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Aspects of nurse manpower planning in British Columbia Ytterberg, Lorea Amolea 1980

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ASPECTS OF NURSE MANPOWER PLANNING IN BRITISH COLUMBIA by LOREA AMOLEA YTTERBERG B.N., M c G i l l  U n i v e r s i t y , 1967  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE  REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE (HEALTH SERVICES PLANNING) in  THE  FACULTY OF GRADUATE STUDIES  (Department o f H e a l t h Care and E p i d e m i o l o g y )  We a c c e p t t h i s t h e s i s as c o n f o r m i n g t o the  THE  required  standard  UNIVERSITY OF BRITISH COLUMBIA October, 1980  (c^Lorea  Amolea Y t t e r b e r g ,  1980  In presenting this thesis  in partial  fulfilment of the requirements for  an advanced degree at the University of B r i t i s h Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this for  thesis  scholarly purposes may be granted by the Head of my Department or  by his representatives.  It  is understood that copying or publication  of this thesis for financial gain shall not be allowed without my written permission.  Department of  Health Care and Epidemiology  The University of B r i t i s h Columbia  2075 Wesbrook P l a c e Vancouver, Canada V6T 1WS October, 1980 Date  ii ABSTRACT  A study was undertaken to determine how the planning process f o r post-basic  clinical  specialty  courses  f o r nurses  in British  Columbia  could be more e f f e c t i v e . In order to answer t h i s question, i t was decided f i r s t to examine the present planning process complexities agencies  i n i t s complexities.  i n educational planning  are involved:  In so doing, the  were described.  the basic  nursing  The following  education  programs, the  u n i v e r s i t y schools o f nursing, continuing education providers, (the community  colleges,  Continuing  the  Education,  University British  of B r i t i s h  Columbia  Columbia I n s t i t u t e  Division  of  of Technology), the  B r i t i s h Columbia Health Association, acute care h o s p i t a l s , the Nursing Administrators'  Association,  the Registered  Nurses'  Association of  B r i t i s h Columbia, the B r i t i s h Columbia Medical Association, the B r i t i s h Columbia M i n i s t r y o f Health, the B r i t i s h Columbia M i n i s t r y o f Education. In order to discover why a l l these agencies became involved, the nursing  education  appropriateness  issues  in British  o f education  Columbia  and t r a i n i n g  are considered.  f o r present  day  The  nursing  functions was reviewed and the importance o f c l i n i c a l s p e c i a l t y t r a i n i n g in a developed From time  medical-technological s i t u a t i o n discussed. to time  since the Second World War the "shortage" o f  nursing manpower has been a matter  o f concern  planners  employers,  whether groups o f nurses,  to p o l i c y  makers and  educational bodies or  governments. Nurse manpower planning as i t now e x i s t s i s described.  I t i s argued  that manpower planning and planning for education and t r a i n i n g o f nurses can be improved only i f the range o f s o c i a l r o l e s and the behaviour o f  iii i n d i v i d u a l nurses i n balancing these r o l e s i s taken i n t o c o n s i d e r a t i o n . Understanding  where nursing r o l e s f i t together  with  other  roles of  married women i s of c r u c i a l importance. , I t would appear that i n d i v i d u a l nurses been making p a r t i c u l a r D i r e c t o r s of Nursing  i n B r i t i s h Columbia have  demands upon employers,  represented  by  the  of h o s p i t a l s , namely demands f o r p o s i t i o n s with  greater d e c i s i o n making autonomy and more l i f e s t y l e advantages, to f i t more c l o s e l y with t h e i r other s o c i a l r o l e s . Judging by the present career choices of nurses, i t seems most do not want to be employed i n a career s t r u c t u r e which o f f e r s mobility.  