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Nursing resources in British Columbia : trends, tensions and tentative solutions Kazanjian, Arminée; Wood, Laura Feb 28, 1993

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NURSING RESOURCES IN BRITISH COLUMBIA:TRENDS, TENSIONS AND TENTATIVE SOLUTIONSArminee KazanjianLaura WoodHPRU 93:SD February, 1993G ALm POLICY RESEARCH UNIT)CENTRE FOR HEALTH SERVICES AND POLICY RESEARCH429 • 2194 HEALTH SCIENCES MALLTHE UNIVERSITY OF BRITISH COLUMBIAVANCOUVER, B.C. CANADAV6T lZ3The Centre for Health Services and Policy Research was established by the Board ofGovernors of the University of British Columbia in December 1990. It was officiallyopened in July 1991. The Centre's primary objective is to co-ordinate, facilitate, andundertake multidisciplinary research in the areas of health policy, health services research,population health, and health human resources. It brings together researchers in a varietyof disciplines who are committed to a multidisciplinary approach to research, and topromoting wide dissemination and discussion of research results, in these areas. TheCentre aims to contribute to the improvement of population health by being responsive tothe research needs of those responsible for health policy. To this end, it provides aresearch resource for graduate students; develops and facilitates access to health and healthcare databases; sponsors seminars, workshops, conferences and policy consultations; anddistributes Discussion papers, Research Reports and publication reprints resulting from theresearch programs of Centre faculty.The Centre's Health Policy Research Unit Discussion Paper series provides a vehicle forthe circulation of preliminary (pre-publication) work of Centre Faculty and associates. It isintended to promote discussion and to elicit comments and suggestions that might beincorporated within the work prior to publication. While the Centre prints and distributesthese papers for this purpose, the views in the papers are those of the author(s).A complete list of available Health Policy Research Unit Discussion Papers and Reprints,along with an address to which requests for copies should be sent, appears at the back ofeach paper.This paper is also listed as Health Human Resources Report #93:3....An earlier version of this report was prepared as abackground document for the Royal Commission onHealth Care and Costs, February, 1991t which madeseveral recommendations specific to nursing resources.These recommendations were not directly related to thematerial in this report.•..iTABLE OF CONTENTSPageList of TablesI. Describing the CurrentSituation . 11.2.3.4.5.Sources of Data & Limitations .Socio-Demographic Profiles: RNs, RPNs, LPNs .Labour Force Behaviour in the Last Decade .Career Opportunities and Wage Structure .Autonomy, Expertise, and Social Value13203440II. Explaining the Current Situation . 441.2.Net Requirements .Efficiency in Deployment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4452m. Principal Factors Underlying Perceived Shortage of RNs 581.2.3.ServiceDelivery Issues: Shift Work, Rotating Schedules,Workplace Conditions .System Structure Issues: Occupational Stratification, ProfessionalGovernance, Health Care Financing .ProfessionaJization Issues: NB for Entry-To-Practice,An Expanded Role. Role Stress .586164IV. Policy Implications and Options 701.2.3.4.5.ReferencesEducation and Training .Recruitment and Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Collective Agreement .RegistrationlLicensure and Scopeof Practice .Delivery Models and Remuneration .707475767779Reports of the Health PolicyResearch Unit•,Table 1Table 2aTable 2bTable 3aTable 3bTable 3cTable 3dTable 4aTable 4bTable 4cTable 4dTable 5Table 6Table 7aTable 7bTable 8Table 9aTable 9bTable 10LIST OF TABLESNumbers, (Numbers Per 10,000 Population) for Nursing Personnel .Numbers (Numbers per 10,000 Population) by Place of "Employmentfor Registered Nurses, Licensed Practical Nurses, and RegisteredPsychiatric Nurses, 1989 .Numbers (Numbers per 10,000 Population) by Place of "Employmentfor Registered Nurses, Licensed Practical Nurses, and RegisteredPsychiatric Nurses, 1991 ... ...... ...... . . •... ............... • •.. • •.Numbers (Numbers per 10,000 Population) in Direct Patient Care,Administration, and Teaching, for RNs and LPNs, 1989 ............... ..•..•Numbers (Numbers per 10,000 Population) in Direct PatientCare,Administration, and Teaching, for RNs and LPNs, 1991 .Numbers (Numbers per 10,000 Population) in Selected Areas ofService for RPNs, 1989 .Numbers (Numbers per 10,000 Population) in Selected Areas ofService for RPNs, 1991 .Numbers (Numbers per 10,000 Population) for Selected EmploymentPositions, RNs and RPNs. 1989 .Numbers (Numbers per 10.000 Population) for Selected EmploymentPositions, RNs and RPNs. 1991 " .Numbers (Numbers per 10,000 Population) for Selected Job TItles,LPNs, 1989 .Numbers (Numbers per 10,000 Population) for Selected Job TItles,LPNs, 1991 .Production of Nurses in British Columbia, 1984-1989 .Practising Registered Nurses, Educational Preparation by Age. 1988 .RNABC Population. Estimated and Actual. 1981-1984 . . . . . . . . . . . . . . . . . • . . . .RNABC Population. Estimated, 1989-1993 : .RN Transition Probabilities, Selected Ages, 1980 and 1988 .Place of Graduation for RNs, RPNs, LPNs, 1989Place of Graduation for RNs, RPNs, LPNs, 1991Practising Registered Nurses, Number of Re-Activations. Attritionand New Registrants, 1981-1991 .47810101111131314141719212125282830Table 11Table .J2Table 13Table 14Table 15Table 16Table 17Table 18LIST OFTABLES (Continued)Unemployment Insurance Claimants· Nursing Groups, 1986-1991Total Difficult·to-Fl1l Positions, RNs, RPNs, LPNs, 1986 to 1991 .Hourly Wage Rates, 1980-1991, Registered Nurses, RegisteredPsychiatric Nurses, Licensed PracticalNurses .Representative Annual Salaries of Selected Personnel as a Percentageof Registered Nurses' Salaries, 1976-1982 .Difficult-to-Fill Vacancies, September 30, 1987-1991 .Total Number of Paid Nursing Hours, by year, for PublicHospitals in B.C. . .Personnel Deployment Indices in Selected Hospitals in B.C., 1985-1986 .Policy Issues and Responsible Stakeholders .3132374549535671,.I. Describing the Current SituationIn the last decade, there have been several studies and reports discussing, describing, or analyzing issuesrelated to nursing resources in British Colmnbia. Invariably, the focus has been on an impending problem (ortwo, at most) or a recent crisis, but never on providing a comprehensive understanding of the context in whichthese minor and major problems keep recurring. The reason for this gap in knowledge is partly explained by thecomplexity of the health system; the study of its component parts has been the most practical approach togaining any type of understanding of the whole. However, this field of research has now attained sufficientmaturity to be able to tackle the more intellecblally challenging tasks of understanding and improving suchcomplex systems. This study was designed as a first step in describing human resource problems in the contextwithin which they occur and in discussing the broader implications of the issues underlying the problems.The purpose of this study is to provide a general understanding of nursing resource issues in B.C.,gleaned primarily from published data on this subject; however, the intent here is not simply to be descriptive.The descriptive detail is provided, along with a discussion of data limitations, in order to develop the analyticframework which can contribute to our understanding of the broader context Finally, the synthesis of thisinformation leads to the delineation of policy implications for the various stakeholders.1. Sources or Data & LimitatiomInformation for a socio-demographic profile of the three nursing groups in B.C. is drawn from themembership data collected by the two membership associations (TheRegistered Nurses Association of B.C. ­RNABC - and the Registered Psychiatric Nurses Association of B.C. - RPNABC), which also function aslicensing bodies for those two professional bodies, and the data available from the Council of Licensed PracticalNurses of B.C. (CLPNBC), which governs the licensing of that groupof nurses. Each of theseorganizationsrequires that membership and the right to practiceconveyed by such membership be renewed yearly, andinformation necessary to the determination of status and right-to-practice is collected from the renewing memberseach year, along with other items essential to registration renewal. In addition, dataare gathered aboutemployment status and conditions, and about educational preparation. These data belong to the memberorganizations and licensing bodies; access to the information is given to Health Human Resources Unit (HHRU)1researchers (at The University of British Columbia) for particular research purposes; therefore, in this report, weare restricted to the discussion of such previously published data except in snuaucns when primary data fromother in-depth studies are under discussion. The Unit has a well-established protocol regarding the use of suchadministrative data in the descriptive analyses found in the ROlLCAlL series and Place of Graduation. Themost recently published information available aboutRegistered Nurses (RNs), Registered Psychiatric Nurses(RPNs) and Licensed Practical Nurses (LPNs) can be found in ROlLCAlL 91, PRODUcnON 91, and Place ofGraduation 1991, and it will be to those documents that we will refer below.It shouldbe noted that the information presented in this report about employment characteristics is drawnentirely from the self-reported data collected in annual membership renewal procedures. Member informationabout basic nursing education is collected upon initial registration and is verified at that time; out-of-provinceregistration, re-activation of membership, and movement from non-practising status to practising status aremembership procedures which also entail data checking by the licensing bodies. The renewal and initialregistration forms ask members for information about three general employment characteristics: place ofemployment (its kind), area of service, and employment position. Each nursing group has a different array ofpossible options for each of those categories; the member is expected to choose the option that best describes hisor her experience. Information of that type is also collected about post-basic education.The reliability of the personal data collected by the registering bodies - birthdate, name, sex, address,basic education - is not in question, and there is no reason to believe that substantial error is attached to the datapertaining to employment, but it is important to establish the limitations of what research can be done with theavailable and accessible data. The registering bodies' pre-selection of employment options within each categoryimposes upon the memberpre-formulated structures supposedly descriptive of aspects of employment By andlarge, the options provided to the members function as an acceptable outlineof the possible constituents ofpractice. However, it is of some concern that. not surprisingly, the options do not remain fixed over time butmay be entered and retired at the request of membersub-groups, such as nurse administrators, or otherprofessional agencies such as the Canadian Nurses Association (CNA), as well as in recognition of changingconditions of practice. The member may find, from one year to the next, that his or her area of servicehasdisappeared, having been subsumed within anotheroption, or that it is being disaggregated for better analysis.As alternative occupational opportunities expand for nursing groups, the number of options which are provided to2more accurately reflect the employment experiences have also increased. But there is limited space on arenewal/registration form, and the licensing bodies are wary of testing the limits of membership patience with anoverly long and/or complex registration form.From the perspective of researchers, the employment information thus compiled is one of only two orthree sources of such information, and linked as it is to data about educational preparation, age, and membershipstatus, can be of great value. But the fluctuations of the imposed structure and the lack of a mandateestablishing the necessity of consistently complete data collection make longitudinal analysis of employment dataalmost impossible. As well, shifting conditions of practice make it difficult for even the well-intentionedmember to know how to characterize or classify his or ber work. In addition to the problems of datacomparability within nursing groups, there is the lack of consistency in the use of options and descriptors acrossnursing groups. Part of this difficulty of comparison arises from the differences in function peculiar to each typeof nurse, so that RNs require a wider variety of possible places of employment than do LPNs, and RPNs requiredifferent options than either of the others. But it is also true that no concerted effort has been made to attemptto reduce the extent of the discrepancies through agreement on employment descriptors which can be shared. Asa result. it is difficult to assess, among types (specialties) of nurses, the appropriateness of job defmitions andareas of service, let alone to compare the distribution across nursing categories and options.2. Socio-demographic Promes: RNst RPNs, LPNsDespite these limitations, we have attempted to construct a socio-demographic profile of nurses as awhole, with reference to nurses in groups, using 100 employment data discussed above. The most recent year forwhich there is published data is 1991. In that year, there were 27,477nurses registered as members of theRNABC, of whom 25,782 were practising members employed in nursing and 2,642 were non-practising. In thesame year, 2,223 registered psychiatric nurses were practising and 441 were non-practising, and 4,842 practicalnurses were licensed and employed in nursing. Figures reflecting the absolutenumbers of nurses of each type,their numberper 10,000 population, and the rates of change of those numbers over time are given in Table 1 (a.b, c). In addition, 100 numbers per 10,000 population and the rates of change considered in terms of wban andnon-urban regional hospital districts are given. These figures reveal that the rate of change in 100 ratio ofpersonnel-to-population for registered nurses has grown faster than the rate of change in the population, both in3Table INumbers, (Numbers Per 10,000Population) for NursingPersonnel(a) 1985 1986 1987 1988 1989 1990 1991Registered Nurses,Practising and Employed in NursingTotal Number 21126 21398 22130 23037 23763 24716 25782Urban 13065 13291 13840 14347 15219 15657 16228Non-urban 8061 8107 8290 8690 8544 9059 9554Ratio per 10,000Population 73.58 72.83 75.69 77.6/J 77.83 78.95 80.49Rate of change in Number (1)Urban 5.28 1.73 2.92 3.66 4.86 2.88 3.26Non-Urban 4.39 0.57 1.41 4.83 1.51 6.03 5.75Rate of Change in Personnel to Population Ratio (2)Urban 3.93 0.69 1.47 1.49 0.56 0.14 0.40Non-Urban 2.82 -0.87 1.48 3.97 3.57 4.06 3.80PercentDistribution Across Urban/Non-Urban DistrictsUrban 61.84 62.11 62.54 62.28 64.04 63.35 62.74Non-urban 38.16 37.89 37.46 37.72 35.96 36.65 37.06(b)Registered Psychiatric Nurses,Practising OnlyTotal Number 1978 N/A 1959 1864 2074 2143 2223Urban 1328 N/A 1310 1233 1450 1478 1528Non-urban 650 N/A 649 631 624 665 695Ratio per 10,000Population 6.82 N/A 6.70 6.28 6.90 6.84 6.94Rate of change in Number ( I)Urban 5.88 N/A -0.68 -5.88 5.21 1.93 2.62Non-Urban -1.44 N/A -0.08 -2.77 -1.94 6.57 5.54Rate of Change in Personnel to Population Ratio (2)Urban 4.57 N/A -2.08 -7.85 0.90 -1.06 -0.22Non-Urban -2.87 N/A -0.01 -3.56 0.04 4.6/J 3.6/JPercentDistribution Across Urban/Non-Urban DistrictsUrban 67.14 N/A 66.87 66.15 69.91 68.97 68.74Non-urban 32.86 N/A 33.13 33.85 30.09 31.03 31.26(1) [(Personnel 1991IPersonnei 1989)I:lIn - 1] x 100, where n =number of months separating the twosets of data(2) Rate of change (in percent) in the number of personnel relative to change in population[«Personnel 1991IPersonnel 1989) x (Population 19891P0pulation 1991»I:lIn - I] x 100, where n =number of months separating the two sets of data4Table 1 (continued)Numbers. (numbers Per 10.000 Population) for Nursing Personnel(c) 1985 1986 1987 1988 1989 1990 1991Licensed Practical Nurses,Employed In Nursing OnlyTotal Number 4579 4425 4390 4334 4584 4758 4842Urban 2139 2076 2055 1998 2232 2239 2275Non-urban 2440 2349 2335 2336 2352 2519 2567Ratio per 10.000 Population 15.78 15.06 15.02 14.60 15.25 15.20 15.12Rate of change in Number (1)Urban -2.91 -2.95 -1.98 -2.77 4.22 0.31 1.41Non-Urban -1.36 -3.73 -2.18 0.04 0.36 7.10 4.03Rate of Change in Personnel to Population Ratio (2)Urban -4.15 -3.94 -3.37 -4.81 -0.05 -2.63 -1.40Non-Urban -2.85 -5.11 -2.11 -0.77 2.40 5.12 2.12Percent Distribution Across Urban/Non-Urban DistrictsUrban 46.71 46.91 46.81 46.10 48.69 47.06 46.98Non-urban 53.29 53.09 53.19 53.90 51.31 52.94 53.02Percent Distribution of B.C. PopulationUrban 52.58 51.34 53.32 53.64 56.39 56.74 57.03Non-urban 47.42 48.66 46.68 46.36 43.61 43.26 42.97Total Number 2871304 2938042 2923595 2968769 3005834 3130448 3203184(1) [(Personnel 1991IPersonnei 1989)I21D - 1] x 100. where n =number of months separating the twosets of data(2) Rate of change (in percent) in the number of personnel relative to change in population[«Personnel 1991IPersonnei 1989) x (population 19891P0puiation 1991»1211I - 1] x 100. where n =number of months separating the two sets of data5urban and non-urban locations. Overall, the same is true of registered psychiatric nurses although their late ofchange was lower than that of the RNs, and their rate of increase was lower than the rate of population increasein the 1980's. Uotil recently, the numberof licensed practical nurses was also shrinking, relative to theprovincial population. The differences between the annual average rates of change in personnel to population foreach type of nurse, when considered in terms of non-urban and urban growth, are striking. The average annualrate of change in personnel to population ratio is lower for RNs in metro (urban) locations than in non-metro(non-urban) settings; while the ratio of registered psychiatric ourses to population iocreased more rapidly inurban than in non-urban areas in 1989, a decline in urban regions and an increase in non-urban regions followedsubsequently. Similarly, the ratio of licensed practical nurses to population is declining in urban regionsandincreasing rapidly in non-urban areas. The relative distributions of the three groups of nurses between urban andnon-urban locations are quite different. Registered nurses and registered psychiatric nurses are moreconcentrated in urban areas (RPNs to a larger extent than RNs), while licensedpractical ourses are found moreoften in non-urban settings.Tables 2a and 2b summarize, in a different format. information about place of employment for all threetypes of nurses. The figures presented for registered psychiatric nurses are aggregate groupings because RPNsreport employment in a numberof settingsnot seen among RNs and LPNs. Most of these have been added tothe Table io the "Other" category in order to maintain comparable categories. The ratios per 10,000 populationillustrate the relative numbers of each nursing group. RNs show the greatest discrepancy between the ratios forurban and non-urban populations; LPNs show a higher rauo for non-urban settings than for urban. The ratiosalso reveal the small numbers of LPNs and RPNs who are employed in the non-hospital sector, relative to thepopulation.For all three groups of nurses, the largest proportion work in hospitals (in 1991: 75.0% of RNs, 77.9% ofLPNs, 42.7% of RPNs), and the largest proportions of hospital-based RNs and LPNs work in acute care andgeneral hospitals (90.3% of RNs, 76.5% of LPNs). The majority of registered psychiatric nurses work inpsychiatric hospitals (63.3%). Registered ourses are the most numerous in all settings except psychiatrichospitals, but it is interesting to note that LPNs are more likely to be working in the hospital sector than either ofthe other two groups (see Table 2b). RNs are slightly more often found in areas other than the hospital whenthey are resident in non-urban areas than when they work in urban settings (75.5% of urban ourses work in6~Table2aNumbers, (Numbers per 10,000 Population) by Place of Employment forRegistered Nurses, Licensed Practical Nurses, and Registered Psychiatric Nurses, 1989Acute Care Rehab. Extended Psychiatric Hospital Long-Term Home Community Drs.Ofc] Self-Hospital Hospital Care Hosp, Hospital Sub-Total Care Care Health Family Prac Education EmploYed Other TotalsRNsUrban 10291 240 836 248 11615 920 428 824 283 422 133 592 15217(60.7) (1.4) (4.9) (1.5) (68.5) (5.4) (2.5) (4.9) (1.7) (2.5) (0.8) (3.5) (89.8)Non-urban 5832 11 418 51 6312 645 280 597 251 172 32 254 8543(44.5) (0.1) (3.2) (0.4) (48.2) (4.9) (2.1) (4.6) (1.9) (13) (0.2) (1.9) (65.2)Total 16123 251 1254 299 17927 1565 708 1421 534 594 165 846 23760(53.6) (0.8) (4 .2) (1.0) (59.6) (5.2) (2.4) (4.7) (1.8) (2.0\ CO.5) (2.8) 09.0)LPNsUrban 1189 135 313 28 1571 285 69 33 62 18 - 100 2232(7.0) (0.8) (1.8) (0.2) (6.8) (4.7) (0.4) (0.2) (0.4) (0.1) - (0.6) (13.2)Non-urban 1579 12 408 5 2004 185 26 10 65 4 - 58 2352(12.0) (0.1) (3.1) (0.04) (15.3) (1.4) (0.2) (0.1) (0.5) (0.03)-(0.4) (17.9)Total 2768 147 721 33 3669 470 95 43 127 22 - 158 4584(9.2) (0.5) (2.4) (0.1) (12.3) (1.5) (0.3) (0.1) (0.4) (0.1)-(0.5) (15.2)RPNsUrban 188 - - 450 638 155 - 349 - 8 - 300 1450(1.1)- -(2.6) (3.8) (0.9)-(2.1)-(0.05)-(1.8) (8.6)Non-urban 125 - - 150 275 124 - 82 - 5 - 138 624(0.9)- -(1.1) (2.1) (0.9)-(0.6)-(0.04)-(1.0) (4.8)Total 313 - - 600 913 279 - 431 - 13 - 438 2074(1.0)- -(2.0\ (3.0\ (0.9)-0 .4)-(0.04)-(1.5) (6.7)00Table2bNumbers, (Numbers per 10,000 Population) by Placc of Employment forRegistered Nurses, Licensed Practical Nurses, and Registered Psycbiatric Nurses, 1991Acute Care Rebab. Extended Psycbiatric Hospital Long-Term Home CommuDity Drs.Ofc} Self-HOSJ)itai Hospital Care Hose, Hosp ital Sub-Total Care Care Health Family Prac Education EmploYed Other TotalsRNsUrban 10937 226 848 248 12259 954 461 914 294 458 54 736 16228(59.87) (1.24) (4.64) (1.36) (67.10) (5.22) (2.52) (5.00) (1.61) (2.51) (0.83) (4.03) (88.83)Non-urban 6445 18 472 51 6986 736 342 632 243 212 152 349 9554(46.83) (0.13) (3.43) (0.37) (50.76) (5.35) (2.48) (4.59) (1.77) (1.54) (0.39) (2.53) (69.42)Total 17382 244 1320 299 19245 1690 803 1543 537 670 206 1085 25782(54.26) CO.76) (4.12) (0.93) (60 .08) (5.28) (2.51) (4.83) (1.68) (2.09) (0.64) (3.39) (80.49)LPNsUrban 1229 150 271 19 1669 293 67 39 64 21 - 122 2275(6.73) (0.82) (1.48) (0.10) (9.14) (1.60) (0.37) (0.21) (0.35) (0.11)-(0.67) (12.45)Non-urban 1661 24 415 4 2104 217 53 16 71 4 - 102 2567(12.07) (0.17) (3.02) (0.03) (15.28) (1.58) (0.39) (0.12) (0.52) (0.03) - (0.74) (18.65)Total 2890 174 686 23 3773 510 120 55 135 25 - 204 4842(9.02) (0.54) (2.14) CO.07) (11.58) (1.59) (0.37) CO.17) (0.42) CO.08)-(0.70) (15.12)RPNsUrban 217- -436 653 182-317-20 - 352 1524(1.19)- -(2.39) (3.57) (1.00) - (1.73) - (0.11) - (1.93) (8.34)Non-urban 137- -164 301 133 - 92 - 3 - 171 694(0.95)- -(1.19) (2.19) (1.03)-(0.67)-(0.02)-(1.24) (5.04)Total 348- - 600 948 315 - 409 - 23 - 523 2218(1.09)- -(1.87) (2.96) (0.98)-(1.28)-(0.07)-(1.63) (6.92)hospitals: 73.1% of non-urban nurses); the opposite is true of LPNs (73.3%of urban LPNs work in hospitals vs.82.0% of non-urban), and RPNs are no more likely to be hospital-based in urban or non-urban