differ from unit to unit and they must acquire new knowledge and adapt to new policies, different techniques and new cultures.

As nurses find themselves caring for sicker patients, dealing with the shift to greater community-based health care, and the impact of new and emerging technologies, it is a challenge for many to ensure that their skills and knowledge keep pace with changing job requirements.

Education and training budgets have been reduced and opportunities to participate in continuous learning are not as readily available, due to both time and money constraints. Access to education is a particular problem for nurses in small urban centres and rural and northern locations, and language has been identified as a barrier for some nurses in certain regions of the province.

As part of restructuring, middle-management nursing positions have been eliminated, meaning there is less support and guidance for front line nurses from supervisors who understand their job challenges from a nursing perspective. The supervisory span of control within nursing has increased considerably and the traditional mentoring and coaching role played by the nurse supervisor is no longer available for the staff nurse.

The Joint Provincial Nursing Committee (JPNC), made up of representatives from key nursing organizations and the Ministry of Health, has completed an operational plan to implement nursing education reforms, which recommend baccalaureate entry for RNs and enhanced education for RPNs. The underlying principle is that increased knowledge will provide improved patient outcomes.

In addition, in mid-December 1998, the Council of the College of Nurses of Ontario, the regulatory body for RNs and RPNs, recommended that, in future, new RNs would require a baccalaureate as the minimum education standard for entry to practice in Ontario. The Nursing Task Force supports the JPNC operational plan and endorses the recommendations of the CNO.

Results of the Task Force's discussion groups indicate that both employers and staff nurses realize that opportunities must be provided in the workplace for RNs and RPNs to acquire the knowledge and skills they need to address the future health needs of Ontarians.

Nurses and the Decision Making Process

A common theme in both the discussion groups and submissions to the Task Force is the balance that's required between managing costs and providing quality patient care. Nurses strongly believe that quality and effective patient care must be a key element in the business and performance management decision-making process.

Nurses view their role as the coordinator of care for the patient and believe their services should be viewed as an investment with tangible paybacks across the health care system. In their joint submission to the Nursing Task Force, George Brown College, The Change Foundation, and The Ontario Hospital Foundation emphasized this point :

"Nurses are essential to providing patient care.   ...Nurses are, in fact, facilitators who empower patients to make informed choices about their health care. And nurses are advocates who help patients negotiate their way through the health care system."

In addition, both nurses and employers have identified the importance of restoring nurse leadership positions in health care delivery organizations. To be effective, these positions must have authority and accountability for nursing resources, quality and practice at the most senior decision-making level.

Further, the ability of nurses to provide sound and informed advice to employers is dependent on the availability of comprehensive information systems to measure nursing workloads, patient outcomes and effectiveness of nursing care.


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Listening to Healthcare Stakeholders

Background

A major part of the Task Force's mandate was to seek out and hear the views and ideas of key stakeholders within the health care system, including nurses, nursing students and educators, employers and consumers.

To this end, a series of discussion groups was held in five Ontario centres, between mid-October and late November 1998.

The first round of these discussion groups was conducted between October 19 and October 22, involving nurses, consumers and employers of nurses. A total of 59 people participated :  25 staff nurses (12 in Ottawa and 13 in Sudbury); 11 health care consumers from the Greater Hamilton area; and 23 senior representatives of organizations that employ nurses (10 in Ottawa and 13 in Sudbury).

On November 18, 42 people in Thunder Bay participated in three discussion groups - one with nurses, one with nursing students and educators, and one with employers of nurses. Although most participants were selected at random, health care organizations and nursing associations referred some as well. Student participants were recruited through university and community college faculty.

In both cases, group composition allowed for the participation of a broad representative group of nurses, consumers and employers of nurses from all health care sectors - hospitals, long-term care facilities, public health, nursing organizations and community-care services.

Registered nurses, nurse practitioners and registered practical nurses were represented in the nursing discussion groups. Students enrolled in both RPN and RN university and community college nursing programs participated in the sessions.

During the week of November 23, five sessions were held in Toronto to consult with key stakeholders on the Task Force's preliminary recommendations.

The Nurses' Viewpoint

The ability to provide quality patient care was the primary desire of the nurses who participated in the discussion groups. However, they indicated they face a number of barriers, including heavy workloads as a result of the increased acuity of patients, the nurse-to-patient ratio, and the elimination of the front line nursing supervisors.

Many said the current focus on task-specific versus holistic nursing has affected patient care, and is adding to their own stress levels and contributing to increased stress for the families and loved ones of those in care.

The "lack of a nursing voice" on the boards and senior management teams of many health care organizations continues to give rise to the issue of "marginalization".

