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The nurse manpower study, volume 1 : report of the Nurse Manpower Study Advisory Committee University of British Columbia. Health Manpower Research Unit Feb 29, 1988

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THE NURSE MANPOWER STUDYVOLUME IREPORT OF THE NURSE MANPOWER STUDY ADVISORY COMMITTEEHMRU 88:1(1)Health Manpower Research UnitDivision of Health Services Research and DevelopmentOffice of the Coordinator of Health SciencesThe John F. McCreary Health Sciences CentreThe University of British ColumbiaVancouver, B,C" CanadaV6T 1Z6 February 1988THE NURSE MANPOWER STUDYVOLUME IREPORT OF THE NURSE MANPOWER STUDY ADVISORY COMMITTEEHMRU 88:1(1)Health Manpower Research UnitDivision of Health Services Research and DevelopmentOffice of the Coordinator of Health SciencesThe John F. McCreary Health Sciences CentreThe University of British ColumbiaVancouver, B.C., CanadaV6T 1Z6 February 19881.2.3.4.5.6.TABLE OF CONTENTSIntroductionTerms of ReferenceThe Analysis of Nurse Manpower in British ColumbiaImplications of the Future Health Care System forNursingRecommendations of the Nurse Manpower Study AdvisoryCommitteeConcluding Remarks135669AppendicesAppendix 1: List of Materials Submitted to the Nurse ManpowerAdvisory CommitteeAppendix 2: A Synthesis of Nurse Manpower Data in BritishColumbia - Executive SummaryAppendix 3: Influence of the Workplace on Nurse Manpower Supplyin British Columbia : An Exploratory Study ­Executive SummaryAppendix 4: Implications of the Future Health Care System forNursingTHE NURSE MANPOWER STUDY:VOLUME IREPORT OF THE NURSE MANPOWER STUDY ADVISORY COMMITTEE1. INTRODUCTIONThe Nurse Manpower Study Advisory Committee originated with theMinistry of Health, more specifically at the request of the then DeputyMinister, Mr. Stan Dubas. The role of the advisory committee was explainedto the various participant groups as encompassing the following:1. To recommend the inclusion of additional members to the advisorycommittee, on a permanent or ad hoc basis.2. To participate in the clarification of the issues and questions basicto nurse manpower, including soliciting the views of interested groupsor individuals regarding key issues .3. To assist in identifying appropriate data sources, especially thoseavailable through informal sources; and to confirm that acomprehensive set of existing data has been identified.4. To assist in the assessment of the quality and relevance of theexisting data.5. To critique drafts of the report and assist in reviewingrecommendations.It was anticipated that the study would take between six and ninemonths to complete (as of March 1987).Concurrently, staff members in the Division of Policy, Planning andLegislation of the Ministry of Health formulated Terms of Reference forwhat was envisioned to be the two major study foci:(i) Data Synthesis(ii) Workplace ConsiderationsThese, as edited and rev!.sed by the Advisory Committee and approved bythe Health Manpower Working Group, together with the final Terms ofReference for the Advisory Committee itself, are included here forinformation as TERMS OF REFERENCE.Those organizations asked by the Deputy Minister of Health to providea member for the Nurse Manpower Study Advisory Committee, and theirappointees were:The British Columbia Health Association: Ms. Lisa Kallstrom, HealthPolicy Analyst .2The Council of University Teaching Hospitals: Mr. Robert McDermit,Chief Executive Officer, UBC Health Sciences Centre Hospital; fromNovember 1, 1987, Mr. James Flett, President, Vancouver GeneralHospital.Ministry of Advanced Education and Job Training: Mr. Gary Bunney,Director, Career and Technical Programs Branch, Colleges andInstitutes Division, Ministry of Advanced Education and Job Training.Ministry of Health - Hospital Programs Division: Ms. Margaret Nugent,Nursing Consultant, Regional Team #5.Ministry of Health - Policy, Planning and Legislation: Mr. NickHaazen, Director, Health Economics and Planning Branch .The Nurse Administrators' Association of British Columbia: Ms. RoseMurakami , Vice-President, Nursing, UBC Health Sciences CentreHospital.The Registered Nurses Association of British Columbia: Ms. ClaireKermacks, Manager, Registration and Manpower Department.At the suggestion of the Hospital Administrators' Council of GreaterVancouver, and with the concurrence of the original committee appointees, arepresentative of the British Columbia Medical Association, Dr. MaryDonlevy, was added to the committee.The staff of the project were:Ms . Diane Layton, Contract Researcher, Ministry of Health - for theWorkplace Considerations portion.Ms. Indra Pulcins, and from September 1, 1987, Dr . Arminee Kazanjian,Research Associates, Health Manpower Research Unit - for the DataSynthesis portion.Throughout, the secretarial and programmer-analyst staff of the HealthManpower Research Unit provided support services.The committee met nine times:May 21. 1987: Ratification/Development of Terms of Reference for:(i) the Advisory Committee(ii) the Data Synthesis study (Pulcins)(iii) the Workplace Considerations study (Layton) .The advisory committee wished to add to its own terms of reference thedevelopment of a list of issues underlying the nurse manpower situation.The results of this exercise, a list of current and future issues is foundin Appendix 4.June 23. 1987: Further clarification of the role of the committee anddelineation of the two specific parts (ii) and (iii) above. Specifically,3following a presentation of several alternate approaches, it was decided toadopt the Institutional Values approach, as presented by Ms. Layton, forthe Workplace Considerations portion and a discussion ensured as to afeasible sample of hospitals for this undertaking.July 27. 1987: This meeting was given over to furtherdevelopment/revision of the list of issues and to a brief introduction tothe Data Synthesis portion (Pu1cins). As well, it was then decided tonotify relevant organizations of the study and to invite from them anyrelevant materials for the Data Synthesis portion. Organizations includedwere the Registered Psychiatric Nurses Association, The Licensed PracticalNurses (initially the Council and at a later date, the Association aswell); the Health Labour Relations Association, The British Columbia NursesUnion. See Appendix 1 for materials received.August 31. 1987: At this meeting Dr. M. Don1evy, BCMA, joined thecommittee. The "Implications of the Future of the Health Care System toNurse Manpower Planning" received further discussion, and Ms. Laytoninformed the group of the progress of her Workplace Considerations study.September 21. 1987: This meeting was devoted to a detailed discussionof the rationale and the existing data for estimating/projecting, thedemand for Registered Nurses, now and in the future (Pu1cins). Preliminaryfindings were presented from the Workplace Considerations study (Layton).October 15. 1987: Further discussion of estimating demand,particularly conversion factors for full-time, part-time and casual workersand their relationship to fu11-time-equiva1ents (FTEs), both paid andworked hours (Pu1cinsjKazanjian).October 29. 1987: Presentation of draft report re: WorkplaceConsiderations by Ms. Layton. Ms. Layton will prepare the final report,taking into consideration the Committee's comments.November 18, 1987: Presentation of the demand projections andrecommendations of the Data Synthesis portion of the study and discussionof same (Pu1cinsjKazanjian).December 4. 1987: Working meeting to finalize the "Report of theNurse Manpower Study Advisory Committee".2 . TERMS OF REFERENCEThe agreed Terms of Reference were:(i) Role of the Advisory Committee1. To define the issues underlying the nurse manpower situation inBritish Columbia.42. To participate in the clarification of the issues and questionsbasic to nurse manpower, including soliciting the views ofinterested groups or individuals regarding key issues.3. To assist in identifying appropriate data sources, especiallythose available through informal sources; and to confirm that acomprehensive set of existing data has been identified.4. To assist in the assessment of the quality and relevance of theexisting data and need for additional information.5. To critique drafts of the report and to assist in formulating andreviewing recommendations.6. To report back to the respective organizations represented on thecommittee and, in turn, to obtain and report input from theseorganizations.7. To recommend the inclusion of additional members to the advisorycommittee, on a permanent or ad hoc basis.