Where We've Been, Where We're Going: Six Commissioned Papers on Nursing Health Human Resource Issues

Office of Nursing Policy
Health Canada
May 10, 2004

Table of Contents

1. Background on the Health Human Resource Accord 2003
2. Key Messages from the Studies and Projects
3. A Progress Report on Implementing the Final Report of the Canadian Nursing Advisory Committee
4. A Proposal to Support the Strategic Plan to Implement the Canadian Nursing Advisory Committee Recommendations
5. Further Development of Work Life Indicators in Canada
6. Examing the Causes of Attrition From Schools of Nursing in Canada
7. Nursing Best Practice Guidelines Project
8. Needs-based Health Human Resource Planning: The Relationship between Population Health and Nursing Service Utilization
9. Links to the full documents

The 2003 First Ministers Accord on Health Care Renewal

The First Ministers' Accord on Health Care Renewal noted that appropriate planning and management of health human resources is key to ensuring Canadians have access to the health care providers they need now and in the future. In the 2003 Budget, the government committed $90 million dollars over five years to improve national health human (HHR) resource planning and coordination.

Funding from the first year of this budget (2003-2004) has been provided for six projects that are consistent with the health human resources themes and priorities identified in the Health Accord. Total funding was $2.2 Million dollars with all projects finishing March 31, 2004.

Brief summaries of the project proposals follow:

1. A Proposal to Support the Strategic Plan to Implement the Canadian Nursing Advisory Committee Recommendations

   Prepared by: Canadian Nurses Association, Canadian Association of Schools of Nursing, Canadian Healthcare Association, Canadian Federation of Nurses Unions, Canadian Practical Nurses Association, Registered Psychiatric Nurses of Canada, and the Academy of Canadian Executive Nurses

   Amount: $650,000

   In 2001, the Canadian Nursing Advisory Committee (CNAC) was created in response to the first recommendation of the Nursing Strategy for Canada. In August 2002, the Advisory Committee on Health Human Resources (ACHHR) released the final report of CNAC. This report was a culmination of research resulting in 51 recommendations designed to provide policy direction to improve the quality of nursing work life at the federal, provincial and territorial levels. This proposal is designed to complement the above-mentioned initiatives and to frame an overall implementation strategy. In addition, the objectives defined in this project are reflective of a consultation process between the Canadian Nurses Association (CNA) and various nursing organizations, academics and the Canadian Healthcare Association. These organizations include the Canadian Association of Schools of Nursing, Canadian Federation of Nurses Unions, Canadian Healthcare Association, Canadian Practical Nurses Association and the Registered Psychiatric Nurses of Canada.

2. Progress Report on Implementing the Final Report of the Canadian Nursing Advisory Committee

   Prepared by: Canadian Policy Research Networks Inc. (CPRN)

   Amount: $91,000M

   Health Canada is interested in learning what actions have been taken across the country to strengthen the nursing workforce since the release of the Canadian Nursing Advisory Committee (CNAC) report. This project will provide an information base for discussion and identification of next steps. CPRN will determine:

   1. what actions have been taken by employers, governments, educators, unions and others to implement the CNAC recommendations,
   2. if there are barriers to implementation of the recommendations, and
   3. what supports and facilitators are required to complete implementation of the CNAC recommendations.
3. Needs-based Health Human Resource (HHR) Planning: The Relationship between Population Health and Nursing Service

   Prepared by: Gail Tomblin Murphy (Dalhousie University) and Dr. Linda O'Brien-Pallas (University of Toronto)

   Amount: $249,614.40

   This project is an expansion of work being completed in Ontario that looks at needs-based HHR. The purpose of this study is to examine needs-based HHR in all other Canadian jurisdictions. The goal of this study is to develop and test a population health needs approach to establish, monitor, and predict nursing service needs at the population level. A systems framework will be used to explore the relationship between the health needs of Canadians (outside of Ontario), their use of community nursing and hospital services, and variations in outcomes.

4. Examining the Causes of Attrition From Schools of Nursing in Canada

   Prepared by: Dr. Dorothy Pringle (University of Toronto)

   Amount: $77,200

   In Canada, we are in a period of nursing shortage and it is important to retain as high a proportion as possible of students who select nursing as their profession. This study will examine the reasons that students studying in all three types of nursing preparation programs leave before finishing their programs. A complementary study will determine actual retention rates (the obverse of attrition) of programs to prepare registered nurses (RNs), registered psychiatric nurses (RPNs) and licensed/registered practical nurses (LPNs).

5. Nursing Best Practice Guidelines

   Prepared by: Registered Nursing Association of Ontario (RNAO)

   Amount: $800,000

   RNAO has submitted a proposal that supports three initiatives:

   Spreading the News: Canadian Nursing Best Practice Guidelines Tour

   It is proposed that twenty full day workshops across all provinces and territories in Canada will be conducted. This workshop will disseminate the BPGs and excite nurses to implement these guidelines. Nurses will also advocate with their provincial Ministers of Health within their regions to support nursing practice through BPGs.