Another major concern cited is the trend toward eliminating full-time nursing positions in favour of part-time or casual jobs. This has resulted in some nurses working two or more jobs to make the equivalent of a full-time wage to support themselves and their families.

Getting the education and professional development required to continue to deliver quality patient care was cited as one of the main challenges the nursing profession faces today.

Most nurses felt that opportunities to participate in continuous learning are not available and are jeopardizing their ability to provide quality patient care. Access to education and professional development is a particular problem for nurses in smaller urban and rural areas of the province.

Most participants felt that health care funding needs to be improved - particularly for home care - and rationalized. Nurses see that part of the solution is to break down the barriers between organizations within the health care system and have consistent policies and rules for utilization of resources.

Nurse Practitioners felt that they have a vital role to fill, particularly in areas where there is an under-supply of family physicians. However, the lack of funding; incentives for employers to include NPs in existing health care organizations; and flexible policies and regulations (e.g. the ability to admit patients to hospitals) prevent their full integration into the system.

In summary, nurses saw their role as the coordinator of care for the patient and believed that their services should be viewed as an investment with tangible paybacks across the health care system as a whole.

The Employers' Viewpoint

Generally, participants representing organizations who employed nurses were concerned about the same issues as staff nurses and health care consumers. These include patient care and managing patient expectations, access to nursing services, doing more with less, and the education and professional development of nurses.

Like nurses, employers reported that the complexity of care is increasing as resources are declining.

The restructuring of the health care system, they indicated, has created the opportunity for health care facilities to work more cooperatively. It has also led to an increase in the customer/client focus, and has resulted in new strategic partnerships among health care agencies.

However, some participants spoke of the consuming focus of senior management on managing workplace stress and morale as a result of on-going restructuring - pending closures, relocation of staff to other facilities, end privatization of home care nursing, etc. As a result, they indicated a decreased focus on forward planning and a greater concentration on managing the immediate issues created by change.

Most employers have reduced full-time nursing positions in favour of part-time and casual labour; eliminated nurse supervisory positions; and implemented task-focused nursing, due to budget constraints. Most participants, however, reported maintaining full-time positions in specialty areas.

While many of these decisions have reduced costs, they have also resulted in the loss of the nursing team concept of management, affected the supervision, coaching and mentoring of the nursing staff, and contributed to increased stress and loss of morale among nursing staff.

There was also a concern raised about the need for greater training and development so nurses are better equipped to handle the new demands on their skills. To address this issue, employers in the Ottawa area, for example, are working closely with community colleges to ensure that the nursing curriculum is more relevant to the today's changing health care environment.

Employers said funding is a critical problem and that cuts have been too deep. There is a particular concern with the privatization of home care services and about the need for home care to receive more funding.

A related concern is with the unpredictability of funding year over year and the inconsistency in application of funding policies and regulations among similar organizations and among different types of facilities.

The Health Care Consumers' Viewpoint

Generally, health care consumers indicated the quality of nursing care is high despite the fact that nurses are continually being required to do more with less. Consumers, regardless of their depth of experience with the health care system, said they feel the stress and pressure being placed on nursing profession.

The impact is felt in a number of ways. Participants who were also patients felt the level of information and comfort they previously received from the nurse at the bedside was diminished. Family members felt they must be vigilant to ensure that their loved ones receive the care they need.

Uppermost in the minds of consumers is their concern over the loss in continuity of care. This is felt most critically in home care, hospitals and long-term care facilities.

As a result, family members are assuming a greater responsibility in advocating for the kind of care required and are becoming "de-facto" care providers - a role for which many ill-equipped.

Consumers expressed the feeling that they are expected to manage their own access to health care and to self-administer certain procedures in the home. In the past, they did this with the assistance of a nurse as the coordinator of their health care needs and/or the procedure was performed in an institutional setting.

Some participants indicated there is enough money in the health care system, but that it is not being appropriately apportioned. Others felt that cuts have been too severe and that more funding must be committed to the entire system in the future.

Conclusion

From the research and our stakeholder discussions, the Task Force determined there were a number of key issues that needed to be addressed quickly and with the proper resources - both human and financial.

We believe Ontario risks a shortage of skilled and experienced nurses if trends continue as they are, with experienced nurses leaving - or about to leave - the system and without a requisite number of new nurses entering the system to replace them.

There needs to be more resources allocated to investments in nursing on a wide range of fronts, from improved research on the impacts of restructuring on nurses and their patients to better data collection and information management systems.

The increasing shift of care and treatment to the home and community - coupled with a greater complexity in the condition of patients - calls for the kind of highly skilled and professional care that nurses are trained to provide.

