Policy and Political Action

Policy & Political Action

Mind the safety gap in health system transformation: Reclaiming the role of the RN

RNAO is the professional association that represents Registered Nurses, Nurse Practitioners and nursing students in Ontario. We advocate for healthy public policy, promote excellence in nursing practice, increase nurses’ contribution to shaping the health-care system, and influence decisions that affect nurses and the public.

I’d like to begin by wishing you all a Happy Nursing Week. Today marks the start of national nursing week, when we celebrate the important contributions of Canada’s nurses and reflect on what is needed to optimize nursing care delivery.

This year’s theme is timely: Nurses – With You Every Step of the Way. As nurses, we build strong connections with the people, families and communities we care for, and they give us a strong sense of what's needed to improve their health and their health-care system.

Nurses are excited for the upcoming and long overdue health system transformation and RNAO has been at the forefront of influencing this change. Indeed, government has listened to our recommendations regarding structural reform contained in RNAO's ECCO report, Now, we are asking government to again -- listen and act. We begin our message today by saying to
Minister's Hoskins that more work is needed to ensure that the necessary fuel to transform the health system -- the health-care workers -- is there to put patients first and deliver best health outcomes. That is not the case when it comes to nursing, today.

RNAO announced to its members at our May 2015 annual general meeting last year, that we would undertake a major study to analyze Ontario's nursing human resources to ensure the public has access to appropriate nursing care. It was in response to our members, who voiced their concerns over a negative trend in the health system, that was robbing Ontarians of the rich knowledge and skills of registered nurses. Today, it is my distinct privilege to unveil the results of these effort: a landmark report titled <em>Mind the Safety Gap in Health System Transformation: Reclaiming the Role of the RN</em>.

RNAO has diligently reviewed the health system priorities outlined by health minister Eric Hoskins and compared them with trends in population health and nursing human resources. We focus our report on two top areas of concern: nursing skill-mix utilization and organizational models of nursing care delivery. Our analysis reveals a shocking reality: trends in nursing skill mix and organizational models of nursing care delivery run counter to the Ontario government's goals for health system transformation.

But, before we move any further, it is important to understand the context of nursing in Ontario, where we have one profession with distinct categories. 1) Registered nurses (RNs) must earn a four year baccalaureate degree and are prepared to care for all Ontarians, regardless of their stability and complexity. 2) Nurse practitioners (NPs) are RNs, with additional education at the graduate level who can, like physicians, serve as the most responsible provider - from running primary care clinics, to hospital admissions, to overseeing the care in nursing homes. 3) Registered Practical Nurses (RPNs) receive a two year College Diploma and are prepared to deliver nursing care to Ontarians with stable conditions and predictable outcomes. Lastly, unregulated care providers - often called personal support workers - work under the direction of nurses and help them deliver care.

When we talk about nursing skill-mix, we are referring to which categories of nurses, and unregulated care providers, are used to deliver care. When we discuss organizational models of nursing care delivery, we are referring to how they are utilized.
What we found in our analysis was shocking: Ontario is set to transform the health system, however, there is no interprofessional health human resource plan to get us there. And in the absence of a plan, current trends in nursing skill mix and care delivery models are going to hinder the government's ambitions of putting patients first. In fact, the contrary is the case. Trends in nursing skill mix and models of nursing care delivery are already putting health and safety of patients at risk. Should this trends not be reversed, they will become a major road block on Ontario's journey toward health system transformation.

Ask any nurse in any health-care setting and they will tell you that their patients have more acute and more complex needs than ever before. Much of this can be attributed to shorter lengths of hospitalizations, and a health system that remains largely focused on illness care with little progress being made in addressing the social and environmental determinants of health.

All hands are needed on deck if we're going to care for Ontarians, without compromising safety and quality. But the rampant replacement of RNs with less educated nursing personnel that is taking place in Ontario is dangerous. Let me share some statistics. From 2005 to 2010, the ratio of RNs to RPNs in Ontario was 3 to 1. That ratio has since dropped significantly and in 2015 was 2.28 RNs to 1 RPN. In fact, Ontario is the second worst in the country!

Indeed, overall growth in RN employment in Ontario, has done little more than keep pace with population growth, and has at times fallen behind it. More concerning even is that in the hospital sector - where the acuity and complexity of patients are often the highest - RPN employment growth rates have more than doubled compared to the growth rates of RN employment. This makes no sense.

Changes are also being made in the way that nursing care is delivered. Instead of having a single nurse provide total patient care to a small group of patients - which is a hallmark of safety and quality -- hospitals are adopting an assembly line-style of fragmented care where an RN, RPN and unregulated provider each perform different tasks on a single patient. Care fragmentation puts patient safety at risk and leaves patients and families not knowing who their care provider is.

As immediate first steps to remedy serious patient safety gaps, RNAO is calling on the government to:
<ul><li>Develop a provincial evidence-based interprofessional HHR plan to align population health needs and the full and expanded scopes of practice of all regulated health professions with system priorities
<li>Issue a moratorium on nursing skill mix changes until a comprehensive interprofessional health human resources plan is completed. This means no more replacing RNs with less qualified care providers
<li>Mandate the use of organizational models of nursing care delivery that advance care continuity and avoid fragmented care</li></ul>

All nurses have a critically important role to play in the health system. However, Ontario is set to position hospitals to care for the sickest of the sick; those with higher acuity, often unstable, and with highly complex needs. In fact, if a patient is stable and has predictable outcomes, they will no longer occupy a hospital bed. Thus:

  • RNAO calls on the Ministry of Health and Long-Term Care to legislate an all-RN nursing workforce in hospitals to be effective within two years for tertiary, quaternary and cancer centres; known in regulation as Group A and D centres. By design, these facilities are meant for very sick, highly complex and unstable patients.