   French Translation of Best Practice Guidelines and Health Education Fact Sheets

   It is proposed that six high demand BPGs and ten HEFS will be translated. Distribution of items will occur via both the RNAO website with linkage to the Health Canada website. Hardcopy materials will be distributed with RNAO's current nursing best practice guidelines infrastructure.

   Best Practice Guidelines Spotlight Organization in Saskatchewan

   It is proposed that the RNAO will work closely with the Registered Nurses Association of Saskatchewan to identify a health care organization that will be appropriate to fund as a BPG Spotlight Organization. A BPG Spotlight Organization is a setting that is committed to providing healthcare based on the best available evidence and will implement multiple BPGs in their setting.

6. Further Development of Work Life Indicators in Canada

   Prepared by: Canadian Council on Health Services Accreditation

   Amount: $308,115.89

   As an extension of CCHSA's work in the area of work life standards and indicators, this proposal outlines a series of projects that move the evaluation of work life forward rapidly and significantly. The work would be carried out in partnership with key stakeholders in the field and importantly, will extend CCHSA's work beyond the nursing community to include all health professionals.

Key Messages From the Studies and Projects

The Office of Nursing Policy has compiled key messages from the six commissioned research projects for this report. These messages reflect our interpretation of highlights and key messages, and are not necessarily those of the respective authors.

A synthesis document of all six reports, as well as the respective full reports themselves, will be available on the Office of Nursing Policy web site in Summer of 2004.

Other Organizations in Canada

•   Canadian Information Centre for International Credentials
•  Canadian Institute for Health Information
•  Canadian Institutes of Health Research
•  Canadian Health Services Research Foundation

Our Health, Our Future: Creating Quality Workplaces for Canadian Nurses

A Progress Report on Implementing the Final Report of the Canadian Nursing Advisory Committee

Lisa Maslove and Cathy Fooks, Health Network, CPRN

In August 2002, the Canadian Nursing Advisory Committee (CNAC) released its Final Report entitled Our Health, Our Future: Creating Quality Workplaces for Canadian Nurses. The report contained 51 recommendations giving priority to improving the quality of work life for nurses and providing a framework for action by identifying implementation roles for governments, employers, unions, professional associations, regulatory bodies, educators and the research community.

The Office of Nursing Policy at Health Canada was interested in learning what actions have been taken across the country to implement the CNAC recommendations. The Canadian Policy Research Networks (CPRN) were engaged in late 2003 to undertake this study.

The purpose of the study was to review the activities of nursing stakeholder organizations and describe trends in how implementation has progressed. Based on this review, barriers to completing implementation and supports required to complete implementation were to be identified.

The data collection for this project was conducted in four phases. First, a scan of websites was conducted to identify relevant reports related to the implementation of the CNAC recommendations. Second, a letter was sent to 94 stakeholder organizations requesting information about what their organizations or jurisdictions have done to implement the CNAC recommendations. Overall, 47 of 94 organizations responded to the information request for a response rate of 50%. Third, interviews were conducted with 14 key informants in order to probe on overall barriers to implementation and supports that would facilitate implementation. Fourth, our initial findings were presented at a Roundtable with 14 representatives from nursing stakeholders in Ottawa. The Roundtable participants provided their views on our initial findings and feedback on the identified barriers and supports.

The findings of these data collection exercises were compiled according to the categories used to group the recommendations in the CNAC Final Report. The CNAC Report was widely viewed as helpful document in distilling the complex issue of nursing shortages into a menu of practical ways to address the shortage.

For a few recommendations, such as increasing the number of education seats for RNs, LPNs and RPNs, implementation has been wide-spread. But on most issues, progress appears to have been made in pockets. For example, individual employers across the country are implementing workload measurement systems, increasing the number of full-time positions, examining absenteeism, hiring nurse mentors and piloting flexible scheduling systems. But it is difficult to know the impact of this implementation nation-wide. Many respondents observed that these changes are likely to be concentrated in acute care facilities, as opposed to community, long-term care or other settings.

Despite the complexity of the policy issues addressed by CNAC, some common barriers to implementation emerge including:

• Accountability: While many of the recommendations identify specific organizations to carry out implementation, the ultimate responsibility for implementation remains unclear to nursing stakeholders
• Resources: Employers require stable funding to plan for workplace improvements and create stable jobs.
• Collective Bargaining : A number of the workplace issues addressed by the CNAC recommendations are introduced at bargaining for collective agreements raising questions about how work life issues are weighed against salary issues in this context.

There are a number of policy-level supports that have facilitated and would continue to facilitate the implementation of the CNAC recommendations including:

• Provincial/territorial-level Nursing Advisory Committees and leadership positions for nursing
• Targeted funding for investments in nursing work life
• Monitoring mechanisms such as surveys and accreditation that identify problems, clarify underlying human resource issues and highlight were the implementation of recommendations has and has not led to improvements at the bed-side.
• Evidence to support decision-making including university-based research, employer-level administrative data, pilot project evaluations and repositories of initiatives that have been implemented across Canada.
• The integration of nursing work life reform with wider health system or population health issues.