We also believe, as do family physicians and many health care consumers, that home nursing care requires an immediate examination in terms of quality and funding.

There needs to be a greater emphasis placed on permanent, full-time employment opportunities for nurses to help enhance both the quality and continuity of care.

Greater resources must be directed at education in nursing - both at the college and university level, and in continuing education and training for practicing nurses.

We believe that nurses must be involved in the decision-making process at all levels and within all health care organizations where the outcome has a direct impact on the health care consumer.

Finally, we believe that the comprehensive set of recommendations developed by the Task Force will help address these issues, both in the coming months and into the new millennium.


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Appendix A : Terms of Reference

Purpose:

To recommend actions that will ensure and enhance the quality of patient care through the effective use of nursing resources within the current and future health care system.

Objectives:

To review access to nursing services, identify changes in nursing services resulting from health system reform, and assess the impact of these changes on the nursing profession and on the delivery of health services. The Nursing Task Force will develop recommendations to ensure: nursing resources are used effectively, appropriate structures exist to allow for the best use of nursing resources, and that the profession is positioned to continue to play a key role in a restructured health system.

Tasks:

Phase 1:

  • Document changes in delivery of nursing services as a result of health system reform and other factors, and identify the impact of the changes.
  • Review changes and lessons learned and identify best practices and innovative system-management solutions in Ontario and other jurisdictions.

Phase 2:

  • Prepare analysis of trends and data from Phase 1.
  • Identify the tools and information required to make evidenced-based decisions on nursing services that will maximize patient outcomes within an environment of health system reform.
  • Make recommendations on the criteria required to make decisions on an appropriate skill mix and utilization of nursing services to ensure ongoing quality of patient care.
  • Make recommendations on how to ensure the appropriate number of nurses are available for demands of hospital care, long term care and community care now and in the future.
  • Identify actions needed to implement recommendations

Scope:

The Task Force will examine services of both registered nurses (RNs) and registered practical nurses (RPNs) in the overall context of other health providers and within a range of health care sectors including but not limited to: hospitals, long-term care facilities, home care, community health centres, public health and mental health.

Reporting:
The Nursing Task Force will report to the Minister of Health

Timeframe:
The Nursing Task Force will deliver its final report by January 1999.


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Appendix B : Task Force Membership

Susan J. Strelioff, MA, MBA Task Force Chair
Irmajean Bajnok, RN, PhD Director of Business and Professional Development, Victorian Order of Nurses (Toronto Branch)
Anne Bender, RN, EdM, MA Dean, School of Health Sciences, Humber College
Joy Calkin, RN, PhD President & CEO, Extendicare
Mary Jo Haddad, RN, MHSc Director of Pediatric Specialties, Hospital for Sick Children
Daniel Ivorra, RN Staff Nurse, The Toronto Hospital
Linda LaHay, RPN Staff RPN, Sunnybrook and Women's College Health Sciences Centre, WCH site;
President, Registered Practical Nurses Association of Ontario
Pat McLean President, Association of Ontario Health Centres;
Board Chair, Woolwich Community Health Centre, St. Jacobs
Margaret Nish, RN, MSc VP, Patient Care Systems, London Health Sciences Centre
Emma Pavlov VP, Human Resources, The Toronto Hospital
Glen Penwarden Executive Director, Soldiers' Memorial Hospital, Orillia
Judith Shamian, RN, PhD President, Registered Nurses Association of Ontario.
Beverley Townsend, RN, BScN, MHA Site Administrator, Belleville General, Quinte Healthcare Corporation
Marilyn Travaglini, RN, BScN, CHE Program Director, Sault Area Hospitals
Barbara Wahl, RN, BA President, Ontario Nurses Association

Advisory to the Task Force

Linda O'Brien-Pallas, RN, PhD,
Co-Director Nursing Effectiveness,

Utilization and Outcomes Research Unit, Director of University of Toronto site.

Andrea Baumann, RN, PhD,
Co-Director Nursing Effectiveness, Utilization and Outcomes Research Unit,
Director of McMaster University site

Joint Provincial Nursing Committee
RPNAO and
Judith Wright, Assistant Deputy Minister, Integrated Policy and Planning, MOH


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Appendix C : Submissions to the Nursing Task Force

The following is a list of organizations and individuals who submitted reports and/or letters to the Nursing Task Force.