areas, althoughRPNs are more often found in general hospitals in non-urban areas (33.2% of urban RPNs work in generalhospitals; 45.5% of non-urban RPNs) than in urban areas. Only RNs report self-employment as nurses; inaddition, very few RPNs andLPNs work in educational institutions. Long-term care and community healthagenciesare other principal employers for RNs and RPNs. Among all employed RNs, 6.6 percent work in long­term care and 6.0 percent in community health, and 14.2percent of the total RPN group work in long-term careand 18.4 percent work in community health agencies. Ten percent of LPNs work in long-term care, but veryfew are employed in community health.It is interesting to note that the proportion of LPNs who reported work in hospitalsdecreasedappreciablybetween 1989 and 1991 (90.2% in 1989, 77.9% in 1991), while the proportions of hospital-employed RNs andRPNs decreased only slightly. However, of the hospital-based RNs and LPNs, the percentages working in acutecare institutions increased a little for RNs (89.9% in 1989, 90.3% in 1991) and to a much larger extent for LPNs(66.9% in 1989, 76.5% in 1991). In consequence, the proportions of LPNs working in hospitals in non-urbanand urban areas dropped significantly (87.4% to 73.3% for urban LPNs; 93.1% to 82.0% for non-urban LPNs),although it remained more likely that non-urban LPNs would report hospital employment than would urbanLPNs. There was a smaller but similarly significant proportionate change for the RPNS; while in 198929.5 percent of urban RPNs worked in hospitals, by 1991, that figure had increased to 33.2 per cent (a percentageincrease of 12.5).With area of service (Tables 380 3b, 3c, and 3d), comparisons between types of nurses become moredifficult. Only RNs and LPNs share a significant numberof areas of practice in common, and because theRNABC registration form provides the members with a wider variety of choices for desaiption-of-work area.Tables 3a and 3b are confined to those areas that are common to both groups and DO totals are included. Theratios per 10.000 population show that. as might be expected, the number of RNs relative to the population ishigber than that of LPNs in all areas of service for both 1989and 1991. The dominance of the RNs, relative tothe other two nursing categories, is especially strong among the critical care/medical-surgical specialties and inadministration and teaching. LPN personnel-to-population ratios are higher in non-urban areas for medical­surgical nursing. geriatrics, paediatrics, and the float pool; RN personnel-to-population ratios are higher in urban9Table 3aNumbers, (Numbers per 10,000 Population)in DirectPatientCare, Administration, and Teaching, for RNs andLPNs, 1989Medical/ Critical Maternityl SeveralSur2ical Care Newborn Psvchiatrv Paediatrics Geriatrics Areas (1) Admin. TeachingRNsUrban 4277 2842 1104 694 684 1902 1097 828 684(25.2) (16.8) (6.5) (4.1) (4.0) (11.2) (6.5) (4.9) (4.0)Non-urban 1945 1473 648 321 268 1118 1509 470 280(14.8) (11.2) (4.9) (2.5) (2.0) (8.5) (11.5) (3.6) (2.2)Total 6222 4315 1752 1015 952 3020 2606 1298 966(20.7) (14.4) (5.8) (3.4) (3.2) nO.1) (8.7) (4.3) (3.2)LPNsUrban 669 138 72 50 60 676 155 15 9(4.0) (0.8) (0.4) (0.3) (0.4) (4.0) (0.9) (0.1) (0.05)Non-urban 903 60 53 33 62 634 381 5 5(6.9) (0.5) (0.4) (0.3) (0.5) (4.8) (2.9) (0.04) (0.04)Total 1572 198 125 83 122 1310 536 20 14(5.2) (0.7) (0.4) (0.3) (0.4) (4.4) (1.8) (0.1) (0.05)Table3bNumbers, (Numbers per 10,000 Population)in DirectPatientCare, Administration, and Teaching, for RNs andLPNs, 1991Medical! Critical Maternityl SeveralSurzical Care Newborn Psvchiatrv Paediatrics Geriatrics Areas (1) Admin. TeachinaRNsUrban 4488 3101 1184 738 692 2037 986 862 754(24.6) (17.0) (6.5) (4.0) (3.8) (11.1) (5.4) (4.7) (4.1)Non-urban 2195 1655 747 371 327 1271 1445 521 343(15.9) (12.0) (5.4) (2.7) (2.4) (9.2) (10.5) (3.8) (2.5)Total 6683 4756 1931 1109 1019 3308 2431 1383 1097(20.9) 04.8) (6.0) (3.5) (3.2) (10.3) (7.6) (4.3) (3.4)LPNsUrban 740 149 65 51 52 637 134 17 12(4.0) (0.8) (0.4) (0.2) (0.3) (3.5) (0.7) (0.09) (0.07)Non-urban 1001 68 54 34 68 683 309 10 4(7.3) (0.5) (0.4) (0.3) (0.5) (5.0) (2.2) (0.07) (0.03)Total 1741 217 119 85 120 1320 443 27 16(5.4) (0.7) (0.4) (0.3) (0.4) (4.1) (1.4) W.08) (0.05)(1) Includes float, smallhospital.10........Table3cNumbers, (Numbers per 10,000 Population) inSelected Areas of Service for RPNs, 1989Geriatric!Acute Adult Chronic Child Mental Psycho- Correctionsl Adult!Psych Adult Psych Psych Retardation Geriatric Forensic Drua Vocational Education Counsellin~ Admin. GeneralUrban 295 206 16 245 263 99 25 8 12 32 39 66(1.7) (1.2) (0.09) (1.5) (1.6) (0.6) (0.1) (0.05) (0.07) (0.2) (0.2) (0.4)Non-Urban 144 93 3 52 129 50 10 3 7 17 19 27(1.1) (0.7) (0.02) (0.4) (1.0) (0.4) (0.08) (0.02) (0.05) (0.1) (0.1) (0.2)Total 439 299 19 297 392 149 34 11 19 49 58 93n.si n.m (0.06) (1.0) (1.3) (0.5) (0.1) (0.04) (0.06) (0.2) (0.2) (0.3)Table 3dNumbers. (Numbers per 10,000 Population) inSelected Areas of Service for RPNs, 1991Geriatric!Acute Adult Chronic Child Mental Psycho- Correctionsl Adult!Psych Adult Psych Psych Retardation Geriatric Forensic Druz Vocational Education Counsellma Admin. GeneralUrban 314 220 18 196 267 92 26 22 22 35 47 75(1.7) (1.2) (1.0) (1.1) (1.5) (0.5) (0.1) (0.1) (0.1) (0.2) (0.3) (0.4)Non-Urban 151 97 7 47 146 62 5 11 6 27 34 26(1.1) (0.7) (0.05) (0.3) (1.1) (0.4) (0.04) (0.08) (0.04) (0.2) (0.3) (0.2)Total 465 317 25 243 413 154 31 33 28 62 81 101(1.4) n.m (0.08) (0.8) (1.3) (0.5) (0.1) (0.1) ro.n <0.2) <0.3) (0.3)locations for all areas of service except the float pool. LPNs show relatively high personnel-to-population ratios,regardless of location, in medical-surgical nursing and geriatrics. Areas of service specific to RPNs areillustrated in Tables 3c and 3d. RPNs appear to be most frequently employed in adult-oriented psychiatricservices, along with geriatric/psycho-geriatric nursing. Few RPNs are involved in educationor administration.The distribution of area of service among RPNs seems to have been fairly stable over time; the only change ofinterest is the increase in the number of RPNs per 10,000population working in vocational areas. RPNemployment in the principal areas of service (acute and chronic adult psychiatry and geriatric/psycho-geriatricservices) bas remained essentially the same during the past few years.Employment positions can be comparedonly between RNs and RPNs (Tables 4a and 4b). Positiondescriptors were grouped this time for RNs, whose membership form includes a greater number of options.However, the categories are analogous across the two types of nurses. Among RNs and RPNs, personnel-to­population ratios have remained essentiallyequal across urban and non-urban locations for the more seniorpositions, although there is a continuing divergence for head nurse/clinician positions, which may result from therelative dearth of jobs for clinical specialists in non-urban hospitals. The greatest discrepancy between urban andnon-urban personnel-to-population ratios for both groups is seen among the general duty nurses. Instructors arealso more common in urban areas for RNs, although RPNs show no such difference. Overall, RPNs are muchless frequently working in positions of leadership than RNs, andare rare as community nurses and instructors.The most evident change over time bas been a decrease in personnel to population ratio for urban RNsupervisors from 2.1 in 1989 to 1.7 in 1991. LPNs describe themselves by job title; their personnel-to­population ratios are higher in non-urban than in urban areas for the titles of LPN and Long-Term Care Aide, butessentially equal for Orderly (Tables 4c and 4d). There have been very slight decreases in the personnel topopulation ratios for most job titles used by LPNs over the past few years; unfortunately, it is not known whatspecific titles are being used in their place since that information is aggregated as "other".Educationalproduction and labour force activity are the general categories within which we can discussthe various elements that are necessary for an assessment of the supply of nurses. As noted before, informationabout basic education is required from every nurse prior to licensing, and the information provided is verified.In addition, on their registration renewal forms, the RNABC and the RPNABC ask their members for their12Table4aNumbers (Numbers per 10,000 Population) forSelected Employment Positions, RNs andRPNS, 1989Gen. DutyDirector(1) Suoervisor (2) HeadNurse (3) Nurse Community (4) InstructorRNsUrban 332 337 1047 11016 941 471(2.0) (2.0) (6.2) (65.0) (5.6) (2.8)Non-urban 202 280 542 6167 681 165(1.5) (2.1) (4.1) (47.0) (5.2) (1.3)Total 534 617 1589 17183 1622 636(l.8) (2.1) (5.3) (57.2) (5.4) (2.1)RPNsUrban 28 55 173 954 86 10(0.2) (0.3) (1.0) (5.6) (0.5) (0.06)Non-urban 30 34 67 366 34 5(0.2) (0.3) (0.5) (2.8) (0.3) (0.04)Total 58 89 240 1320 120 15(0.2) (0.3) (0.8) (4.4) (0.4) (0.05)Table4bNumbers (Numbers per 10,000 Population) forSelected Employment Positions, RNs and RPNS, 1991Gen. DutyDirector(1) Supervisor (2) HeadNurse(3) Nurse Community (4) InstructorRNsUrban 358 306 1106 11700 1063 523(1.9) (1.7) (6.0) (64.0) (5.8) (2.9)Non-urban 237 322 564 6890 737 213(1.7) (2.3) (4.2) (50.0) (5.3) (1.5)Total 595 628 1680 18590 1800 736(1.9) (1.9) (5.2) (58.0) (5.6) (2.3)RPNsUrban 36 655 154 946 112 17(0.2) (0.4) (0.8) (5.2) (0.6) (0.09)Non-urban 31 44 73 377 47 8(0.2) (0.3) (0.5) (2.7) (0.3) (0.06)Total 67 109 227 1323 159 25(0.2) (0.3) (0.7) (4.1) (0.5) (0.08)(l) IncludesDirectorand AssistantDirector(2) IncludesSupervisor, AssistantSupervisor, andCoordinator(3) IncludesHead Nurse,Assistant HeadNurse.Team Leader. and ClinicalSpecialist(4) IncludesCommunity Occupations, HomeCare andCommunity Worker13Table4cNumbers (Number per 10,000 Population) forSelected Job nOes, LPNs, 1989Long-TermLPN Care Aide Orderlv OlherUrban 1657 180 51 286(9.8) (1.1) (0.3) (1.7)Non-urban 1833 239 45 186(l4.m (1.8) CO.3) (1.4)Total 3490 419 96 472(11.6) (1.4) (0.3) (1.6)Table4dNumbers (Number per 10,000 Population) forSelected Job Titles, LPNs, 1991Long-TermLPN Care Aide Orderlv OtherUrban 1695 192 48 259(9.3) (1.05) (0.3) (1.4)Non-urban 1958 288 41 182(14.2) (2.1) (0.3) (1.3)Total 3653 480 89 441(11.4) (1.5) (0.3) (1.4)14higbe~t completed level of post-basic education, both in nursing and in non-nursing fields. Two of the samelimitations exist with these data as did with the employment data previously desaibed: the structure is imposedand, beyond the level of basic education, the information is not verified for the membership data record.However, these are the only sources of our knowledge aboutpatterns of educational preparation of individualnurses.Registered nursescan be educated in two to three year programs at community colleges and graduatewith a diploma in nursing. They are then eligible to write the standardized Canadian Nurses' Associationexaminations, which, if passed, enable them to practise as registered nurses. Somenurses choose to obtain theirbasic education at the University of British Columbia (UBC), where they receive a baccalaureate degree innursing and are eligible to write the registration exams. Othernurses with diploma preparation also enter post­basic programs at UBC or the University of Victoria from which they obtain baccalaureate degrees after a twoyear period. Registered nurses who have been out of practice for some length of time, usually at least fiveyears, or who have been working very infrequently over a number of years, may enter refresher programs atseveral community colleges and, after six weeks to one year of retraining, may be eligible for practising statusagain. One such program is designed for nurses for whom Fnglish is an alternate language. Lastly, practicalnurses and psychiatric nurses may enrol in the nursing access programs givenat five community colleges, and,after a further year or sixteen months of education, be prepared to write registration exams. In addition,registered nurses increasingly obtain specialty certification through courses taken primarily through The BritishColumbia InstibJte of Technology. These courses range in length from six to twenty-two months. Such courses,along with the post-basic baccalaureate programs, can be taken part-time, and, in the specialty courses, someproportion of entrants will complete the clinical course workbut not the academic component essential to theachievement of certification. All these programs, basic and post-basic, may expandand contract in size inrelation to funding, course demands, and smdent demand. The availability of part-time status and the promisein university programs of an extended period for completion, taken together, allow some students to move in andout of educational institutions as they need. Thus, matching the number of entrants to the number of graduatesfor a particular year can be difficult, and attempting to assess the real rate of attrition from nursing educationprograms of any type is futile unless it becomes possible to trace the progress of individual students through theeducational stages.15·Registered psychiatric nurses are educated at Douglas College in a two-year program which allows themto practise in psychiatric settings in a mannerequivalent to registered nurses after their psychiatric nursingpreparation. Thus,RPN training is an instance of specialty preparation at the basic level of education.Registered psychiatric nurses, should they wish to practise in another specialty area, must complete their generalnursing educations by going through an access program. Registered psychiatric nursing programs also operate inAlberta and Manitoba, but the training and the professional status are unavailable in Central and Eastern Canada.Licensed practical nurses are trained in ten month programs which, when completed, permitthem to sitfor licensing examinations. They are prepared to givebasic nursing care. but are not expected to perform a fullrange of nursing functions. A practical nursing refresher program is offered for nurses who have not practisedfor some time or whoare unable to meet the requirements for licensure. Practical nurses are also able to enterthe registered nursing access programs, after which theyare eligible to write the registration examination.The figures presented in Table 5 are drawn from the biennial publications called the Production series.Every two years, the institutions responsible for the training of a wide variety of health professional groups aresurveyed about the number of their current entrants and graduates, and for estimates of the following years'projected intake and output The totals included in the tableare erratic because of fluctuations in program sizeand they also reflect changes in program venue. The numbers for nursing certification programs are especiallyunstable, as the enrolment in those short-term courses can vary widely over time, and because at the beginningof the period shown in the table, some certification programs, then supported at UBC, weremoved to BCrr,necessitating a reduction in intake. What is of interest is lhal the number of graduates from basicprograms(including access) remained between 650 and 800 until 1990-91, despite the concern over a perceived shortage ofnurses which peaked in 1990. The last year for which we have data, 1990-91, shows an inaease of 18.6% overthe previous year. The number of graduates who obtained post-basic baccalaureates remained relatively staticuntil 1989-90, when it increased by 62.9% (from 116 in 1988-89 to 189 in 1989-90. The figures shown in thistableshould be treated with caution; until 1988-89, those for even-numbered years (or academic years ending ineven-numbers) are projections, reported in the previous year. The figures from 1988-89 onwards werecollectedrettospectively, and should be more reliable.The multiplicity of programs for the education of registered nurses (more than twenty colleges anduniversities offer somekind of nursing training) points to one of the central issues facing licensing bodies and16­~Table 5Production of Nurses in British Columbia, 1984 - 1989Entrants Graduates1984 1985 1986/87 1987/88 1988/89 1989/90 1990/91 1984 1985 1986/87 1987/88 1988/89 1989190 1990191R~lstered NursesBasic EducationBaccalaureate 113 80 79 84 86 133 120 68 90 88 62 62 62 63Diploma 882 833 871 965 510 507 700 537 - 546 696 457 491 591Access 75 70 83 127 66 75 78 66 60 86 123 71 67 81Post-Basic EducationBaccalaureate 210 151 257 332 335 391 475 101 124 141 152 116 189 186Refresher 214 223 281 230 133 125 151 176 174 202 211 114 114 110Certification 326 161 136 · 174 719 693 670 192 63 174 196 32 32 45Master's 37 35 22 26 93 103 131 7 15 10 8 21 19 25Registered Psychiatric NursesBasic EducationDiploma 100 106 114 120 95 92 104 73 - 71 80 69 44 55Licensed Practical NursesBasic EducationCertificate ~76 235 243 243 170 149 163 192 196 233 205 123 113 113Post-Basic EducationRefresher- -40 40 19 21 27 - - 38 38 19 17 21Source: PRODUCflON series, Health Human Resources Unit (formerly Health Manpower Research Unit), University of British Columbia.human resource planners, which is the existence of three distincteducational routes which lead into registerednursing practice. Multiple methods of entry-to-practice are not typically found among members of otherprofessional occupations (physiotherapy, occupational therapy, medicine, law, public school education), althoughcertain of the helping professions can be entered at either a baccalaureate or a graduate level (e.g, social work).While post-basic education outside the professional domain does occur with other professions, it is less commonamong members of the more established health occupations than among registered nurses.Table 6 illustrates the breakdown of basic and post-basic educational attainment among practisingmembers of the 1988 nursing population. The first two groups include only RNs who were practising and whohad no furtherdegree-level education. The third comprises three groups of diploma-edueated nurses: those whohad completed some level of post-basic, degree-level nursing education, most of whomhad baccalaureatedegrees, and a smallerpercentage with master's and doctoral degrees; those who had post-basic nursing degreesand post-basic degrees in fields other than nursing; and those nurses whose post-basic education was confined tonon-nursing fields. The fourth group contains those nurses with basic baccalaureate nursing degrees andadvanced degree-level preparation in nursing, some of whom also had degrees in other fields, and thosebaccalaureate-edueated nurses who only had post-basic baccalaureate or advanced degrees in non-nursing areas.As can be seen from the table, some 84 percentof practising nurses in 1988had no degree-level educationbeyond the diploma level, while5.6 percentreceived basic baccalaureates. Approximately 10 percentof thenurses had diploma and further degree-level education, and 1 percentwere baccalaureate-prepared nurses withfurther degrees in nursingand/or other fields. This is to be compared with the 12.4 percentof registered nurseswho had degree-level education beyond the diploma level in 1980 (Kazanjian, 1982). For the total of practisingnurses of wOOcing age, the percentage distribution of education type is very similar to that of the entire nursepopulation, but among nurses between the ages of 25 and 49, a total of 17.5 percent were educated beyond thebasic diploma level. Among younger nurses, the proportion with basic baccalaureate or diplomaand post-basicdegrees is even larger.A diplomain nursing is as yet the principal route for entry into practise for registered nurses; the basicbaccalaureate remains the choice of a relatively small proportion (as the numbers in Table 6 demonstrate).However, the proportion of diploma nurses who have returned to obtain baccalaureates and furtherdegrees isgrowing. Undoubtedly, these nurses have been encouraged by the development of more programs which offer18Table 6Practising Registered Nurses, Educational Preparation by Age. 1988Aaes25 - 49 Aaes 18 - 64 Aaes 18 - 99Baccalaureate Only 1222 1445 1447(6.1) (5.6) (5.6)Diploma Only 16531 21608 21707(82.4) (83.7) (83.7)Diploma PlusFurtherDegreets) 2086 2503 2518(10.4) (9.7) (9.7)Baccalaureate PlusFurther Degreets) 221 269 271(l.l) 0 .0) (1.0)TOTAL 20060 25825 25943Percent 000.0) 000.0) (100.0)Source: HHRU Cooperative Database19post-basic degrees; the most recent is one to be offered through BCITand the Open Learning Agency, which isunique in that it depends upon achieved credit in specialty certification programs for the bulk of its course work.This program will meet a particular demand of diploma-educated nurses seeking further degrees, which is thatthere should be some academic recognition of specialty preparation. As yet, The University of Victoria does notacknowledge specialty certification as contributing towards academic credits, and UBC only recently changed itspolicy to allow for advance credit for some types of post-basic certification.3. Labour Fon:e Behaviour in the Last DecadeA discussion of the labourforce activity of nurses can draw on membership data, as wen as publishedresearch and some forms of administrative data. Because the concerns about nursing shortages wereconcentrated on the acute care sector, the patterns of labour force activity characteristic of registered nurses havebeen the focus of most of the research, especially in Canada. Nursing labourmarket behaviour or labour forceparticipation can be described in anyone of three ways (Laing and Rademaker, 1990). F1I'St, it is possible tosummarize the quantity of labour supplied in a particular year by measuring annual hours worked. A secondmethod attempts to study labour force participation longitudinally and descriptively. The third takes the yearlydecision to work or not to work. as expressed in the registration renewal process, and treats it as a question ofprobability estimates. The routinely collected membership data of the RNABC are especially amenable to thethird method of analysis, because a five-year membership history variable is included in the member file, therebyenabling the researcher to trace back over a six-yearperiod the decisions of individual nurse members and non­members regarding yearly labour force participation. Inactive members can be included because the RNABCkeeps on file aU individuals registered at any lime with the association. This inactive file does not correspond tothe actual numberof non-registered nurses who are willing to work as nurses and who are eligible forregistration in the province. That figure is unknown. However, the decision to remain registered to practise. toremain registered but become a non-practising member, or to abandon registered status (by non-payment of fees),as wen as the decision to return to practising or non-practising status, can be tabulated for aU members and non­members. if the limitations of the probability methods are taken into accountThe first attemptof the HHRU to describe nursing labourmarketparticipation occurred in 1982(Kazanjian and Wong, 1982). This report was essentially descriptive in nature; percentage distributions of socio-20Table 7a, RNABC Population, Estimated, and Actual, 1981 - 19841981 1982 1983 1984Kazanjian and Wong, 1982Practising 21223 21804 22419 23065Non-Practising 4115 4271 4426 4581Total 25338 26075 26845 27646Kazanjian, Brothers, Wong, 1985Practising 21557 22444 23341 24250Non-Practising 4233 4497 4738 4957Total 25790 26941 28079 29207Actual RNABC Figures, 1985Practising 21959 22187 22042 22891Non-Practising 4213 4518 4702 4374TOlal 26172 26705 26744 27265Table 7bRNABC Population, Estimated, 1989-19931989 1990 1991 1992 1993Kazanjian, 1989Practising 27054 28175 29294 30334 31283Non-Practising 4373 4651 4933 5219 5511Total 31427 32826 34227 35554 3679421Figure 1Historical Data on New RegistrantsNumber of New Registrants2500 I I..