Policy and Political Action

Policy & Political Action

The 70 Per Cent Solution: A progress report on increasing full-time employment for Ontario RNs

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Download: 70 Per Cent Solution: A progress report on increasing full-time employment for Ontario RNs [PDF - 12.4 MB]
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:

  1. Improved Patient/Client Outcomes
  2. Efficient RN Utilization and System Cost-Effectiveness
  3. Improved RN-Physician Collaboration and Team Work
  4. Enhanced Organizational Commitment
  5. Successful Recruitment and Retention of RNs
  6. Sustainability of the Nursing Profession
  7. 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 outcomes
depend 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,
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
Toronto, 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!
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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.
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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 RNs.
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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
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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
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!
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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.”
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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).
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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. .