(ii) Data Synthesis1. To develop a set of questions and issues intrinsic to nursemanpower in British Columbia.2. To outline the data requirements for the investigation of theseissues.3. To identify and compile currently available data, including thosefrom both formal (i.e. British Columbia Health Association,Registered Nurses' Association of British Columbia, Commission ofEmployment and Immigration Canada) and informal (i.e. Difficu1t­to-Fill, RNABC vacancy monitoring, other reports) sources.4. To assess the quality of the data and determine:(a) The technical quality of the data (based on reliability,accuracy, consistency);(b) The relevance of the data to the assessment of the nursemanpower situation in British Columbia.5. To determine the extent of omissions, overlaps and conflictinginformation in the resulting nurse database.6. To assess the current status of nurse manpower, as indicated bythe synthesis of the currently available data.7. To suggest other data requirements necessary to provide acomprehensive overview of nurse manpower, if such voids have beenidentified.58. To outline a structure for the long term assessment of the nursemanpower situation in British Columbia.9. To report findings and recommendations to the Health ManpowerWorking Group of the Ministry of Health.(iii) Workplace Considerations1. To conduct a literature search regarding workplace factors andtheir impact on nurse manpower.2. To design a questionnaire guideline for interviews with healthpersonnel.3. To select a sample of hospitals representative of size andregional distribution of the hospital sector in British Columbia.4. To conduct interviews with a variety of management personnel aswell as front-line nurse staff within the selected hospitals.5. To analyze data obtained from the interviews.6. To incorporate the findings of the 12 HOUR NURSING SHIFT STUDYinto this project.7. To prepare a report including findings, analysis andrecommendations for future action.3. THE ANALYSIS OF NURSE MANPOWER IN BRITISH COLUMBIAThe reports of the Data Synthesis and the Workplace Considerationsstudies comprise respectively Volumes II and III of this report. A set ofrecommendations has emerged from each of the two separate initiatives whichcomprise The Nurse Manpower Study. These recommendations have beenreviewed by the Advisory Committee but do not necessarily reflect the viewsof the respective organizations. The Executive Summaries of both the DataSynthesis and Workplace Considerations portions, including recommendations,may be found respectively as Appendices 2 and 3 of this volume while therecommendations of the Advisory Committee arising therefrom are found asSection 5 of this report. Brief abstracts of Vo1s. II and III are offeredbelow.1. A Synthesis of Nurse Manpower Data in British Columbia (Vol. II)This report was primarily the work of the Health Manpower ResearchUnit staff, with guidance and constructive criticism provided by theAdvisory Committee. It builds on previous work of the Unit but advancesconsiderably the methodology, essentially quantitative in nature, forestimating demand for registered nurses in the hospital sector. Thesynthesis of manpower supply and demand data leads to an assessment of boththe data and the nurse manpower situation in British Columbia.62. Influence of the Workplace on Nurse Manpower in British Columbia: AnExploratory Study (Vol. III)This report, commissioned separately, but placed within the mandate ofthe Advisory Committee, provides both a review of the nurse manpowersituation in general and a qualitative assessment of workplace factorsaffecting nurse manpower in British Columbia . In this study, the essentialfactors influencing nurse manpower are defined and examined as they pertainto several groups of the main players in the nursing and health arenas.4. IMPLICATIONS OF THE FUTURE HEALTH CARE SYSTEM FOR NURSING.This brief overview, presented in chart form (see Appendix 4), resultsfrom the deliberations of the Committee (see Terms of Reference). Appendix4 serves to identify areas of current and future issues pertaining not onlyto the current nurse manpower situation, but also the future of the healthcare system and the implications of such changes on nurse manpowerplanning . Specific economic, technologic, demographic, delivery moderelated and educational, professional, workforce and management issues wereisolated as central determinants of the nurse manpower situation. Athorough examination of such factors adds to the understanding of the nursemanpower milieu and renders a more meaningful interpretation of thecombined study results.The committee recognized that in the future, greater emphasis in thehealth care system will be placed on the geriatric medicine and Long TermCare sectors. This, together with technological advances in all sectors,makes it essential that the measurement of health care needs and servicesincorporate less tangible indices of supply and demand and quality of carethan are considered in the present study. For example, whereas it has beencustomary to consider mainly concrete criteria in manpower deploymentdecisions (e .g. number of beds, occupancy rates, patient acuity), these maybe more suitable in areas such as ICU/CCU, for example, where biologicalsurvival can be directly attributed to services provided. It is noted thatto keep in step with constantly changing foci in health care, as well aswith the desire to offer high levels of care, other more subjective andcertainly less tangible barometers of both the quantity and preparation ofnurses, and the outcomes of care provided, must be incorporated in additionto existing criteria. This also has implications for job satisfaction fornurses and especially for the broader health care delivery policies whichmay be considered in the future.5. RECOMMENDATIONS OF THE NURSE MANPOWER STUDY ADVISORY COMMITTEEThe Recommendations of the Nurse Manpower Study Advisory Committeehave been formulated taking into account the results of the Data Synthesisand Workplace Considerations studies in order to highlight the basiccomponents for addressing nurse manpower issues. These are seen to be theessentials and they are therefore not priorized. Rather together they form7the suggested basis for ongoing Nurse Manpower Planning in BritishColumbia.1. In view of the identified gaps and weaknesses in the currentlyavailable data on nurse manpower activity and deployment, IT ISRECOMMENDED THAT:Improved monitoring and reporting systems be developed to provideinformation on:a) nurse attachment and turnover;b) vacancy rates, including Difficult-to-Fillc) personnel deployment, including both hours and persons.Ref: Data synthesis recommendations:Workplace recommendations:1, 6, 7, 9, 11.2, 3.Responsible Parties: MOH, BCHA, Institutions2. Both studies indicated that nurse manpower planning and relatedactivity at the local level is largely undeveloped at the presenttime. Accordingly, IT IS RECOMMENDED THAT:Hospitals and other health care agencies be encouraged andassisted in developing the internal capability for nurse manpowerplanning, analysis and management.Ref: Data synthesis recommendations: 11, 12, 21.Workplace recommendations: 1, 2, 4, 6.RNABC Nurse Manpower Planning Project.Responsible Parties: MOH, BCHA, RNABC, RAABC, NAABC, Institutions.3. Attempts to develop comprehensive measures of nurse supply and demand,using existing data sources revealed some significant differences andproblems in terms of data linkage, definitions and so on. Therefore,IT IS RECOMMENDED THAT:A provincial nurse