•20008l!I8 8l!l8 l!li!J 8 I!I~ 1500l!lIB I!J r;:I IiJI'J.. 1'I1'I ..88B10008 8.. l!ll'J88 I!I 8E1 1!18 E1.. 8I!J1!I8 !!I!!Il!Il!J8l!I liJ 1!I !!JIlll!l !!J 8 80110l'l IIIl!Il!I500 ,mIll"'''' III i!Jo I, i 1111' i IIIII "" j I I t I I Iii II III iii" I I Ii"" II i II I I I i I I I I Ii il i III Ii Iii1920 1930 1940 1950 1960Year1970 1980 1988demographic variables and supply-side factors were detailed for the 1980 RN population. In addition, the futuresupply of nurses (1981 to 1985)was projected, using a model based on Markovian transition probabilities. whichprovidedestimates of the numbers of nurses who would be non-registered, non-practising, and practising,according to five-year age groups, for each of the next four years.Table 7a summarizes the total projected supply of practising and non-practising members for the period1981 to 1984, and compares it with the actual RNABC figures. It is clear that the initial use of the Markovmodel, which entails the estimation of the nmnber and age disbibution of future registrants. under-estimaled theintake of nurses unti11983, and then over-estimated it for 1983 and 1984. The errors resulted from the larger­than-expected yearly intakes of new registrants in the late 19708 and especially 1980. A graph of the numberofnew registrants from 1918 to 1988demonstrates the degree of fluctuation in absolute numbers of new registrantssince 1965. It suggests that simple methods of nurse supply estimation, and thus of hmnan resource planning,might be inadequate, based as these often are upon assumptions about steady growth, unchanging agedistributions, and uniform career patterns (see Figure 1).Projections of future supply were repeated for the 1981 to 1984period in 1985 and 1986, using aregression sub-model to estimate new registrants (Kazanjian, et al., 1986). The re-calculated figures also showsome degree of over- and under-estimation of total population figures (see Table 7a). The lack ofcorrespondence in the estimates owes something to the instability of the new registrant intake for the yearsbetween 1981 and 1983,wherein 1981 registered a record high, and 1983 saw an unprecedented decline in actualnumbers. In addition, the 1986 report adopted a more sophisticated approach to the study of nursing labourforce participation. The 1980 da1a were used to modelnursing life-cycle activity patterns through theconstruction of ttansition probabilities. These were then used to calculate professional life expectancy, measuredas the total number of years expected in a membership stale given current membership status. Theseprofessional life expectancies were calculated for the 1980membership group along with estimates of thecontinuous numberof years in one membership state, given that an individual nurse began as a practisingmember.The likelihood of movement between membership states was seen to vary with age (see Table 8). Withinthe 1980 nurse population, it was shown that 5.8 percentof the 18 to 29 year-olds might move from registered tonon-registered status in a given year, a percentage that would drop to a low of 2.0 percentat age 50 and rise23abruptly (and not unexpectedly) to 14.8 percent at age 64. The probability of a 25 year-old nurse taking non­praclising status was 0.085, and the probability that he or she would remain in practice was 0.857, indicating thatout of every 1000practising nurses aged 25 years, 857 would continue as practising members, 85 would takenon-practising membership, and 58 would become non-registered. The highest probability of remaining inpractice from one year to the next was seen among 50 to 54 year olds; 945 out of every 1,000 would continue topractise.The model used in 1985-86 was employed again with 1988 data to yield new estimates of future supplyand to constructnew projections of nurse life-cycle activity patterns (Kazanjian, 1989). In order to Increaseaccuracy, future supply was estimatedusing the Marlcovian probabilities and a moving average of the previousfive years for new registrants. The projected totals for practising and non-practising nurses for the years 1989 to1993 are shown in Table 7b. The HHRU has elsewhere published data for June 30, 1989, but the actual dataquoted in Table 7a are based on RNABC figures from December31 of each year, these being the more completeyear-end datasets, Due to the discrepancy in dales of record, a valid comparison of the projections with actualtotals is not possible for 1989, 1990 & 1991.Estimates for the likelihood of movement between membership states for nurses of different ages, asindicated by the transition probabilities., are shown for 1988 data in Table 8, along with the transitionprobabilities associated with the 1980 study population. The probability of movement from practising to non­registered status dropped markedly for all ages except the 64 year-olds; whereas in 1980, 35 of 1000practising35 year-old RNs would become non-registered in one year, in 1988 only 11 of 1000 would be expected to droptheir professional affiliation and right to practise. The percentage of non-practising nurses at ages 25 to 50 wasalso lower for the 1988 nurses than for their predecessors, but in 1988, the 55 year-old nurses were more likelyto take non-practising status than were their counterparts in 1980. There were appreciablegains in thelikelihood of continuing in practice for the 1988nurses aged 18 to 64 as well, after which age the 1988 nursesappear to have been much less likely to retain practising status.The comparison between 1980 and 1988 suggests that the labour force participation of registered nursesin B.C. is increasing, at least when measured as a single, annual decision to renew registration. Over a 13 yearperiod (the data used in 1985 described the membership between 1975 and 1980),RNs appear to have becomemore likely to remain in practice and less likely to let lapse their professional affiliations when they leave the24Table8RNTransition Probabilities, Selected Ages. 1980and 19881980 (I) 1988 (2)NOD- NOD- NOD- NOD-A2e FromPractisio2 To: Reaistered Practising Practisinz Rezistered Practisin2 Practisin225 0.058 0.085 0.857 0.018 0.049 0.93330 0.048 0.075 0.876 0.016 0.044 0.94035 0.035 0.050 0.915 0.011 0.035 0.95440 0.024 0.035 0.940 0.010 0.025 0.96545 0.022 0.036 0.942 0.008 0.023 0.96950 0.020 0.035 0.945 0.007 0.027 0.96655 0.027 0.050 0.923 0.012 0.045 0.94360 0.070 0.088 0.842 0.035 0.095 0.87064 0.148 0.108 0.744 0.136 0.243 0.620(1) Kazanjian, Brothers & Wong, 1985.(2) Kazanjian, 198925workforce. Such changes in behaviourmight be attributable to economicconditions or to socio-culturaI factors,or to changes in the practice of nursing and in the education and socialization of nurses which have in tumaItered nurses' perceptions of professional adherence. The type of analysis described above cannot determinesuch attributions. .The study previously mentioned (Laing and Rademaker, 1990) examines the question of nurses' labourforce participation from a differentperspective. These researchers surveyed a sample of members of theSaskatchewan Registered Nurses Association who had been registered at any time between 1980 and 1985 andwho had been married when registered, to see what relationship might exist between a selected group ofvariables and the labour force behaviourof married nurses (since most nurses are married. the effect of marriageon participation patterns is an important issue when considering rational human resource planning). Regressionanalysis was undertaken using variables such as sex role atumde, position, interruptions (when nurses ceased towork for some period), children of different ages, spouses' salary, shift rotations, and educational preparation.The researchers found that sex role attitude was the most important variable to be associated with labour forceparticipation. Nurses whose orientation was more "egalitarian" were more likely to work a larger number ofhours each year, and to work full- or part-time continuously over a five-year period. Position, a variableindicative of achieved job status, and therefore expressive of commitment, was the second most importantvariable, followed by number of interruptions. This variable, denoting the occurrence of fewer work stoppagesover the study period, was positively associated with a greater likelihood of remaining in the work force and wastherefore also taken to represent commitment. The presence of children between the ages of two and five wasclearly negativelyassociated with labour force participation, and spouses' salary was important as well,indicating that economic need played some part in decisions to continue working.There are few Canadian studies which have taken as their subject nurses' labour force participation. TheMarkovian analyses done by the IDIRU yield information about age-specific probability of membership staws,and in future studies, may be used to forecast nurse supply in terms of educational preparation or marital status.The importance of sex role attiwde in Laing and Rademaker's paper can be laid alongside the increase in thelikelihood of continuing in practice which was observed in the Kazanjian. et al. reports. Changing attitudestowards marriage and career may partly explain the higher percentage of 1988 nurses of all ages who chose to26remain in practice.To enlarge our understanding of the factors involved in the participation of nurses in the labour force.more work needs to be done, both of the modelling type (useful for forecasting and planning), and of thedescriptive type. So far we have described some aspects of the supply of registered nurses who are practisingand employed in nursing. The membership of the three nursing organizations is affected by the yearly additionof new registrants, by the re-activation of former registrants, and by the attrition of current registrants.Additional members are gained through local production and by immigration. Tables 9a and 9b detail the patternof place of graduation for the membership of practising registered nurses and psychiatric nurses, and for theentire population of licensed practical nurses, for 1989 and 1991. Approximately fifty percent of RNs receivedtheir basic education in B.C.• 34.7 percent received theirs from other provinces in Canada, and the remaining15.6 percent from outside Canada. Non-urban areas are more likely to have graduates from other provinces, butgraduates from outside Canada are even more Iilcely than B.C.eduC&ted RNs to be living in urban areas. About64 percentof RPNs obtained their basic education in B.C., and about 17 percent from other provinces, and about18 percentcome from outside Canada, chiefly from Great Britain. Seventy percent of all RPNs live in urbanareas; graduates from other provinces in Canadaare more Iilcely to be living in non-urban areas than RPNs withdiplomas from B.C., but RPNs with degrees from outsideCanadaare concentrated in urban areas, as with theirRN counterparts. Among the LPNs, 70 percent are B.C. graduates, and of these, nearly 57 percent reside in non­urban areas, and the distribution across non-urban and urban areas is similar for graduates of other Canadianprovinces. Most of the LPNs who received their diplomas from outsideCanadareside in urban areas. Tables9aand 9b show clearly that while B.C. is highly dependent upon immigration for its registered nurse recruitment,most of the RPNs and LPNs working here were educated in the province.Reliable data on nurse attrition, reactivation, and initial registration are available only for registerednurses. Attrition occurs when a registered nurse fails to renew his or her membership by the close of the currentcalendaryear. Attrition figures reflect emigration and loss of license in addition to work stoppages. which maybe short-term as well as enduring. When a nurse who has let her registration lapse applies to the RNABC torenew her membership. the re-instatement is counted as are-activation. Re-activation also reflects immigration,27Table 98Place of Graduation for RNs, RPNs, LPNs, 1989.OtherB.C. Canada Other TotalRegistered Nurses (1)Urban 7527 4899 2783 15209Non-urban 4269 3341 929 8539Total 11796 8240 3712 23748Registered Psychiatric Nurses (2)Urban 952 217 261 1430Non-urban 363 136 116 615Total 1315 353 377 2045Licensed Practical Nurses (3)Urban 1871 670 272 2813Non-urban 2263 748 82 3093Total 4134 1418 354 5906• Source: PLACE OF GRADUATION 1989, Health Human Resources Unit,The University of British Columbia.Table 9bPlace of Graduation for RNs, RPNs, LPNs, 1991tOtherB.C. Canada Other TotalRegistered Nurses (1)Urban 7927 5264 3029 16220Non-urban 4876 3690 985 9551TOLaI 12803 8954 4014 25771Registered Psychiatric Nurses (2)Urban 950 198 266 1414Non-urban 384 140 III 635Total 1334 338 377 2049Licensed Practical Nurses (3)Urban 1755 667 274 2696Non-urban 2289 846 86 3221Total 4044 1513 360 5917t Source : PLACE OF GRADUATION 1991, Health Human Resources Unit,The University of British Columbia.(1) Practising and employed in nursing.(2) Practising(3) All Registrants28as nurses who were once registered in B.C., having moved elsewhere, soneumes return and renew theirregistration. Since 1988, the right to re-instatement has been monitored by the Association and has beendeterminedpartly by the total number of hours spent in nursing employment during the past five years; thus,nurses who decide not to practise for extended periods of time may experience increasing difficulty in re-enteringthe nurse labour force. New registrants are counted as individuals who have registered to practise for the fusttime in B.C.; some are nurses who were registered for the first time as nurses elsewhere in Canada. Others mayhave once been registered and practising in other countries.The figures in Table 10 show some nwked fluctuations in re-activation, attrition, and new registrationsbetween 1981 and 1991. Since 1981, the absolute number of nurses entering into membership has 'been greaterthan the number leaving, although the imbalance created by the large number of attritionsbetween 1981 and1983 wasjust counteracted by the numbers of re-activations and new registrants, both unusually low during thisperiod. The percentage distribution of re-activations between urban and non-urban locations remained essentiallystable at about S6 percent and 44 percent respectively until 1987-1989, when the urban proportion rose to 63percent, after which it increased again slightly, to 64%. The proportion of urban attrition has grown during thesame period, from 61 percent in 1981-1983, to almost 66 percent in 1987-91. The percentageof new registrantslocated in urban locationsalso rose between 1981 and 1987, from 6S percent in 1981 to nearly 70 percent in1987, and then dropped to 6S percent in 1989 and to 62% in 1991. What implications the shifting urbanproportions may have had on the distribution of urban and non-urban nurses would appear to have been slight,although it might be that the percentage of nurses working in non-urban areas has not been growing to the sameextent as the corresponding urban percentage.One other element contributing to the supply of nurses is the number of nurses of each type who arereceiving unemployment insurance at any time. These data are provided to the IDIRU by the Regional Office ofEmployment and Immigration Canada. Table 11 lists the total number of VI recipients who are characterized byEmployment and Immigration Canada as belonging to the general CCOO categories of "GraduateNurses" and"Registered Nursing Assisrants-. RegisteredD1D'Sing assistants are equivalent to licensed practical nurses, as aregraduate nurses to registered nurses and registered psychiatric nurses, although ~e element of "registration" - theright to an exclusive use of title for each of the three B.C. groups - is absent from the federal definitions. Thus29Table 10Practising Registered Nurses, Number of Re-Activations,Auritlon and New Registrams, 1981-1991 (1)1979-1981 1981-1983 1983-1985 1985·1987 1987-1989 1989·1991Re-Acttvatlons (1)Urban 1119 887 1033 891 1054 991Non-urban 890 695 809 672 623 540Tolal 2009 1582 1842 1563 1677 1531AttritionUrban 1356 2070 1605 1840 1927 1744Non-urban 906 1328 968 1105 1011 917Tolal 2262 3398 2573 2945 2938 2661New RegistrantsUrban 2357 1486 1523 1739 1989 2018Non-urban 1977 742 740 752 1062 1135Tolal 3627 2228 2263 2491 3051 3153(1) Numbers quotedare lWO year totals.Source: ROLLCALL SERIES, 1979 - 1991, Health Human Resources Unit,The University of British Columbia.30Table IIUnemployment Insurance Claimants - Nursing Groups, 1986 to 1991March June September December1986Nurses, General Duty 668 638 586 585Nurses, Psychiatry 43 41 34 36Registered Nursing Assistants 278 276 255 2681987Nurses, General Duty 601 562 571 658Nurses, Psychiatry 38 42 43 52Registered Nursing Assistants 277 253 235 2471988Nurses, General Duty 648 638 660 678Nurses, Psychiatry 48 45 50 49Registered Nursing Assistants 254 258 242 2621989Nurses, General Duty 673 610 580 574Nurses, Psychiatry 57 56 48 48Registered Nursing Assistants 231 207 211 2011990Nurses, General Duty 492 508 513 601Nurses, Psychiatry 53 45 43 43Registered Nursing Assistants 205 179 166 1841991Nurses, General Duty 676 714 706 776Nurses, Psychiatry 33 41 43 42Registered Nursing Assistants 192 176 185 208Source: Employment and Immigration Canada, B.C. Regional Economic Analysis Dept.,31Table 12Total Difficult-to-Fill Positions.RNs. RPNs, LPNs. 1986to 1991March June September December1986RNslRPNs- - - 193LPNs . - . 61987RNslRPNs 188 188 198 168LPNs 6 2 3 41988RNslRPNs 178 317 322 314LPNs I 2 0 41989RNslRPNs 388 476 353 375LPNs 15 5 2 11990RNslRPNs 307 301 230 164LPNs 2 12 8 01991RNslRPNs 90 73 91 68LPNs 0 2 0 0Source: DIFFlCULT-TO-FILL VACANCIES REPORTS. December 1986toDecember 1991. Health Human Resources Unit,The University of BritishColumbia.32the federal categories probably include persons who are not "registered" or "licensed" in B.C., and may indeedinclude persons who may not be eligible to become members of any of the professional bodies in this province.The figures in Table 11 are the monthly totals for March, June, September, and December, for the periodbeginning in March 1986 and ending in December 1991. Until recently, the numbers for graduate nurses ingeneral duty and psychiatry, as well as for nursing assistants, have fluctuated within relatively D8ITOW limits,although there was a steady decline for all three groups after June of 1989, which shifted to a steady increase forgeneral duty nurses and nursing assistants after December 1990. The number of psychiatricnurse claimants basremained about the same since June of 1990. When comparing the totals to the total of difficult-to-fill positionsfor the same period (see Table 12), it becomes apparent that the unemployment levels do not appear to be greatlyaffected by the increases in the number of nursing vacancies, although the dramatic decrease in the number ofnursing vacancies which is shown after September 1990 did occur at the same time as a rise in the number ofunemployment insurance claimants. While the figures recorded in Table 11 show graduate DIne unemploymentat above 600 for each month cited between December 1987 and June 1989, the count of difficult-to-fill positionsremained at a stable level below 200, before jumping by 78 percent between March and June 1988 andcontinuing above 300 tmtil September 1990. H the unemployment rate does respond to increased demand, thenthere must be a considerable time lag in the expression of its response. But it does seem more sensitive todownward shifts in demand, as bas occurred in B.C. since the fall of 1990, when acute care budget shortfallshave been met with bed closures and hiring freezes.It is difficult to account for the phenomenon of stable numbersof unemployed nurses of all three types.The figures in Table 11 do not include individuals on maternity or disability leave. Some portion of the totalmay be the result of migration; the nurses represented in Table 11 may be short-termrecipients who are emoledonly to cover a inter-provincial move. It is also possible that some proportion arenurses with specialty ttaining(or who lack such training) who are looking for employment in regions where skills they possess arenot indemand. This would include nurses who wish to be employed only in certain areas or undercertain conditions.Lastly, certain of these nurses may be individuals who have decided to leave the nursing labour force; they seekwork in another field, but are registered with Employment and Immigration by their original professionaldesignation.334. .Career Opportunities and Wage StructureThe discussion of labour force behaviour becomes more meaningful when presented from the context ofcareer opportunities. Several routes exist for nursing careerdevelopment. The most common is also the leastlike a conventional "career"; a large number of nurses, usually with diploma education, take staff-level positionsand work for a few years, have children, and workpart-time or casual until the children are older, when theymayor may not return to full-time employment for a number of years in middle age. These nurses will passthrough sections of the salary increment system, but often spend much of their working life at the lower levels,because after their childbearing they are less likely to be working in regular positions that permitsteadyincrement. Other diploma-educated nurses will obtain post-basic baccalaureates, which they will use to move outof staff positions into positions as head nursses or into employment in community health. Baccalaureate­educated nurses often begin in clinical positions and move into community health or head nurse positions.Employment at the higher levels of nursing management is more or less restricted to individuals with moreadvanced preparation. The position of clinical nurse specialist can be reached by a nurse with extensive clinicalexperience and a baccalaureate degree, but master's degrees are becoming necessary in tertiary-care bospitals.EduCators almost all have baccalaureate preparation, and, increasingly, master's and doctoral degrees. These lastare still infrequently found; almostall the PhD degrees that are held by nurses were taken in non-nursing areasand those who hold such degrees are usually employed in academia.Registered psychiatric nurses operate in a parallel system; those with diplomas are to be found mostly ininstitutions, where some head nursing and senior nursing management positions are also open to them. A smallnumber with fmther education, usually advanced degrees, can work in community mental health centres.Licensed practical nurses cannot expect much advancement; their increment system is limited, and it is only withfunher education that it is possible for LPNs to movebeyond the performance of delegated nursing tasks.Preparation and function are not entirely consonant with one another in nursing practice. Diploma- andbaccalaureate-prepared nurses are both employed as general duty nurses, and specialty certification is not alwaysnecessary for employment in specialty areas. Practical nurses can be employed to perform a specific set ofnursing functions as designated by registered nurses in certain settings. The complete range of tasks and roleswhich definebasic nursing practice can be performed by graduates of both diploma and baccalaureate programs,34and psychiabic nursing practice is open to those graduates as well, although individuals trained only inpsychiabic nursing