H o r i z o n t a l m o b i l i t y a t the l e v e l of "bedside" nursing care  seems to be more a t t r a c t i v e . kept i n jobs i n bedside better  vertical  preparation  However, i n order to be a t t r a c t e d i n t o and  nursing care, nurses need to be provided with  than  a t present,  through  more adequate  clinical  s k i l l s based on a comprehensive knowledge ba.se. Recognition  of  the  changing  activities  of  nurses  and  the  i m p l i c a t i o n s of the changes should lead to r e v i s i o n o f planners' views about accepted  patterns i n education, t r a i n i n g and work o r g a n i z a t i o n .  This r e v i s i o n o f views could form the b a s i s f o r : a)  more r a t i o n a l planning o f education,  t r a i n i n g and  manpower  deployment b)  r e c o n s i d e r a t i o n o f the  importance of handling b u r e a u c r a t i c  planning f a i l u r e s more e f f e c t i v e l y and c) in  trade  forcibly.  more a t t e n t i o n being given to the growing i n t e r e s t o f nurses union  bargaining  i n order  to express  their  demands more  TABLE OF CONTENTS PAGE ABSTRACT  ii-iii  LIST OF APPENDICES LIST OF TABLES ACKNOWLEDGEMENTS  v vi vii  PART I  INTRODUCTION A. A Note on Method B. D e f i n i t i o n s and A b b r e v i a t i o n s  PART I I  PLANNING FOR NURSESEDUCATION AND TRAINING IN BRITISH COLUMBIA 7 A. Definitions . 7 B. B a s i c N u r s i n g E d u c a t i o n Programs 10 C. Degree Programs 13 B a c h e l o r ' s Programs 13 Master's Program 14 D. Continuing Education 1*4 E. P o s t - B a s i c C l i n c i a l S p e c i a l t y Courses 16 A v a i l a b i l i t y and Adequacy o f E x i s t i n g Programs 16 Funding I s s u e s 19 C l i n i c a l and C l a s s Room Resources 22 I s s u e s i n L o c a t i n g t h e Courses 22 A v a i l a b i l i t y o f Teaching Expertise 22 A v a i l a b i l i t y o f Students 23 F. PRESSURES TO IMPROVE CONTINUING EDUCATION SPECIALTIES: WHO IS CONCERNED? 23 1. Nurses' Concerns About C l i n i c a l S p e c i a l t y Courses . . 24 2. Peer Group Concerns: Competency 26 3. Employers' Concerns - E f f e c t i v e n e s s and E f f i c i e n c y . . 28 4. Government Involvements i n P l a n n i n g P o s t - B a s i c C l i n i c a l S p e c i a l t y Courses 32 5. D i s c u s s i o n : Who has the Power t o Make Decisions Relating to Nursing Education 34  PART I I I HISTORY OF THE NURSING FUNCTION IN THE CONTEXT OF CHANGING WOMEN'S ROLES A. The B e g i n n i n g s B. The D e p r e s s i o n Years C. The War Years and A f t e r  1 5 5  37 37 41 41  V  TABLE OF CONTENTS (cont'd) PAGE D. E. F. G. PART IV  HOW CAN THE PLANNING PROCESS BE MADE MORE EFFECTIVE? A. B. C. D.  PART V  The Last Two Decades Development of C l i n i c a l S p e c i a l t y Units Unionization Implications o f Changing A t t i t u d e s For Nurse Manpower T r a i n i n g  From S e c t o r a l Educational Concerns to Comprehensive Manpower Planning A c t i v i t i e s Nursing Manpower i n B.C I n e f f e c t i v e Cooperation between S e c t o r a l Groups i n B.C P o s s i b l e Reasons f o r I n e f f e c t i v e Planning  44 45 49 50 52 52 56 63 65  TOWARDS MORE EFFECTIVE PLANNING  72  A. B. C. D. E.  72 76 76 77 78  R a t i o n a l Planning Bureaucratic Planning Negotiation Planning Conclusions Recommendations  REFERENCES AND BIBLIOGRAPHY  80  APPENDICES  90  Appendix A  Post-Basic Nursing Programs  90  Appendix B  Process f o r Course Approval and Funding i n the Province of B r i t i s h Columbia  98  Appendix C Appendix D Appendix E  Nursing Administrators' Reaction Paper to Nursing Education: Study Report (Kermacks' Report), (1979)  . . 111  A c t i v i t i e s i n the 70's i n B r i t i s h Columbia to Support Continuing Education f o r Nurses  114  T h e o r i t i c a l Way to Determine Manpower Needs  125  vi  LIST OF TABLES  TABLE 1.  PAGE Number o f F u l l Time E q u i v a l e n t Graduate Nurses i n S p e c i a l i z e d U n i t s i n B.C. H o s p i t a l s and as P r o p o r t i o n o f T o t a l Employed Graduate Nurses 1976  78  vii  ACKNOWLEDGEMENTS  T h i s study those  people  experience  i n v o l v e d the e f f o r t s  who c o n t r i b u t e d  perspectives  to  this  of  study  many p e o p l e . by  offering  i n numerous c o n v e r s a t i o n s ,  My thanks  go  t h e i r knowledge  meetings  and  to and  interviews.  