Nursing Issues: Education

Office of Nursing Policy
Health Canada
November 2006
ISBN: 978-0-662-44710-8 (PDF Version)
Cat. No.: H21-281/1-2006E

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• Introduction
• Nursing Programs Across Canada
• Level of Education for Nurses
• Attrition of Nursing Programs
• Endnotes

Introduction

This fact sheet examines the education of nurses and pertains to the following groups:

• Registered Nurses (RN, Reg.N.). RNs (inclusive of Nurse Practitioners) represent the largest regulated health care provider group in Canada. Registered nurses must complete a nursing program either at a baccalaureate or diploma level and register with their respective provincial or territorial nursing regulatory body which permits them to perform the authorized functions of a registered nurse. All provinces and territories have RNs, who work in a variety of settings.
• Licensed Practical Nurses (LPN). LPNs are the second-largest regulated health profession in Canada. Prior to 1945, "auxiliary workers", as they were known, were employed and trained on the job to meet nursing service needs in hospitals and nursing homes. LPNs now receive theoretical and clinical education in one to two-year community college programs. Like RNs, all provinces and territories have LPNs, who work in a variety of settings.¹ In Ontario they are called Registered Practical Nurses. (Please see note in next paragraph.)
• Registered Psychiatric Nurses (RPN). RPNs represent the largest single group of mental health professionals found in Manitoba, Saskatchewan, Alberta and British Columbia where they are a separate regulated health profession. (Note: LPNs in Ontario are called Registered Practical Nurses and the acronym should not be confused with Registered Psychiatric Nurses (RPNs) in the four western provinces). RPNs must complete an education program either at the diploma or baccalaureate level.

Nursing Programs Across Canada

Registered Nurses

In the 1960s and 1970s, many nursing students graduated from two- or three-year hospital programs with a diploma in nursing. Few nurses earned a baccalaureate degree because it was generally not required to practice, but was an expectation for teaching or administration.

By the 1990s, most educational programs in nursing were provided either by community colleges (a three-year diploma) or universities (a four-year baccalaureate degree). This evolution in nursing education came about as a result of several factors, including: changing technology; increased patient complexity and acuity; increased responsibility and accountability for RNs; changes in scopes of practice; changes in health care delivery; and particular requirements for specialized care.

By the late 1990s, most provinces had announced a four-year baccalaureate degree as a requirement for entry to the practice of nursing in their respective jurisdictions within the next decade. As a result, some diploma programs in nursing closed while others merged with university programs.²

The tables below outline by type, the total number of nursing programs offered in Canadian educational institutions in both 2001 - 2002³ and 2002 - 03.⁴ As the tables show, the number of nursing programs for baccalaureate, Post-RN, Master's, Doctoral degrees and Nurse Practitioner certification have remained steady, while the number of nursing programs that provide graduates with a diploma have declined by over one-third. ⁵

Nursing Programs Offered in Canadian Schools of Nursing, 2001 - 2002
Total	Diploma	BACC	Post-RN	Nurse Prac	Master's	Doctoral
242	76	83	37	14	24	9

Nursing Programs Offered in Canadian Schools of Nursing, 2002 - 2003
Total	Diploma	BACC	Post-RN	Nurse Prac	Master's	Doctoral
224	50	86	35	18	25	10

Year	BACC Program Enrolment	Diploma Program Enrolment
1998	855	13171
1999	10270	11609
2000	10264	11248
2001	19126	15788
2002	23333	7256

Proportionately, enrolment rates for diploma programs in nursing have declined by almost half since the late 1990s while enrolment rates for baccalaureate programs have increased almost threefold, as the above table on enrolment data shows.⁶

Level of Education for Nurses

Registered Nurses

Given these developments, it is not surprising that increasing numbers of RNs are entering the workforce with a baccalaureate in nursing.

