Briefing Note: Strengthening the Nursing Workforce for a Stronger Health Care System
1999 was a watershed year for nursing in Ontario. After a period of years of benign neglect, during which RN employment growth was stagnant while Ontario's population continued to grow and age, the mid - to late 1990s brought thousands of nursing layoffs, as then Premier Harris infamously likened nurses to hula hoops. A tough nursing HR situation dramatically worsened: workloads spiked for an aging nursing workforce, while enrolments in nursing schools were slashed and many thousands of RNs left the province or the profession. Only half of all RNs had full-time employment. Ontario earned the dubious distinction of having the worst RN-to-population ratio in the country, needing 13,000 RNs just to the catch up to the ratio for the rest of the country. Burnout was rampant and the profession was in dire straits. Nurses demanded and got a Nursing Task Force, whose 1999 report signalled a turning point in Ontario policy towards nursing. The government accepted the recommendations in the report, and was able to deliver partially on some of them. The McGuinty government made very substantial commitments to nursing, and has made significant progress in stabilizing the nursing workforce. But, recent messages from the Premier are creating fear amongst nurses and may once again destabilize the profession. This must be avoided at all costs as the damage would be irreparable.
As Ontario weathers stormy economic conditions it is particularly urgent that the government invest in the people, communities and infrastructure, including health care, of this province. That means, more than ever, the government must keep its promises to strengthen nursing.
Issue: Keep the Promised Additional 9,000 Nursing Positions On Track
RNAO calls for:
Meeting the $500 million commitment in the 2008 budget to increase Ontario’s nursing workforce by 9,000 additional positions by 2011, including 3,000 FTEs (2,250 RNs and 750 RPNs) funded in 2009.
In the 2003 election campaign, the current government promised 8,000 nursing positions in its first mandate. According to College of Nurses of Ontario data, there were 9,669 more nursing positions than there were at the start of the mandate: 6,327 more RNs in the general class, 338 more nurse practitioners, and 3,004 more RPNs. This shows that the government was more than able to meet its target. The RN-to-population ratio rose from 69 RNs per 10,000 to 71 over the time period for Ontario, meaning that access to RN care improved. Ontario still has a considerable distance to go to recover to the levels prevailing in 1980s, when the ratio exceeded 80. When RNs talk about burnout, the RN-to-population ratios help to explain this condition. If anything, these ratios are underestimates of workload, as the general population has aged and health needs have increased.
In the 2007 election campaign, the government promised to add 9,000 more nursing positions. Given its performance in the previous mandate, the 9,000 target is very feasible, and necessary, given the ongoing workload challenges faced by nurses.
In the 2008 spring budget, the government allocated $500 million for the 9,000 additional promised nursing positions by 2011-12.
However, the response to a looming recession threw up a roadblock and the McGuinty government has chosen to target nursing. This is unacceptable! In the 2008 fall economic update, the brunt of government cutbacks fell on nurses ($50 million) in a delay in nursing hires. The government quite correctly undertook substantial deficit spending ($1 billion), but it chose to focus its budget cutting in an ill-advised way, and RNAO publicly pointed this out. The additional nursing positions are needed and are needed immediately. The focus on delaying nurse hires is a terrible signal to send to the nursing workforce, to new nursing graduates, and to potential nursing students. Teamed with austerity measures in the hospital sector, the potential for losing essential nurses from the system skyrockets. When each and every nurse is needed, the government must move quickly to undo the damage that this measure is causing.
Issue: 70 per cent Full-Time Employment for RNs
RNAO calls for:
· Achieving the goal of 70 percent of nurses working full-time by 2011.
- As noted above, the situation of RNs in the province had deteriorated dramatically by the late 1990s. Not only had RN employment levels fallen dangerously low, but the share of RNs working full-time dropped to about half. This situation is not appropriate or sustainable for an essential health care profession. There are very negative implications for the quality of nursing practice, continuity of care and nurse retention and recruitment.
- RNAO has long campaigned for 70 percent full-time employment, and successive governments have undertaken to rectify the situation. The current government promised to deliver 70 percent full-time for nurses in its 2003 campaign.
- From a low of 50 percent full-time in 1998, the RN workforce rose to 64.7 percent in 2008 (64.9 percent if nurse practitioners are included). This has been a dramatic turnaround, and has resulted in better retention, better quality of patient care and more people wanting to enter the profession.