manpower database be developed to provide theappropriate linkage of registration, payroll and otherinformation for use by researchers and institutional manpowerplanners. The necessary steps should be taken to developguidelines for the provision, linkage and distribution of thesedata, paying particular attention to ensuring the confidentialityand encryption of personally identifiable information.Ref: Data synthesis recommendations:Workplace recommendations:1, 2, 3, 4, 5, 6, 7, 12.2, 4, 6.Responsible Parties: MOH, RNABC, BCHA, HMRU, Institutions.84. In light of the findings in both studies that the provision ofcritical care nursing is currently a major problem in BritishColumbia, especially in Greater Vancouver, IT IS RECOMMENDED THAT:Steps should be taken immediately to train 75 additionalcritical care nurses, including providing the appropriateincentives to undertake such training.Ref: Data synthesis recommendations:Workplace recommendations:16, 17, 18.8, 11, 22.Responsible Parties: MOH, MAEJT, Institutions5 . Both studies, as well as the internal discussions of the AdvisoryCommittee about the changing nature of the health care system and therole of nursing in that system, pointed to significant recent andanticipated future changes in the required educational preparation fornursing practice and management. Accordingly, IT IS RECOMMENDED THAT:A major review of the nursing education system in the Province beconducted, including the examination of the form, funding, andarticulation of policies and programs, the role and educationalrequirements of various nursing levels and specialties (bothclinical and managerial), and the relative responsibilities ofeach major group with respect to the nursing education system.Ref: Data synthesis recommendations:Workplace recommendations:19, 10, 22.1, 7, 8, 9, 11, 15, 16. 19.Responsible Parties; MAEJT, MOH, RNABC, NAABC, COUTH.6. In view of the identified weaknesses of the current remunerationsystem in terms of attracting and retaining qualified nurses, as wellas the changing nature of nursing practice, IT IS RECOMMENDED THAT:Work begin immediately to redevelop the existing remunerationsystem for nurses in the Province, including classifications andthe appropriate recognition of experience and specialized skillsor job requirements.Ref: Data synthesis recommendations:Workplace recommendations:7, 8. 18, 19, 22.1, 8, 10, 11, 12, 14, 16.19, 22.Responsible Parties: MOH, HLRA, BCNU, RNABC, BCHA.97. In light of the critical importance of the work environment inensuring job satisfaction and retention among nurses, IT ISRECOMMENDED THAT:Hospitals and other institutions make a concerted effort toimprove the work environment for nurses. including developingmore effective staffing. scheduling and utilization practices.enhancing the organizational support and communication systems.and improving current practices for attracting and retainingnurses.Ref: Data synthesis recommendations:Workplace recommendations:11, 14, 15, 19.I, 4, 5, 6, 13, 14, 17, 20.Responsible Parties: Institutions, BCHA, RAABC, NAABC.6. CONCLUDING REMARKSPolicy guidelines that define the level and type of services to bedelivered, together with the budgetary allocation to accompany them, areessential to determining the number of persons required to provide themandated level of service in the health care sector. Within the presentsystem, if the status quo (in terms of currently observed employmentpatterns) is maintained, it appears that at least 2000 additionalregistered nurses are required to fulfil the existing budgetary allotmentsin British Columbia. This goal may be partially attained through trainingprograms and increasing the number of new recruits in the system. orselective immigration policies. It must be emphasized, however, that thenumber of additional registered nurses required is largely andsignificantly contingent upon patterns of manpower deployment. employmentmix. turnover. retention and indirectly. the future monitoring of the nursemanpower situation in British Columbia.A number of interventions addressing such issues, designed with thepurpose of alleviating the current situation, have been identified in theaforementioned recommendations. No single intervention, just as no singleparty, will be able to successfully deal with shortages of registerednurses; rather, the recommendations must be viewed as complementary andmutually reinforcing strategies. Considering the alternative, it isadvised that these be explored and implemented without delay.APPENDIX 1LIST OF MATERIALS SUBMITTED TO THE NURSE MANPOWER ADVISORY COMMITTEEAl-lLIST OF MATERIALS SUBMITTED TO THE NURSE MANPOWER ADVISORY COMMITTEE1. Registered Psychiatric Nurses Association of British ColumbiaReport of the Manpower Committee Survey, RPNABC, November, 1984 .2. British Columbia Council of Licensed Practical NursesCouncil for Nursing Assistants Task Force Report on the Presentand Future Role of the Registered Nursing Assistant, January,1987, St . John's, Newfoundland.The Future of Nursing Assistants in New Brunswick. Prepared forthe Association of New Brunswick Registered Nursing Assistants,March, 1987, Fredricton, New Brunswick.Unpublished survey statistics on LPN's not renewing theirlicenses to practice. BCCLPN, 1987.3. The Hospital Administrators' Council of Greater VancouverCorrespondence with the Deputy Minister of Health regardingpossible areas of study. January, 1987. Vancouver, E. Azzara,Chairman.APPENDIX 2A SYNTHESIS OF NURSE MANPOWER DATA IN BRITISH COLUMBIAEXECUTIVE SUMMARYA2-1THE NURSE MANPOWER STUDY:VOLUME IIA SYNTHESIS OF NURSE MANPOWER DATA IN BRITISH COLUMBIA1. INTRODUCTIONE X E CUT I V E SUMMARYThe data synthesis study focusses on the use of existing data toassess the perceived shortage of nurse manpower, especially registerednurse manpower. In particular, the questions that are addressed in thisreport are:1. Is there a supply/demand imbalance?2. If so, what is the extent of the imbalance (specifically withrespect to actual numbers, geographic areas, specialty areas,sectors, qualifications)?3. How good is the evidence supporting this assessment?4. What would improve it?This report presents a synthesis of existing supply and demand data,proposes a methodology for the estimation of demand for registered nurses,and, based on this discussion, offers an assessment of both the data andthe nurse manpower situation in British Columbia.2. APPROACHES TO THE ASSESSMENT OF SUPPLY AND DEMANDThere exist a variety of approaches to the measurement of supply anddemand, many of which are applicable to the assessment of registered nursemanpower. The use of demand models for projection and building ofscenarios to determine not only possible future situations but also theefficacy of possible intervention strategies constitute a viable andnecessary component of this process.3. THE CONCEPTUAL MODELA conceptual model was developed to identify data requirements and toprovide a framework within which to classify the mechanisms underlyingnurse manpower. This model points out the links between health outcomes,consumer and provider behaviour and the health care delivery system withother indices of nurse supply and demand in order to identify net nursemanpower requirements.A2-24. REGISTERED NURSES IN BRITISH COLUMBIA: SUPPLY SIDE DATASupply data for registered nurses as well as for licensed practicalnurses and registered psychiatric nurses are presented and discussed.First, the activity rates among RNs and LPNs are found to comparefavourably to those among the general female population in B.C., althoughit is pointed out that the actual number of trained but not employed nursesis impossible to ascertain. Specialty information indicates that themajority of RNs and LPNs are employed in the Hospital Programs Divisionsector, and more specifically for RNs, in the Acute Care sector. Anincrease in geriatric practice has been observed for LPNs while practice inother areas has contracted.It is debatable whether unemployment rates act as a good barometer ofsupply, since these data are not sufficiently