• Admissions to entry-to-practice nursing programs rose to 12,361 (60%) from 1998 to 2004.
• The trend shows a peak of 13,068 admissions in 2001, with a levelling off in the subsequent years.
• In 2004, 8,076 nurses graduated from entry-to-practice programs. This is a 76% increase in the number of graduates since 1999.
• In 2004, more than 400 faculty members were recruited; however, projections indicated that by 2005 there were 500 faculty vacancies.
• A number of schools commented on the difficulties encountered in attracting and retaining faculty, including equitable compensation levels. In common with the rest of the nurse workforce is the reality of an aging professoriate. The data show that the proportion of nurse educators in the 45-64 years age group significantly exceeds that seen in the total nurse workforce.
• Faculty retirement projections considered in conjunction with current staffing challenges indicate a need for 3,673 master's-prepared nurses annually.
• While more RNs are entering the profession with baccalaureate degrees, there is a continuing shortage of RNs with nursing education at the master's, doctoral, and post-doctoral level. As noted by the Canadian Nurses Association (CNA) and the Canadian Association of Schools of Nursing (CASN), RNs with master's, doctoral, and post-doctoral education are needed to: enhance quality care and improve health outcomes; conduct research that advances nursing knowledge and practice; assume faculty positions; provide professional leadership; and, influence nursing and health policy.⁷ In 2003, only 275 (approximately 0.11%) of the 241,342 RNs within the nursing workforce reported that they had earned a doctorate level of education in nursing,⁸ practically unchanged since 1996.⁹ The number of graduates from doctoral programs in nursing in Canada from 2000-2004 varied widely, but ultimately the number of graduates are on the rise. Since 2000, the number of graduates from master's and PhD programs has doubled.¹⁰

Graduates¹¹

<

Year	Master's	Doctorate
2000	218	10
2001	303	20
2002	336	18
2003	434	31
2004	418	25

CNA and CASN note that the current general nursing shortage and the shortage of nursing faculty within Canada, act as barriers to increasing the number of nurses who are able to achieve a doctoral degree or post-doctoral opportunities. These Associations recommend that professional nursing associations, educational institutions, employers of RNs and governments share responsibility to plan collaboratively, remove barriers to higher education, and support students and academic programs.¹²

An analysis of the 2004-2005 data reveals some positive indicators, including program innovations, a consistent level of interest in continuing education, and an increase in the number of students graduating from entry-to-practice and some post-graduate programs. New program innovation include fast tracking and distance education. In 2004, there were 31 programs offering to fast-track the nursing educational preparation process. These include accelerated, fast track, second degree entry, and bridging programs. The number of programs offered increased by 16% in 2004. In 2004, 41 programs (20 baccalaureate, 16 master's, and 5 PhD) were offered, in full or in part, electronically. This innovation facilitates access to education for students living outside urban centres, and for working nurses seeking to update credentials.

Licensed Practical Nurses

Registration or licensure as an LPN in Canada requires graduation from an approved LPN diploma program, offered in post-secondary institutions. Equivalency status can be granted to individuals from LPN programs in other jurisdictions or educated in another country. In 2003, all provinces and territories reported that 92% of LPNs or higher had an initial education of a diploma, as opposed to equivalency status.¹³

Registered Psychiatric Nurses

Most RPNs currently employed in psychiatric nursing earned diplomas before entering practice. The first baccalaureate in psychiatric nursing was offered only in 1998 in Manitoba. Manitoba has the highest percentage of RPNs with a baccalaureate as their initial education (5% in 2003) at 3.3%, British Columbia has the second-highest. In Alberta and Saskatchewan, less than 1% of RPNs enter practice with a baccalaureate.¹⁴

Attrition of Nursing Programs

RNs, LPNs and RPNs

Research has noted that students leave nursing programs mainly within the first two years.¹⁵

• Top three personal reasons why students withdraw from programs:
  • Baccalaureate programs: finances, health, stress, and family responsibilities.
  • LPN programs: finances, stress, and family responsibilities.
  • RN (diploma) programs, RPN program: personal health, stress and finances.
• Top program reasons prompting students to withdraw from programs:
  • Baccalaureate programs and LPN programs: academic standards (too demanding), structure of program and lack of academic support.
  • RN (diploma) programs and RPN program: academic standards, structure of program, and other.
• Top three professional/career reasons students withdraw from programs:
  • Baccalaureate programs: poor fit with nursing, negative feedback from practicing nurses, and treatment of students in clinical.
  • LPN programs: poor fit with nursing, treatment of nursing students in clinical, negative impressions from practicing nurses, and dissatisfaction with status and respect.
  • RN (diploma) programs and RPN program: poor fit with nursing, negative impressions from practicing nurses and other.¹⁶

Research has suggested actions schools of nursing could take to try to reduce attrition. They include:

• Explaining the current state of the health system to students, including the impact on nursing as a profession and on the satisfaction of some nurses with their careers, including dissatisfaction within nursing about the role of nurses in the health system. This, as well as policies and practices to improve the system and how nurses can survive and develop rewarding careers, should be the subject of ongoing discussion.
• Attempting to make clinical placements for nursing students "student-friendly." Accrediting bodies for organizations that have clinical practice opportunities for students should add the quality of the environment for student learning for review and develop standards against which these organizations will be assessed.
• Examining the issue of faculty support to students and whether courses are meeting the needs of mature and diverse groups of students, particular in RN programs. Schools of nursing should develop strategies and programs to ensure that students receive the support they require, especially early in their programs.
• Many nursing students require sources of funding to ensure their success. The significant number of clinical hours demanded of nursing students leaves little available time for them to earn money to support themselves. Nursing schools should develop solutions that will allow students to work less and therefore potentially stay in their programs and succeed.¹⁷

