Policy and Political Action

Policy & Political Action

Bill 97: To Standing Committee on Social Policy

Ensuring a Sustainable Health Care Workforce
RNAO Submission on Bill 97: To Standing Committee on Social Policy
Oct. 27, 2008
Summary of Recommendations

RNAO Submission on Bill 97

The Registered Nurses’ Association of Ontario (RNAO) is the professional organization for registered nurses who practise in all roles and sectors across this province. Our mandate is to advocate for healthy public policy and for the role of registered nurses in enhancing the health of Ontarians. We welcome this opportunity to present to the Standing Committee on Social Policy our recommendations on Bill 97.
The Urgency of Addressing the Nursing Shortage
RNAO applauds any measure that acknowledges or addresses the need for access to an adequate number of health-care professionals. We believe that Bill 97 does both and is a helpful step forward.
Registered nurses have a lot at stake here because many of us have been working under difficult circumstances for many years. This is not sustainable.  The root cause of the difficult circumstances was prolonged system neglect of nursing issues.  In particular, employment opportunities in nursing lagged far behind population growth.  Combined with an aging population with growing and complex needs, nurses started experiencing workloads that many found unbearable.  Compounding the stress were mass layoffs of nurses in the later 1990s, which further raised the burden on the remaining nurses. A low point was reached when former Premier Mike Harris famously likened nurses to hula-hoops. Thousands of nurses left the province for work elsewhere, or left the profession entirely, and enrolment in nursing schools plummeted. With large number of nursing retirements on the horizon, the profession was facing a dangerous time in Ontario. 
Halting this dangerous trend called for a massive effort, as pointed out in the Nursing Task Force report of 1999. The government of the day reversed its policy with respect to nurses and started rehiring them. It made a number of commitments to nurses, including the creation of 10,000 new positions. When the current government came to power in 2003, it committed, among other things, to creating 8,000 nursing positions in its first mandate. It promised  9,000 additional positions in its second.
Because nurses comprise the bulk of Ontario's health-care professionals, this is a very crucial but massive undertaking, and it must be dealt with urgently.  Progress is being made: according to College of Nurses of Ontario statistics, over the first three years of the government's first mandate, the nursing workforce rose by 6,501 and the share of RN employment that was full-time rose from 59 per cent to 63 per cent.[1] [KJ1] We are, however, alarmed that the Minister of Finance in his October 22 statement postponed by a year the implementation of the commitment to hire 9,000 more nurses and deliver 50 more family health teams.  It is ironic that a Bill seeking to ensure access to health professionals is going to Committee at the same time much-needed nursing positions are being delayed.
A Made-In-Ontario Solution to the Nursing Shortage
Bill 97 acknowledges that it is in the public interest that Ontarians have access to adequate numbers of qualified, skilled and competent regulated health professionals. The Bill would make it an obligation of the regulatory bodies to work with the government to ensure that access. Below, we discuss what that obligation should entail.
Bill 97 is a step forward, but it is not in itself a solution to the nursing shortage, which requires a concerted nursing strategy with recruitment and retention components. That would include creating enough nursing positions to meet population needs; supporting inter-disciplinary practice; allowing RNs to work to their full scope of practice, supporting healthy work environments; funding enough seats in nursing programs; and ensuring that there are sufficient faculty, facilities and preceptors to educate the nursing students who will renew the nursing workforce. Implementation of this strategy is the responsibility of the government, and not of the colleges, which do not have the capacity to educate the needed nurses or to create the positions for them. 
The government has committed to some key elements of a nursing strategy, and we will work with the government to ensure timely implementation of those commitments. With respect to internationally educated nurses (IENs), the RNAO has long been a strong advocate in support of those who exercise their human right to migrate and choose to make Ontario their home. There must not be any systemic barriers to internationally educated nurses with permanent status in Canada from practising their profession and serving the public.
IENs comprise an increasing share of the nursing workforce in Ontario. In 2005, IENs accounted for 34.1 per cent of new RNs.[2] Recent research shows that IENs face challenges at all stages of the process of moving into practice in Ontario. These include: difficulties and delays completing the application process for licensure; required investments in upgrading and further education to become eligible to take the RN exams; difficulties writing the exam due to lack of familiarity with Ontario nursing culture and with exam formats; and integrating into the nursing workforce. As a result, pass rates for IENs were much lower than for nurses educated in Ontario.[3]
There are several existing programs that facilitate registration of IENs in Ontario.  The CARE Centre for Internationally Educated Nurses has had success in assisting internationally educated nurses to prepare for qualifying exams once they have met their academic requirements. A number of Ontario nursing schools offer bridging programs for IENs.[4]  For example, the Post-RN Bachelor of Science in Nursing Program at York offers a 20-month program for internationally educated RNs to more quickly meet current academic entry-to-practice requirements in Ontario. The first class graduated in December 2006. The program also offers an intensive ESL component created for health professionals. The government must continue to support programs of this sort, to ensure we do not waste the skills of internationally educated health professionals.
While the RNAO’s commitment to facilitating the practice of IENs in this province  is clear, we are just as convinced that such a  nursing strategy must not include resorting to the international recruitment of nurses. We must not to contribute to global health inequities[5] and the human[6] and economic[7] costs of stripping vulnerable populations of access to health care professionals. RNAO supports the World Health Organization,[8] the International Council of Nurses,[9] and the Canadian Policy Research Network[10] in calling for ethical international recruitment guidelines within the context of a responsible national and provincial health human resources strategy. International recruitment is not an acceptable substitute for the substantive investments in nursing education, improved interdisciplinary work and focus on workplace health that must be key components of a Made-in-Ontario nursing strategy.
The Role of the Colleges
The colleges' first duty is to ensure that regulated health professionals meet practice standards.  In response to the Bill, they would work with government to quantify shortages and advise on strategies to address those shortages. They may be in a position to streamline procedures for internationally educated health professionals and remove unnecessary obstacles, while still maintaining standards. Under no circumstances should colleges be expected to lower standards in order to raise the supply. Colleges may also be able to advise the government on developing programs that would make it easier for internationally educated health professionals to meet requirements for registration in Ontario, and practice most effectively in the Ontario environment once they are registered.  But to repeat, relying on the recruitment of internationally educated health professionals is not a solution to shortages of health professionals. 
How Many More RNs are Needed in Ontario?
There are different methodologies that could be used to determine the number of additional RN positions required in Ontario.  However, it is safe to say that most would not want Ontario's RN/population ratio to fall below that of the rest of Canada, particularly given that Canada's ratio is considerably worse than it was in the past. Based on the latest data available, Ontario would require over 10,000 more RNs alone to catch up to the rest of Canada.[11] At the very least, the 9,000 promised nursing positions should be delivered as expeditiously as possible, to enhance access to health care.
RNAO supports Bill 97 as it is written. It is a step forward in providing a mechanism for identifying the magnitude of the shortage or surplus in each health profession. However, the Bill must not be interpreted as an obligation on colleges to water down standards to meet health human resource objectives.  Nor is it a substitute for a health human resource strategy, which remains the responsibility of the government to implement. 
In closing, RNAO welcomes Bill 97, but remains deeply concerned about the contradictory message sent last week with the delay in the government's commitment to hire 9,000 nurses and deliver 50 more family health teams.  We would urge the government to rethink its position and keep its original promise on track. 


For complete text and references, please see the full version of the RNAO Submission on Bill 97: To Standing Committee on Social Policy.


To view the speaking notes from the presentation to the Standing Committee on Social Policy on Oct. 27, 2008, please click here


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