disaggregated to provideinformation on either the level of preparation of unemployed nurses orclinical specialties.S. ESTIMATING DEMAND FOR REGISTERED NURSESIn this section, existing measures of relative demand are reviewed,and a model for projecting demand is presented. Demand estimates ingeneral tend to be limited by several methodological problems, namely thedefinition of "need" in the absence of clearly articulated health manpowerpolicy, the existence of non-quantifiable determinants of demand and,frequently, incompatible units of measurement in the data.Measures of relative demand, such as vacancy statistics, indicate thedirection and severity of unfilled demand. Difficult-to-Fill (DTF) vacancystatistics point to relatively high vacancy rates for RNs as compared tothe average rate for other health professions in British Columbia.Furthermore, the data show that the highest DTF rates occur in the lCU/CCUareas, as well as in general nursing. Difficult-to-Fill nursing vacanciestend to be concentrated in the GVRHD, where the rates, as well as theabsolute numbers, are higher.The model for estimating registered nurse requirements consists ofseveral steps. First, an undifferentiated demand estimate is produced.Secondly, two sets of conversion factors are applied to this estimate toderive the total required number of nurses, expressed in number of persons.This latter estimate is computed for a static scenario (which considersonly continuous employees) and a dynamic scenario (which incorporatesmovement between employment status or RHDs). The projection model andcomputation of the conversion factors are described in detail in thereport, and an example using 1986 data for the GVRHD is presented.The assessment of the effects of movement in the labour force, thespecialty and regional components of demand and the sensitivity of thehealth care system to fluctuations in both employment mix and manpowerdeployment are outlined. The analysis indicates that the greatest degreeof movement in the system lies in the Casual employment component. On theother hand, the Part-Time component in the GVRHD remains relatively stableand does not seem to be particularly affected by movement in the labourA2-3force. In British Columbia as a whole, the Part-time component isnoticably more affected by labour force movement.Interesting results emerge from the development of hypotheticalscenarios depicting changes in the composition of Full-time to Part-time toCasual staff as well as the average number of hours worked by each. Thescenarios illustrate the magnitude of the decrease in the number of nursesrequired that results by either increasing the proportion of Full-time andPart-time staff or increasing the average annual number of hours worked.This method of constructing scenarios could be applied with equalvalidity to test certain management decisions or manpower interventionstrategies at the facility or regional/provincial levels respectively.Similarly, the method of estimating demand in its entirety, as presented inthis section, has been developed to generate demand estimates at theprovincial, regional or possibly hospital level.6. ASSESSMENT OF THE AVAILABLE NURSE MANPOWER DATAThe existing nurse manpower data were assessed with respect to supply,demand and demand estimation considerations.Despite the high quality of the registered nurse supply informationthat is provided, for the most part, by the RNABC registration database, itis limited by the lack of detail with respect to nursing specialties andsubspecialties. This same criticism applies to CEIC Unemployment InsuranceStatistics.The two major sources of relative demand, the RNABC Vacancy Survey andthe HMRU Difficult-to-Fill Positions Survey offer excellent insights intocurrent nurse manpower trends. Although the DTF data do not considerCasual nursing positions, they are subjected to methodologically sound datacollection techniques. Both sets of statistics are very amenable toconversion to rates, but the lack of an acceptable denominator (due mostlyto lack of detail in specialty areas or incompatible categories) limits theutility of such an approach.The forecasting model represents a rigorous and internally consistentmethodology but the data which emerge from it must be interpreted keepingin mind several things. First, it must be considered that the conversionfactors are derived from observed trends rather than from stated manpoweror management policy. This is not a problem in itself, since the questionof identifying "ideal" employment mix or deployment ratios is a difficultone, but it is vital to identify the criteria on which the demand estimatesare based. Second, vacancy figures used to reflect unmet demand mayproduce a proportionately small degree of error in calculating totaldemand. Third, the lack of a unique identifier may affect the derivationof the demand figures, since despite efforts to overcome the possibility ofdouble counting individuals in the exercise it cannot be guaranteed thatthis attempt was successful. It should be noted that the model, in itscurrent state, applies only to the Hospital Programs Division sector.The matching of estimated demand to known supply is problematic sinceA2-4the two are not directly compatible, and therefore a precise figure ofimbalance between estimated demand and known supply is not attainable.Still, a good estimate of demand may be derived from the model presentedhere. In addition, it also provides a forecasting function and a capacityto test and construct any number of scenarios which would providedescriptive information to be used for decision making at the provincial,regional or institutional levels.7. ASSESSMENT OF THE NURSE MANPOWER SITUATION IN BRITISH COLUMBIASeveral observations regarding the nurse manpower situation in BritishColumbia may be made on the basis of the aformentioned data. While it isclear that apparent nurse shortages are of a recurring nature, it seemsthat the current situation is unique in terms of its effects at theregional level (greater severity is currently noted in the GVRHD inhospitals of all sizes) and the predominance of ICU/CCU vacancies. Theexact magnitude of the supply/demand imbalances in individual nursingspecialties and subspecialties has not been quantified at this time due tothe unavailability of detailed supply data or even criteria on which tobase such estimates.Furthermore, the considerable degree of labour force motility (interms of attrition and movement between districts and employment status)for RNs in British Columbia markedly effects demand. The greatest degreeof movement occurs in the Casual sector.Estimates of requirements for registered nurses in British Columbia in1986 exceed supply, when supply is defined as the number of registerednurses employed in the acute care sector (with the exception of psychiatrichospitals which are not part of the Hospital Programs Division) as ofDecember, 1986. This shortage is exacerbated by current patterns ofemployment mix, personal deployment and attrition in the nurse labourforce. The total number of RNs who are prepared to participate in thenurse labour force is unknown. Similarly, it is not known whether nursesavailable for employment will match the level of preparation and specialtyrequired in the vacant positions. Lastly, while the supply figuresrepresent employed RNs up to a specific point in time, the demand estimateincludes the total number of persons required to fill demand over the givenyear. For example, it is known that the December, 1986 supply data(employed nurses) do not include new recruits who have not yet engaged innursing employment. Therefore the estimate of net balance must beconsidered according to the terms outlined above.In conclusion, a supply imbalance as defined by a set of specificcriteria has been identified. The data, taken together, indicate that theseverity of the problem tends to be greatest in the ICU/CCU areas andespecially in the GVRHD as compared to the province as a whole. Althoughthere undoubtedly exist limitations to any analysis of supply and