On the whole, there are positive signs that improvements in quality of nursing work life are occurring but these changes are not wide-spread. System-wide change requires that the barriers and supports identified in this study be addressed. Further analysis of the recommendations in the CNAC report is required to more clearly identify responsibilities and implementation mechanisms.

Proposal to Support the Stategic Plan to Implement the Canadian Nursing Advisory Committee Recommendations

Academy of Chief Executive Nurses
Canadian Associtation of Schools of Nursing
Canadian Federation of Nurses Unions
Canadian Healthcare Association
Canadian Nurses Association
Canadian Practical Nurses Association
Registered Psychiatric Nurses of Canada

Project Overview

In December 2003 a seven partner collaborative (Canadian Nurses Association (CNA); Canadian Practical Nurses Association; Registered Psychiatric Nurses of Canada; Canadian Association of Schools of Nursing; Canadian Federation of Nurses Unions; Canadian Healthcare Association; and Academy of Chief Executive Nurses) initiated a project to facilitate the implementation of recommendations contained in the final report of the Canadian Nursing Advisory Committee (CNAC). The CNAC report, released by federal / provincial / territorial governments in 2002, includes 51 recommendations designed to improve the recruitment and retention of Registered Nurses, Registered Psychiatric Nurses, and Licensed Practical Nurses.

There has been some action in response to the majority of the recommendations in the CNAC report. However, the seven partners, in a proposal to Health Canada, suggested that there needed to be attention given to those recommendations where there has been little or no response, and specifically that the barriers and enablers to action be identified. Eleven (11) subprojects were proposed in three areas: workforce management, education and leadership. The tactics included literature reviews, surveys, focus groups and data analysis. Nurses in all communities of practice (clinical, education, management and research) and students across the country were invited to participate in various activities. A sincere thank you to all those nurses who participated in this project. With funding support from Health Canada and with the guidance of a Steering Committee composed of representatives of each of the seven partner organizations, eleven sub- project s were undertaken between January and March 2004.

The Steering Committee, reviewed the findings of each of the 11 subprojects and their inter-relatedness. As a result, the Steering Committee proposes the following eighteen policy-oriented recommendations to accelerate action in the three chosen areas of focus.

Workforce Management

The seven partners chose to focus on four specific CNAC recommendations, namely:

• Employers should work with their managers and front-line nurses to assess and describe existing workloads and contrast them with current staffing patterns and patient/client demands by October 2002. In each work setting, the demands should be contrasted with the supply of nurses, and compared with workload measurement data, where available. Where workload measurement systems do not exist, they should be implemented by June 2003.
• Regarding location and availability of functioning equipment, provincial/ territorial and federal governments should fund a one-time cross-country survey of each employer's equipment status versus needs and fund the upgrade now. The project is to be completed by January 2003 with one-time funding.
• Governments and employer organizations should work with nurse leaders and unions to provide phased-in retirement programs for older nurses, allowing them to do some work without negatively affecting pension benefits, by January 2004.
• All employers should abandon the practice of regulating nursing practice and should put in place policies that will allow each Registered Nurse, Licensed Practical Nurse and Registered Psychiatric Nurse to function to the maximum of her or his professional practice abilities according to the respective provincial/territorial licensing body. Regulators are urged to work with nurses, employers, unions, educators and governments to maximize the scopes of practice of Registered Nurses, Licensed Practical Nurses and Registered Psychiatric Nurses in all settings and jurisdictions, as appropriate, given the acuity and complexity of patients, residents, clients, and/or families in the setting.

The Steering Committee recommends:

1. Health Infoway and employers integrate workload measurement systems into electronic health records and capture the work of all health care providers.
2. Employers develop or modify workload measurement systems to:
   • Provide for education and training of nurses about how to use workload measurement tools, their purpose and utilization of data generated from them;
   • Ensure the tools are user-friendly;
   • Ensure adequate human and financial resource supports to analyze the information provided by the workload measurement tools and to evaluate and improve the tools themselves
3. Governments provide funding for the purchase and maintenance of "LOW TECH" equipment, as well as training in the operation of the equipment.
4. Employers and nursing regulatory bodies establish local nursing advisory committees to oversee the implementation and support of the evaluation framework for staff mix decisions developed as part of this project. The results of the evaluation framework should be publicly reported.
5. Governments review and reform pension requirements to facilitate the retention of experienced nurses beyond the usual age of retirement.

Education

The seven partners chose to focus on two specific CNAC recommendations:

• Educators should collaborate with employers to offer creative clinical experiences for students and maximize readiness for the work world by September 2004.
• Provincial/territorial governments should collaborate with schools of nursing and employers to fund, design, maintain and evaluate the infrastructure necessary to support clinical and other nursing education; a plan should be developed and submitted to governments by June 2003.