And, within five years, we are calling for the legislated all-RN workforce to apply to large community hospitals with more than 100 beds; known as Group B centres in regulation. These hospitals deliver a high degree of specialty care and are often referral centres for smaller community hospitals. They are managing unprecedented levels of acuity and complexity.

The changes we are proposing re-claim the role of the RN as care providers for those with a high degree of complexity, instability and a lack of predictability. Our focus is on putting patients first and our position is grounded in evidence.

In addition to an all RN staff, we also need to increase nurse practitioners across the system and enable them to deliver the care they are educated to provide. NPs bring advanced knowledge, skill and competencies that serves to improve timely access to high quality care. This is why we are calling for:
<ul><li>The Ministry and the LHINs to eliminate all barriers preventing NPs from practising to their full scope. This includes authorizing NPs to prescribe controlled substances and act as most responsible provider in all sectors; implementing their legislated authority to admit, treat, transfer and discharge in-patients; and utilizing fully the NP-anaesthesia role inclusive of intra-operative care.</li></ul>

We know that care delivery is being shifted to the community and we support that because that's what Ontarians prefer. But, we all read in the media and see in our own lives the increased complexity in our communities. Whether these are issues of bullying or drugs in schools, or homelessness, doing our best to help seniors remain as long as possible living at home, helping seniors adjust in making nursing homes their new homes; to successfully shift more care into the community, we must ensure the right care is there, delivered by the right provider, at the right time, and in the right way. Our schools, for example, are in dire need of more nurses.

We also need to strengthen the capacity of primary care. A robust primary care sector is a hallmark of a high performing health system. RNAO sees timely access to interprofessional care as a key enabler for change. To get us there, we continue to call for the:
<ul><li>re-location of the 3,500 care co-ordinators currently working in CCACs to primary care. </ul></li>

Supporting people to stay in their homes means Ontarians need consistent and high quality access to home health care and support services to assess their needs and provide the care they need. This is why RNAO is calling on :
<ul><li>LHINs to mandate that first home care visits be always completed by an RN. This will allow the RN to perform a holistic assessment and develop a comprehensive plan of care to ensure a patient’s needs are safely met, and determine the most appropriate caregiver, whether it be an RN, RPN or unregulated provider.</ul></li>

Surprisingly, in three policy reports from the Ministry of Health in 2015, there is little mention of the pivotal role of long-term care. These services are critically important to strengthening the health and well-being of Ontarians.

While all efforts should be made to keep people well in their homes, there can come a time when a person’s needs are more safely managed in a long-term care setting. Therefore, it is critical that this sector is resourced effectively, to deliver the best possible care. RNAO recommends that:
<ul><li>the Ministry legislate minimum staffing standards in long-term care homes. This means requiring one attending NP per 120 residents, and a workforce that consists of 20 per cent RNs, 25 per cent RPNs and no more than 55 per cent personal support workers. This will be in addition to other interprofessional providers and supports. Realizing this goal will finally achieve the adequate staffing that residents deserve.</ul></li>

Nursing is one profession and each nursing category RNs, NPs and RPNs, have an important role to play as we work together to transform the system. But, we cannot let budgetary constraints guide decisions regarding skill mix and nursing care delivery models - and that is what's going on today. Worse even, those are misguided budgetary decisions that carry costs, both in people's health outcomes and in real financial cost.

As a professional association that is rooted in evidence; we have an obligation to speak out when short-sighted decisions run counter to the evidence. The research is conclusive: fewer RNs means a higher risk for patients and health outcomes, by increasing morbidity and mortality. And, when nurses work in fragmented care models, their view of the patient is partial; nurses’ focus becomes limited to physiologic need and emotional needs are dismissed; accountability becomes blurred; and the risk for infections due to cross contamination increases. These fragmented models, referred to as "functional nursing," make it more difficult for nurses to establish a holistic understanding of the patients, because the big picture is lost when care becomes so fragmented. By design, functional nursing includes interruptions, or what my own research has termed "structural interruptions" that increase the risk for errors. Patients and their families feel lost not knowing who their nurse is. Fragmented care means putting patients last.

The future is exciting, but important work is paramount to ensure brightness and not tragedy. We cannot and will not allow the public to fall down the path of the 1990s when RN care was decimated and we saw higher than ever rates of complications and death. This time, we are on guard. And we are sounding a strong alarm bell before it is too late. We are providing evidence-based, sound and pragmatic recommendations for government and its agencies.

All nurses share the health minister's goal of an improved and more person-centred health system. Our commitment to our patients and positive outcomes unites us together. Our proposals today will enable collaboration, advance role clarity and promote continuity and the best possible outcomes. We cannot let changes to skill mix and models of care erode patient safety and the quality of their health outcomes.

As RNAO’s CEO, I am pleased to issue this call to action to Minister Hoskins, Premier Wynne, members of the opposition and health bureaucrats. Our team looks to the future with optimism, and we commit to mobilizing efforts to realize the recommendations being brought forward.

Thank you. At this time we are pleased to take questions from the media.

<a href="https://rnao.ca/policy/reports/mind-safety-gap-health-system-transformation-reclaiming-role-rn" target="_">See the report now.</a>

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Speaking Notes