demand,much of the available data represent methodologically rigorous and soundapproaches to reliable assessment of the nurse manpower situation inBritish Columbia.A2-5RECOMMENDATIONS OF THE DATA SYNTHESIS STUDYNurse Manpower Supply and Demand DataImproving the Nurse Manpower DatabaseIt is recommended:1. that a province-wide system of collecting and maintaining selectedpayroll data which is based on a common coding scheme for nursepersonnel classification and/or cost-centre identification, as well ascommon definitions (see recommendation 7) of the reported data for allhospitals, be considered.Responsible Parties: BCHA, RNABC, MOH, HMRU2. that a central data management system be identified and designated tofacilitate access to and retrieval of data.Responsible Parties: BCHA, RNABC, MOH, HMRU3. that data ownership, physical location and access to the databank forresearch purposes be clearly stated and agreed upon by all partiesinvolved.Responsible Parties: BCHA, RNABC, MOH, HMRU4. that a method of developing and using unique identifiers beimplemented province-wide (or at the central databank level) in orderto accurately track individuals' movements and examine life-cycleactivity patterns in a comprehensive fashion.Responsible Parties: HMRU, BCHA5. that data be archived for at least 10 years in order to provide forlongitudinal analyses.Responsible Parties: BCHA, HMRU6. that hospitals and other health care agencies be urged tosystematically collect and carefully maintain payroll data thatprovides reliable information on individual nurses' employment status(e.g. fu11-time/part-time/casua1) and particularly, changes in suchstatus, as well as other movement (temporary or permanent) in and outof the nurse labour market.Responsible Parties: BCHA, NAABC, RAABC7. that germane definitions and disaggregated categories of nursingspecialty and subspecialty areas that are comparable to those used byemployers and are, therefore, more appropriate for measuring manpowerimbalances, be developed for the purpose of collecting nurse supplydata.Responsible Parties: RNABC, Hospital Programs Division of MOH, BCHA8. that these more fitting specialty definitions be routinely used byeducators, employers, professional associations, as well asresearchers, planners and po1icymakers.Responsible Parties: NEABC, BCHA, RNABC, MOH, MAEJT, HMRUA2-69. that the Difficult-to-Fill Positions Survey incorporate vacancies forcasual nursing positions, and initiate reporting procedures that wouldallow for greater disaggregation by nursing specialty and subspecialtyareas.Responsible Parties: HMRU10. that the Unemployment Insurance statistics for hospital nurses bereported and collected on the basis of more disaggregated unit groupcodes in order to be comparable to nursing specialty and subspecialty(see recommendation 7) areas.Responsible Parties: EIC, CNAUtilization of Existing Data for the Monitoring of the NurseManpower Situation in B.C.It is recommended:11. that individual hospitals and other health care facilities examine andanalyse staff records pertaining to turnover, personnel mix and totalpaid hours per status category for the purpose of using thisinformation in planning for effective approaches to nurse manpowerdeployment. The RNABC Nurse Manpower Plan may be examined as afr~ework for use in conjunction with this analysis.Responsible Parties: RAABC, NAABC, RNABC12. that agencies be encouraged to identify personnel responsible fornurse manpower planning and to prOVide them with basic training inManagement Information Systems.Responsible Parties: MOR, NAABC, RNABC, RAABC13. that greater use be made of the Difficult-to-Fill Positions Survev indecision making concerning the nurse manpower situation in B.C. Thesurvey (especially if enhanced as suggested in recommendation 9) hasproven to be a reliable barometer of both regional and specialtyimbalances.Responsible Parties: MOR, MAEJTII. The Nurse Manpower Situation in B.C.Nurse ManagementIt is recommended:14. that, in the light of the known impact of Full-time, Part-time andCasual nurse staffing ratios, and the average number of paid hours ineach employment category, hospitals be made aware of the sensitivityof the system to those factors and be urged to ensure that optimallevels of nurse manpower deployment are attained.e.g. increasing the Full-time and Part-time components by 5percent and decreasing the Casual ratio accordingly ina hypothetical scenario in the GVRHD resulted in aA2-7decrease in the number of nurses required over a periodof one year by 650 persons; upward adjustments of theaverage number of paid hours, expressed as a proportionof an FTE, to 1.0 (FIT). 0.6 (PIT) and 0.4 (Casual),respectively, resulted in a further expected decreaseof 1686 persons.Responsible Parties: BCHA, RAABC, NAABC, BCNU15 . that, in the light of the known impact of current recruiting patternson new graduates, an advance planning system for the expedient andefficient placement of new graduates be implemented so that moreeffective deployment is made of available supply.i.e. as evidenced by the 40 percent increase in PractisingRNs, not employed in nursing between June and December,1986, which coincided with the introduction of 805initial registrants.Responsible Parties; BCHA, RAABC, NAABC, NEABC, BCNUNurse Manpower Policy and PlanningIt is recommended:16. that the various existing reports and recommendations on preparationfor Critical Care Nursing be reexamined in light of the documentedlong term vacancies in this area, especially in the GVRHD.i.e. 57 (average) quarterly reported DTF vacancies forCritical Care Nurses in 1986 in B.C., 82 percent ofwhich were in the GVRHD; 71 DTF vacancies for CriticalCare Nurses in June 1987 in B.C., 94 percent of whichwere in the GVRHD.Responsible Parties: MOH, MAEJT, NAABC, BCNU17. that methods for optimum deployment of skilled Critical Care Nurses beinvestigated, particularly in the GVRHD.Responsible Parties: RAABC, BCNU, NAABC18 . that additional incentives be offered to encourage nurses to undertakeCritical Care training and employment, particularly in the GVRHD.Responsible Parties: RAABC, NAABC, BCNU, NEABC19. that, in the light of the recurring nature of nurse shortages,systematic educational and workplace incentives be developed andimplemented, even in the absence of perceived imbalances.Responsible Parties: MOH, RNABC, BCNU, MAEJT20. that the outcome of these incentives (see recommendation 19) bemonitored and evaluated for its impact on the nurse manpowersituation.Responsible Parties: HMRUA2-821 . that scenarios of the likely future health care system, especially inrelation to nurse manpower, be articulated and constructed. In thismanner possible intervention strategies could be planned and testedbefore such action is necessary.Responsible Parties: MOH, RNABC22. that the long term monitoring and evaluation of the nurse manpowersituation also consider other nurse manpower categories, such asregistered psychiatric nurses, licenced practical nurses, and nursingaides, as well as the manpower situation of related professions in theworkplace.Responsible Parties: MOH, RNABC, BCCLPN, RPNABCAPPENDIX 3INFLUENCE OF THE WORKPLACE ON NURSE MANPOWER SUPPLY IN BRITISH COLUMBIA:AN EXPLORATORY STUDYEXECUTIVE SUMMARYA3-1THE NURSE MANPOWER STUDY:VOLUME IIIINFLUENCE OF THE WORKPLACE ON NURSE MANPOWER SUPPLY IN BRITISH COLUMBIA:AN EXPLORATORY STUDYA. Introduction:EXECUTIVE SUMMARYThe report on the influence of the workplace on nurse manpower inBritish Columbia forms part of the larger Nurse Manpower Study commissionedby the Deputy Ministry of Health in March, 1987. This report attempts todefine workplace factors and their influence on future nurse supply inBritish Columbia. The report includes findings, analysis andrecommendations for future action.B. Methodology:The study was conducted in an exploratory manner in order to documentthe attitudes and opinions of a cross-section of industry representativesin institutions across the province. The survey took place in tenfacilities in four regions of British Columbia. Hospitals