I would l i k e t o thank my committee members; D r . Anne C r i c h t o n , D r . Annette  Stark,  support and  and  Ms.  Shirley  their  perspectives My  for  their  assistance  and  valuable  advice.  I am most g r a t e f u l shared  Brandt  concerns  to my n u r s i n g c o l l e a g u e s ,  about  nursing  with  me  and  who over the y e a r s helped  to  increase  extends  to  my  fellow  students  in  Health  Services  P l a n n i n g , who have added to my u n d e r s t a n d i n g o f n u r s i n g i n the c o n t e x t h e a l t h c a r e system. would  like  am i n d e b t e d  completing t h i s  of  the  of  the  A s p e c i a l thanks to Mr. K e i t h L o u g h l i n . to  thank  John P o u s e t t e ,  K i t i m a t R e g i o n a l D i s t r i c t f o r h i s support and I  my  of nursing.  appreciation  I  have  to  Evangeline  Secretary-Treasurer  encouragement.  K e r e l u k whose  efforts  assisted  me i n  study.  Finally,  I would l i k e t o express my s i n c e r e g r a t i t u d e t o Bob and my  mother, who were always u n d e r s t a n d i n g ,  encouraging and s u p p o r t i v e .  PART I  PART 1  INTRODUCTION As  Clinical  Hospital,  D i r e c t o r of Medical  Nursing  i t became evident to the author  at  Vancouver  that there were some  d i f f i c u l t i e s i n nurses' education emerging i n the 1980's. special c l i n i c a l  General new  Nurses, with  s k i l l s , were not a v a i l a b l e i n s u f f i c i e n t numbers to  staff special c l i n i c a l units.  Discussions with other nursing admin-  i s t r a t o r s i n d i c a t e d that t h i s was a general problem and, f u r t h e r , l i t t l e t r a i n i n g was c u r r e n t l y a v a i l a b l e , i n B r i t i s h Columbia, to prepare nurses to f u n c t i o n i n s p e c i a l c l i n i c a l areas. The  professional association,  educators  and  others  had  been  cognizant of t h i s problem and although a great deal of a c t i v i t y was going on, very l i t t l e concrete a c t i o n was being taken to solve t h i s problem. This s i t u a t i o n l e d to a question which seemed to need an answer and i t became the f i r s t theme of t h i s study.  The question was:  how can the  educational planning process f o r post-basic c l i n i c a l s p e c i a l t y  courses  become more e f f e c t i v e ? In  order to answer t h i s question, i t was  decided to examine the  present educational planning process i n i t s complexities. The f o l l o w i n g agencies  seemed to be involved: basic nursing education schools (the  community c o l l e g e s , and the B r i t i s h Columbia I n s t i t u t e of the  University  Education,  the  of  British  British  Columbia D i v i s i o n  Columbia  Health  of  Technology),  Continuing  Nursing  A s s o c i a t i o n , acute  care  h o s p i t a l s , the Nursing Administrators' A s s o c i a t i o n of B r i t i s h Columbia, the Registered Nurses'  A s s o c i a t i o n of B r i t i s h  Columbia, the  British  Columbia Medical A s s o c i a t i o n , the B r i t i s h Columbia M i n i s t r i e s of Health and Education.  2.  Then, to understand seemed to be necessary  why  a l l these  agencies  became involved, i t  to look at the nursing educational  B r i t i s h Columbia, and consider the confusion in planning.  issues i n  This aspect i s  examined i n Part I I . Because there were a number of d i f f e r e n t objectives being pursued by the educational planners — building  upon  researchers important  and  in  order  clinical  to examine two  educational education  it  planners  and  to  train  specialists  administrators,  i n nursing  further questions.  closely  training  r a i s i n g the l e v e l of basic education  related  plans  likely  to  —  educators,  i t seemed to  Were the  nursing  be  objectives of  functioning?  to cope with  and  nursing  Were  shortages?  There has been a concern by the nursing profession and nursing employers, about  the  "shortage"  of nurses since  the  Second  World  War.  This  "shortage" seems to come and go but i n recent years has been increasing in B r i t i s h Columbia.  