Dear Minister Matthews:

The Registered Nurses’ Association of Ontario (RNAO), the professional association
representing Registered Nurses (RNs) working in all roles and sectors in Ontario, is gravely concerned with the evolving nursing health human resources crisis being experienced across the province.

More specifically, RNAO is referencing the most recent data compiled by the Canadian Institute for Health Information (CIHI), which examined the number of registered nurses (RN) in the workforce between 2008 and 2012. While the RN workforce in the rest of Canada increased slightly from 8.29 in 2008 to 8.30 in 2012 per 1,000 people, Ontario’s declined (Appendix A). In fact, the RN workforce in Ontario for the same period decreased from 7.18 to 6.99 per 1,000 people, making it the province with the second worse RN-to-population rate in Canada. This gap has significant workload and patient outcome implications.

Sadly, the time has come for RNAO to publicly ring the alarm bell on how the declining number of RNs will negatively affect patient care in our province (Appendix B). RNAO has been consistently forecasting and communicating this reality to government for the past three years, with no meaningful response. While the current government in its first two mandates made great strides in recovering from the disastrous cuts produced during Premier Mike Harris period prior to 2003, Ontario is now sliding back on an unhealthy path. The solution is clear; Ontario requires a minimum of 9,000 additional RNs by 2015 to begin catching up with the gap of about 17,600 positions.

Minister, RNAO and the public expect the MOHLTC to value evidence-based nursing human resource policies. Therefore, we were shocked to read comments you made in the Ottawa Citizen (January 11, 2013) where you validated the replacement of RNs with other providers to balance budgets. You stated: "If nurses are trained to do more, we want them to do more. So if an RPN can do more, and it's within their scope of practice and it's high-quality care, and they can do it just as well but at lower cost than an RN, then that is happening." While RNAO promotes the full scope of practice utilization of all regulated health professionals and obtaining the best value for every health-care dollar spent, the evidence vigorously calls for the use of RNs when patients’ status is complex, unpredictable, unstable, or unclear. Without this expertise, quality deteriorates and costs rise accordingly. Moreover, we know all too well that patient care complexity is continuously increasing, thus we must upskill our health human
resources accordingly.

RNAO supports the Ministry’s direction of shifting care towards the community, and focusing our hospitals on patients with the highest degrees of complexity and acuity. This shift, however, demands a strong and sustainable RN workforce that is practising to their full scope. Proceeding with health system transformation while at the same time excusing and even supporting deskilling of patient care, as it appears MOHLTC is intent on doing, is unsafe for patients as well as fiscally irresponsible. This will result in a revolving door syndrome of the kind
we suffered during Premier Harris’ era.

As additional background, RNAO is pleased to include a matrix that summarizes several key research projects from the past three years, which demonstrate both the positive impacts of increasing RN staffing and the negative impacts of decreasing RN staffing on patient outcomes (Appendix C). There is a wealth of additional evidence available that could be added, however, our aim is to provide you with a focused summary.

Minister, as a first step, RNAO’s executive is calling for an urgent meeting with you and Premier Wynne before the end of the month (October 2013) to develop a plan of action. If action is not taken, Ontario will be faced with an unprecedented crisis in ensuring patient safety and quality care delivery. RNAO is hopeful that government will work with us before a tipping point is reached. In the meantime, RNAO respectfully requests that you refrain from commenting in favour of substituting RNs for other providers as a means of achieving cost savings, as this is
inappropriate and inconsistent with the evidence.

Warm regards,

Doris Grinspun, RN, MSN, PhD, LLD(hon), O.ONT.
Chief Executive Officer, RNAO

Rhonda Seidman-Carlson, RN, MN
President, RNAO

cc. Hon. Kathleen Wynne, Premier of Ontario