were selected onthe basis of size, location and variable experience with difficu1t-to-fi11nursing positions over a seven year period.Data collection involved semi-structured interviews with the hospitaladministrator, nurse administrator, financial manager, nursing staffrepresentatives, a physician staff representative and a director of a non­nursing patient care service in each agency. A descriptive survey was alsoconducted to collect data on current B.C. hospital employer practices andprograms for tracking, monitoring, attracting and retaining registerednurses in facilities.C. Limitations of the Study:The sample size of the study is small (9% of total B.C. facilitieswith beds) but reflects the historic nursing manpower problem in B.C. Thestudy findings are not representative of the total hospital or nursingexperience in the province. Given the qualitative nature of some of thedata, the study is subject to researcher bias. Even with these limitationsin mind, the study was successful in exploring a number of RN manpowerissues endemic to the hospital workplace. The interviews were directed atmany organizational participants responsible for change. This approachincreased the profile of the issue outside of the nursing service, as itshould be regarded as an industry wide problem.A3-2D. Compliance:All ten of the hospitals in the sample agreed to participate in thestudy. A total of 77% of the planned (100) interviews were completed. Atotal of 11 (multi-site) facilities completed the employer survey.E. The Policy Environment:Working conditions have always been a concern for the nursingoccupation. However, its importance in manpower discussions waxes andwanes with general economic conditions and the strength of the"professional" movement within nursing. The subject of working conditionscannot be divorced from the observation that the nursing profession is in aperiod of transition. Nor can we define the problems within the workplaceoutside of the "legacy of Canadian manpower policy" (Lomas and Barer,1986). Our history will not allow us to start from scratch to redress someof the manpower problems of the non-physician professions in the HealthCare System.Solutions or improvements in working conditions for nurses will haveto be implemented in an increasingly "constrict~d environment." The policyenvironment includes many forces which are likely to further "diminish ourcontrol of human resources" in health care. This will mean many internaland external pressures on organizations to make operational adjustments tomeet the "new demands" for human resource management.F. The Workplace, the Work and the Workforce:Working conditions for nurses involve all of the organizationalfeatures of the environment in which they are employed. In general,hospitals seem to have become less satisfying places to work. Given thehospital's setting's complex, stressful and somewhat unmanageableenvironment, employee alienation occurs. Nursing discontent with hospitalworking conditions manifests itself in four ways; job dissatisfaction,intent to leave, turnover, and an inactive workforce.The major reasons for nurse discontent with hospital employmentinclude:1. Lack of organizational power and influence of nursing withininstitutions;2. Lack of organizational support for the nursing function and theworking nurse in hospitals;3. Poor communication practices at all levels of the organization;4. Poor supervision and leadership issues between levels of the nursingservice;5. Use of the RN resource; staffing; scheduling; and utilizationpractices within facilities;A3-36. Lack of economic incentives and rewards for job demands,specialization and performance;7. Role/career barriers to individual growth, autonomy, opportunities foradvancement and clinical practice;8 . Lack of educational opportunities, support and funding. Discrepanciesbetween educational values and operational settings. Confusededucational systems for nurses;9. Physician/nurse relationships;10. Changes in the acuity, type, age of patients and practice demands ofpatient care. Insufficient recognition of these changes by consumers,funding bodies and nursing management systems;11. Stress;12. Low status of nursing as a job, as a profession and as a career.Many studies have pointed out that it is the nature of the nursingjob, not the nurse, which needs to be addressed if we are going to maintainadequate supply.Nursing work has changed dramatically in the last 30 years. Thehealth care systems expansion, intensification of hospital work, increasedsophistication of medical technology, sub-specialization of medicine andthe proliferation of paraprofessionals in hospitals have all contributed tothe increasing complexity and demanding nature of today's nursing job. Thesubstance of the majority of the work that nurses do in hospitals is laborintensive and technical. Stresses of work life, personal and family lifeand the long, variable hours of work make the nursing job far lessattractive and competitive than it once was.There have also been changes in the labor force participation patternsof nurses. Even more significant are the educational and social changesfor women that have occurred since the 1960s. These trends are having animpact on supply.Employers in B.C. can now expect a maximum of 20 years of practicelife from the youngest cohort of nurses currently in the system (Kazanjianet al, 1986). Within this 20 year period, there may be at least sixdistinct phases in nurse worklife attachment. In addition to thetraditional patterns of job mobility for nurses, there is an increasingtrend towards part time and casual or temporary employment.Evidence suggests that hospital employers in B.C. no longer have a"captive" nurse workforce and must increasingly adapt attitudes, marketingand retention strategies if they are going to attract and retain nurses.A3-4G. Turnover:It is to the mutual advantage of both employers and employees toinstitute manpower policies which promote RN career longevity,re-recruitment , job stability and decreased turnover. A certain proportionof turnover is preventable. Strategies to interrupt the process of RNturnover can be developed and implemented. Rates of annual turnoverreported for nurses in the U.S. and Canada range from 50% to 0%. A 1984survey of B.C. hospitals found the average annual turnover to be 32% of theRN positions in the 52 reporting hospitals (Division of Health ServicesResearch and Development, 1984). The cost of replacing a nurse has beenestimated to vary from 1/2 of the first years wages to $3,000 per nurse(Nova Scotia, 1981). Although we have no cost estimates for B.C., turnovermanagement can be cost-effective during a time of cost restraint. Yet thecost!benefit of programs for RN retention have rarely been evaluated.H. RN Workforce Attachment in B.C.:Much of the "big picture" on overall workplace attachment patterns forB.C. Nurses can only be pieced together from existing databases and "oneshot" surveys. This initial information gives a general direction to go inestablishing a meaningful set of indicators to measure workplace factors asthey impact on RN nurse supply over time. The workplace study found thatone-fifth (20%) of all currently registered and practicing nurses (RNABCmembership tapes) have been with their employers one year or less. In1987, a large portion of the B.C. RN workforce had been with employersthree years or less (41%). However, the majority of nurses in B.C. (51.6%)stay with employers five or more years.Although a statistically significant association was found between thelength of stay and employment setting for nurses in B.C., no significantdifference was found between length of employment in acute care whencompared to all other settings of RN employment. The study found thatthere is a significant difference in length of stay and position (staffnurse, head nurse, etc.) in acute care hospitals. Approximately 52% of allstaff nurses in B.C. hospitals stay four years or less compared to allother acute care positions (30% stay four years or less). The fourth yearof service for