Several educational institutions have implemented innovative approaches to nursing education. The innovations offer a base from which to move forward on the recommendations below.

The Steering Committee recommends:

Governments and educational institutions develop a national strategy to facilitate and maximize admission of nursing students.

1. Governments and educational institutions develop an evaluation framework related to clinical placement, simulation, service learning and community learning.
2. Educational institutions clarify the learning outcomes of clinical placement and develop national criteria to identify best practices of clinical education.
3. To support inter-professional practice teams, governments and health sciences educational institutions develop inter-professional curricula for theory and simulated learning, and develop appropriate practice settings.
4. Educational institutions assess the use of part-time, and/or non-PhD faculty and/or educators from other health science disciplines, in terms of attainment of learning outcomes, motivation of students, student attrition, and costs.
5. The nursing community (educational institutions, professional associations, regulatory bodies) develop a standardized definition of student attrition for all types of nursing programs to support data collection, analysis and HHR planning.
6. Governments and educational institutions develop and implement an evaluation framework to assess models of nursing student selection.
7. The nursing community (educational institutions, professional associations, regulatory bodies) develop and implement a pan-Canadian process of exit interviews for all students leaving nursing programs.

Leadership

The seven partner organizations chose to focus on three specific CNAC recommendations that have received minimal attention, namely:

• The number of first-line managers should be sufficient to allow reasonable levels of contact with nurses in the setting. In settings where the majority of staff are nurses, the first-line manager should be an experienced nurse with strong leadership abilities. We encourage employers to examine and assess the growing body of literature suggesting the characteristics of a reasonable, manageable span of control for nurse managers and directors that allows them to complete assigned functions and be present to meet nurses' and patients' needs. Changes should be completed by April 2003.
• First-line managers should be supported with human (e.g., clerical) and technical resources that allow them to do the required work within reasonable hours of work. Programs should be in place by April 2003.
• Researchers should continue to study and refine their understanding of nursing workforce information. In particular, the focus should be on the impact of relationships between nursing human resources and patient outcomes, including economic impacts.

The Steering Committee recommends:

1. Unions and employers provide formal recognition of mentorship and preceptorship responsibilities.
2. Employers provide nurse managers with appropriate technical and clerical support.
3. Governments, employers, professional associations and other agencies facilitate participation of nurses in interdisciplinary leadership/management development programs.
4. Governments review the economic framework developed as part of this project and other frameworks or approaches to calculating the economic contribution of health providers and/or nurses.
5. Governments fund applications of an economic framework to determine nursing's economic contribution to the health system.

Further Development of CCHSA Worklife Dimensions of Quality and Accreditation Standards

Canadian Council on Health Services Accreditation

Background

CCHSA has incorporated work life as a key dimension of quality in its standards and accreditation program. When it was first introduced as a part of the quality framework of CCHSA accreditation program in 2001, very little work had been carried out that examined the key elements of work life that have a direct impact on the quality of health services delivered to patients. After having tested this quality element and standards in the last couple of years, there is a need to further develop this work based on CCHSA learning and developments in the health service environment. To accomplish this task, an advisory committee of 17 experts in work life areas was convened to a meeting on March 9th, 2004 to advise CCHSA on future directions about work life.

Findings obtained from this one-day meeting will be used to revise the CCHSA worklife dimension and descriptors, improve the worklife standards, enhance the requirements for information from organizations prior to the accreditation survey, and develop a set of guidelines for surveyors to effectively evaluate these standards in health service organizations. Information gathered on these standards would be reported back to organizations in their accreditation reports and the findings for all organizations could be aggregated and reported at a national level through CCHSA's public accreditation report.

This report summarizes the results of the first advisory committee meeting and outlines an action plan for the next steps or activities that need to be carried out for the remainder of the year.

Findings from the Worklife Advisory Committee Meeting

The Worklife Advisory Committee meeting on March 9th, 2004 at the Canadian Council on Health Services Accreditation (Ottawa) gathered 17 experts in various areas of worklife. These experts included researchers, senior managers and policy consultants. They represented the areas of nursing, organizational behaviour, industrial psychology, occupational health and safety, evaluation and outcome measurement, technology use and ergonometrics, leadership, human resources, best practices and innovative initiatives.

The discussion revolved principally around the need for:

• A model to conceptualize CCHSA's approach to worklife through its accreditation program;
• Appropriate and meaningful indicators to support health services organizations to monitor improvements in worklife practices
• Revision of the current CCHSA worklife dimension and descriptors to reflect the increasing body of evidence on worklife in the field.

Findings of the Literature Review

In preparation for the first Advisory Committee meeting, an extensive literature review was carried out to search for articles on worklife, healthy workplace, quality workplace, and magnet hospitals. The articles found an increasing body of evidence on the impact of healthy workplace initiatives or quality worklife approaches on employee and organizational outcomes. CCHSA's interests were to find good models that conceptualized the potential causal links between structures and processes in the health workers' workplace environment and their impact on outcomes of quality worklife at the employee and organizational level. A number of models were retained for further analysis and for the development of a model that would effectively capture CCHSA's approach to worklife through its accreditation program.