- In the 2007 election campaign, the government reiterated its promise to get to 70 percent full-time for nurses, this time in its second mandate. Its rate of progress over the first mandate suggests this is a very achievable target.
- The rise in the share of full-time employment has afforded many more recent graduates the opportunity to obtain this crucial opportunity to transform academic knowledge into best clinical practices through continuity of engagement with their patients, socialize and fully integrate into their chosen workplace and develop their careers. Along with increased nursing employment, more full-time employment has increased access to nursing care.
Issue: Full-Time Employment for all Nursing Graduates in Ontario
RNAO is pleased that the McGuinty government remains committed to:
· Continuing the guarantee of full-time jobs for new nursing grads, and, importantly, working with employers to ensure continuation of full-time employment for these new grads after the six months of government funding ends.
· In February 2007, the government announced an $89 million new nursing graduate guarantee program. Preliminary statistics show that 86 percent of participants retained their positions after their seven-month guaranteed period ended.
· We know that most new graduate RNs need and want full-time employment, but in the past most were unable to secure it. This made it very challenging for new graduates to develop clinical expertise and work attachment. The result was under-utlization of knowledge and skills, and an exodus from Ontario to other jurisdictions. Things have improved of late for new Ontario RNs, with those securing full-time employment rising from 39.1% in 2005 to 58.9% in 2007 and 75.7% in 2008. However, continued progress is required, particularly in light of the announced delay in creating 9,000 additional nursing positions. In order to attain 70 percent full-time RN employment, Ontario will require far more than 70 percent of new graduates to obtain full-time employment.
Issue: 80/20 Program for Late Career Nurses
RNAO calls for:
l Supporting innovation and healthy workplaces, and enhancing retention by providing funding that would allow participating institutions to offer an 80/20 option to late-career nurses (aged 55 and over).
· The 80/20 program is an innovative program that provides full-time, experienced RNs with the opportunity to spend 80 percent of their time in direct patient care and 20 percent of their time in mentoring or other professional development activities. This program will open up full-time positions for new graduates and help keep experienced nurses in the workforce. In trials to date, results have been very positive: 30.2 percent of respondents in one study indicated that their retirement plans had changed as a result, while another study showed reduced overtime hours, low sick time, no rise in variable direct labour costs, and higher patient satisfaction.
Issue: Equity for RNs Across Sectors
RNAO calls for:
l Equitable remuneration and working conditions for RNs working in the acute care, primary care/family practice, home care and long-term care sectors.
· There is a need to address the great variation of remuneration and working conditions across sectors. A shift from an illness-based model of care to a preventive one will require a shift of nursing services out of the hospital sector and into the community, yet wage differentials are a disincentive to nursing employment in home care. This sector has lost 27 percent of its nursing workforce between 1998 and 2004, and saw an increase in the share of older nurses working in the sector. Disparities in compensation from one public health unit to another and employment instability were identified as recruitment and retention issues for the public health workforce, a majority of which is comprised of public health nurses. To meet the increasingly complex needs of clients in long-term care settings with appropriate staffing, it is also essential that nurses in this sector receive comparable remuneration to the acute sector. In summary, to retain and attract RNs across all sectors, inequitable gaps in remuneration and working conditions must be urgently addressed.
Issue: International Recruitment? No: Let’s keep a Made-in-Ontario strategy
RNAO is pleased that the government remain committed to:
- Ensuring that government and those health organizations funded by the government do not engage in international recruitment of nurses and other health professionals.
- Establishing permanent funding for existing upgrading and bridging programs for internationally educated nurses who make Ontario their new home.
- A significant ethical concern in a context of a global shortage of 4.3 million health workers is the growing disparity as poor nations with the fewest nurses and greatest burden of disease are losing them to wealthy countries with the most nurses.
- A key push factor that has driven nurses from their home countries has been economic structural adjustment programs and fiscal restraint programs that have resulted in cuts to health services, increased casualization of the nursing workforce, and nursing unemployment. Both industrialized and developing countries alike are faced with the paradox of nursing shortages existing alongside unemployed nurses.
- Recruiting internationally educated nurses as a quick fix for industrialized countries that have not addressed their own HHR needs has a negative impact of destination countries as potential implications for public safety, the viability of nursing as a self-regulating profession, and the ultimate sustainability of the nursing workforce.
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