all acute care nurses represents a transition point, withthe majority staying less than three or more than five years.This study found that there is currently no ongoing standardizedmechanism or responsibility to monitor employee attachment and turnoverrates for RNs in B.C. This is a manpower planning deficiency when it comesto:1. defining whether or not we have a problem;2. determining the magnitude of the problem;3. monitoring how the problem is changing over time.4. comparing the nurse workforce with other health professions oroccupations.A3-5I. British Columbia Employer Tracking and Monitoring Practices for RNs:The workplace study also examined current employer practices toroutinely collect and monitor RN employment patterns. The study foundthat:1. The majority of the study hospitals (91%) have some means of assessingthe conditions surrounding RN employee separation.2. However, fewer than half (45%) of the sample have ongoing systems tocalculate the institution's rate of RN turnover.3. A slight majority (55%) of the hospitals have a system of positioncontrol and vacancy monitoring in place.4. The majority (91%) of the hospitals studied participate in the HMRUQuarterly Difficult-to-Fill Survey of provincial RN positions vacantfor more than 30 days.5. Most facilities (82%) have placed a high priority on the monitoring ofabsenteeism of RN employees.6. Only 18% of the sample have any means to track length of servicepatterns for RNs in the facility.7. The actual cost of RN turnover for the study hospitals is generallyunknown (5%).The study found that some of the necessary data to track and monitorRN employee practices in B.C. facilities is collected. However, thedistribu~ion of these systems by hospital size and region appears to beuneven in the province. The extent to which this data is standardized,analyzed and used for human resource management and manpower planning innursing services is currently unknown. This is clearly a direction thatmanagement information systems in B.C. hospitals and nursing services inparticular require. Without such baseline data on RN employment patterns,very few rational or targeted manpower and retention policies are likely tobe instituted and properly evaluated in specific institutions.J. Workplace Factors Most Likely to Influence Supply:The Nurse Workplace Study assessed the impact of specific workplacefactors on the future supply (next ten years) of nurses in B.C. Theoverall identification and ranking of workplace factors by the 77 peopleinterviewed is contained in Table VI. Factors were given a weightingaccording to the order of importance individuals or groups assigned to theissue.The ten major workplace factors (in order of importance) likely toeffect the long term supply of RNs in B.C. are:1. staffing, scheduling and utilization practices2. education/service disparitiesA3-63. economic incentives4. a) organizational supportb) leadership5. patient care6. specialization7. organizational power8. nurse/physician relationships9. clinical recognition10. statusTable VII looks at the relative importance assigned to each of the tenmajor factors by hospital region. The major difference in the regionalbreakdown of issues is the dominant concern of the large urban hospitalswith the issues of education. Other groups see staffing, scheduling andutilization as the most important factor. This may be due to thepreponderance of teaching hospitals in the area who feel the stresses ofadvanced educational needs most acutely. For the smaller hospitals «400beds) nurse-physician relationships and organizational support issuesfigure prominently in working conditions. All hospitals in the sampleshare the concern for staffing, scheduling and utilization practices onsupply. Table VIII itemizes the relative ranking of issues by category ofparticipant.Perhaps telling, nurse administrators, hospital administrators andfinance directors do not see staffing, scheduling or utilization as one ofthe three major working conditions issues for nurses. Others closer to theaction; nurses, doctors and other department heads, view it as the mostimportant issue . Educational issues are the number one concern ofadministrators on future supply. Nursing administrators view leadership asthe key hope for the future . Finance directors, perhaps true to theircalling, view revised financial incentives as a key to long term supply.For working nurses, organizational supports for the nursing function andthe working nurse are the second most important issue in future supply,followed by educational issues. Economic incentives rank fourth, alongwith patient care issues. Within each of the ten major workplace factorsidentified by the study sample, a number of sub-issues emerged. These aredetailed in Chapter IX, along with specific recommendations for each issue.K. Existing Efforts in B.C. to Attract and Retain RNs:Another aspect of the Nurse Workplace Study identified current B.C.hospital practices to attract and retain nurses . Figure 5 contains thedistribution of the programs or activities currently being used byhospitals to attract, maintain or increase RN work satisfaction in B.C.Assuming that these programs make a difference, areas which need moreattention by employers include:1. day care2. transportation/parking/relocation assistancejhousing when necessary3. guaranteed placement on shifts4. clinical ladders/advancement opportunities5. primary nursingA3-76. omission of non-nursing tasks7. exchange programming8. refresher programs9. flexible scheduling10. participatory management11. open staff forumsFurther efforts should, however, be associated with clear manpowerobjectives and an evaluation component.L. Conclusions:The workplace study identified a comprehensive set of work placefactors influencing nurse manpower in B.C. Specific recommendations andassociated responsibilities have been developed to promote the retention ofthe nurse workforce in facility settings.Many people contacted during the study felt that throwing money atthese problems was not the answer. Many of the identified workplacefactors can be improved with managerial, attitudinal and improved humanresource systems. Manpower, institutional and professional policy must bedirected at three levels of intervention:1. removing job dissatisfaction and enhancing jobs for individual nurses;2. adjusting organizational leadership styles, structures, supports,policies and procedures to attract and retain nurses;3. addressing significant environmental determinants of malaise,including; economic, educational, professional, interprofessiona1,political and image problems.No one action or party in the system can resolve these problems.However, the most significant gains are likely to take place withenlightened and determined nurse manpower planning and policy developmentsat the institutional level in British Columbia.RECOMMENDATIONS OF THE NURSE WORKPLACE STUDYThe general study recommendations are oriented to developing a moreresponsive environment and direction for solutions to the workplace factorsfound to be currently operating on the long term supply of RNs in B.C.hospitals.Organization of Recommendations:The following section outlines the general recommendations of thestudy and is organized in order of priority as well as indicatingassociated responsibilities for intervention. Overall studyA3-8recommendations parallel many of the proposed solutions identified in theliterature review summary (Appendix V) .Due to the analytical focus of the study, many other studyrecommendations are detailed in nature and are most often addressed to theinstitutional level of intervention. These recommendations have beenincluded in Chapters VIII, IX, and X in conjunction with the study results.These specific recommendations are also presented in order of priority andindicate predominant players in the system who need to be involved inimplementation planning or problem solving.Strategic Planning:It should be noted that many other nurse manpower issues need to beaddressed (i.e. production, demand) but are considered outside