predominate. Roles in advanced nursing practice, community health nursing, andadministration are more or less available only to nurses who have preparation at the baccalaureate level (basic orpost-basic) or with master's degrees, and specialty certification added to basic preparation is increasinglyrequired for complex clinical nursing functions. These trends are especially obvious in urban locations, whereasdiploma-prepared nurses in non-urban areas are still better able to move up the nursing hierarchy even when theyhave not acquired additional nursing credentials. Teaching is most circumscribed; diploma-prepared nurses canstill be found in diploma educationprograms, but, increasingly, those nurses are obtaining bachelor's degrees.Master's degrees are required in university programs and most community college programs, and, to providefurther advanced education, a doctoral program in nursing is now established at The University of BritishColumbia.In general, career ladders in nursing are controlledby educational preparation, and traditionally, the careerladder has led away from "hands on" nursing. Indeed, it would not be unfair or inaccurate to say that thebaccalaureate degree, whether basic or post-basic, was and still is a way to move away from direct bedsidenursing. Community health and nursing administration offer nurses more autonomy and often more respect fromother health professionals, as well as an escape from shift work and general working conditions that are moreamenable to family life. For those who are interested in acute care nursing, the role of the clinical nursespecialist, of recent provenance and likely to remain localized in urban, tertiary care centres, is the only route toa similar level of autonomy. The problem with traditional nursing career ladders is that they are essentiallyunavailable to general duty nurses working in community or non-urban hospitals, or to nurses who do not seekor fmd it difficult to obtain post-graduate qualifications. It has been proposed that some kind of vertical gridshould be established to meet the need for staff nurses to advance in accordance with their clinical competencies,one that would offer monetary as well as structural rewards for remaining in practice and gaining clinicalexpertise. In addition, some argue that opportunities for horizontal movementshould be enlarged, so thatexperiencednurses would be able to move across specialties and general services to offer their expertise to less­experiencednurses, and so that they could expand their fields of practice.The earnings structure in place for general duty nurses does not promote either the acquisition of35additional nursing education, degree-level or certificate, or the development of vertical grids. The academicbonus which is paid to baccalaureate prepared nurses was S70.00/month in 1980 and only rose to SI00.OOImonthin 1990. Specialty certification was worth an extra S25.00/month in 1980and is still at that level. Moreover, anurse who is qualified to receive both of these bonuses can only obtain one of them - they are DOt cumulative.ID addition, the increment sttucture in place for general duty RNs and RPNs has only six steps, so that after sixyears of work, a nurses' wages wiD not increase again except through ordinaryscheduled increases.The wage figures in Table 13 reveal some interesting aspects of earnings and nurstng career ladders. Thesix-step increment system that has been in place for general duty RNs for the last teD years has preserved a 15.5to 15.7 percent difference between entry-level and maximum-level hourly wages for all classifications since1981. Despite arguments from those concerned about retention, the range of possible earnings for general dutyregistered nurses has not been expanded. For registered nurses in the head nurse category, the range has alsoremained around 15.6 percent since 1981. The head nurse classification was split into two tiers in 1986; nodifference in the range of the increments was available to those nurses either. Supervisors, the nurses classifiedin the highest category, saw their range decrease in extent to 13.2 percentbetween 1982and 1985, after whichtime it returned to 15.6 percent Registered psychiatric nurses and registered nurses working for government-runfacilities have seen their originally more extensive incrementrange drop from 18.1 percent in 1980 to a low of17.1 percent through to 1991, when it jumped to 20.4 percent. Again, there was no real difference over time forthose RPNs in government facilities between the ranges of nurses working at the general duty level and thoseworking in a head nurse classification. For LPNs, the number of steps was limited to four until 1984, when itincreased to five, but the last step disappeared after 1989. The extent of the difference between the lowest andhighest steps for LPNs was at its highest in 1980 at 10.6 percent; in 1991 it has reached its lowest point at 6.8percentThe percent difference between hourly wages of an entry-level general duty nurse and his or her headnurse counterpart has remained steady at 15.0 percent over the ten year period. The differential between headnurses and supervisors was 8.7 percent in 1980 and 8.0 percent in 1990. ForRPNs in government facilities, thepercent difference between general duty nurses and head nurses was 14.9 percent in 1980; it dropped to 13.6percent in 1984 and has reached 16 percent in 1991. Thus, the percent difference between the minimum andmaximum earnings for general duty nurses actually exceeds the percent difference between entry-level staff and36w...,JTable 13HourlyWageRates. 1980 - 1991Registered Nurses, Registered Psychiatric Nurses, Licensed Practical Nurses1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991Reglstered NursesBasicMin 8.89 10.42 11 .64 12.59 12.85 13.11 13.43 14.21 14.78 16.02 17.52 18.23Max 10.34 12.04 13.46 14.55 14.85 15.15 15.53 16.42 17.09 18.53 20.27 21.08Head NurseMin 10.22 11.98 13.39 14.47 14.77 15.07 15.44 16.33 16.99 18.42 20.16 20.96Max 11 .89 13.85 15.47 16.72 17.07 17.42 17.85 18.88 19.64 21.29 23.30 24.23HeadNurse IMin 15.75 16.66 17.33 18.78 20.56 21.38Max 18.2 19.26 20.04 21.71 23.76 24.71SupervisorMin 11.11 13.03 14.55 15.73 16.06 16.38 16.79 17.76 18.48 20.02 21.90 22.78Max 12.93 15.06 16.82 18.18 18.56 18.93 19.40 20.53 21.36 23.15 25.33 26.34Registered PsychiatricNursesBasicMin 9.66 11.04 11.94 13.15 13.45 13.53 13.81 14.15 14.46 14.90 15.83 17.11Max 11.41 13.04 14.11 15.38 15.73 15.84 16.15 16.56 16.92 17.43 18.52 20.60HeadNurseMin 11 .09 12.68 13.71 14.97 15.32 15.42 15.73 16.12 16.48 16.97 18.03 19.85Max 13.11 14.99 16.21 17.54 17.94 18.06 18.42 18.88 19.34 19.88 21.12 23.91Licensed PracticalNursesMin 7.76 9.05 9.78 9.98 10.17 10.60 11.02 11.35 lU)6 13.03 13.21Max 8.58 9.75 10.53 10.74 10.95 11.38 11.82 12.17 12.94 13.92 14.12MaxI 11.02 11.24 11.67 12.12 12.48 13.26Sources: MasterAgreement betweenHospital Employee's Unionand HospitalLabourRelationsAssociation, 1982-1986, 1986-1989,1989-1991;MasterCollectiveAgreement betweenthe BCNUand the lll..RA, 1980-1991; Government of B.C. Personnel Division 1980-1991 (personalcommunication).bead nurses. This does suggest at least a static view of the notion of providing monetary incentives to staffnurses both to remain in practice throughout a working life-time, and to aspire to greater responsibility inleadership positions. The efforts of some employers to move bead nurses out of union membership and intosalaried management categoriesmay have some effect on this simation; nursingmanagement saIaries migbt beexpected to be bigher than earnings tied to staff positions. Of course, such an alteration may or may not haveany effect on the range of increments for general duty nurses.Another aspect of the issues surrounding nurse oompensation wbich bas been thought to have an influenceon buman resource factors is the relationship between registerednursing wages and those of licensedpracticalnurses. The ratio between basic earnings for the two groups was 1.14 in 1980 and it bas increased to 1.4 in theintervening period. The recent gains in RN oompensation have expanded this difference between the two groups,and if cost is an important element in decisions about staff mix, then it may be that LPNs win becomemoreattractive to employersas RNs become relatively more expensive. However, the bistorical evidencedoes notsupport this. It is of interest that wages for registered psychiatric nurses working in government facilities werehigher than those of registered nurses in the public bospital system until 1986, wben the RNs overtook the RPNs.The absolute difference was small; the salary ratio was 1.1 (for the RPNs) in 1980, 1.03 in 1986, and .87 in1990. This relationship bas not been thought to be an important factor in the determination of nurse-mix ratiosby employers.The relationship between career development and remuneration is a complex one. As bas been noted,wbile problems with the retention of staff nurses in acute care institutions are generally considered to be heavilyimplicated in the "shortage" of nurses, and tying wages to experience is thought to encourageretention, the wagestructure is flattened and static. Wbi1e entry-level salaries have risen by about 105 percent over abe past tenyears, with concomitant increases for the increment strucmre and the levels of advancement, abe emphasis stillappears to be upon recruitment rather than retention. "Career development" does not yet appear to be a priorityfor employersof general duty acute care nurses, althougb recent contractual provisions like the EducationalLeave Fund and the arrangements for Bridgingof Servicepoint to some increased employer sensitivity to theneeds of nurses for further education and to their willingness to return to work after childbearing wben there isdue recognition of their previous service.There is some disagreement within nursing groups about the meaning of increments and career ladders.38Unio~ tend to rake the position that the absence of vertical grids in male-dominated occupational categoriespoints to an essentially sexistuse of step frameworks to under-value the work of women. The progression fromentry-level to maximum levels of earnings as periods of service lengthen implies that the employee is notperforming at an adequate level at the beginning. The underlying notion may be that nurses as a group shouldbe considered to be initially competent to practise and worthy of an appropriate wage, and that monetaryadvancement be available to the groupas a whole, not just to select individuals who have been able to remain ina particular position for an arbittary length of timeor who haveconformed to the employer's standard ofadequate practice. In other words, the standard of practice and the relationship between practice andremuneration should rest with the practitioner, not with the employer. Mter all, medical practitioners arepermitted to set theirown standards of practice and to determine the framework of remuneration that isappropriate to that practice. From another standpoint, the concept behind career laddering and step incrementsrakes monetary incentive to be of "paramount importance in encouraging and rewarding advanced skill andpreparation as well as loyalty and experience. Professional ethics would suggest that the fostering of individualskill and a commitment to life-long learning should be natural to the practitioner, who should always wish toimprove herselfso as to serve her clientas best as possible. The career ladder concept suggests that professionalsocialization does not provide for incentives sufficient to ensure commitment to either the profession as a wholeor to the maintenance of standards of professional practice, while step increments function as a reward for joblongevity rather than for excellence in practice or professional development.Part of the problem is no doubtrelated to nursing's lack of control over its definition of practice. Solong as scopes of practice, conditions of practice, and actual performance are all within the powerof theemployer to determine, it may not be so surprising that unions prefer to keep the grid fIXed and static, and thatthey are concerned about differentials based on unitassignment or length of service. To maintain that all nursingpractice within job categories is of equal value may appear to be more supportive of the membership than togive the employer even more powerover employees by tying remuneration to the attributes of individual nurses.Given some employers' past attitudes towards nurses - that they are a renewable resource: versatile,undifferentiated, and pre-eminently flexible - it may be that the resistance of nurses' labour representatives is notentirely without merit. Control over defmitions of practice - so-called "working conditions" - is thus involvedin the debate over career ladders and remuneration. Job definitions, staffing responsibilities, level of care, and39workload assessment are all determined by employers. The 1989-91 British ColumbiaNurses' Union contractmandates the establishment of Professional Responsibility Committees to allow for the resolution of concernsrelating to nursing practice conditions, the safety of patients and nurses, and workload. Information about howmany of these committees are in place and how well they function is not available.5. Autonomy, Expertke, and Sodal ValueSlaws relationships between groups of nurses can be described as articulated through assessments ofautonomy, expertise, and social value. Licensed practical nurses rank lowest on the nursing status hierarchybecause they are least likely to be working with even a small degree of independence and they have the shortestperiod of educational preparation. Since the currency of expertise is increasingly education, the experienced andskillful LPNs are often seen as unusually personally gifted, rather than as contributing to specific nursingpractices with particular LPN expertise. In addition, basic bedside nursing - the bed-pan emptying, bathing,feeding, etc. - is the area to which LPNs are restricted, and these activities are the parts of nursing practicewhich most conform to the stereotype of "women's work". Indeed. they are the stuff of home-making andchildrearing - the unpaid labour of women - and thus particularly destitute of social value.Insofar as RNs and RPNs are employed in parallel acute care and community care systems, their statusrelations are essentially collegial, so long as the intra-group status gradations which have formed aroundeducation are respected. Each type of nurse then works in an approximately similar environment. and has anequal oppornmity to exercise autonomy and to develop expertise. There is perhaps some different socialvaluation of psychiatricnursing because of the frightening images of institutional life with which we are allfamiliar, but then equally demeaning and critical images of general nursing are also traditional. However,because the overwhelming majority of Canadian nurses are educated to be generalists, the restricted focus ofpsychiatric nursing practice probably results in assumptions on the part of registered nurses that the expertise ofRPNs is too narrow. As the parallel work world of the psychiatric nurse begins to contract with the shift tocommunity-based living for the chronically mentally ill, registered psychiatric nurses may find themselves withless status. Already, employers in acute care general hospitals are said to prefer to hire registered nurses to workin acute care psychiatry because those nurses can move elsewhere within the hospital without concern.Community health nursing is the preserve of the baccalaureate-educated nurse; RPNs will be expected to40acquire furtherdegree-level education in order to make the transition to community mental health work. Tosome degree, the autonomy of the RPN is constrained by the limits that generalist registered nurses are able toplace upon their practice. (There is anecdotal evidence to suggest that RPNs who have been trained solelyfor thetraditional institutional setting experience difficulty in adjusting to the more self-directed style of practiceexpected in community settings. This would tend to support the contention that more extensive, non-institutionaleducation is necessary for nurses who may find themselves employed in non-acute care non-institutionalsettings.) Moreover, acute care hospital nursing bas the highest social value; public concern about waiting listsmakes that clear. The public's perception that hospital nursing is all medical and surgical specialty nursing thatis also technologically complex bas given a real boost to the RNs in the past few years, so much so that there isa growing tendency even among nurses to place special value upon the most technically difficultnursing task.Using the framework of autonomy, expertise, and social value is also useful in the consideration of statusrelations between nursesand other health occupational groups. Like nursing, physiotherapy, occupationaltherapy, medical social work, dietetics, and speech-language pathology are professions with overwhelmingmajorities of femalemembers; for each of these other groups, its status position in relation to nursing is moresecure. To begin with, members of the other professions have greater autonomy than nurses because they havewell-defined and specific fields of practice and are considered to be more knowledgeable about those practicesthan anyone else. Nurses have particular problems with the well-defmed fields of practice of other professionsbecausenursing roles often cross over into several other disciplines. Nurses have a much less clearlydefinedfield of practice, one that incorporales skills from a number of other disciplines and which is often directlyconcerned with the coordination of the care delivered by other professionals. However, nurses lack the authorityconferred by clear autonomy and expertise to exercise the coordinating role to its fullest extent The concept of"continuity of care" depends for its implementation on the existence of a sufficiently powerful figure with theauthority to organize the disparate elements that come together into a continuous-care situation. Nurses wishing10 take on the task of developing real continuity of care are handicapped by their lower sWUS position among thehealth professions. Nurses also suffer in sWUS position in relation 10 the other groups by reason of their morelimited educational preparation. As described before, all the other health professions require at least abaccalaureate degree for entry-to-practice. Two- or three-year diplomas do not carry the same weight in healthcare delivery settings. Due 10 their greater autonomy and their perceived expertise, deriving in part from the41baccalaureate requirement, the other professional groups enjoy more control over working conditions than nursesdo.Nurses have struggled against physician-dominated defmitions of autonomy, expertise, and social valuefor the last twenty years, but despite some improvement in doctor-nurse.re1ations, it can still fairly be said that"while physicians encourage a form of 'team work' in which nurses are subordinate, nurses seek mutualcollegiality with physicians" (Campbell-Heider and Pollock, 1987). After all, physician identity and practiceprovide the ideal against which concepts of autonomy, expertise, and social value are measured for all healthoccupations, perhaps for all of society. Nurses have attempted to determine a field of practice that incorporatesnon-medical roles and tasks, and have advocated for the development of an expanded scope of practice in theposition of the nurse practitioner as primary care giver. However, they have been unsuccessful in thedevelopment of nurse practitioner roles, having been stymied by the legislative barriers, the resistance fromphysicians, and inaction by governmentIn the redefined field of practice described above, nurses find themselves contesting the ground inpsycho-social care with social workers and psychologists, and, at the same time, some nursing administrators andsections of the membership appear to continue to give precedence to the medical model of illness and cure. Thegrowing tendency among some nurses to elevate technically difficult cure-oriented nursing tasks over the moresocially and emotionally challenging task of helping patients with demanding psycho-social problems reflectsboth our society's interest in the technologically sophisticated and medicine's thrust to become more scientific.There exists a 'glamour' hierarchy in nursing (as in medicine); highly technical life-saving surgical nursing is atthe top, with critical care of any kind and emergency nursing following close behind, while long-term care isprobably at the bottom. Some appear to see the increasing delegation to nursing of technically demanding tasks(c.f. critical care) as providing greater legitimacy to the claims of nurses that they deserve improved social,inter-professional and fmancial recognition . But it could be argued that tying nursing practicer moee closely tomachinery will also anchor it even more f1l'Dlly to the doctor's side and under his control. To some extent, thetendency to glamourize the technical is balanced by the response of nursing leaders to inaeased public concernabout health promotion and disease prevention . In two recent discussion papers, the RNABC asserts that nurses,by virtue of their training and outlook, are especially well-suited to the promotion of the health of the generalpopulation, given the importance of patient teaching and "holistic" care in nursing education.42Some observers see "the doctor-nurse game" - the role-playing and managed interactions integral to themaintenance of an uncontested hierarchal relationship - as altering in the present day (Stein, et al., 1990). 