Findings of the National Consensus Meeting on Work Life Indicators

On March 25th, 2004, 28 stakeholders were invited to attend a meeting to discuss a vast array of local initiatives on worklife indicators from across the country, including the findings of phase one of the University of Toronto Nursing Work life Indicator Study. The session was facilitated by Graham Lowe, who assisted the group in determining the next steps in the development of work life indicators as well as the formulation of recommendations to CCHSA.

Presentations on what works and what does not, as well as the lessons learned were shared with all participants. A substantial amount of material was also shared among participants including conceptual frameworks, methodologies, tools and best practices guidelines. Participants to the national consensus meeting discussed and identified concepts common to the ones identified by the Worklife Advisory Committee. They recognized the value of the accreditation program to support improvements of worklife in health services organizations. The recommendations for action to CCHSA have implications to the further development of CCHSA worklife dimension and descriptors, as well as the worklife-related accreditation standards, and the integration of important worklife indicators into the accreditation program. In particular, these findings will provide guidance to the development of these elements.

Findings from the Worklife Regional Educational Sessions

Approximately eight regional educational sessions will be delivered across the country from March 24th until April/May 2004. The target audience includes accredited health service organizations. The purpose of these educational sessions is to build awareness of worklife from different perspectives, identify strategies and tools to address worklife at the organizational level, obtain information about CCHSA's initiatives to support quality of worklife and identify how the accreditation standards can be enhanced to address worklife issues.

These sessions provided an opportunity to gather meaningful information at the organizational level and from over 500 participants representing the Leadership & Partnership teams, the support services teams (Human Resources, Environment and Information Management) as well as the care teams. Practical input was sought from a series of small group exercises. The exercises featured valuable discussions and recommendations on quality improvement initiatives that proved effective in the local settings. They also provided the opportunity for participants to examine the CCHSA worklife dimension and descriptors and brainstorm on them.

Next steps for the ongoing development of Worklife dimension, descriptors, standards and surveyors guidelines

From the discussions, findings and recommendations that emerged from the work completed from each of the activities outlined in the broader proposal to Health Canada to further pursue the collaborative project of work life indicators, CCHSA realizes the need for a comprehensive Worklife strategy that will guide future developments of worklife in its accreditation program. A comprehensive Worklife strategy will identify key goals and objectives that direct the ongoing development of the accreditation program and move the evaluation of worklife forward rapidly and significantly for health services organizations.

Specifically, the strategy will target (1) the enhancement to the accreditation program to better evaluate worklife in health services organizations and support their quality improvement efforts; (2) the delivery of education programs and materials to surveyors and organizations; (3) the establishment of strategic partnerships to promote worklife in health services organizations and the broader health care system; and (4) the effective communication with stakeholders to build awareness and understanding on the importance of uptake of worklife standards, criteria and indicators.

Building on the findings and recommendations from the Worklife Advisory Committee meeting, six specific actions are outlined below and describe the steps to be undertaken for the remainder of the year.

Action 1:

Development of A Model That Conceptualizes CCHSA's Approach to Worklife

Action 2:

Refining CCHSA Worklife Dimension and Descriptors

Action 3:

Enhancement of Worklife Standards and Criteria across Standards Sections (Leadership & Partnerships, Support Services, and Client Services)

Action 4:

Enhancement of 'Requirements for Information' From Organizations Prior To the Accreditation Survey

Action 5:

Development of a Set of Guidelines for Surveyors to Evaluate More Effectively These Standards in Health Service Organizations

Action 6:

Development and Delivery of Educational Programs

Conclusion

CCHSA is committed to assisting health services organizations improve worklife in their workplaces through: (1) the development of a sound quality framework as the foundation for its accreditation program; (2) the promotion of quality improvement as an effective tool to design, implement, monitor and improve specific aspects of worklife; (3) and the ongoing improvement of its accreditation program, namely the standards, criteria and other components to assist organizations in effectively evaluating their worklife practices. The five actions outlined in this report will help CCHSA bring worklife forward at the organizational level and across sectors. A comprehensive worklife strategy will set a long-term agenda for CCHSA to determine the priorities and set goals that will ensure ongoing and sustainable improvements of worklife in the accreditation program.

Examining the Causes of Attrition from Schools of Nursing in Canada

Dorothy Pringle RN PhD
Faculty of Nursing, University of Toronto
Principal Investigator

The study was undertaken to answer questions about why students withdraw from schools of nursing without completing their programs, if RN students leave for different reasons than LPN students and RPN students, what actions might be taken to reduce the number who withdraw, and what role, if any, low admission averages from high school play in the withdrawals. The results shed some light on these issues but, unfortunately, because the sample is small, definitive answers to the questions are not possible.