Name/Organization Location Title of Submission
Canadian Nurses Association Ottawa Let's Get Back to Basics
Canadian Practical Nurses Association Scarborough Issues in Practical Nursing-
A National View
College of Nurses of Ontario Toronto Submission to the Nursing Task Force
LeGroupe des Infirmières et de s Infirmiers Francophone de L'Ontario Toronto Mémoire Pour Le Nursing Task Force
Nurse Practitioner Association of Ontario Ottawa The Role of the Acute Care Nurse Practitioner: Barriers to their Utilization and Recommendations to Overcome these Barriers
Registered Nurses Association of Ontario Toronto Untitled
Registered Practical Nurses Association of Ontario Mississauga Submission to the Nursing Task Force Ontario Ministry of Health
Ontario Council of Teaching Hospitals Toronto Untitled
The Salvation Army
Bethany Home
Toronto Untitled
Nurse Practitioner, North York General Hospital North York Enhancing Quality Care in Long-Term Care Facilities :
How Nurse Practitioners Can Make a Difference
Community Health Nurses' Interest Group Toronto Untitled
Victorian Order of Nurses (Ontario) Toronto Untitled
ANDSOOHA, Public Health
Nursing Management
London Health Care Restructuring
- Its Impact on Public Health Nursing
Ontario Association of Non Profit Homes and Services for Seniors Woodbridge Untitled
Ontario Public Health Association Toronto Untitled
Regional Municipality of Ottawa--Carleton Ottawa Untitled
Waterloo Region Community Health Waterloo Untitled
Local 79 Canadian Union of Public Employees (CUPE) Toronto Report on the Effectiveness of
Public Health Nursing
Public Health Nurses, Region of Waterloo, ONA 15 Waterloo Untitled
Ontario Provincial Council 22 of the Service Employees International Union Don Mills Untitled
SEIU Local 220 Don Mills Untitled
SEIU Local 183 Belleville office Untitled
Centre for Rural & Northern Health Research Sudbury Graduates of the Ontario Nurse Practitioner Education Program:
Employment and Practice Profile
Collège Boréal Elliot Lake Untitled
Chair, Heads of Health Sciences, Colleges of Applied Arts and Technology Sudbury Untitled
Council of Ontario University Programs in Nursing Toronto Untitled
George Brown College of Applied Arts & Technology Toronto Ensuring Excellent Patient Care by Strengthening Nursing Education
George Brown College of Applied Arts & Technology,
The Change Foundation,
The Ontario Hospital Foundation
Toronto Building a Clear and
Collaborative Vision for Nursing
Fleming College, Humber College, Centennial College, Mohawk College, Confederation College, George Brown College of Applied Arts & Technology Toronto Untitled
Public Health Nurses (11) Mississauga/ Brampton Untitled
Registered Practical Nurses/ Kitchener Waterloo Waterloo Untitled
Nurse Practitioner Walden Untitled
Nurse Practitioner Guelph Untitled
Nurse Practitioner Toronto Untitled
Clinical Nurse Specialist Guelph Untitled
Registered Practical Nurse Guelph Untitled
Medical Doctor Richmond Hill Untitled
Medical Doctor Thornhill Untitled
Nurse Practitioners (3) Newbury Nurse Practitioners
in the Emergency Department
Registered Practical Nurse Harley Untitled
Registered Practical Nurse Brantford Untitled
Registered Practical Nurses (3) Unknown Untitled
Nurse Practitioner North Bay Untitled
Registered Nurse Pembroke Untitled Registered Nurse
Registered Nurse(s) New Liskeard Untitled
Registered Nurse Halifax Untitled
Confederation College Thunder Bay Untitled
Public Health Nurse Pembroke Untitled
McMaster University Hamilton Untitled
Nurse Practitioner Richmond Hill Untitled
Markham Family Physicians Markham Untitled
Patient Care Manager Milton Untitled
Nurses Employed by Ministry of the Solicitor General Toronto Untitled
Health Care Consumer Toronto Untitled
Registered Practical Nurse Kakabeka Falls Untitled
Humber College School of Health Sciences Etobicoke Untitled
Richmond Hill Children's Clinic Richmond Hill Untitled

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Appendix D : Discussion Groups

A total of 13 groups - representing key professions, organizations and sectors within the health care system - were consulted during the Nursing Task Force's information gathering and stakeholder consultation phases. In sequence, by location, they were :