10 thepast, open disagreement between doctors and nurses could not be tolerated, and while nurses could have opinionsand could be consulted, their advice could never be given or taken as authoritative. It is argued that nurses arenow seeing benefits from the effects of the women's movement, as well as from the push towards increasededucation and self-defmition that bas come from within the profession, and are more and more willing to regardcertain areas of patient care as within their field of expertise. Nurses are said to be more willing to question,complain, and confront Such changes in behaviourare not universally welcomed by doctors; they cansometimes be heard to remark that nurses no longer seem to want to "be nurses", which for the doctors seems tomean willing to carry out orders without question or comment A recent proposal by the American MedicalAssociation (AMA) to create a new class of health care worker, the "registered care technician" is, in part, anexpression of physician discontent with developing nursing practice. The registered care technician would betrained for about a year in hospital and would be largely responsible for implementing doctors' orders. Thesetechnicians were likened directly by the AMA to the hospital-trained diploma nurses of the past The AmericanNurses'Association was quick to recognize the proposal for what it was - an attempt to re-establish an out-dated,inefficient and repressive regime that would primarily function as a prop to physician authoritarianism.43D. Explaining the Current SituationHuman resource requirements in general, and nurse requirements in particular, are influenced by thecomplex interaction of many economic, political, and social factors. Therefore, research efforts can not hope toquantify and fully measure all the variables concerned. Alternative methodologies for estimating requirementsare available to planners and policy-makers, but no one method bas been identified as being superior to others.All methodologies are tools for research and the quality of the product is as much a reflection of the insightandgoodjudgement possessed by the researchers as of the excellence of the instrument used.1. Net RequirementsIt bas been suggested that the ideal way to undertake supply/demand research is to smdy both sidessimultaneously (Mejia and Fulop, 1978). A major drawback, however, bas been the reluctance of researchers toproceed from studies of supply alone to those which combine supply and requirements in an analytic frameworkthat does not make a priori assumptions of "shortages" or "surpluses". Usually, the deceptively simple-appearingtask of enumerating health personnel proves to be a major undertaking which comes to an abruptend after thecount is completed. Another drawback bas been the tendency of researchers to focus narrowly on the traditional"economic demand" model. which is of somewhat limited value in studies of the public sector, particularly whenthe bulk of the workforce is female.In B.C., a smdy of nurse requirements was undertaken some years ago (Kazanjian and Chan, 1984). Fourmajor questions were raised:i) What is the levelof utilization (the effective demand) of nursing services? Does it varyappreciably over time?ii) Is there any substitution among nurse categories? Does this vary over time or accross geographicareas?iii) What are the major factors that affect nurse requirements?iv) What are the inter-relationships among the major quantifJable factors that affect nurserequirements?The report contains large quantities of information analyzed in a systematic fashion; it provides a detailedoverview of the six-year period from 1976 to 1982. While the specific findings from that study may beconsidered obsolete, nevertheless. someof theseare of a general nature and have remained valid over time. The44~Table 14Representative AnnualSalaries of Selected Personnel as a Percentageof RegisteredNurses' Salaries, 1976-1982Registered Practical Nurses Health Record Medical Social All Savings & FoodYear Nurses(I) Nurses(2) Aides (3,4) Admin. (5) Workers (5) Teachers (6) Credit Workers (7) Canners (7)1976 100.0 85.7 78.5 95.9 108.9 75.3 83.1 81.31977 100.0 86.0 80.3 96.3 109.4 76.9 83.0 75.71978 100.0 85.8 80.3 96.3 109.4 78.4 85.4 74.21979 100.0 86.6 81.1 97.5 110.7 79.8 86.5 79.51980 100.0 88.6 79.7 89.4 105.4 74.2 80.7 69.81981 100.0 83.2 74.8 91.8 103.3 74.0 84.9 74.21982 100.0 83.6 75.2 94.1 105.9 80.6 90.8 79.4(1) Data provided by BCNU (for General Duty RN, Step I).(2) Data providedby Health Labour Relations Association of B.C. (for minimum starting salary rates). TIle 1980rate includesJanuary andAugust increases; the 1981, 1982rates me as of August of the respective years.(3) Canada Departmentof Labour, "Wage Rates, Salaries and Hoursof Labour", 1970-1973, unpublished data for 1974-1977 period provided byCanada Department of Labour. Annualsalaries estimated from average monthly salaries.(4) Increasesestimated according to 1978-81 Master Agreementbetween Hospital Employees Union and HealthLabour Relations Associationof B.C.(5) Data providedby Health Sciences Association(Grade I, lst year salaries),(6) Data providedby B.C. Teachers' Federation (minimum basic salary).(7) StatisticsCanada, "Employment, Earningsand Hours", Cat 72-002. AnnualFiguresestimated from average weekly wages.data were obtained from the central payroll system of B.C. Info Health and the other payroll systems of severalmajor hospitals. All hospitals funded by the Care Services branch of the Ministry of Health were included in theanalysis.A brief discussion of such fmdings provides some insights. When RN starting salaries were compared tothose of other health personnel and other service personnel, RNs fared well relative to both subgroups (Table14). The salary differential between RNs and the more highly paid medical social workers decreased over time,and that between RNs and LPNs increased. Although teachers and bank tellers bad obtained much higher salaryincreases than bad RNs during the study period, these groups bad appreciably lower salary scales.A study of actual relative wages indicated that the average RN wage was 22 percent higher than theaverage LPN wage in 1979, 20 percent higher in 1980, 28 percent higher in 1981, and 27 percent higher in 1982.While RN relative wages increased in 1981 and remained higb in 1982, the ratio of registered to practical nursepaid hours steadily increased from 2 to 3 during the study period. The vast majority of RN paid hours were forregular staff, but wben this proportion decreased in the two later years, part-time and casual hours compensatedfor the drop in regular bours. When bospital budget cut-backs occurred in 1982, however, the impact wasabsorbed mainly by reductions in the casual RN bours.A regression model was developed that defmed nurse requirements as a function of bed stock, supply ofphysicians, relative supply of other nurse categories, relative wages of nurses, bealth expenditures and patientvariables. The unit of analysis or observation was the Regional Hospital District In general, physician supplyand bed stock jointly accounted for almost 80 percent of the variation in nursing paid hours. With all sevenoperationalized variables included, the model bad very higb predictive value (approximately 90% of the variationwas explained).The four specific research questions raised earlier in this discussion were addressed by the study:i) The data provided clear indications to guide the preferencesof employers for nurse personnel mixand for the deploymentof regular/casual, full-time/part-time personnel within each of the twocategories, RN and LPN. For both of these groups, the proportion of "regular" bours steadilydecreased over time, although absolute hours increased until 1982, when total hours decreased forboth groups (with a steeper' decline for LPNs than RNs). Thus, RN utilization patterns during thestudy period appeared fairly stable for regular and part-time nurses until 1982, with appreciable46••variation reported for casual nurses. The largely unanticipated Iluctuauon of 1982 was absorbedby the decreasing requirements for casual RNs. The LPN picture was much less stable pre-1982,as well as during that year, and yet the LPN servicesmarket appeared to be parallel to that forRNs;ii) There did not appear to be substitution of RNs by LPNs, at least not in that direction. Both thedirection and the degree of substlmtion was shown, surprisingly, to be counter-intuitive. Whenrelative wages (RNILPN salaries) declined, the RNILPN ratio increased by only five percentWhen relative wages increased appreciably in 1980-81, the RNILPN ratio increased by sevenpercent. followedby an increase of 12 percent in 1981-82when relative wages had remainedstable. An attempt to explain this type of trend can only be made after a close examination of thechanging roles and functions of each of the nursing categories and of the political environmentwithin which nursing and hospital management make staffing decisions; this examination shouldbe made within a broader context of the changing nature and complexity of the health caredelivery system;iii) There is always some positive correlation between available supply and effective demand, and thehighly regulated and largely non-profit nature of the hospital sector determines the parameters ofcapital input availability; given that premise, major factors that have impact upon the requirementsfor nurses have been examined. It is not surprising that the per capita physician supply wasshown to be the most importantpredictor variable for RN requirements; for LPNs, it was percapita bed stock. The latter was the second most important predictor of RN requirements, whereasbudget per patient day ranked second for LPN requirements;iv) The study fmdings indicated complex inter-relationships even among the minimum of threeexplanatory variables which accounted for the optimum variation in the dependent variable. Forexample, the direct influence of pliysician supply - mostly due to the variability in specialiststock - on RN requirements varied more than three-fold between the earlier years and later yearsunder study. Thus, simply calculating physician supply will not yield as accurate an estimate ofRN requirements as knowing physician supply and total bed capacity. The interaction effect ofthese two factors was clearly quantified by the analysis.47One general conclusion that can be drawn from this study is that the most important factors needed toestimate RN requirements are neither patient- nor budget-related. That patient-related factors are less importantis. perhaps, not so surprising, since RNs are not the gate-keepers to the delivery system. The relationship ofthese factors to physician numbers in the provision of nursing care was clearly quantified there, with someindication as to the strength of the statistical relationship, given the influence of other variables consideredin thestudy.The discussion of the factors that influence nurse requirements in B.C. bas never been an impassioneddebate or even a reasoned argument It has simplybeen upstaged by the controversy about nursing vacancies.The upstaging probably results from the policymakers' preferences (for a variety of reasons) to address short­term rather than long-term issues. To monitor nursing vacancies. data are compiled from the reports of 122acute care institutions around the province which count their vacant positionsat the end of each quarter. TheHHRU survey counts only difficult-to-fill vacancies; these are positions that have been vacant for at least onemonth for which there has been active recruiting. This excludes temporary and casual postings, and relies oninstitutional defmitions of area of service. Because the numbers are collected on a quarterly basis, vacancies thatmay occur between the time of the previous report and the current one are not counted. No distinctions aremade between registered nurses and registered psychiatric nurses when the positions are reported, so none can beobserved in this analysis. The "demand" which can be inferred from the number of difficult-to-fill vacanciescannot be taken as expressive of the real extent of nurse requirements, either in total or by specialty. Demandwould best be assessed in terms of population diseaseand treatment needs, evaluated according to a schedule ofnecessary tasks and the standards of nursing practice. Shortages arise from variations in acuity, workload,utilization, deployment, and appropriateness of care, as well as from vacant positions. The number of difficult­to-fill positions can be used as a very rough measure of the perimeterof demand, but it is not a substitute foraccuratemeasures of patient need and the capacityof professional practice.The figures in Tables 12 and 15 illustrate the main point to be made about "shortages" - that they arerecurrent but not cyclical;~ shortages will be observed repeatedly, but not with predictable regularity. Thusthe totals for four consecutive Septemberend-of-quarter periods show a rise and fall, but are not consistentlyhigh or low. The differing percentage distributions of the specialty areas (Table 15) are especially indicativeof48•Table 15Dlrncult·to·Flll Vacancies, September 30,1987-19911987 1988 1989 1990 1991Urban Non-Urban Urban Non-Urban Urban Non-Urban Urban Non-Urban Urban Non-UrbanRegistered Nurses andRegistered PsychiatricNursesGeneral 8 16 7 32 38 49 20 16 - 2(5.6) (29.6) (3.2) (30.5) (14.3) (55.7) (11.3) (30.2) (22.2)Medicine 12 - 24 4 16 3 7 1 1 -(8.3)-(11.1) (3.8) (6.0) (3.4) (4.0) (1.9) (1.2)Surgery 8-27-23-19 1 1 -(5.6)-(12.4)-(8.7)-(l 0.7) (1.9) (1.2)Paediatrics 14 - 36 3 16 8 8 2 1 -(9.7)-(16.6) (2.9) (6.0) (9.1) (4.5) (3.8) (1.2)Obstetrics 2 4 1 6 14 2 3 3 - 2(1.4) (7.4) (0.5) (5.7) (5.3) (2.3) (1.7) (5.7) (22.2)lCUlCCU 79 13 34 26 65 15 38 16 12 1(54.9) (24.1) (15.7) (24.8) (24.5) (17.0) (21.S) (30.2) (14.6) (11.1)Psychiatry - 2 57 4 30 - 22 - 52 1-(3.7) (26.3) (3.8) (11.3) - (12.4) - (63.4) (11.1)ECU 11 1 12 15 54 7 24 6 3 1(7.6) (1.9) (5.5) (14.3) (20.4) (8.0) (13.6) (11.3) (3.7) (11.1)OR 2 3 3 9 1 3 7 5 5 -(1.4) (5.6) (1.4) (8.6) (0.4) (3.4) (4.0) (9.4) (6.1)Emergency 1 - 3 6 8 - 13 1 5 2(0.7)-(1.4) (5.7) (3.0)-(7.3) (1.9) (6.1) (22.2)Administration - - 1 - - 1 1 2 1 -- -(0.5)- -(1.1) (0.6) (3.8) (1.2)Other 7 15 12 - - - 15 - 1 -(4.9) (27.8) (5.5)- - -(8.5)-(1.2)Sub-Total 144 54 217 105 265 88 177 53 82 9Percentage (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0)TOTAL 198 322 353 230 91LPNs/Orderlies-3- -1 1 2 6 - -TOTAL 3 0 2 8 049the recurrent but non-cyclical nature of the vacancies. Vacancies in lCU/CCU services for urban areas,expressed as a proportion of the total urban vacancies, bas ranged from a low of 15.7 percent to a high of 54.9percent. General nursing bas bada higher vacancy rate over time in non-urban areas rather than in urban areas,a reflection of the type of care givenby such hospitals. Psychiatric vacancies are almostall concentrated inurban areas because the primary employing instiwtions are located there. ECU difficult-to-fl1l positions appearto be of increasing importance in hoth urban and non-urban locations, where lCU/CCU shows consistentlyelevated numbers over time as weD.In contrast to the persistent fluctuation of RN and RPN difficult-to-fill vacancies is the low number ofLPN vacancies. Only in 1990was tha1 nwnberworth noting, and these werealmostall located in non-urbanareas. Given the concentration of LPNs in non-urban areas, this increase in difficult-to-fill positions for LPNsmay indeed have been indicative of a shortage of that type of nurse. What mightaccount for such a shortagecannotbe deduced from the D1F reports themselves; a survey of institutions which concentrated uponLPNutilization, staff mix, recruitment policies, and patientacuity would be necessary to begin to address such aproblem.There are, of course, different approaches to the measurement of net requirements. Those discussed herefollow the Health Services Research tradition, using an utilization-based definition of requirements. The needs­based approach (Figure 2) is often called the epidemiological approach because it has traditionally drawn onepidemiological techniques to assess the prevalence of disease and the burden of illness in the target population.But the process shouldnot end with the identification of conditions tha1 have an impacton health status and themeasurement of their prevalence. It should involve consideration of the appropriateness of the care used inmanaging those conditions. Then, health deficits can be converted to health care serviceor task requirementsand alternative mixes of inputs (human and complementary non-human resources) tha1 can be used to meet thesetask requirements should be identified. Human resource requirements set againstavailable skills wiD determinenet requirements. This approach was recently identified as the preferred method by a national panel of experts(Kazanjian and Friesen, 1990).so•Figure 2Framework For Establishing .Research PrioritiesPopulationHealthNeedsEfficient MixProgramsl of Human andServices Non-HumanResourcesContext ofPolitical, Social,Economic Barriers/OpportunitiesCurrentSupplyScope ofPractice &TrainingOrganizationDesignWorkshop on Priorities In Health Human Resources ResearchSeptember 27 & 28, 1989Vancouver, B.C.512. .Efficiency in DeploymentAmong the most difficult problems of measurement is the matching of estimated demand to actualsupply; supply is enumerated through registration statistics - a person count - whereas demand is usuallymeasured in terms of paid hours, budgeted FTEs, etc. These latter are fmancial measures and are therefore morelikely to be accurately documented and available for research purposes. A number of serious limitations areimposed on research that is based on incompatible units of measurement for solving the supply/requirementsequation. For that reason, information about demand or requirements for nurses in this province is sketchy. Forinstance, the total number of RNs who are prepared and willing to participate in the nurse labour force isunknown. Similarly, it is not known whether nurses available for employment will meet the level of preparationand specialty required by the vacant positions. Detailed supply data on specialty and sub-specialty qualificationdo not exist, and hence net requirements for these cannot be estimated. This is a major drawback from aplanning perspective since, as discussed previously, the number and duration of vacancies vary not only byregion but also by specialty. Lastly, while supply statistics provide a person-count at one point in time. estimatesof requirements include the total services needed to flll demand over a given period (usually a year).Thus, while the 1984 study on requirements (Kazanjian and Chan, 1984) provided baseline informationabout nursing hours consumed during the years examined, it but did not estimate net requirements measured asthe number of nurses required to provide that many hours of nursing services. Paid hours information isavailable at the national level through Statistics Canada.; provincial disaggregated data are derived from theAnnual Hospital Returns (liSl and HS2 data), which are required by the Statistics CanadaAct Table 16provides the most recent statistics for B.C . As indicated in the table title, these data pertain to !I!nurses;different nursing categories cannot be distinguished. As weD, the reporting system was changed by StatisticsCanada in 1986; in the new reporting format, the most recently published data were for 1986-87. It is diffICultto dnlw any conclusions regarding the utilization of nurses in B.C. from these data. One conclusion that can bemade, however, is that in the absence of a comprehensive nursing resources planning database, research in thisarea will be limited to narrowly-focused questions regarding shon-term problems.Research intended to update and build on the knowledge gained from the 1984 requirements study wasundertaken as part of a larger study about nurse shortages (Pulcins, Kazanjian. Kerluke, 1988). This study wascommissioned by the Deputy Minister of Health in 1987, and a three-volume report was produced in 1988 . In52.../Ithis smdy (Volume n of the report), an attempt was made to convert paid nursing hours to the number of nursesrequired to generate these hours. These estimates were based on actual "observations" from the B.C. Info Health1985-86payroll data, and included an extensivedata clean-upand development effort in order to ensure that the"observations" were of unique nurses (to eliminatemultiple counting). The employment behaviour of individualnurses was quantified along three dimensions: the proportion working full-time, part-time, and casual; theaverage number of paid hours per status category; and, movement in to and out of the workforce. This researchprovided, for the first time, information about productivity (including the movementof nurses), as well as aboutthe "wastage" of nursing resources in B.C.The data demonstrated the considerable degree of motility experienced by registered nurses, in terms ofattrition from the labour force, movementof nurses between hospitals in different regionalhospital disbiets, andchange of employment status. Using data f<r the Greater Vancouver Regional Hospital District, it was shownthat a reduction in motility greatly affects requirements by reducing the number of persons needed to provide agiven number of nursing hours. While this did not measure turnover~ - a complex calculation whichentails the monitoring of positions to count the number of persons required to ftll the same position in a givenperiod of time - this measure provides a clear sense of the extent of the movement in and out of the worlcforceand betweenjobs, and the switching back and forth between full-time. part-time, and casual employmentThe greatest amount of movement was shown to occur in the casual sector, and hence the most"wastage". It is in this sector that the least average number of hours are workedand the largest proportion ofnon-continuous employment is observed. Conversely, although part-time employees comprisea relatively smallproportion of the nurse labour force, it is in this sector that the least motility is evidenced. The measurement of"wastage" involved the examination of data for two different situations: employment statistics for all payrollrecords, and employment records for those who had worked continuously throughout the year under snidy butwho had not changed employment status during that time. This latter group, referred to as the "ideal" group,was considered the gold standard against which the employment behaviourof the "real" group was examined.This analysis provided detailed descriptive information on productivity; as expected, average paid hoursdecreased with increased motility. The existenceof this inverse relationship was ascertained by comparing the"ideal" and "real" groups. As well, regional statistics were compared to provincial averages to establish relativedegrees of "wastage".54Table 16Total Number of Paid Nursing Hours,by year, for Public Hospitals in British Columbia (l)Total Number of PaidYear Nursing Hours (2)1981· 1982 (3) 34,966,4771982·1983 (3) 33,904,3871983 - 1984 (3) 36,490,9051984· 1985 (3) 37,309,0771985· 1986 (4) 35,809,5521986 - 1987 (5) 36,524.442(1) Includes all nurses; excludes medical staff, interns. residents. and all students.(2) Calculation: Total Services of Public Hospitals x (Percentage Distribution of PaidNursing Hours I 100)(3) Source : Statistics Canada. "Hospital Annual Statistics". Ottawa: Minister of Supplyand Services Canada. (Catalogue: 83-232), 1984, 1985, 1986.(4) The format was changed by Statisucs Canada in 1986.(5) Source: Statistics Canada. "Health Reports". Ottawa: Minister of Supply and ServicesCanada, Catalogue: 82-0035), 1990..S3This study was further extended to develop a new analytic tool for the examination of issues pertaining tothe efficient management of nursing bmnan resources (Kazanjian, Pulcins, Kerluke, 1990and 1992). Thepurpose of this project was to demonstrate dult mvestment in the "front-end" of the management process is thebest approach to solving the shortage problem. That is, preventing buman resource problems by optimizingregular (full- and part-time) staff deployment through increased retention and productivity is more cost-effectivethan reacting repeatedly to shortages of qualified personnel through casual or agency staffing.A management model to optimize the deployment of existing nursing resources was developed. Optimaldeployment was defined as the smallest number of nurses required to provide a given quantity (expressed ashours) of nursing services. Indices were developed for the three dimensions of employment behaviour discussedabove: a stability index to quantify movement and "wastage", an employment mix index to denote proportion offull-time employees, and a productivity index quantifying average hours paid per status category. These indiceswere calculated for nine different groupings of "peer hospitals", and patterns of nurse deployment were analyzed.Interesting differences by peer-grouped hospitals weredelineated (Table 17). The urban group ofhospitals displayed a markedly higher utilization of full-time staff (79%) than the other groups, as well as a morerestricted use of casual (13%) and especially part-time staff (8%). Conversely, hospitals in wbich more than 40percent of the beds are extended care displayed a tendency to show a relatively high proportion of part-timenursing staff (23%)and a correspondingly low proportion of full-time staff (60%). In contrast, the measure ofaverage hours was quite different. The highestproportion of casual staff (18%) in the smallerhospitals inGVRHD provided the lowestaverage hours of any casual group. In fact, substantial fluctuations in these indicesamong the various bospital groupings was very clearly shown. While full-time staff in urban bospitals wmkedthe lowestaverage number of hours, the smaller hospitals in GVRHD obtained the highestnmnber of averagehours from their full-time nursing staff. The analysis showed that if deployment practices like those of Table 17persist (given average annualpaid hours and the distribution of full- and part-time and casual staff), a managerwho wanted to generate 200,000 bours of nursing care (the average amount per year in a community hospital)would have to have a staff of between 158 and 176 nurses.Overall, lower wastage levels were exhibited by those facilities with a high proportion of extended carebeds, as well as non-metropolitan hospitals, hospitals with fewer than 500 beds, and non-teaching hospitals inGVRHD. The highest level of wastage occurred in urban hospitals, closely followed by teaching hospitals.55Table 17Personnel Deployment Indices in Selected Hospitalsin British Columbia. 