Earlier research on attrition from degree programs in nursing has shown that most attrition occurred during the first two years (Jalili Grenier, 1993) and the results from this study corroborate these findings. By the end of first year, close to 60% of the former RN students had begun to think nursing was not for them and 85% of them were of this opinion by the end of second year. The majority of the LPN group also came to this decision by the time they were part way through first year. This speaks to the need to do a better job of preparing potential students for what they will encounter in nursing prior to admission and to monitor very closely how students are responding to the program through their first and second years. If students are into the third and fourth years of nursing studies before they decide it is not for them, different strategies are needed to intervene to have them consider if withdrawal is the best course of action.

These two groups of students differed also in the degree of difficulty they experienced in leaving their programs. While about half the RN students found it relatively easy to leave and more than half had few regrets about leaving, only 15% of these LPN students found it easy and only 20% had few regrets. A much higher percent of the LPN students failed out of their programs than did RN students so they had no choice about leaving. The high level of regret may be a reflection of the loss of a dream that many LPN students had held for a long time and which they were not permitted to pursue.

Why students withdraw from nursing programs

The most compelling and interesting finding from this study is the range of reasons that contribute to nursing students' decisions to withdraw. No one or even two or three reasons dominate and hence, no one or two interventions will be effective in addressing the problem.

The state of nursing as a profession was an important contributing factor in the decision to leave nursing for a considerable number of students in RN programs (18-23%) but fewer (15%) LPN students. Nursing has received considerable media attention over the last few years including interviews with practicing nurses who describe aspects of the profession and the work of nursing that they find difficult and unsatisfying. It seems that the students who were disillusioned with nursing and nurses, the majority of whom were in university nursing programs, were not aware of this situation and were not expecting to find this in the profession that they had chosen to pursue. The almost universal recommendation of former RN students and a majority of former LPN students to provide a very realistic picture of nursing in information sessions for interested potential students confirm this.

In previous research on attrition in nursing, too many family responsibilities have been identified as an important contributing factor to withdrawal of students (Glossop, 2001; Jalili Grenier, 1993; Smith, 1990), and, indeed for about a third of LPN students and around 20% of RN students, this was selected as a significant reason. These figures are consistent with the fact 25% of respondents entered nursing programs after having a family. However, in the list of three most important reasons for leaving, family responsibilities were not listed frequently.

Costs of programs, lack of financial resources to meet those costs and still have money for living expenses, and the need to work too much to cover their costs were significant factors in their decision to withdraw for 20-25% of RN students. Fewer LPN students found tuition problematic but more than a third identified living expenses as a significant reason contributing to their decision to withdraw and 25% of them also found that the amount they had to work interfered with their studies. These were the students who found the course loads too high. Financial difficulties have also been identified in previous studies (Glossop, 2001; Jalili Grenier, 1993; Smith, 1990).

A quarter of the RN students who left their programs did so at least partly because they did not like nursing. This was not true of LPN students where only one respondent indicated this was a reason. Wrong choice of career has previously been identified as a major reason why students withdraw (Glossop, 2001; Jalili Grenier, 1993; Smith, 1990).

Student suggestions for reducing attrition

The respondents were offered a list of potential changes to admission processes and nursing programs designed to reduce attrition. The only ones that students did not support were to increase admitting averages and to delay starting clinical practice till later in the program. The former has the potential to reduce failures and the latter to increase time available to students to improve their knowledge and skills before being confronted with the stress associated with clinical practice. In contrast, 80% of RN students and 65% of LPN students supported introducing clinical practice early in the program. Three RN students wrote that clinical practice be introduced early but that students receive more support while in practice to reduce the anxiety they experience and two students recommended increasing the amount of clinical practice in RN programs (and reducing the number of theory courses). LPN students did not support increasing admission averages but they did want more academic and personal support through the programs so they could succeed.

Conclusions and Recommendations

The study suffers from the same problems that have plagued previous research on attrition (Glossop, 2001). The low response rate to the questionnaires reduces the ability to draw definitive conclusions from this study. However, that does not mean there is not a great deal to be learned. Students leave schools of nursing for a lot of different reasons and those that leave start to think about it early in their programs. The major reasons for leaving relate to complaints about the programs and lack of support from faculty members, costs of the programs and insufficient funds to cover these costs and provide for living expenses, disillusionment with nursing as a career and academic failure. There are differences between students in RN and LPN programs. Disillusionment is an RN student problem and failure and inability to manage the demands of programs, an LPN problem. More RN than LPN students have complaints about courses and programs but both experienced less faculty support and encouragement than they needed, and both were led to withdraw by costs and lack of financial resources. Other reasons for withdrawal that have been identified as significant in previous studies such as personal problems, stress, illness and family responsibilities were identified by only a few students in this study. The fact that these issues were identified by only a very few respondents should not diminish the important role they played in their decisions to withdraw. A sizeable percent of students who withdraw find it a difficult decision, particularly LPN students and many of them, also particularly LPN students, regret having made it. High school averages that are considerably lower than the class average may serve as an indicator of a student at-risk of withdrawing from RN programs but not LPN programs.

