The 70 Per Cent Solution: A progress report on increasing full-time employment for Ontario RNs
Since 2000, RNAO has advocated for 70 per cent full-time (FT) employment for RNs in the province of Ontario (RNAO, 2000). Other key reports have also recommended moving to 70 per cent FT as a minimum target. For example, the Canadian Nursing Advisory Committee’s (CNAC) 2002 report entitled: Our Health, Our Future: Creating Quality Workplaces for Canadian Nurses recommends: “Governments, employers and unions should collaborate to increase the proportion of nurses working full-time to at least 70 per cent of the workforce in all healthcare settings by April 2004, with an improvement of at least 10 per cent to be completed by January 2003.”
While there is no specific study that looks directly at 70 per cent FT employment for nurses as the ideal, there is significant evidence that, by logical deduction, leads to this conclusion. RNAO’s rationale for 70 per cent FT employment is based on the fact that this is VITAL to ensuring continuity of care and continuity of caregiver for patients/clients in Ontario. And both continuity of care and continuity of care provider are centrepieces for:
- Improved Patient/Client Outcomes
- Efficient RN Utilization and System Cost-Effectiveness
- Improved RN-Physician Collaboration and Team Work
- Enhanced Organizational Commitment
- Successful Recruitment and Retention of RNs
- Sustainability of the Nursing Profession
- Economic Sense
RNAO believes continuity of care and continuity of care provider cannot be achieved with the current low levels of full-time employment amongst RNs; and the over-reliance on part-time, casual and agency employment. The evidence and rationale are detailed below:
1. Improved patient/client outcomesdepend on 70 per cent FT:
“The ability of nurses to know their patient is significantly compromised when nurses are assigned to different patients every day which is mostly the case for agency, casual and part-time nurses, and in particular for those who work for multiple employers. Caregiving requires the nurse to have a detailed understanding of the patient’s condition, response, needs, and wishes. It is through this human relationship that nurses develop the comprehensive understanding essential to respond to patients’ needs in a way that is relevant to them. Undoubtedly, patient care is profoundly affected when the nurse-patient relationship is short-lived due to intermittent, interrupted, and inadequate interaction time” (Grinspun, 2003).
Several studies clearly demonstrate the links between continuity of care and hospital patient outcomes (Aiken, 2002) and in home care (O’Brien-Pallas, 2001).
Failure to rescue (Clarke and Aiken, 2003) links nurses’ experience directly to permanency in one unit (not a patchwork of two, three or four employers). This paper also makes the link between the quality of surveillance and the number of experienced nurses compared to inexperienced nurses. Units with more experienced nurses are more likely to detect problems/complications in a timely manner. RNAO asks, how can nurses that run between several employers attain expertise? Did you know that across Ontario, excluding oronto, 30 per cent of casual nurses and 18 per cent of part-time nurses work for multiple employers? The situation is worse still in Toronto where 42 per cent of casual nurses and 25 per cent of part-time nurses work for multiple employers? This is simply outrageous!
2. Efficient human resources utilization and system cost-effectiveness requires 70 per cent FT:
A home care sector study (O’Brien-Pallas et al, 2001) found that reducing the number of nurses going into a patient’s home reduces the overall number of visits; more so if the principal nurse makes the greatest proportion of visits. Thus, utilization is improved when continuity of care provider is maintained. This study also reveals that continuity of care provider (and for that RNAO argues you need to have more FT nurses), significantly contributes to cost-effectiveness. The study also demonstrates the greater effectiveness of BScN prepared nurses compared to diploma RN or RPNs.
Overtime and related sick time are also linked to insufficient numbers of full-time nurses and an over-reliance on part-time, casual and agency staff. We all know that when a nursing unit receives a last minute sick call for the upcoming shift, it is often the full-time nurses who, by the mere fact of being there, are requested to fill in the gap. “The excessive use of a part-time and casual workforce has introduced job insecurity, intensification of work, and added stress among full-time employees. The impact is expressed in organizational performance through indicators such as absenteeism and overtime” (Grinspun, 2003). O’Brien-Pallas’ interim results from focus groups conducted by the Nursing Effectiveness Utilization and Outcomes Research Unit (NRU) reinforce this reality. As a consequence, absenteeism is also higher among full-time nurses than their casual and part-time counterparts (Shamian et al, 2002). Indeed,
we have created a truly sick cycle that must urgently be reversed.
3. Improved nurse-physician collaboration and team work necessitates 70 per cent FT:
Much has been written about the poor working relationships between nurses and physicians. Aiken’s work (2002), stresses the importance of good working relationships between nurses and physicians to encourage nurse satisfaction and optimal patient outcomes. The importance of nurse–physician collaboration has also been supported in Canadian-based replications of Aiken’s work (Laschinger et al, 2001). RNAO believes that it is impossible to foster greater collaboration without moving to 70 per cent FT employment for RN
4. FT nurses and enhanced organizational commitment:
There is much “talk” among CEOs and others about the lack of organizational commitment that “nurses today” demonstrate.