During  the  last  few  summers, i n Vancouver, the  acute care hospitals have closed patient beds, because not enough nurses have been available to provide  staffing  for them.  But no one  really  knows i f there i s a shortage of registered nurses or only a shortage  of  nurses w i l l i n g to come into the labour market. The author,  i n her capacity as administrator and employer's repre-  sentative, began to consider why for educational planning. to education of new the  Nursing  Why  the shortage was  regarded  did the planners and administrators look  r e c r u i t s to resolve the shortages?  Administrators'  as a matter  Association of the  The reaction of  Lower Mainland, at  a  meeting i n February 1980, had been to look to t r a i n i n g programs for the preparation of nurses for vacant c l i n i c a l specialty jobs. Do these planners understand the employment demands of individual nurses  in British  Columbia?  Before  committing  themselves  to  being  3.  r e c r u i t e d and a g r e e i n g to s t a y i n a j o b , the nurses p r e s e n t t h e i r demands to  the  D i r e c t o r s of Nursing  demands appear  to be  of  specific  hospitals.  g r e a t e r f o r b a s i c bedside  These  employment  care nursing p o s i t i o n s  than f o r a d m i n i s t r a t i v e p o s i t i o n s or f o r p o s i t i o n s i n which c o o r d i n a t i n g o f the work o f the l e s s w e l l t r a i n e d a s s i s t a n t s i s to be done. basic  care  specialists  nurses  (and,  more  particularly,  among b a s i c care nurses)  need  clinical  However,  technological  to b e l i e v e themselves to  be  w e l l t r a i n e d and competent to take the r e s p o n s i b i l i t i e s which have t o be handled  i n these  The  jobs.  t r a d i t i o n a l model o f a n u r s i n g c a r e e r s t r u c t u r e i s p y r a m i d a l ,  not f l a t ,  but these i n d i v i d u a l nurses have t h e i r own  t o t h e i r view o f p r e s e n t how  day  n u r s i n g f u n c t i o n s and  l o g i c which  t h e i r perception of  these can b e s t be f i t t e d i n with t h e i r o t h e r s o c i a l r o l e s .  made  Directors  structures.  of  Nursing  aware  that  I t seems t h a t t h e r e may  they  be  relate  prefer  They have  h o r i z o n t a l career  misunderstandings  about  these  employment demands and time l a g s i n responding to them among manpower and educational planners. A number o f o t h e r first  two  of  questions  these  were  occurred  educational  to  the  planning  author  but  only  questions.  the What  competencies o r standards should a nurse have i n o r d e r to work i n s p e c i a l c l i n i c a l areas?  Do nurses f e e l c o n f i d e n t to perform the f u n c t i o n s which  they are b e i n g asked  Have  Others  were  the  nursing  functions  to  do?  more g e n e r a l manpower  for special  employment/manpower planners  care areas?  clear  planning  definitions  What e f f e c t  questions. of  does the f a c t  nursing that  m a j o r i t y o f nurses are women have on t h e i r a v a i l a b i l i t y f o r work? the p l a n n e r s i n c o r p o r a t e d adequate demographic i n f o r m a t i o n about i n t o t h e i r planning?  the Have  nurses  Many nurses today seem to be " l e a v i n g " n u r s i n g f o r  4. jobs i n other areas.  Have e i t h e r the employers or planners considered  the work environment and i t s r e l a t i o n s h i p to other r o l e s i n a t t r a c t i n g and keeping nurses on the job?  I s i t c l e a r what the nurses who a c t u a l l y  provide nursing care want? Why are nurses l e a v i n g nursing?  What e f f e c t s  to o r g a n i z a t i o n a l s t r u c t u r e s and career prospects have on the nursing manpower s i t u a t i o n ? On  f u r t h e r thought,  questions  about  the r e l a t i o n s h i p  nursing manpower planning and nursing education were r a i s e d .  Why are so  few post-basic c l i n i c a l courses a v a i l a b l e i n B r i t i s h Columbia? nurse  manpower planners not been able to be s p e c i f i c  needs? they  between  Have the  i n identifying  Why are so many separate groups involved i n t h i s issue?  work  education?  together  to develop  the area  o f manpower  Who coordinates t h e i r a c t i v i t i e s ?  