1985-1986Employment StatusRatio Average HoursHospital Group Full-Time Part-Time Casual Full-Time Part-Time CasualMetropolitan 0.681 0.168 0.151 1632.8 1137.6 602.2Non-Metropolitan 0.640 0.183 0.177 1666.2 1173.0 619.2GVRHD. > 500 Beds 0.667 0.178 0.155 1582.6 1145.4 625.2GVRHD. < 500 Beds 0.603 0.213 0.184 1709.0 1165.1 527.6GVRHD Non-Teaching 0.636 0.195 0.169 1601.6 1122.4 605.0GVRHD Teaching 0.698 0.161 0.141 1564.7 1176.1 652.8> 40% Extended CareBeds 0.599 0.232 0.169 1629.4 1174.9 552.7Suburban 0.624 0.209 0.167 1640.7 1140.2 607.0Urban 0.791 0.082 0.127 1540.9 1132.8 608.1Source: Kazanjian et aI.• 199256Wastage was much higher in the casual sector for all groupings. This suggests a greater sensitivity of the marketto fluctuations in the supply of casual rather than regular RNs, since every position staffed by casuals will bringan appreciably greater number of individual nurses through the system than will positions staffedby regulars. Aheavy reliance on casual or agency staffing as a stop-gap measure in response to local nursing shortages isobviously not the most appropriate solution; and in fact, it leads to a large increase in the total number of nursesemployed in a facility in one year, since more of them work fewer hours and have discontinuous employmentpatterns.The impact of optimal staffmg and scheduling OIl net nurse requirements cannot be underestimated.While much attention has been focused on reducing overall nursinghours to deal with shortages (e.g. by bedclosures), the absence of any serious discussion about maximizing existing resources through optimal deploymentis distressing. Research on nurse turnover indicates that the organizational context - that is, each hospital"culture" • may be the key to otherwiseapparently similar working conditions between facilities. For example, ifshifts are less negotiable in one hospital than another, the pattern of rotating shifts will be more likely to causedissatisfaction in the first facility than in the second. Thus, the key for a manager is to monitor deploymentpatterns and to assess the magnitude of the problem along the dimensions discussed, in order to achieve theappropriate mix of regular (full· and part-time) and casual staff for the specific hospital. Finally, the optimaldeployment of nursing resources invariably implies that appropriate specialty and skill mixes are in place.Unfortunately this is one area for which data are so totally lacking that it is impossible to draw even a broadbrush picture of the situation.57m. Principal Factors Underlying Perceived Shortage or RNsRegardless of the extentof the imbalances in nursing resources or public perceptions of such imbalances,consideration of three principal factors which are generic to all health systems provides a betterunderstanding ofrecurring nurse shortages. During 1987-89 seven different provinces studied their respective nursing resourcessituations. While all of these studies and others discuss particular issues and situations specific to each provinceor country, three major themes common to all can be delineated. These are servicedelivery issues, systemstructure issues, and professionalization issues. Each will be discussed in detail.1. Service Delivery Issues: Shift Work, Rotating Schedules, Workplace ConditionsOur health care system, like those in otherjurisdictions, is based mainly on sick care; institutionalizedservicescomprise the bulk of the delivery system. Nurses are the single most important category of healthpersonnel, both in numbers and role, for the provision of hospital-based care; patients are hospitalized becausethey require nursing care. All nursing care (but only some medical care) is provided 24 hours of the day andhospitals are staffed around the clock. This is a universal phenomenon and applies to all countries regardless ofpayment systems. cultural values, or levels of economic developmentTo provide twenty-four hour coverage, hospitals rely on staffing through shift work. While collectiveagreements specify the length and sequences of shift work, most nurses will work the early shift, the afternoonshift or the night shift for a defined period of time, but will still have to rotate to anothershift f(X' a subsequentcycle. Thus, two problems arise f(X' the hospital-employed nurse: fU'SL, that of working shifts, and second, therotation of those shifts. Many other industries rely on shift workand yet do not appear to have staffmgdifficulties of the scale that nursing seems to experience. The reason for the problem in hospitals is twofold.FU'St, and foremost, family responsibilities (invariably assigned to women in most societies) can be incompatiblewith late shifts. Nursing is still a female-dominated occupation; furthermore, fewer younger women have beenentering the profession in recent years. While there is some evidence of change in traditional family roles, it ismore likely to occur in societies where structural changes are also underway so as to accommodate changingsocietal values. Thus the participation of women in the labour force is higher in countries where social progmmsexist to support it. In the absence of such facilitators, society can not expect to benefitfrom increases in the58labour marketparticipation of women with family responsiblllties.A second reason for the problem with shift work is the lack of sufficiently attractive fmancial incentivesto work the "less desirable shifts" (Aiken and MulUnlx, 1987; Friss, 1988). Whereas collective bargaining setsshift differentials, it is clear that these have not been significant enough to attract the number of nurses requiredfor "permanent" late shifts. Shift premiums for registered nurses were SO.4OIbour in 1980; they rose toSO.SO/hour in 1981 and SO.60lbour in 1987. In 1991, RNs received SO.70/hour when working evening shifts,Sl.OO/hour for night shift. and SO.501bour for weekend work. LPNs receive the same shift compensation, whileRPNs are paid SO.SSlbour for evening work and SO.6S/hour for nights. No weekend differential is paid to RPNs.For the individual nurse, the problem is further aggravated by the rotation of her shifts. It is hard enough tosecure affordable reliable child care during regular working hours; it must be almost impossible to secure suchserviceson a rotating basis!While night shifts and rotating shifts have been part of hospital work since that sector was created andhave always been regarded as problematic, the difficulty associated with them has taken on a new dimension inrecent years. The rapid escalation of the problem with shift work is partly explained by another general societalphenomenon - that of increased career opportunines for women. As they gain access to occupations other thanthose ttaditiona1ly permitted to women (the ones usually described as fostering "nurturing" roles), dissatisfactionwith conditions of work in traditional settings is more clearly and emphatically articulated; because women nowcan have a choice of occupation, they have acquired the self-confidence to express their discontent with shiftwork and rotating schedules.There has been a flurry of activity in the most recent years to improve what have been termed "workplaceconditions" in nursing; the RNABC has compiled a volume on retention that has bibliographic references torecent studies of related issues, and a Nurse Scheduling Committee funded by the federal and provincialgovernments has been active since 1990. The consultant's report commissioned by Ibis group made somesuggestions in the form of pilot projects that need to be evaluated, such as self-scheduling, the lo-hour day,automated scheduling, job sharing, flex-hours and cost-analysis of part-time work. The workplace is an areaparticularly lacking in systematic documentation and study; the first such work in this province was undertakenin 1987 (Layton, 1988). While other provinces are equally uninformed, there is ample evidence from U.S.59studies, which are often only indirectly applicable 10 the Canadian setting (for a discussion of such literature, seeKazanjian, Pulcins, Kerluke, 1990).Workplace conditions appear 10 coalesce mto variable combinations of faclOrs which culminate in thecreation of a hospital culture that is perceived as hostile 10 staff nurses. Other than the harsh realities of shiftwork and rotating shifts, situations over which the individual nurse has very little control. the reliance on largenumbers of casual staff on specific wards contributes 10 stress and burn-outfor both the regular and casual staff.High turnover rates indicate the magnitude of such problems. More mundane • but no less tangible> factorssuch as the lack of on-site child care facilities, designated parking, staff rooms, and representation on hospitalcommittees, 10 name a few, contribute 10 the general dissatisfaction with workplace conditions. In short, the listof factors involved with job dissatisfaction can be described as issues of management and organization whichmay be amenable 10 policy intervention.What has been most striking so far has been the reaction of hospital and nursing management 10 nurseshortages. Typically, hospitalmanagement has been critical of government funding levels, expressed concernswith numbers trained in the province, relied heavily on casual staffing, and concentrated on the recruitment ofnew personnel. One.apparent reason for the failure of management 10 initiate more innovative practices 10increase the retention of nurseshas been the lack of competition among hospitals. Given that the hospital sectoris the major employer of nurses (a monopsony market>, and that wage levels are uniform throughout the provincedue to a collective agreement that is negotiated at the provincial level, there is no incentive for hospitals 10competefor nurses. This is the opposite of the situation in the U.S., where the existence of a private hospitalsector and a different labourunion situation encourage some competition among hospitals for nurses. Whilenurse shortages occur periodically in the U.S. as well, the factors contributing 10 the American shortages areslightly less likely to be of the organizational and managerial kind. A copious literature exists which documentsthe organizational factors and evaluates the management initiatives that have been developed to solve theseproblems, such as self-scheduling, permanent shifts, dedicated float pools, job sharing, etc. In the light of suchinformation, it is interesting that hospital management in Canada has not been more creative in their approach 10nursing resources managementIronically, a currently popular system for the delivery of nursing care, approvedby almost all registerednurses, may be contributing to the unfavourable working conditions. The Primary Care nursing model60establishes individual nursing responsibility and accountability for specific patients. Its central concept is thatcare of a specific patient is under the continuous guidance of one registered nurse from admission to discharge.This is the model being used.in more and morehospitals which have switched from either the Total Patient Caremodel or the Teamapproach. The former is somewhat similar to Primary Care nursing in that the registerednurse is responsible for total care of a patientbut only for the hours that the specific nurse is present.Conversely, the Teamapproach provides care to a group of patients by coordinating the RNs, LPNs, and aidesunder the supervision of one nurse, the team leader(Hegyvary, 1977).Undercurrent market conditions, where perceptions of registered nurseshortages persist, the adoption ofthe Primary Care nursing model does not appear to be an efficient management practice. Furthermore, thevirtual disappearance of LPNs and aides from the tertiary care settings, in part because of adherence to thismodel of nursing care, frequently leads to articulated disapproval by registered nurses because they are thenexpected to perform non-nursing duties. The lack of a logical basis to this complaint does not diminish theproblem: if registered nurses already takeon heavy workloads, can it be expected of them that they will happilyassume other, non-nursing responsibilities?Finally, the funding system for B.C. hospitals has created a perverse incentive to rely on recruitmentrather than retention to meet staffmg requirements. Initiatives to increase retention yield mainly longer-termremms on dollars invested, and, therefore, are not favoured by hospitals thatare on the brink of incurringdeficits. Ironically, hospitals in that situation often close beds as a cost-saving measure and cite nurse shortagesas their reason for doing so.2. System Structure Issues: Occupational Stratification, Professional Governance,Health Care FinancingThe elaborate stratification of health occupations - a salient characteristic of our system - hashistoricroots, but is maintained and expanded as our system continues to become more complex and as the number ofcategories of health care workers continues to increase. Nursing is not among the handful of dominantprofessions. Especially in thehospital sector. medicine dominates in all aspects of the delivery of care. What isinteresting (and peculiar) in this regard is that there is ample evidence to suggest that, in certain settings and at61particular levels of care, nurses provide bettercare than doctors (Spitzer, 1984). Yet the system is structured sothat nurses are not allowed to provide care independent of physicians. This lack of congruence between whatnurses are trained to do and what theyare allowed to do culminates for nurses in feelings of powerlessness andvarious degrees of role stress. The position of powerlessness is reflected in the historically subordinate andsubservient relationship they occupy in relation to physicians, one that is still maintained in modem timeswithout mucb serious questioning of its validity. Various degrees of role stress are experienced wben a newnurse, inculcated with the professional ethic to provide full nursing practice. is confronted with the realities of ahierarchical system and employer- and physician-regulated scope of practice.Feelings of powerlessness and role stress experienced by nurses are also reflected in their relationship tohealth care executives and high-level hospital managers. Most nurses have almostDO direct involvement inmanagement and administrative decisions, despite their pivotal role in the delivery of care. For example, mostbospital boards do not have nursing representatives, few formal mechanisms exist in hospitals for input fromnurses regarding organizational decisions, and staffing levels are rarely determined by nursing diagnoses ofpatientcare requirements. Again, evidence of the merits of the involvement of nurses in theseareas does exist(Halloran & Halloran, 1985), but the involvement is rarely considered to be necessary by management; feelingsof powerlessness in the face of such workplace conditions are thus oftenexpressed by staff nurses. Furthermore,the bureaucratic ethic that prevails in most hospital settings conflicts with the nurses' professional ethic, leadingto role stress among new (and sometimes not so new) nurses. In fact, this is the type of situation most oftendescribed - in the popularpress - as the frustration of nurses at not being able to offer more "empathy" time totheir patients, because they are too busy providing clinical care.Equally important is the relationship of nurses with government in general, and the Ministry of Health inparticular. In the absence of formal Sb'UCbJreS or mechanisms for communication between providers and policy­makers, such communication, even if it did exist, would be less effective and more subject to variation. Thecreation of the SeniorNursing Consultant position and the Provincial Nursing Advisory Committee are recentdevelopments, only undertaken in reaction to persistent expressions of concern from the professional association.The Committee is concerned only with registered nurses; this limitsappreciably the Committee'S potential forlong-term rational planning for nursing and greatly undermines the importance of breadth of vision to understandand address what are often problems with health systems rather than health personnel.62· Most nurses are employed in the public sector and are, therefore, subject to conditionsand trendsregulated by public policy. The total absence of a private market for nurses contributes to unfavourableeconomicconditions for nurses; the supply of and requirements for nurses' labour are not regulated by marketforces so that a point of equilibrium is reached at the price consumers are wUling to pay for such services. Inhealth care systems where public and private health sectors co-exist side-by-side, differences in levels of nurseshortages are indicative of varying conditions of employment in the different sectors. This does not imply thatthe solution lies in aeating a private sector in health care; rather, that the inevitability of this structuralimpediment should he compensated for by ensuring maximum resolution of other barriers, In short, manystructural barriers and impediments appear to exist that set the underlying conditions within which nursing .resource imbalances continue to exist and perhaps even to increase.These structural barriers are sometimes formidable because they are often entrenched in legislation andother public policy. Provincial statutes give to physicians the power to defme and control their exclusive scopeof practice, and also the power to define the standards and scope of practice of their "ancillary" groups. Thus,while the Nursing Statutes Amendment Act of 1988 restricts the practice of nursing to individuals registered withone of the three nurses' associations, nurses do not have formally defined exclusivescope of practice. Nursescan not diagnose, prescribe or initiate technical procedures even if such tasks would come within the bounds ofnursing practice. It is somewhatparadoxical, a "reverseCinderellasyndrome", that those restrictionsare liftedsomehow, (although only implicitly), during the night shift Thus, professional governance policy that wasformulated with an objective to protect the public from incompetent medical practitioners bas, in effect, vestedthe latter with monopoly power; through scope-of-practice clauses, physicians have control over the conditionswithin which care can be delivered, as well as control over the roles of and relationships between other healthpersonnel, This is particularly restrictive to registered nurses.Anotherbanier to change in employment cooditions for nurses is the Hospital Insuranceand DiagnosticServices Act of 1957. An unintended consequence of this Act bas been the creation of an unfavourable situationfor salariedhospital personnel. As previously discussed. hospitals have a comparative advantage in theirnegotiations with salaried personnel. Within the confmes set by this Act, other provincial public policies alsohave direct impact upon employment conditions for nurses. When the intent is to curtail rising medicalexpenditures, and only indirect measures such as freezes or roll backs of hospital budgets (as was the case in63mid-eighties) are used, nursing employment is greatly affected . The adverse effects of such budget coostraintsinclude reduced nursing staff, higher reliance on casual staffing , less accommodating rotation of schedules, moreovertime for regular staff, etc.A more recent provincial policy to encourage hospital-community partnership had allocated 0.5 percent ofhospital budgets to community-based programs. That proportion of the total hospital budget was held back andhospitals were encouraged to submit proposals in conjunction with community agencies for such partnershipprojects. This policy is aligned with other activities undertaken by the Ministry of Health in order to shift thecurrent structure of the delivery system to one that is more community-based. There are, however, seriousimplications for nursing (and nurse requirements) in such a move. If the shift to community-based care issuccessfully implemented, the level of acuity of patients receiving hospital-based care will be much higher, onaverage, than it is right now, given the broad range of patients currently admitted to acute care hospitals. Inorder to train adequately prepared nurses for the new delivery system, rational planning of future human resourcerequirements bas to take place now. A health systems perspective is needed to coordinate seemingly unrelatedpolicy areas - physician supply, hospital funding, delivery system structure - all of which will, obviously, haveserious effects upon nursing resource requirements.As previously mentioned, the changing role of women in society provides the perspective from which tointerpret nurses' feelings of powerlessness. While nurses may always have felt this way, the recent gains offeminism and the women's movement in the promotion of gender equality permits a better articulation of nurses'dissatisfaction with their status in the hierarchy of health professions.3. Professionalization Issues: BN for Entry.To-Practice, An Expanded Role, Role StressHistorically, there bas been a continuing trend toward the professionalization of registered nurses, partlyas a way of differentiating and defining this group as distinct among a number of other "auxiliary" occupationssuch as nursing assistants and orderlies. and also as a way of defining nurses vis 4 vis other health professionalsin medicine, in rehabilitation, etc. (Brown et al., 1987; Wuthnow, 1986; Fagin and Diers, 1983). The literaturedefines professions as intellectual, learned, and practical; professions have techniques that can be taught. they areguided by altruism and deal with matters of great human significance. Also, their members are organized into64associations (McGlothlin, 1964). Registered nurses in this province appear to have only some of these attributes.They do not have one of the most essential professional characteristics: exclusive scope of practice.However, they do have control over entry-to-practice. The Nurses (Registered) Act (RSBC. 1979, Chap.302), under Section 13 charges the association with the authority to approve all nursing education programs thatprepare nurses f(X'registration. Since much of the control over a profession's ideology accrues from controloverthe education process (Olmsted and Paget. 