It is difficult to understand how organizational commitment can improve with nurses coming and going all the time. Nurses feel that organizations are not committed to securing FT work for them; thus, they owe nothing to organizations.
RNAO’s Executive Director, Doris Grinspun, explained this “broken psychological contract” to the CEOs of the Toronto Academic Health Science Council in 2000 when they invited her to help them address this issue. CEOs at that meeting said: “We call them and they don’t want to come.” The issue was also addressed in Hospital Quarterly (Grinspun, 2000). The notion of commitment, both by the nurse and towards the nurse, is one that in many reports/analyses has been linked to nurse satisfaction and patient satisfaction. RNAO conducted a survey of nurses’ assessments of changes after the Nursing Task Force released its initial report: Tracking the nursing task force: RNs rate their nursing work life (2002). The report provides clear evidence of the importance of organizational commitment. It is a theme that appears in other key reports such as Baumann et al (2001), which finds that commitment is much harder to build given the numbers of casual/part-time compared to full-time nurses. This issue was also discussed in Laschinger et al (2001).
Aiken et al’s work (2002) identifies nurses’ work environment as a key organizational trait explaining higher patient satisfaction in magnet hospitals. Not only were magnet hospital patients were more satisfied, but they were also more likely to have a single nurse taking prime accountability for care. RNAO believes that this cannot be achieved under current staffing patterns.
5. Successful recruitment and retention outcomes mandate 70 per cent FT:
So many more registered nurses want full-time employment. Earning Their Return: When and Why Ontario RNs left Canada and What Will Bring Them Back (RNAO, 2001) found that the lack of full-time positions was a key reason why Ontario RNs left the country in the first place.
Further, the availability of full-time positions was a key factor that would encourage the return of those same RNs to Ontario. RNAO’s Survey of Casual and Part-time Registered Nurses in Ontario (2003) revealed similar findings. We found that despite current work environment challenges, if respondents had their preferred status, there would be an immediate net shift of 11 per cent from part-time and casual to full-time.
This would translate into almost 4,000 more full-time RNs and, if certain conditions changed (and it must be emphasized that these are not unreasonable conditions) 42.7 per cent, (the equivalent of well over 15,000 more full-time positions, or more than 6,000 FTEs) would move to full-time, putting Ontario at 74 per cent full-time employment for RNs. RNAO believes this is absolutely doable and an absolute must!
6. Sustainability of the nursing profession depends on 70 per cent FT:
The fundamental question is: What kind of profession – and professionals – do we need to have? If we believe – and we do – that the nursing profession is central to health and health care, then how can we allow it to be structured in a way that makes relationships with patients/clients, other professionals and the organizations where nurses work sporadic? If we believe – and we do – that nursing is so much more than “doing tasks to patients,” then why would we allow so many RNs to continue to practise in a way that makes familiarity and engagement with patients, families and other agency resources more difficult and less meaningful? How can we support a system that obliges nurses to run between two, three and four employers to make ends meet, therefore rendering commitment almost impossible to achieve?
What other profession would tolerate this percentage of their members practising in this fashion?
How can one actively engage in the structures of organizational decision-making when there is so much coming and going?
How can we appropriately mentor our new graduates?
We challenge those who say “nurses want casual work because they want control over their lives.” Our response is (and our survey data show) that much of this so-called interest in part-time and casual employment is a result of a lack of full-time opportunities and unacceptable working conditions. We must immediately open the doors to full-time employment for RNs or they will continue to leave the country. We must fix work environments to improve the employment experiences of all nurses.
When it comes right down to it, we simply cannot afford to encourage members of our profession to believe that nursing is something in which you “casually engage.”
7. 70 per cent FT makes economic sense:
It makes little sense that nursing education programs, which are highly subsidized by government, would produce a workforce with approximately 50 per cent of its professionals working less than full-time hours, or leaving for the U.S.
O’Brien-Pallas has demonstrated significant cost efficiencies can be realized through reductions in workload. Reduction in sick time through improved workloads would save over $39M, the equivalent of 765 full-time equivalent positions (O’Brien-Pallas, et al., 2001).
A final comment:
How many nurses have you heard say, “I can’t find part-time or casual work?” RNAO has not heard of a single one!
How many nurses have shared with you their frustration of not being able to find full-time work? RNAO has received hundreds of calls like that, and every year we help new graduates look for full-time work; often all they can find is casual or part-time work.
On the other hand, the U.S. consistently makes 71.6 per cent full-time employment available to its RNs. .