The results of this study suggest that there are some actions schools of nursing can take to try to mitigate attrition. Students interested in nursing careers at this point in time need to have the state of the health care system carefully, honestly and explicitly explained to them including the effect this has had on nursing as a profession and on some nurses in terms of their satisfaction with their careers. While it is important to recruit the best students available into nursing, it is equally important that these students make the decision to enter a nursing program knowing that there is a good deal of dissatisfaction within nursing about their role in the health care system. They also need to know the effect the current level of resource and the way the system is organized is having on nursing and its ability to flourish. It is also important that schools indicate that the state of the health care system and nursing as a profession will be the subject of ongoing discussion and debate throughout the program, along with discussions of policies and practices that can improve the system and how individual and groups of nurses can not only survive but develop rewarding careers and influence the system. Then the schools have to deliver on these commitments. An associated issue is the 'student-friendly' nature of the clinical environments where students practice. Clinical practice for students is anxiety provoking enough without students having to cope with unhelpful and sometimes even hostile staff who will not assist them and may actively discourage students about their career choice. Since most organizations that provide clinical practice opportunities for students undergo accreditation, the accrediting bodies should add the quality of the environment for student learning to their list of areas for review and develop standards against which these organizations will be assessed.

Schools also need to look at the issue of faculty support to students and at whether the courses and individual classes are meeting the needs of mature and diverse groups of student, particularly in RN programs. Schools of nursing need to develop strategies and programs to insure students receive the support they require, particularly early in their programs. Students cannot be relied upon to recognize that they need support and to seek it out. It will have to come to them.

Many students in nursing programs need sources of funding for them to succeed. The number of clinical hours nursing students must work is significant, so the hours they have available to earn money to support themselves is limited. This puts many of them under more financial pressure than students in other university programs. Nursing needs to take on the problem of student funding and develop solutions that will allow more students to work less and hopefully as a result, stay in their programs and succeed.

It may not be possible to entirely eliminate attrition from schools of nursing, but every effort should be made to reduce it to the lowest level possible. Attrition is costly. It can cost students who withdraw a year or two of subsequent earning power and it can have a devastating effect on their sense of self worth. It costs schools of nursing faculty effort and resources that do not result in a student who graduates, and for every student who does not complete a program, one fewer nurse is available to the health care system. It is worth trying to eliminate.

Nursing Best Practice Guidelines Project Status Report as of April 2004

RNAO NBPG project received $800,000 funding from Health Canada to work on three key deliverables:

1. Establishment of two Best Practice Spotlight Organizations outside of Ontario
   • Two Quebec organizations were selected: McGill University Health Care and Hôpital Charles LeMoyne.
   • Ten nurses, five from each site, spent a week with the BPG project team in February. They attended a two-day Champions workshop, several site visits to Ontario Best Practice Spotlight Organizations and several meetings with the project staff.
   • On-going assistance is being provided to these organizations by email, phone and by sharing of materials.
2. Twenty full-day workshops across Canada on best practice guidelines have been completed.
   • Five facilitators were trained by the project team (2 from Toronto, I from Calgary, 1 French speaking facilitator from Montreal and 1 bilingual from Ottawa).
   • All workshop materials were translated in French for the 4 workshops conducted solely in French (3 in Quebec and 1 for the Maritime nurses).
   • The workshops were held in Victoria, Vancouver, Prince George, Yellowknife, Calgary, Edmonton, Fort McMurray, Regina, Saskatoon, Winnipeg, Moncton, Gatineau, Montreal, Quebec City, Charlottetown, Halifax, Fredericton, and St.John.
   • In total 1100 nurses participated in the workshops.
   • The response was phenomenal. Over 1200 nurses were not able to be scheduled in the workshops and have asked to remain on a waiting list should further funding be available to support additional workshops.
   • Follow up debriefing of the workshops will be held in April along with analysis of the post workshop evaluation by the participants.
   • Additional 3 and 6 month follow up will be conducted to evaluate the extent by which developed action plans by the participants is being carried out.
   • A full colour BPG Brochure outlining the vision, achievements and products of the NBPG project was developed, printed and widely distributed amongst all workshop participants.
3. Translation into French of select BPGs, Health Education Fact Sheets and Toolkit for guideline implementation.
   • Five BPGs, Toolkit and 10 HEFS have been translated in French

Hospital Utilization: Implications for Nursing Human Resource Planning

Principal Investigators:

Professor Gail Tomblin Murphy and Dr. Linda O'Brien-Pallas

Co-Investigators: Dr. Stephen Birch and Dr. George Kephart

Project Staff: Adrian MacKenzie

Goal of the study:

This study is an extension of our recent study "Health Human Resource Planning: An Examination of Relationships among Nursing Service Use, an Estimate of Population Health, and Overall Health Status Outcomes in the Province of Ontario (Project Identifier: RC1?0618?06)", funded by the Canadian Health Services Research Foundation (CHSRF) (Tomblin Murphy and O'Brien-Pallas, et. al., 2003). Using an open systems framework, this study estimated the association between the number of hospital days and patient outcomes in acute care hospitals in Canada. Because utilization is influenced, in part, by non-need factors (local availability of hospital beds, local practice patterns, etc.), we use the difference between reported and expected bed days as the measure of utilization. Expected days are estimated from data on the presence of chronic conditions and demographic factors, independent determinants of the need for services. The expected use model is estimated at the national level in order to 'liberate' expected use from the influences of local availability of resources and practice patterns.