the i n t e r e s t e d groups get implemented?  How do  planning and  Do recommendations from  I f not, why not?  Are resources  a v a i l a b l e to provide the t r a i n i n g needed to meet the manpower r e q u i r e ments?  How i s i t decided which educational i n s t i t u t i o n w i l l provide  which program where? These questions caused the author to explore the o v e r a l l problem rather than only a segment o f i t .  This was begun by reviewing the  e v o l u t i o n o f nursing r o l e s and women's p o s i t i o n s i n Canadian s o c i e t y and by r a i s i n g questions about nurses' needs as women with other  social  roles. The  techniques  o f nurse  manpower planning  and a p p l i c a t i o n to  B r i t i s h Columbia are described i n Part IV. In  a final  section after  following  through  the questions and  analyzing documentary evidence, prospects f o r improving nurse manpower planning (and educational planning as part o f that) are reviewed, and recommendations made.  5. Since  the  focus  is  upon  clinical  specialties practised in hospitals,  little  specialties  in  attention will  be  nursing, given  to  o t h e r n u r s i n g a c t i v i t i e s such as p u b l i c h e a l t h and mental h e a l t h i n the d i s c u s s i o n which f o l l o w s . B e g i n n i n g with an i n t e r e s t i n p o s t - b a s i c c l i n i c a l s p e c i a l t y  courses  f o r nurses, the f o c u s changed to manpower i s s u e s s i n c e i t seemed t h a t c o u l d not be c o r r e c t e d without  one  the o t h e r b e i n g d e a l t w i t h .  A Note on Method T h i s i s a study o f p l a n n i n g i n the f i e l d o f n u r s i n g .  The f o l l o w i n g  methods were used: a)  analysis  of  documents  -  primary  and  secondary  source  materials, b)  d i s c u s s i o n o f the i s s u e s with p l a n n e r s i n the n u r s i n g  field,  c)  d i s c u s s i o n o f i s s u e s with a d m i n i s t r a t o r s i n the n u r s i n g f i e l d ,  d)  evaluation of planning a c t i v i t i e s against a s e r i e s of planning  paradigms, e)  development  of  recommendations  for  change  in  planning  approaches. D e f i n i t i o n s and For  Abbreviations  the purposes o f t h i s study  the f o l l o w i n g terms are d e f i n e d as  follows: B a s i c N u r s i n g E d u c a t i o n Programs practice  of nursing  i n a generalist  q u a l i f i e s them f o r r e g i s t r a t i o n .  -  prepare  role  These may  in a  students supervised  be diploma  or  to enter  the  setting  and  baccalaureate  degree program C o n t i n u i n g E d u c a t i o n - as a term, can be used b r o a d l y t o d e s c r i b e a l l e d u c a t i o n which o c c u r s f o l l o w i n g attainment o f a b a s i c q u a l i f i c a t i o n . F o r the purposes o f t h i s d i s c u s s i o n i t i s d e f i n e d as ad hoc or i n f o r m a l  6. workshops, duration  conferences,  seminars,  night  school  courses  of  limited  o r i n s e r v i c e e d u c a t i o n ( t h a t i s up t o f o r t y hours o f f u l l  study).  I t i s designed  t o develop  or maintain  nurses'  time  currency or  competency i n any a r e a o f p r a c t i c e . Post-Basic - prepare clinical (full  C l i n i c a l S p e c i a l t y Programs ( P a r t o f C o n t i n u i n g E d u c a t i o n )  nurses  for positions  specialty role,  beyond  the b a s i c  and a r e o f l o n g e r  level,  duration  than  focus  on a  forty  hours  time). Post R.N. B a c c a l a u r e a t e Degree, Master's and D o c t o r a l  - prepare nurses f o r upper l e v e l p o s i t i o n s i n c l i n i c a l , or e d u c a t i o n a l The  Direct  administrative,  roles.  following abbreviations  quotes  Degree  a r e used:  R.N.  -  Registered  RNABC  -  R e g i s t e r e d Nurses' A s s o c i a t i o n o f B r i t i s h Columbia  RPNABC  -  R e g i s t e r e d P s y c h i a t r i c Nurses' A s s o c i a t i o n o f B r i t i s h Columbia  BCHA  -  B r i t i s h Columbia H e a l t h  UBC  -  University of B r i t i s h  BCIT  -  B r i t i s h Columbia I n s t i t u t e o f Technology  CNA  -  Canadian Nurses'  BCMC  -  B r i t i s h Columbia M e d i c a l Center  BCMA  -  B r i t i s h Columbia M e d i c a l  CMA  -  Canadian M e d i c a l  HMRU  -  H e a l t h Manpower Research U n i t a t UBC  and r e f e r e n c e s  Nurse  a r e numbered  Association  Columbia  Association  Association  Association  i n the t e x t  and  listed  a l p h a b e t i c a l l y a t the end o f the n a r r a t i v e . Appendices i n c l u d e not  need t o be i n c l u d e d  l e t t e r , when a p p r o p r i a t e  s e v e r a l s e c t i o n s which support the n a r r a t i v e but do i n the argument. i n the n a r r a t i v e .  Appendices w i l l be r e f e r r e d t o by  PART I I  PLANNING  FOR  NURSES' EDUCATION AND IN B R I T I S H  COLUMBIA  TRAINING  7.  PART I I  PLANNING FOR NURSES' EDUCATION AND TRAINING IN BRITISH COLUMBIA The problem which p r e s e n t e d i t s e l f t o the author was the shortage o f n u r s e s w i t h adequate c l i n i c a l s p e c i a l t y t r a i n i n g f a i l i n g t o come forward f o r employment i n a l a r g e g e n e r a l h o s p i t a l i n Vancouver. There seemed t o be a g e n e r a l agreement among n u r s i n g p l a n n e r s and n u r s i n g a d m i n i s t r a t o r s t h a t t h i s was an e d u c a t i o n a l problem,  t h a t the  c u r r e n t shortage was a t l e a s t p a r t l y due t o the i n a d e q u a c i e s o f p r o v i s i o n for continuing education i n c l i n i c a l s p e c i a l t i e s . Although p o s t - b a s i c c l i n i c a l s p e c i a l t y programs were the main f o c u s o f the study i t seemed t o be n e c e s s a r y  t o c o n s i d e r the r e l a t i o n s h i p  between the d i f f e r e n t p a r t s o f the system o f n u r s i n g e d u c a t i o n i n o r d e r to show how these c l i n i c a l programs f i t i n t o the whole, how a p p r o p r i a t e they a r e now and what a r e the problems a s s o c i a t e d w i t h t h e i r development o r l a c k o f development. A.  Definitions The d i s c u s s i o n o f p r e s e n t p l a n n i n g f o r n u r s i n g e d u c a t i o n must b e g i n  with a c l a r i f i c a t i o n  o f the uses o f the words " e d u c a t i o n " and " t r a i n i n g "  f o r t h e r e a r e semantic  problems.  In g e n e r a l use, " e d u c a t i o n " i s a broader term which i m p l i e s i n t e l lectual learning.  I n Canada today  i t o f t e n r e f e r s t o a minimum o f  college or u n i v e r s i t y education. "to develop m e n t a l l y and m o r a l l y e s p e c i a l l y by i n s t r u c t i o n " (124) T r a i n i n g i s a term which i m p l i e s l e a r n i n g o f r o l e m o d e l l i n g o r learning o f a t e c h n i c a l nature.  I t does n o t mean simply r o t e l e a r n i n g o f  t a s k s , b u t encompasses c o n c e p t u a l t h i n k i n g r e l a t e d t o the p r o f i c i e n c y achieved.  8. "to form by i n s t r u c t i o n , d i s c i p l i n e or d r i l l " "to teach as to be f i t t e d , q u a l i f i e d or p r o f i c i e n t " (124) Dr. Helen Mussalem (85), Executive D i r e c t o r of the CNA i a t e s between t r a i n i n g and educating the nurse.  different-  She says that educating  a nurse equips her mentally to work f a r beyond the r o l e of a t e c h n i c i a n and develops a nurse's a b i l i t y to f u n c t i o n a t a policy-making and at an administrative  level.  Traditionally,  encourage more emphasis on  education  i t has  been  of nurses,  CNA  policy  a policy  to  strongly  supported by the p r o v i n c i a l nursing a s s o c i a t i o n . But the majority o f nurses do not f u n c t i o n at t h i s l e v e l , although every nurse makes many decisions every working day.  Does t h i s then imply  that basic beginning l e v e l nurses are t r a i n e d but not w e l l educated? Nurses do not l i k e the word t r a i n i n g applied to t h e i r p r o f e s s i o n . I t has a negative connotation since i t i s o f t e n equated by nurses with the apprenticeship system of l e a r n i n g , or the rote system of l e a r n i n g to perform s k i l l s without knowing the conceptual reasons behind them. Today's nurses are engaged i n strong d i s c u s s i o n about minimum entry q u a l i f i c a t i o n s to p r a c t i c e nursing. One school of thought suggests that current preparation i s adequate.  