1969), entry-to-practice restrictions tend to be dermed in terms ofstringenteducational qualifications. In 1982, the Canadian Nurses Association (CNA) resolved to require thatnurses have a Baccalaureate in Nursing degree (BN) to enter practice by the year 2000. National and provincialefforts to meet this objective have since been underway; activities in this regard are part of a larger effort toimprove the status of nursing among the health professions. Ten yearsago, prior to the CNA resolution. only 12percent of the B.C. nurses were baccalaureate-trained - a slightly higher proportion than the national average; thatproportion in 1989 was estimated at 16 percent,Questions about the BN for entry-to-practice have caused concern about the problem of clinicalpreparation for entry-to-practice. Nursing education was tmditionally conducted inhospitals; indeed, until theGreatDepression, most acute care institutions depended almostentirely upon their student population to stafftheir facilities. and graduate nurses were employed in private duty nursing (Bramadat and Chalmers, 1989). Fora long time, basic education for baccalaureate nurses consisted of training in the hospital for a diplcma innursing, with the addition of two years of university-level science courses. The clinical aspects of training werenot under the direction of the university. After World War n, it became customary for hospitals to employ theirown graduates and thus it was rare for nurses to require orientation or additional preparation to be capableofcompetent practice. With the advent of non-hospital based nursing education in the 1960&, hospitaladministrators (and physicians) began to express concern about the (more limited) extent of the clinicalpreparation evidenced by the college-trained nurses. It should be noted that. until the 1980s, most nursingmanagers were themselves diplomagraduates who bad risen through the ranks, often remaining in the sameinstitutions. The concerns of employers have not been relieved with regard to the problem of clinical readiness.although the distinction between institutional familiarity and competence bas been recognized, and moreextensive and appropriate orientation programs are now routine in most acute care facilities.The problem arose with the replacement of apprentice-style training with a more academic approach; the65catchword in the early 19705 was that one did not need to make a thousand beds in order to learn to make one.But even as the new programs at the colleges and UBC were beginning, it was already becoming apparent thatmore specialized areas of nursing practice required extra training. As the technological complexity of nursingpractice has increased and patient acuity has intensified, the need for special clinical preparation f(X' competentpractice in areas like aitical care, cardiac care, obstetrics, and paediatrics bas become more and mere widelyaccepted. At the same time, the graduate nurse is prepared as a generalist; she is expected to be prepared topractise with an appropriate, if minimal, degree of clinical competence in the five areas defined by theregistration exams - namely, surgery, medicine, obstetrics,paediatrics, and psychiatry.This is the context for the debate about basic baccalaureate education and the length of diplomaeducation. Baccalaureate preparation takes in a wider range of academic options than diploma education; thesocial sciences are especially favoured, although some universities require basic science credits as well. Theextent of clinical preparation is determined by the registering body which bas the legislative right to approveeducational qualifications at the basic level. Theoretically, all registered nurses are prepared to wOOc in acutecare settings, but it is still felt by some observers that baccalaureate programs are better at preparing nurses forwork in community health than in acute care institutions. At the same time, many of the colleges are extendingthe length of their diploma programs, both with clinical courses and by adding preceptorships, in order to allowfor better development of clinical skills and organizational coping skills. (The preceptorships and the intensive.short-term "real world" courses are designed, in part, to acquaint presumptive graduates with the realities of acutecare employment in terms of workload and shift work.)A recent doctoral thesis addressed the issue of the expectations held by five groups: educators, employers(nurse administrators), nursing leaders (RNABC), physicians, and government in relation to the content ofregistered nursing education (Frissell, 1989). The author asked representatives of each of these groups todescribe and rank in importance those skills and subjects that were necessary to competentnursing practice. Theaverage ranking of each group was then tested for its degree of similarity or difference from each or the others.Physicians were least in sympathy with educators, employers, and leaders about what was appropriate nursingeducation; the doctors appear to have preferredan approach emphasizing technical ability, less focused ondecision-making skills, autonomous practice. or the exercise of inter-personal skills. Educators andadministrators were in general agreementabout the basic areas to be covered and skills to be acquired, but66nursing leaders were less likely to value the same items as representatives of other nursing groups. Nursingleaders were apt to be more concerned with promoting professional behaviour and goals. Government officialsappeared to be supportive of the status quo, opposed to more education and, in general, protective of publicfunds.The study population was also asked to advise on the proper length of nursing education, andan outlineof a new program for basic education in nursing, one that would accomodate the perceived need for increasedclinical sophistication, was compiled based on this advice. Frissell suggests a four year baccalaureate in whichthe fU'St three years would include some basic scienceand socia1 science, along with a concentration on generaladult medical-surgical nursing. She had observed that most new graduates are employed initially in those areas,and she argues that basic nursing skills can be acquired with intensive exposure to those services. The last yearshould allow for specialization in one of the other major clinical areas.In 1990/91, three nursing programs were part of what the B.C. Ministty of Advanced Education, Training,and Technology has called "bridging" college to lDliversity education. Students from certain programs withinthese colleges can earn baccalaureate degrees from the partner university while remaining enroled at the college;the university is thus responsible for the curriculum and instruction of the last two years of study. As well, thelast of the hospital schoolsof nursing (at the Vancouver General Hospital) has joined the UBC SchoolofNursing, and VGH graduates will now receive Baccalaureates of Sciencein Nursing. These efforts willaccelerate the rate of increaseof baccalaureate-prepared nurses. Anotherarea of activity is control over theregistration process. Registered Nurses, Registered Psychiatric Nurses and Licensed PracticalNurses have justrecently gained control over their own licensing process (Ibe Nursing Statutes Amendment Act, 1988),restricting the,practice of nursing to only those registered with their respective association.These developments in the areas of education and professional governance indicate that the nursingprofession is lDldergoing a transition in role defmition; that is, the profession is giving serious reconsideration toits social role. An initially undifferentiated pictureof nursing appears to be fading with the recent emphasisupon the need for more specialization in acute care settings. and the higher levels of competence requiredfor theuse of complex medical technology. Discussions of the expanded role of nurses indicate potential for conflictingdefinitions of nursing roles.67The greater the congruence of the norms, values, and behaviourial expectations among members of aprofession, and between its educatorsand the realities of the work setting, the smootherthe transition of theneophyte nurse to full-fledged professional. Given that the definition of the role of nursing is in a state of flux,it is perhaps not surprising that neophytenurses become quickly disenchanted with the realities of the workplace.Reality shock (Kramer, 1974) occurs when the new nurse experiences conflictat work. Hospitals have to bebureaucratic structures in order to ron efficiently, especially with the recent emphasis on cost-containmenL Thisbureaucratic ethic is in conflict with the professional ethic acquired by the nurse in school andbecomes a sourceof structural stress. The extent of the incompatibility of the goals of hospital administrators and professionalspartly depends on the type of organization. In organizations where lbe professionals function primarilyasexperts and fmal authority rests wilb the administration, the degree of incompatibility will be greatest, lbusresulting in role stress. Also, to the degree that the educational organization is out of touch wilb the realities ofthe workplace, the neophyte nurses's level of role stress will vary. Nurses in hospitalshave traditionally beenregarded as "semi-professionals" whose work is less autonomous than that of "real" professionals. Yet, the morerecent efforts towards professiona1ization greatly increase the potential for role stress in the workplace. Inaddition to the disjuncture between the bureaucratic and professional ethic, the disjlDlcture of the latter with lbeservice ethic which the nurse feels towards lbe patient intensifies the reality shock.Thus, two aspects of professionalization affect nurses' disenchantment with worlc conditions. To beginwith, lbe higher entry-to-practice qualifications and expanded roles which are key attributes of professionalizationare difficult to reconcile with the realities of acute care employment; unless hospital structures are changed to beless bureaucratic, and patient expectations of service are reduced, increased professionalization will lead togreater incongruence between the professional, bureaucratic. and service ethics that nurses must espousesimultaneously. Secondly, some educational institutions appear to be out of touch with the exigenciesof theworkplace, especially lbose of the small or remote hospitals. Unlessjob-specific training requirements areestablishedfor all types and levels of care so as to prepare the DeW nurse for the realities of the work situation,the degree of reality shock wi11likely continue to increase.Undoubtedly, the complexity of medical technology, the explosion of knowledge, and the shift tocommunity-based care warrant advanced qualifications for some nurses. A central question must be addressed68by public authorities before a rational plan for nursing can be developed: What types of nursing personnel andwhat mix are required to delivercare to meet the nursing needs of the health care system? Effective nursehuman resources planning efforts should also take into consideration the changing opportunity structure in thelabour force for women with equivalent education and similarcareeraspirations. Whereas in the past this waslimited to "a few female" occupations, the choices are more numerous today and ever increasing.The problems encountered in nursing human resources are inextricably tied with those of genderinequalities brought to the public's awareness by the women's movement during the previous decade. Ananalysis of the education and income of health personnel is indicative of a historic genderbias, where there basoccurred the superimposing of a gender hierarchy onto an occupational hierarchy characteristic of the healthlabour force. The non-competitive, complementary aspectof the traditional division of labour in the family isreflected in the health labour market in the form of non-competing gender groups, where "feminine" occupationsare placed in supportive roles and "masculine" professions in dominant roles (Kazanjian, 1993). To the degreethat macro-social forces are reducing the inequalities between men and women, the micro-socia1 situation of thehealth human resources market will require concomitant adjustment to meet these and other environmentalexigencies. To be sure, the traditional nurse-doctor game with all its elements reflecting stereotypical roles ofmale dominance and female passivity will no longerappearas quaint as before.69IV• Polley implications and OptionsThe purpose of any human resources planning activity is to make the most efficient use of resources; thatis, to have in place the oplima1 number and mix of health care personnel. Three policy areas which have impactupon this goal are professional governance and regulation, human resource supply policy, and system structureand financing (Lomas and Barer, 1986). Existing health human resource problems are as much a result offailures within each of these areas as they are a result of the failure to coordinate efforts among these threeareas. These crucial inter-relationships have not, heretofore, been fully investigated and certainly are rarely, ifever, considered when planning and policy decisions are made. Furthermore, a failure to coordinate planningand policy formulation for all health personnel, rather than for each group in isolation from others, is in partresponsible for the group-specific human resource problems of long duration. Thus, while the followingdiscussion of policy implications and future options is focused on nursing personnel, in an ideal world thesewould be integrated into policy regarding all health personnel.Table 18 summarizes the issues and identifies the key stakeholders; only those directly responsible forpolicy are identified here. This table clearly shows that responsibility over nursing human resources policy isfragmented, spread among governments, educational institutions, professional associations and employers.1. Education and TrainingTraining of nurses at the basic level takes place in numerous colleges and one university; the latter isfunded on a global basis whereas the former have a more program-specific funding formula and are accountableto the Ministry of Advanced Education, Training and Technology (MAE'f&T). Thus, numbers and mix ofnursing specialties is not negotiable at UBC; colleges. on the other hand, have a strict protocol for developingnew programs and making submissions for funding.The Health Human Resources Working Group (IllIRWG) is the official body responsible for suchplanning for the province; it is chaired by the Ministry of Health and has representatives from the Ministry ofAdvanced Education, Training & Technology, and the Ministry of Finance. A staff member of the HHRU alsoparticipates, as the Unit provides research support for this group. The Worlcing Group providesa forum forinter-ministerial communication regarding matters of concern. For example, when MAETT tables a new70Table 18PolicyIssuesand Responsible StakeholdersPolicY Areas& Issues StakeholdersHuman Resource SupplyBducauon/Tralning Enrollments Colleges and Ministry of Advanced EducationTraining & Technology; UniversitiesCuniculum Professional Associations and Colleges;UniversitiesPracticum Educational Institutions and HospitalsCollectiveAgreement - Wages Employers (HLRA) and BCNUForeignRecruitment Employment & Immigration Canada; EmployersProfessional RegulationRegistrationlLicensure Professional Associations. Ministry of Health(Legislation)Scope of Practice Professional Associations; Ministry of Health(Legislation)Funding and System StructureDelivery Models Ministry of HealthRemuneration Methods Ministry of Health71program, they also request protocols and seek input from the members of the HHRWG on the implications of theprogram with regard to the health care delivery and costs. There is more discussion and more co-ordination forfields which require clinical placements. Ultimately, it is MAETI that makes the funding decision for educationprograms.Despite the existence of this.forum, there are many instances when a policy formulated by one Ministry isin conflict with a policy from another Ministry. For example, MAEIT's COllege/university bridging programs(which include more than just nursing) will have serious implications for baccalaureate training for nurses;Ministry of Health's official position has been not to support the baccalaureate as entry-to-the practice ofnursing. While this is an issue of national importance, neither Provincial governments nor the Federalgovernment are co-ordinating their policies in this regard. There is a Federal position statement that does notsupport the CNA resolution; however, unofficial provincial positions may be contradictory. Prince EdwardIsland, for example, has not in the past trained nurses; in 1990, the first and only school of nursing was fundedat the university level. Nurse educators and nursing associations appear to be more organized and bettercoordinated in their activities to achieve the "BN for the Year 2000" goal. At a national symposium in Manitobain November, 1990, the nursing community showeda collective purpose. In contrast, there is no policy actionon the part of public authorities despite the fact that inaction is usually interpreted as a supportive position.There are several options ranging between the two extreme ones of active rejection or fu~ support for theCNA resolution. Only the full support position requires no policy action; all other options will necessitate newpolicy development in the form of new legislation.Three different models for basic nursing education could be considered for their value to the health caresystem. The first, suggested by Frissell and discussed in Chapter rn. would be a four-year baccalaureate inwhich the ftrSt three years will include basic sciencesand sociaJ sciences and a concentration on general adultmedical surgical nursing. The last year would allow for specialization in one of the other major clinical areas.Another model for basic nursing education is the pattern preserved in engineering faculties. In this case. smdentswould choose general specialty areas after one or two years of introductory course work, and would be restrictedin practice to the area in which their undergraduate training occurred. This model could also be used as aframework for the implementation of the Frissell design described above. It would adapt well to current methodsof registered psychiatric nurses' training, and would probably be attractive to employers, although the lengthof72the program - four years - is considered, as always, to be an impediment However, nursing leaders argue that.in order to preserve as many optionsas possible for career practice, undergraduate nursing education shouldremain generalist. although they would prefer that some degree of concentration be integrated into a four-yearbasic curriculum. That third model wouldbe rather like undergraduate education in the humanities, wherestudents major in a discipline and take courses that cover a range of subjects providing for a basic inttoduction tosome circumscribed area of the discipline. Specialist training would continue to be post-basic, and would remainat the certificate level for general duty nurses, although clinical specialists would be expected to obtain master'sdegrees.Indeed, the length of training is a particular concern of employers and government. both of which fearthat the volume of nurse graduates will decrease as education is extended, thus precipitating a crisis inrecruitment, In addition, human resources planners worry about extended training as a disincentive toprospective workers. Currentnursing students are drawn from groups of women who expect to enter the workforce at a fairly high level wage after a relatively brief educational period - a smallermvestment of time andmoney than is required from future teachers, physiotherapists, or social workers (to name a few). It is possiblethat some substantial proportion of this pool may be unwilling to make a larger investment in their education;those who do may expect a better return of their mvesunem in terms of increased wages. There are alsoimplications for the nurses' union. The ~jority of British Columbia Nurses' Union members are diplomanurses and their future promotion and tenure become more uncertain, even if they are all "graodfathered" inwhen the BN policy is implemented. Neither the CNA resolution nor RNABC's endorsement statement provideany detail as to the effect of the BN entry-for-practice on seniority and job mobility,Higher education and better remuneration to attract and retain a more dedicated professional worlc forcewill not provide sure solutions to nurse supplyproblems if workplace conditions do not changeas well. Unlessthe problems of scheduling and rotating shifts, availability of supportin the workplace, more decision-makingresponsibility, and improved doctor-nurse relations are resolved, the expectations of nursing practice developed innursing school will seem even more inconsistent with workplace conditions than they are now. Highereducationleads to heightened expectations; it means that "reality shock" comes sooner in the work experience of nursesand createsmore disappointment and frustration for the individual. In short, attrition may stay the same, perhaps73even increase, thus augmenting existing shortages.Conversely, longereducation is also believed to increase professional adherence, so that nurses whoinvestmore time in their basic education may be more likely to survive the reality shockand to stay and work toimprove conditions. There is increasing evidence which suggests that nurses are beginning to speak up todoctors. to participate in administrative decision-making, to be permitted to experiment with alternative models ofshift rotation, etc. It is not unlikely that some of this less passive and subordinate behaviour is related to themore extensive education which is typical of head nurses, nurse managers, nurse educators, and an increasingnumber of general duty nurses.2. Recruitment and RetentionWhereas recruitment bas ttaditionally attracted more attention from all stakeholders - and it involvesemployers, public authorities, unions, and educational institutions - retention bas been almost ignored. This ispartly a result of the hospital financing system. Less than satisfactory and sometimes downright poormanagement practices remain unchecked because there is no mechanism to create incentives for bettermanagement Inefficient practices are counterbalanced by continuous recruitment efforts and, when an employerincurs a deficit. bed closures ensue and recruitment efforts cease (vacant positions are frozen). Government isblamed for not training a sufficient number of nurses, since attrition rates always surpass production rates.However, with cost-constraint in the early '80s, the need for efficient management of nursing (andother)human resources bas come into focus. Despite that trend, in many hospitals new nurses (recent graduates) areemployed only as casuals so they will get their orientation to the hospital at no cost to the employer. Thesenewnurses are assigned to float poolsand movebetween wards as needed without any suppon from a more seniormenu or a group of peers. lbat some survive this experience and obtain a regularposition is against all odds.Most win seek another employer and some will leavenursing altogether. A common fallacy exists amonghuman resource planners regarding the willingness of nurses whohave left the workforce to return to nursing