the terms ofreference of this project. All study recommendations assume continuationof the status quo in relation to identified social and economic trends.Use of the recommendations for strategic planing purposes should proceedfrom the priority recommendations made in the General RecommendationsSection. More detailed implementation planning within each issue area canthen flow to the specific ranking of other workplace recommendations foundin Chapters VIII, IX and X.A. General:It is recommended:1. that the registered nurse workforce no longer be considered an"inexhaustible resource" by the pool of hospital employers in theprovince. Registered Nurse employers in the province need to:a) recognize and further adapt to the identified changes in thecharacteristics, trends and attitudes of the nurse workforce.b) increasingly invest in competitive marketing and retentionstrategies to attract and maintain employees.Responsible parties: MOH, BCRA, HLRA, BCNU, Institutions.B. Monitoring:It is recommended:2. that institutions and nursing services, in particular, be givenresources to develop systems and expertise for improved human resourcemanagement, monitoring and manpower planning. This includes thedevelopment of more rational, targeted and evaluation approaches toretention and recruitment programming.Responsible parties: MOH, BCRA, Institutions, NAA.3. that an ongoing, simple and cost-effective provincial mechanism beestablished to monitor RN workforce attachment in B.C., includingA3-9standardized industry turnover rates and RN length of employmentpatterns by service, age, setting, etc.Responsible parties: MOH, RNABC, BCHA.C. Staffing Scheduling and Utilization Practices:It is recommended:4. that hospital, nursing and financial administrators place morepriority on improved staffing, scheduling and utilization practices toensure the long term supply of RN staff in facilities.Responsible parties: MOH, Institutions.5. that more alternatives be developed in the marketplace (part timework, job sharing, "one" only or weekend shifts) which would assistsupply, yet remain cost-effective.Responsible parties: HLRA, BCNU.6. that more expertise be developed within institutions and across theprovince in order to develop options for scheduling and deploying thenurse resource in facilities.Responsible parties: NAA, BCHA.D. Education:It is recommended:7. that parties in the province responsible for the form, funding andarticulation of nursing education in B.C. formally address theconfusion and controversy in the nursing education system.Responsible parties: RNABC, MAEJT, MOH, BCHA, NEC, NAA, BCMA,Institutions.8. that nursing educational policy, funding bodies and institutionsaddress three simultaneous production requirements:a) adequate definition, provision and incentives for specialty, headnurse and staff development training for today's nurses;b) transitional, articulation and support strategies to upgradethose in the current workforce who seek it;c) definition of future system supports to provide a critical massof academically prepared nurses for all fields of endeavour(clinical, management, research, teaching).Responsible parties: RNABC, MAEJT, MOH, BCHA, NEC, NAA, BCMA,Institutions, RAABC.9. that stronger alliances and joint ventures be formed between employers,colleges and universities in order to effectively deal with theprovision of realistic nursing education and training in the province.Responsible parties: Institutions, RAABC, MOH, MAEJT, NEC, NAA.A3-10E. Economic Incentives:It is recommended:10. that the Ministry of Health recognize the limits that existing fundinglevels place on improving overall working conditions for nurses in theprovince.Responsible parties: MOH.11. that there be more explicit recognition of hospital training needs forRNs in the health dollar. There must be improved sources of funding(public or private) in order to provide better employer assistededucation and training programs. There should be consideration ofrelaxed policies to encourage entrepreneurial or profit makingactivities by hospitals to fund or manage employee support/developmentprograms.Responsible parties: MOH, MAEJT, BCHA.12. that the growing specialization of nurses be addressed professionallyand economically.Responsible parties: RNABC, CNA, MOH, BCNU, HLRA.F. Organizational support:It is recommended:13. that senior hospital administrative support for nursing vis A visbudget, equipment, nurse/physician conflicts be demonstrated, as wellas nursing administrative support for nurses and delegation ofdecision making to the lowest level of work, whenever possible.Responsible parties: Institutions, RAABC, NAA.G. Leadership:It is recommended:14. that hospital administrative assistance/training for senior nursingpersonnel in the province be improved, as they adapt nursing servicesand systems to the management and financial demands of today'shospitals. Re-examination of the leadership, structure and style ofnursing administrations, where appropriate.Responsible parties: MOH, Institutions.15. that the requirements for management training programs available tohead nurses in the province be defined and augmented.Responsible parties: MOH, MAEJT, NAA, RAABC, BCHA.A3-11H. Patient Care:It is recommended:16. that nursing role in facilities be examined and clarified.Responsible parties: Institutions.17. that cost-benefits of alternative delivery modes, personnel anddelegation of work within nursing services be examined.Responsible parties: Institutions.18. that patients and families be educated as to the changing objectiveand forms of nursing care in today's hospital.Responsible parties: MOH, BCHA.I. Specialization:It is recommended:19. that there be a greater understanding by employers of the specialtyimpact on nursing skill, competence and willingness to work in areasin which they do not feel confident.Responsible parties: Institutions.J. Organizational influence:It is recommended:20. that more attention be paid to two-way communication and staffparticipation in nursing services.Responsible parties: Institutions.K. Nurse/Physician Relationships:It is recommended:21. that there be better development of team work norms and reciprocalexpectations among physicians and nurses in B.C. hospitals.Responsible parties: BCMA, NAA, RNABC, HAABC, Institutions.L. Clinical Recognition:It is recommended:22. that alternative mechanisms of rewarding clinical practice be exploredby responsible parties in the province (i.e. levels of practice, jobclassification, decompressed salary ranges, merit increases, rolemodeling, teaching).Responsible parties: BCNU, HLRA, NAA, MOH, RNABC.A3-12M. Status:It is recommended:23. that there be a concerted effort on the part of the profession tomarket and sell its image, both within hospitals, to the. generalpublic and to those of high school age.Responsible parties: RNABC.APPENDIX 4IMPLICATIONS OF THE FUTURE HEALTH CARE SYSTEM FOR NURSINGFactorWorkforceOrganizationandManagementIssues Underlying theCurrent Nurse ManpowerSituation• effect of workplaceconsiderations (qualityof -wor kl i f e - , powerless ­ness, lack of satisfac­tion)• demands outside of theworkplace• economic/psychological/demographic character­istics of the workforce• inconsistency of roledefinition with respectto functions and duties• human resource managementstyles and practices• union/employee/mansgementrelations• remuneration and compen­sation• resource deploymentThe Future of theHealth Care System• increasing , of women in theworkforce and as heads ofhouseholds• non -nursing career optionsfor women will continue toexpand• more artificial intelligenceand information retrievalsystems• greater definition of re ­sponsibilities in healthcare (e.g. role and refer­ral mix)Implications for NurseManpower Planning• see Workplace Considerations• improved clinical and manage­ment skills for those in nurseleadership positions (alllevels)• evaluation of nursing workorganization (e.g. wardstructure)• re-evaluation of long term wagestructures for nurses~Iw

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