The other school argues that a univer-  s i t y bachelor's degree should be the minimum q u a l i f i c a t i o n . The d i c t i o n a r y d e f i n i t i o n of t r a i n i n g , "to be f i t t e d , q u a l i f i e d or p r o f i c i e n t " does apply to nurses at the beginning l e v e l and t h i s i s often the goal of nursing schools. positive  connotation.  T r a i n i n g used i n t h i s way  has a very  P o s s i b l y too much a t t e n t i o n has been given to  education rather than t r a i n i n g  i n recent years for there has been a  recent surge o f concern about the adequacy of t r a i n i n g f o r these c l i n i c a l nurses,  and  the  numbers a v a i l a b l e  services i n B r i t i s h Columbia.  to provide  t e c h n o l o g i c a l nursing  9.  Who,  then, i s responsible for planning education and t r a i n i n g of  nurses?  Are  these education planners  i n touch with the employment  situation? B r i t i s h Columbia has only prepared 35 to 40$ nurses i t needs i n the work force.  of the t o t a l number of  I t has depended on immigration from  other countries and t r a n s f e r s from other provinces to provide s u f f i c i e n t numbers o f nurses.  As other provinces are reducing the numbers of  students i n t h e i r nursing programs, t h i s province w i l l have to provide more of i t s own basic nursing education. The  Foulkes' Report  (60)  - a review of health care i n B r i t i s h  Columbia - addressed these issues and recommended expanding the number of t r a i n i n g  programs i n u n i v e r s i t i e s and  community c o l l e g e s .  More  r e c e n t l y , the Open Learning I n s t i t u t e has begun to o f f e r some courses to students i n i s o l a t e d areas.  Funding f o r nursing education continues to  be a problem f o r some p o t e n t i a l r e c r u i t s .  Whilst the RNABC set aside  some money f o r b u r s a r i e s t h i s comes nowhere near meeting demand. In two phases, 1968  and 1971,  the RNABC developed reviews of basic  and post-basic education of nurses i n the province (93,  94).  The report (125)  in  The second report  (93)  r e i t e r a t e d the continuing need i d e n t i f i e d i n the Weir Report 1934  f o r nurses educated at the u n i v e r s i t y l e v e l .  reviewed  the f a c i l i t i e s a v a i l a b l e f o r post-basic education  (only  UBC  School of Nursing) and suggested ways i n which more candidates could be admitted  to programs and how  entering  UBC.  nurses could gain degree c r e d i t s before  I t recommended a c o l l a b o r a t i v e approach by  Canadian  u n i v e r s i t i e s to developing nursing Master's programs and a l s o recognized the need f o r d o c t o r a l programs i n Canada. The educational planning process i n confused and there has grown up a complexity of bodies responsible f o r d i f f e r e n t aspects of p r o v i d i n g  10. education  and  training  or  providing  funding  for  the  purpose  evaluating and i n f l u e n c i n g education and t r a i n i n g a c t i v i t i e s .  of  The des-  c r i p t i o n of present day curriculum and course planning which f o l l o w i n g i s concerned with e x p l a i n i n g these inputs into education and p o l i c y making and  the gaps and  overlaps i n the process  training  of planning  programs. B.  Basic Nursing Education Programs Entry i n t o the p r a c t i c e of nursing i n B r i t i s h Columbia i s provided  by four kinds of basic education programs.  These are:  nursing  (2) psychiatric  programs  (diploma  or  degree)*,  ( 1 ) general nursing  (diploma), ( 3 ) p r a c t i c a l nursing**, ( 4 ) nursing aide***. Basic nursing programs are institutions*  except  for  general  offered p r i m a r i l y nursing  diploma  in  post-secondary  programs  at  the  Vancouver, Royal J u b i l e e and V i c t o r i a General H o s p i t a l s .  General and P s y c h i a t r i c Nursing Programs General  and  psychiatric  o b j e c t i v e s f o r t h e i r graduates  programs except  do  graduates  to  assess,  differ  greatly  in  i n making them competent i n the  c l i n i c a l areas i n which they are prepared programs expect  not  to f u n c t i o n .  