Date: Monday, October 19, 1998
Location: Ottawa
Group: Employers of Nurses
Number of Participants: 10
Date: Monday, October 19, 1998
Location: Ottawa
Group: Nurses
Number of Participants: 12
Date: Tuesday, October 20, 1998
Location: Hamilton
Group: Health Care Consumers
Number of Participants: 11
Date: Wednesday, October 21, 1998
Location: Sudbury
Group: Employers of Nurses
Number of Participants: 13
Date: Wednesday, October 21, 1998
Location: Sudbury
Group: Nurses
Number of Participants: 13
Date: Wednesday, November 18, 1998
Location: Thunder Bay
Group: Employers of Nurses
Number of Participants: 14
Date: Wednesday, November 18, 1998
Location: Thunder Bay
Group: Nurses
Number of Participants: 12 (one via teleconference)
Date: Wednesday, November 18, 1998
Location: Thunder Bay
Group: Nurse Students and Nurse Educators
Number of Participants: 16
Date: Monday, November 23, 1998
Location: Toronto
Group: Mixed Demographic
Number of Participants: 9
Date: Monday, November 23, 1998
Location: Toronto
Group: Mixed Demographic
Number of Participants: 10
Date: Tuesday, November 24, 1998
Location: Toronto
Group: Mixed Demographic
Number of Participants: 8
Date: Tuesday, November 24, 1998
Location: Toronto
Group: Nurses
Number of Participants: 12
Date: Wednesday, November 25, 1998
Location: Toronto
Group: Employers
Number of Participants: 11

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Appendix E : Bibliography

  1. Baumann, A. Giovanetti, P. O'Brien-Pallas, L. Deber, R. Blythe, J., Hibberd J., DiCenso, A. Mallette, C., Brady-Fryer. (1998) Restructuring of health human resources: A critical issue. Funded by the National Health, Research and Development Program, Project 6606-6284-012.
  2. Canadian Nurses Association, The Future Supply of Registered Nurses in Canada: A Discussion Paper, October 1997.
  3. Canadian Institute of Health Information (CIHI), Public Sector Health Expenditures by Province, Territory and Canada, 1975 - 1998, Fall 1998.
  4. CIHI, Tables Provided for Health Survey in Maclean's Magazine, June 1988.
  5. College of Family Physicians of Canada, National Home Care Survey Results, October 1998.
  6. Decter, Michael. The Road to better health, Maclean's, December 7, 1998, pp. 52 - 56.
  7. DeVoretz, Don and Laryea, Samuel, Canadian Human Capital Transfers: The United States and Beyond. C.D Howe Institute, 1998.
  8. Hiscott, Robert D., and Sharratt, Michael T., The Effect of Legislated Nurse Participation (Regulation 518) on Fiscal Advisory Committees Within Ontario Hospitals, Ontario Nursing Human Resources Data Centre, University of Waterloo, October 1991.
  9. Kovner, Christine and Gergen, Peter J. The Relationship Between Nurse Staffing Level and Adverse Events Following Surgery in Acute Care Hospitals. Image: Journal of Nursing Scholarship, 4th Quarter 1998 pp. 315 - 321.
  10. O'Brien-Pallas Linda, RN, PhD, Baumann Andrea, RN, PhD, The State of Nursing Practice in Ontario: The Issues, Challenges and Needs, The Nursing Effectiveness, Utilization and Outcomes Research Unit, November 4, 1998.
  11. O'Brien-Pallas, L.L., Murray, M., Irvine, D., Cockerill, R., Sidani, S., Laurie-Shaw, B., & Lochhass-Gerlach, J. (1998), Factors that Influence Variability in Nursing Workload and Outcomes of Care in Community Nursing, (Nursing Effectiveness, Utilization and Outcomes Research Unit Working Paper Series No. 98-1) Hamilton, ON: University of Toronto & McMaster University, Nursing Effectiveness, Utilization and Outcomes Research Unit.
  12. O'Brien-Pallas Linda, RN, PhD. Baumann Andrea, RN, PhD, Lochhass-Gerlach Jacquelyn, RN, BScN, (1998). Health Human Resources: A Preliminary Analysis of Nursing Personnel in Ontario, The Nursing Effectiveness, Utilization and Outcomes Research Unit, November 1998.
  13. Office of the Chief Coroner of Ontario, Coroner Jury Recommendations re: Peter Hanna, September 1998, and Jury Recommendations re: Kyle Martyn, December 1998.
  14. Ontario Hospital Association, Key Facts and Figures, October 1998.
  15. Ontario Hospital Association. The Hospital Report '98, A System Wide Review of Ontario's Hospitals, October 1998.
  16. Ontario Ministry of Health, 1998-99 Business Plan.
  17. Taunton, R.L, Kleinbeck, S.VM, Stafford, R. Woods, C., and Bott, M. Patient Outcomes: Are They Linked to Registered Nurse Absenteeism, Separation or Work Load? Journal of Nursing Administration, Vol. 24, No. 45, April 1994 pp. 48 - 55.

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Summer 2001

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