atsome point in the future. The evidence is clear and to the contrary; the vast majority win never return. Somedo, and more should be encouraged by efforts to make available more refresher courses at appropriate levels.Recruitment without proper orientation is not cost-effective for the neophyte or moreexperienced nurses,and, as well, the province reliesheavily on nursing personnel trained outside the province. Often nursesmigrate74as part of family units, and broader socio-economic factors enormously influence these migration trends.Employers cannot predict about the pool of candidates from which they will be recruiting. When this poolshrinks in some years, shortages are announced. If nurses did not work reduced hours and/or did not quit jobs,and/or did not leave nursing at the rates they do, the number of nurses registeredannually with the Associationwould be sufficiently large to meet the needed amount of nursing services.Improved retention is the key factor in reducing shortages; it is the cost-effective option. It can beachieved with improved workplace conditions which require some commitmentfrom nursing and hospitalmanagement Among their options, increasing the proportion of pan-time workers (who have been shown to bea more stable wode force) is not particularly difficult to implement; providing good orientation programs to newnurses and establishing dedicated float pools have only minimal cost implications. Automated scheduling modelsthat accommodate individual nurses' shift preferences, provision of on-site child care, and job-sharingopportunities all have some cost-implications. These, however, have been proven to be more cost-effective interms of increased retention and quality of care, as well as reduced recruitmemcosts.Until such time as the impact of poor retention on shortages has been assessed through efforts atincreased retention, the assumption of causally linking production and shortage rates cannot be justified. Onlywhen retention is not considered a problem any longer can shortages then be attributed to insufficient productionof trained personnel.More power at the wodeplace and a sense of appreciation can be achieved by nurses also throughinnovative managementpractices. The appointment of nurses to hospital committees and the allocation of moreplanning responsibility to Head Nurses involve organizational changes that seem to be more difficult toimplement immediately. An importantconsideration should be: can the hospitals afford to ignore theseproblems?3. Collective AgreementWhile career ladders - to the extent that these are possible, - are controlled by educational preparation,earnings are controlledby a stepwise grid that has remained quite static since 1981. The minimmn andmaximumpoints of the incrementhave remained in the same range for a decade. This range has been low forall nursing groups, but particularly unfavourable for the LPNs.75Nurses' lack of control over the definition of practice is in large part responsible for the incongruities ofthe vertical grid of wage increments. It reinforces the "a nurse is a nurse is a nurse" mentality. Yet, from thenursing unions' perspective, it provides one of the few levers of bargaining power, sincemostother levers, suchas definitions, level of care, workload assessment, etc. are controlled by the employer. Thereare also someincongruities in reconciling professionalism and career ladders established by the terms of collective agreements.Given the current wage structure, shortages in high stress specialty areas such as lCU/CCU andEmergency are often attributed to the lack of remunerary incentives, based on comparisons with the privatehealth sector in the U.S. As well, regional imbalances, it is argued, could be corrected by financial incentivessuch as higherwages, isolation bonuses, etc. There is the pbysician model, with northern and non-urban practiceincentives; in areas where a physician cannot expect to maintain a viable medical practice, his earnings aresupplemented to a level commensurate with the average for his peers. However, nursing difficult-to-fl1lvacancies are often highest in the lower mainland, indicating thatregional discrepancies are not simply a functionof the degree of isolation.Finally, the suggestion to compensate casual nurses at a higher rate for being available on very shortnotice has received support from hmnan resources planners. Once again, this appears contradictory to the imageof professionalism that organized nursing is attempting to promote. This type of incentive would probably workin reverse: more nurses would work on a casual roster, thereby creating more instability and wastage.4. RegistrationILkensure and ~ope or PracticeLegislation exists to regulate entry to the practice of nursing, and that function rests with the twoprofessional associations (RNs, RPNs) and the licensing body (LPNs); in order to practise as a nurse in B.C., anindividual musthold current membership in one of the above-mentioned organizations. The RNABC exercisesits legislated responsibilities to the public and its members through a constitution and by-laws. Theorganization's 26-member Board of Directors is the governing bodywhich sets rules and policies. Five amongthe members of the Board are not nurses; twoare appointed by the provincial government, the others representconsmner groups.However, nurses almost always work for an employer, and, therefore have to abide by the employer'sdefinition of nursing care (in conformance with policies set by the agency). Nursing does not enjoy the type of76self-regulation that medicine, dentistry, and pharmacy enjoy. Where necessary, the professional association willevaluate the adequacy of individual nurse performance and may take discipllnary action. New legislation wouldbe required to provide a mandate to the professional association for self-regulatory functions.While all three nurse groupshave professional autonomy of some degree or another, they do not haveexclusive scope of practice. Furthermore, the delegation to nursing of medical tasks increases nursing activities,but the responsibility for care remains with the ordering physician and the agency. As nurses move towardsprofessionalization in its full sense, these restrictions will have to be overcome, presumably by new legislation.Legislative change is difficult to initiateand slow to develop. It is unclearwhether there wouldbe publicsupport for such efforts. It wouldall be justified,however, because it would clearly delineate the roles of thethree types of nurses and empower them with a sense of mission. As well, if baccalaureate-level educationbecomes preponderant - regardless of how the entry-to-practice issue is resolved - an expanded role for nursesmay be more cost-effective for meeting population health needs. Of course, new legislation to increase scope ofpracticewill have to be coordinated with new policies to introduce alternative delivery models and to financenursing care.5. Delivery Models and RemunerationThe humanresource implications of changing delivery models are often the last of the problems to beconsidered. In B.C., past efforts - small as they may have been - to shift to a community-based delivery systemhave been met with general approval by all stakeholders. The changes will have serious implications for nursingresources, and it would serve the public better if these policies were coordinated with those in the area of nursesupply.In the community sector, nurses would be expected to function more independently and will need newskills in decision-making and case management At the same time, acute care hospital nurses will need higherskills to care for the high-acuity patient populalion. With the increasing use of more complex technologies,nurses will be expected to practice to more stringentstandards of care that require better knowledge of bothtechnology and disease. The planning and policy development for alternative models of servicedelivery shouldbe coordinated with the similaractivities involved in introducing alternative paymentmethods to providers ofcare.77If nurses are to function more independently, should they not be paid in other than wages? It bas beenshown that nurse practitioners cannotexpect to have a viable career if they can only work as salariedstaff in amedical group practice. Fee-for-service remuneration bas traditionally been an attribute of professions andpresumably provides better incentive for labour-market participation. This optionmay increase the currentlyDaITOW range of options which allow intelligent, motivated, and dedicated nurses to remain in the field whilepursuing a rewarding career. As a sma11 scale demonstration project, it may prove to be an astute mvesunent;to put savings realized from the provision of cost-effective care, and from improved quality of life, towards thecreationof improved career opportunities for nursing professionals. After all, the costs incum:d by society atlarge and by the health care system for an unstable nursing workforce are much more than the immediate costsincurred by reducing nurse shortages.78REFERENCESAiken, L. and Mullinix, C. 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The Banff Centre School of Management, Calgary: University of Calgary Press. 221-286.Master Agreement between Hospital Employees' Union and Health Labour Relations Association of BritishColumbia, 1982-86; 1986-1989; 1989-91.Master Collective Agreement between BritishColumbia Nurses' Union and Health Labour Relations Associationof British Columbia, January I, 1980- March 31, 1982; April I, 1982- March 31, 1985; April 1, 1985 - March31, 1989; April 1, 1989 - March 31, 1991.McGlothlin, W.J. (1964), The Professional Schools. New York: Center for Applied Research in Education.Oleson, V. and Whittaker, E. (1968), The Silent Dialogue. San Francisco: Jessey-Bass.Olmsted, A.G. and Paget, M.A. (1969), "Some Theoretical Issues in Professional Socialization", Journal ofMedical Education, 44:663.Pulcins, I., Kazanjian, A. and Kerluke, K. (1988), The Nurse Manpower SbJdy. Volume n: A Synthesis of theNurse Manpower Data in British Columbia. HMRU 88(1):2. Health Manpower Research Unit, The University ofBritish Columbia, Vancouver.Stein, L., Watts, D. and Howell, T. (1990), "TheDoctor-Nurse Game Revisited", New England Journal ofMedicine, 322(8):546-549.80HEALTH POLICY RESEARCH UNITCentre for Health Services and Polley Research429 • 2194 Health Sciences MallUniversity of British ColumbiaVancouver, B.C. CANADAV6T 1Z3Telephone: (604) 822-4810FAX: (604) 822-5690DISCUSSION PAPERS & REPRINTS. .HPRU 88:1R Barer, M.L., Gafnl, A. and Lomas, J. (1989), "Accommodating RapidGrowth In Physician Supply: Lessons from Israel, Warnings for Canada",International Journal of Health Services 19(1):95-115. Originally releasedIn February, 1988.HPRU 88:2R Evans, R.G., Barer, M.L., Hertzman, C., Anderson, G.M., PUlclns, I.R. andLomas, J. (1989), "The Long Goodbye: The Great Transformation of theBritish Columbia Hospital System", Health Servius Research 24(4):435­459. Originally released March, 1988.HPRU 88:3R Evans, R.G. (1989), "Reading the Menu With Better Glasses: Aging andHealth Policy Research", In S.J. Lewis (ed.), Aging and Health: LinkingResearch and Public Policy, Lewis Publishers Inc., Chelsea, 145-167.Originally released April, 1988.HPRU 88:4R Barer, M.L. (1988), "Regulating Physician Supply: The Evolution of BritishColumbia's Bill 41", Journal of Health Politics; Polley and UlW13(1}:1-25HPRU 88:5R Anderson, G.M. and Lomas, J. (1989), MReglonalization of Coronary ArteryBypass Surgery: Effects on Access", Medical Care 27(3):288-296.Originally released May, 1988.HPRU 88:6R Barer, M.L., Pulclns, loR., Evans, R.G., Hertzman, C., Lomas, J. andAnderson, G.M. (1989), -rrends In Use of Medical Services by the ElderlyIn British Columbia", CanadIan Medical AssocIation Jouma/141 :39-45.Originally re/eaSMl July, 1988HPRU 88:70 The Development of Utilization Analysis: How, Why, and Where It'. Going.August 1988. (G.M. Anderson, J. Lomas)D I: Discussion Paper R =ReprintHPRU 88:80 Squaring the Circle: Reconcll/ng Fee-for-ServICfl with Global ExpenditureControl. September 1988. (R.G. Evans)HPRU 88:90 Practice Patterns of PhyslcIBns with Two Year Residency Versus One YearInternship Training: Do Soth Roads Lead to Rome? September 1988.(M.T. Schechte~, S.B. Sheps, P. Grantham, N. Finlayson, R. Sizto)HPRU 88:10R Anderson, G.M. and Lomas, J. (1988), "Monitoring the Diffusion of aTechnology: Coronary Artery Bypass Surgery In Ontario", AmericanJournal of Public Health 78(3):251-254 .HPRU 88:11R Evans, R.G. (1988),""We'U Take Care of It For You": Health Care In theCanadian Community", Daedalus 117(4):155-189HPRU 88:12R Barer, M.L., Evans, R.G. and Labelle, R.J. (1988), "Fee Controls as CostControl: Tales From the Frozen North", The Milbank Quarterly 66(1):1-64HPRU 88:13R Evans, R.G. (1990), "Tension, Compression, and Shear: Directions,Stresses and Outcomes of Health Care Cost Control", Journal of HealthPolitics, Polley and Law 15(1):101-128. Originally released D8C#Imber,1988.HPRU 88:14R Evans, R.G., Robinson, G.C. and Barer, M.L. (1988), "Where Have All theChildren Gone? Accounting for the Paediatric Hospital Implosion", In R.S.Tonkin and J.R. Wright (eds.), Redesigning Relationships In Child HealthCare, B.C. Children's Hospital, 63-76HPRU 89:1D Physician Utll/zstlon Sefortl and After Entering a Long Term careProgram: An Application of Markov Modelling. January 1989. (H. Krueger,A.Y. Ellencwelg, D. Uyeno, B. McCashln, N. Pagllccla)HPRU 89:2R Hertzman, C., Pulclns, I.R., Barer, M.L., Evans, R.G., Anderson, G.M. andLomas, J. (1990) "Flat on Your Back or Back to your Flat? Sources ofIncreased Hospital Services Utilization Among the Elderly In BritishColumbia", Soclsl Science and Medicine 30(7):819-828. Originally ,./asedJanuary, 1989.HPRU 89:3R Buhler, L, Glick. N. and Sheps, S.B. (1988), "Prenatal Care: A ComparativeEvaluation of Nurse-MidwIves and Family PhysIcians", Canadian MedicalAssociation Journs/139:397-403D =Discussion Paper R =Reprint2..HPRU 89:4R Anderson. G.M. and lomas. J. (1989). "Recent Trends In Cesarean sectionRates In Ontario", CalJlld/sn Medlcsl Association Jouma/141:1049-1053.Originally released February 1989.HPRU 89:50 The Canadian Health Care System: A King's Fund Interrogatory. March1989. (R.G. Evans)HPRU 89:6R Anderson. G.M.• Spitzer. W.O., Weinstein, M.C., Wang, E.• Blackburn, J.l.and Bergman. U. (1990). "Benefits. Risks, and Costs of PrescriptionDrugs: A Scientific Basis for Evaluating Polley Options", CllnlcslPharmacology and Therapeutics 48(2):111-119. Originally released April,1989.HPRU 89:7R Evans. R.G. (1990), "The Dog In the Night Time: Medical PracticeVariations and Health Polley", In T.F. Andersen and G. Mooney (eels.). TheChallenges of Medical Practice Variations, The McMillan Press ltd,london. 117-152. Originally released June 1989.HPRU 89:8R Evans, R.G. (1991), "life and Death. Money and Power: The Politics ofHealth Care Finance", In T.J. LItman and L.S. Robins (eds.) Heafth Politicsand Policy (2nd edition) Part 4(15):287-301. Originally released June, 1989.HPRU 89:9R Barer. M.l.• Nicoli, M., Dlesendorf. M. and Harvey. R. (1990), "FromMedibank to Medicare: Trends In Australian Medical Care Costs and UseFrom 1976 to 1986". Community Health Studies XIV(1):8-18. Originallyreleased August 1989.HPRU 89:100 Cholesterol Screening: Evaluating Afternative Strategies. August 1989.(G. Anderson, S. Brlnkworth, T. Ng)HPRU 89:11R Evans. R.G•• lomas. J., Barer. M.l., labelle, R.J., Fooks, C., Stoddart, G.l.,Anderson, G.M•• Feeny. D., Gafnl, A., Torrance, G.W. end Tholl, W.G.(1989). "Controlling Health expenditures - The Canadian Reallty-, NewEngland Journal of Medicine 320(9):571-&77HPRU 89:12D The Effect of Admission to Long Term Care Program on Utllizlltion ofHeafth &lTVlcas by the Elderly In British Columbia. November 1989. (A.Y.Ellencwelg, A.J. Stark. N. Pagllccla, B. McCashln, A. TOUrigny)D =Discussion Peper R =Reprint3HPRU 89:130 Utilization Patterns of Clients Admitted or Assessed but not Admitted to aLong Term Care Program· Characteristics and Dmerences. November1989. (A.Y. Ellencwelg, N. Pagllccla, B. McCashln, A. Tourigny, A.J. Stark)HPRU 89:14R Anderson, G.M., Pulclns, I.R., Barer, M.L., Evans, R.G. and Hertzman, C.(1990), N Acute Care Hospital Utilization Under Canadian National HealthInsurance: The British Columbia Experience from 1969 to 1988", Inquiry27: 352-358. Originally released December, 1989.HPRU 9O:1R Anderson, G.M., Newhouse, J.P. and Roos, L.L. (1989), "Hospital Care forElderly Patients with Diseases of the Circulatory System. A Comparisonof Hospital Use In the United States and Canada", New England Journal ofMedicine 321 :1443·1448HPRU 90:20 Poland: Health and Environment In the Context of SocioeconomIc Decline.January 1990. (C. Hertzman)HPRU 90:30 The Appropriate Use of Intraparlum Electronic Fetal Hearl RateMonitoring. January 1990. (G.M. Anderson, D.J. Allison)HPRU 9O:4R Anderson, G.M., Brook, R. and Williams, A. (1991) "A Comparison of Cost­Sharing Versus Free Care In Children: Effects on the Demand for Office­Based Medical Care", Medicsl Care 29(9}:890-898. Originally releasedJanuary, 1990.HPRU 9O:5R Anderson, G.M., Brook, R., Williams, A. (1991) "Board Certification andPractice Style: An Analysis of Office-Based Care", The Journal of FamilyPractice 33(4):395-400. Originally released February, 1990.HPRU 90:60 An Assessm8nt of the Value of Routine Prenatal Ultrasound SCfHnlng.February 1990. (G.M. Anderson, D. Allison)HPRU 9O:7R Nemetz, P.N., Ballard, D.J., Beard, C.M., LUdwig, J., Tangalos, E.G.,Kokmen, E., Weigel, K.M., Belau, P.G., Bourne, W.M. and Kuriand, L.T.(1989) "An Anatomy of the Autopsy, Olmsted County, 1935 through 1985",Mayo Clinic Proceedings 64:10~1064D =Discussion Paptr R =Reprint....HPRU 9O:8R Nemetz, P.N., Beard, C.M., Ballard, O.J., Ludwig, J., Tangalos, E.G.,Kokmen, E., Weigel, K.M., Belau, P.G., Bourne, W.M. and Kurland, L.T.(1989) "Resurrecting the Autopsy: Benefits and Recommendations", MayoClinic Proceedings 64:1065-1076HPRU 90:90 Technology Diffusion: The Troll Under the Bridge. A Pilot Study of Lowand High Technology In British Columbia. March 1990. (A. Kazanjian, K.Friesen)HPRU 9O:10R Sapphires In the Mud? The Export Potential of American Health CareFinancing. Enthoven, A.C. (1989), "What Can Europeans Learn fromAmericans?", Evans, R.G., Barer, M.L. (1989), Comment. Health careFinancing Review, Annual Supplement 1989HPRU 90:110 Healthy Community Indicators: The Perils of the Search and the Paucity ofthe Find. March 1990. (M. Hayes, S. Manson Willms)HPRU 90:120 Use of HMRI Data In Nineteen British Columbia Hospitals and FutureDirections for Case Mix Groups. April 1990. (K.M. Antioch)HPRU 9O:13R Evans, R.G. and Stoddart G.L. (1990) "Producing Health, ConsumingHealth Care", Social Science and Medicine 31(12) 1347-1363. Originallyreleased April, 1990.HPRU 90:140 Automated Blood Sample-Handling In the Clinical Laboratory. June 1990.(W. Godolphln, K. Bodtker, O. Uyeno, L.-Q. Goh)HPRU 9O:15R Anderson, G., Sheps, S.B., Cardiff, K., (1990) "Hospltal-based UtilizationManagement: a Cross-Canada Survey", Canadian Medical AssociationJournal 143 (10):1025-1030. Originally relsaS#KI JUM, 1990.HPRU 90:160 Hospital-Based Utlllzstion Management: A Literature Review. June 1990.(S. Sheps, G.M. Anderson, K. Cardiff)HPRU 90:170 Renectlons on the Financing of Hospital Capital: A Canadian Perspective.June 1990. (M.L. Barer, R.G. Evans)o=Discussion Paper R =Reprint6HPRU 90:18R Evans, R.G. Barer, M.L. and Hertzman, C. (1991), "The 2G-Year Experiment:Accounting For, Explaining, and Evaluating Health Care Cost ContainmentIn Canada and the United States", Annual Review of Public Health 12:481­518. Originally released September, 1990.HPRU 90:190 Accessible, Acceptable and Affordable: Financing Health Care In Canada.September 1990. (R.G. Evans)HPRU 90:200 Hungary Report. October 1990. (C. Hertzman)HPRU 90:210 Unavailable for Circulation.HPRU 9O:22R Anderson, G.M., Pulcins, I. (1991), "Recent trends In acute care hospitalutilization In Ontario for diseases of the circulatory system", CMAJ145(3):221-226. Originally released October, 1990.HPRU 90:230 Environment and Health in Czechoslovakia. December 1990. (C.Hertzman)HPRU 90:240 Perceptions and Realities: Medical and Surgical Procedure Variation ALiterature Review. January 1991. (S. Sheps, S. Scrivens, J. Gait)HPRU 91:1R Nemetz, P.N., Tangalos, E.G. and Kurland, L.T. (1990), "The Autopsy andEpidemiology - Olmsted County, Minnesota and Malmo, Sweden", APMIS98:765-785HPRU 91:20 Putting Up or Shutting Up: Interpreting Health Status Indicators From AnInequities Perspective. May 1991. (C. Hertzman, M. Hayes)HPRU 91 :3R Barer, M.L. (1991), "Controlling Medical Care Costs In Canada" (Editorial),Journal of the American Medical Association 265(18):2393-2394HPRU 91 :4R Barer, M.L. and Evans, R.G. (1992), "The Meeting of the Twain: ManagingHealth Care Capital, Capacity and Costs In Canada", Technology andHealth Care In An Era of LImits, A..Gelijns, ed., III (7)97-119. Originallyreleased June, 1991.•..,..o =Discussion Paper R =Reprint6•l'...HPRU 91:5R Barer, M.L., Welch, W.P. and Antioch, L. (1991) "Canadian-American HealthCare Comparisons: Reflections On The HIAA'S Analysis", Health Affairs10(3):229-239. Originally released June, 1991.HPRU 91:60 Toward Integrated Medical Resourcs Policies for Canada: BackgroundDocument. June, 1991. (M.l. Barer, G.L. Stoddart) Cost: $45.00HPRU 91:70 Toward Integrated Medical Resourcs Policies for Canada: Ap/»ndlcss.June,1991. (M.l. Barer, G.l. StodClart) Cost: $30.00Note: /Iyou are ordering 91:60 or91:7D, pleasemake your cheque payable to The University ofBri6sh Columbia and enclose it with this list.HPRU 91:80 Bulgaria: The Public Health Impact of Environmental Pollution. August,1991. (C. Hertzman)HPRU 91:90 Reflections on the Revolution In Sweden. September, 1991. (R.G. Evans)HPRU 91:100 The Canadian Health Care System: Where are We; How Did We Get Here?October,1991. (R.G. Evans, M.M. law)HPRU 92:10 On Being Old and Sick: The Burden of Heafth Care for the Elderly InCanada and the United States. December,1991. (M.l. Barer, C. Hertzman,R. Miller, M.V. Pascali)HPRU 92:2R Manson Willms, S. (1992) "Housing for Persons with HIV Infection InCanada: Health, Culture and Context", Western Geographic Series Vol.26:1-22.HPRU 92:30 Environment and Health In the Baltic Countries. April,1992.(C. Hertzman)o=Discussion Paper R =Reprint7HPRU 92:4R Barer, M.L., Evans, R.G. (1992) "Interpreting Canada: Models, Mind-Sets,and Myths", Health Affairs 11(1):44-61HPRU 92:5D Aids Risk Taking Behaviour Among Homosexual Men: Soclo­demographic Markers and Polley Implications. June, 1992. (R.S. Hogg,K.J.P. Craib, B. Willoughby, P. Sestak, J.S.G. Montaner, M.T. Schechter)HPRU 92:6D The Adequacy of Prenatal Care and Incidence of Low Birth Weight Amongthe Poor In Washington State and British Columbia. June, 1992. (S. Katz,R.W. Armstrong, J.P. LoGerfo)HPRU 92:7D Medication Profiles on Admission vs. Discharge In Patients at a GeriatricReferral Centre. November, 1992. (J.H. Schechter, M. Donnelly, M.T.Schechter)HPRU 92:8D What Seems to be the Problem? The International Movement toRestructure Health Care Systems. November, 1992. (R.G. Evans)HPRU 92:9D A Compendium of Studies on Environmental Risk Perception In B.C.November,1992. (C. Hertzman, S. Kelly, A.S. Ostry, D. SClarretta,K. Teschke)HPRU 93:1D Evaluation of VI-Care: A Utilization Management Program of the GreaterVictoria Hospital Society. January, 1993. (G. Anderson, S. Sheps,K. Cardiff)(File: bjrmhpru9.new)•"D =Discussion Paper R = Reprint8

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