In this study we address some new issues and extend our work in the following ways: 1) expanding our examination beyond Ontario to all of Canada; 2) using the Canadian Community Health Survey (CCHS) to increase our sample size, to increase power while doing jurisdictional estimates; 3) using improved modelling techniques to adjust for local variations in non-need factors such as health services supply and access.

Objectives and Research Questions:

1. How does health vary as a function of relative levels of inputs (days of hospital care and, by proxy, exposure to nursing care) compared to that expected given a patient's age, sex, income level, employment status, education level, location type, living arrangement, depression score, and chronic health conditions?
2. How does the expected utilization of hospital services per capita vary between provinces and territories as a function of differences in the provincial populations by age, sex, income level, employment status, education level, location type, living arrangement, depression score, and major chronic health conditions?

In approaching these research questions, we focused primarily on the deployment and utilization components of the model, as well as population health status and health outcomes. Although controlling for supply, management practices, and financial resources for health services are key components of our model, it is important to note that development of national-level measures of these factors, and thus incorporation of them into our study, was not feasible given the three-month preparation time. Despite such constraints, this study explored some of the very difficult methodological issues associated with need.

Methods

Analysis was restricted to respondents 18 years of age and older, and the CCHS sample size for adult respondents in Canada was 112921. The gender split in this sample was 46% males to 54% females. The 40-44 age group was the largest in the CCHS at about 11%, followed by the 35-39-year-olds at just under 11%. About 20% of respondents were seniors (aged 65 and over), and only 2% were over 85. The largest group of respondents (about 38%) resided in major metropolitan areas, with 23% residing in urban, non-metropolitan areas, and the remainder in rural areas. The majority of respondents were employed (58%), with 35% out of the labour force and 5% unemployed. More respondents had no high school diploma (27%) than had a university degree (14%). Roughly 27% of respondents had a high school diploma only, and 31% had earned a community college or trade school diploma. The CCHS was afflicted with a high rate of non-response on income-related questions (roughly 11% nationally). Income level was missing for about 10% of our sample. Over half the respondents (54%) were classified as living in an upper-middle or upper income household (about 31% and 22% each), compared to about 14% in the lower-middle and lower income groups (about 9% and 4%, respectively). About a quarter (25%) of respondents reported living alone, with roughly 6% being living in single-parent homes. The remaining respondents did not fall into either category.

Policy Messages

We believe that the findings of this study have important policy implications and suggest that policy makers consider and integrate the following five policy messages into Health Human Resource Planning:

1. There was no evidence that lowered numbers of nights of stay were associated with lower levels of health status after controlling for other population based factors. It is important to note that our results reflect associations between variables and not cause-effect relationships; that is, they do not suggest that extra hospital bed days cause decreases in health status. Rather, they point to the existence of some relationship between extra hospital days and health status that is not captured by our models. It is important to note that this is based on one health care input (hospital days). In our CHSRF study, where we examined the relationship between nursing intensity and lengths of stay in Ontario, we found that lower lengths of stay were associated with increased levels of nursing input.
2. Populations that have higher rates of chronic conditions (such as diabetes and heart disease) have higher numbers of hospital days, and numbers of hospital days differ by jurisdiction.
3. There needs to be significant investment in creating and maintaining readily accessible databases and methods that allow HHR researchers and planners to compare differences between and across jurisdictions, to understand the health needs of the population, and to determine whether the system is working in effective and efficient ways to meet these needs. More effective ways to access data on health care use and factors that influence needs for health care are essential.
4. Planning for HHR should be based on the health needs of the population in the context of the availability of other health care human and non-human resources, and it should consider as many factors that affect use of health care services as possible, including social, political, geographical, technological, and economic factors.
5. HHRP cannot depend on simple solutions to provide short term answers. To gain a better understanding HHR, planning must be comprehensive and the complexity of the work demands partnerships including policy makers and researchers with different perspectives.

This study highlights the potential benefit of intensive preventative initiatives to reduce overall hospital admissions and lengths of stay for people suffering from chronic conditions and/or depression.

Links to the full text documents referred to in this ONP summary

Needs-based Health Human Resource (HHR) Planning: The Relationship between Population Health and Nursing Service

 Nursing Best Practice Guidelines