Despite concerns by nursing organizations and employers, most nursing programs of all types consider attrition to be a minor problem to which they are responding well. Between 50 - 75% of nursing programs investigate why attrition occurs.¹⁸

There appears to be major difficulties with calculating attrition. Only some nursing programs have a definition. There is a lack of information about all aspects of attrition; this is compounded by different reporting periods when students are admitted to nursing programs. Several programs also have difficulty tracking transfer students.¹⁹

CASN advocates having student attrition carefully defined and analyzed to reflect:

1) differing philosophies in entry requirements between universities and colleges; 2) gender-related challenges to nursing students; and 3) two very different types of students:

1. those who, due to academic failures within the nursing program, are required to withdraw and are not eligible to return; and
2. those who discover that their desire to become a nurse has changed and leave the program to undertake studies in another profession or program.

CASN believes that students who encounter a program extension should not be counted within attrition numbers until at least one academic year after the semester from which they withdrew has been completed (i.e., equivalent to four academic semesters). In addition, extended program students (i.e., those who withdraw because of failure of prerequisite course(s), personal circumstances, pregnancy or health problems and subsequently re-enter the program) should not be calculated in student attrition statistics.²⁰

Endnotes

1. Canadian Institute for Health Information (CIHI). Licensed Practical Nurses Database: Workforce Trends of Licensed Practical Nurses in Canada, 2002, 2003, p. 36.

2. CIHI. Registered Nurses Database: Workforce of Registered Nurses in Canada, 2003, 2004, p. 25.

3. From "Table 2: Nursing Programs Offered in Canadian Schools of Nursing, 2002 - 2003", National Student and Faculty Survey of Canadian Schools of Nursing, 2001 - 2002. Canadian Nurses Association (CNA) and Canadian Association of Schools of Nursing (CASN), 2002.

4. From "Table 2: Number and Type of Nursing Programs in Canadian Schools of Nursing, 2001 - 2002", National Student and Faculty Survey of Canadian Schools of Nursing, 2002 - 2003. CNA and CASN, 2003.

5. It should be noted with regard to the National Student and Faculty Survey that not all Schools of Nursing that were sent the survey responded; as such, the data does not contain information on programs from these schools. As is noted for each survey: "Data contained in this table is based on information provided by responding schools. A thorough review of the Notes Section is essential."

6. From "Table 5: Degree Programs in Canadian Schools of Nursing, 1998 - 2002. Admissions, Enrolment and Graduates by Type of Nursing Program" and "Table 3: Diploma Programs in Canadian Schools of Nursing, 1998 - 2002. Admission, Enrolment and Graduates", National Student and Faculty Survey of Canadian Schools of Nursing, 2002 - 2003.

7. Registered Nurses Database: Workforce of Registered Nurses in Canada, 2003, 2004, op. cit.

8. CNA and CASN. Joint Position Statement on Doctoral Preparation in Nursing, 2004, p. 1.

9. CIHI, op. cit, p. 100.

10. CNA and CASN, op. cit.

11. From "Table 5: Degree Programs in Canadian Schools of Nursing, 1998. Admissions, Enrolment and Graduates by Type of Nursing Program," National Student and Faculty Survey of Canadian Schools of Nursing, 2002 - 2003.

12. Joint Position Statement on Doctoral Preparation in Nursing, op. cit.

13. Licensed Practical Nurses Database: Workforce Trends of Licensed Practical Nurses in Canada, 2003, 2004, p. 18.

14. Registered Psychiatric Nurses Database: Workforce Trends of Registered Psychiatric Nurses in Canada, 2003, 2004, p. 18.

15. Rene Day, RN, PhD et al. (Authors). Canadian Nurses Association et. al. (Project Steering Committee). "Proposal to Support the Strategic Plan to Implement the Canadian Nursing Advisory Committee Recommendations: Educational Preparation Objective B - Student Attrition." Funded by Health Canada, 2004, p. 3.

16. Day et al., p. 65.

17. Dorothy Pringle, RN, PhD. "Examining the Causes of Attrition from Schools of Nursing in Canada." Funded by Health Canada, 2004, p.p. 28 - 29.

18. Day et al, p. 65.

19. Ibid.

20. Canadian Association of Schools of Nursing. CASN Position on Student Attrition, 2004.