plan,  Both types of  implement and  evaluate  nursing care f o r i n d i v i d u a l s of a l l age groups.  *Degree programs are described i n Section C of t h i s chapter. The f i r s t two years of the baccalaureate curriculum at UBC have been s i m i l a r to the diploma years, but t h i s program has now been r e v i s e d so that students must complete a l l four years of the program before they are q u a l i f i e d to enter p r a c t i c e and w r i t e the r e g i s t r a t i o n examinations. Nurses graduating from diploma programs are accepted for f u r t h e r education i n degree programs i n the province. * * P r a c t i c a l nursing and aide programs are not discussed f u r t h e r because graduates generally have to s t a r t over i n a general nursing program i n order to advance i n nursing.  .11.  General  nursing  programs focus  on 'providing care  for  medical,  s u r g i c a l , p e d i a t r i c , post-partum and nursery and p s y c h i a t r i c p a t i e n t s . Psychiatric  nursing  programs  psychiatric  i l l n e s s and  emphasize  the  care  mental r e t a r d a t i o n .  of  patients  There are  ten  nursing diploma courses and two p s y c h i a t r i c nursing programs.  with  general Programs  vary from two to three years. The current trend i s f o r programs to be longer  to provide more c l i n i c a l experience  i n various forms f o r the  students. Graduates of these programs receive a diploma and are e l i g i b l e to write n a t i o n a l r e g i s t r a t i o n Responsibility provinces  for  i n Canada;  examinations.  the  control  therefore,  of  education  a l l educational  rests programs  with  the  for  the  preparation of health manpower must be approved by the p r o v i n c i a l authorities.  I f an agency or i n s t i t u t i o n i s to obtain approval to conduct a  school, the agency  (or i n s t i t u t i o n ) , must meet c e r t a i n standards  in  regard to length of program, curriculum, f a c u l t y , and other aspects of educational  administration.  Under  the  health  practitioner  acts,  a u t h o r i t y to c o n t r o l healing a r t s has been delegated i n most cases to the respective  professional associations  established c r i t e r i a .  in  the  provinces  which  have  The a s s o c i a t i o n s set f o r t h minimum requirements  for the conduct of schools to prepare t h e i r p r a c t i t i o n e r s . Any educational body can provide a program to t r a i n nurses, but i n B.C.  only nursing students who  graduate from a program which has been  approved by the RNABC can write r e g i s t r a t i o n exams. The graduates of these programs may  also w r i t e standardized exam-  i n a t i o n s f o r the purpose of r e g i s t r a t i o n . examinations,  These are n a t i o n a l l y set  but allow f o r r e g i s t r a t i o n only w i t h i n the province i n  which the graduate i s w r i t i n g the exam.  12. Curricula  o f diploma  programs are s t r u c t u r e d i n a v a r i e t y o f  patterns, the most common being a s i x semester program i n two years. The major part o f the f i n a l  semester  i s usually  concentrated  clinical  p r a c t i c e to consolidate s k i l l s p r i o r t o graduation. A l l diploma programs include i n s t r u c t i o n i n nursing, the p h y s i c a l and  social  sciences  and most  include general  education subjects.  Courses i n the p h y s i c a l and s o c i a l sciences and other f i e l d s are u s u a l l y taught by f a c u l t y i n other d i s c i p l i n e s .  Nursing students r a r e l y share  common c l a s s e s with other students because o f scheduling complications, content  needs  not  shared  by  other  programs  and  institutional  organization o f separate programs i n s e l f - c o n t a i n e d u n i t s .  Nursing i s  the major component o f a l l programs, compromising 72% to 93% o f the content o f each program. There are s i g n i f i c a n t v a r i a t i o n s i n the amount of time spent i n nursing theory and p r a c t i c e from program to program. Laboratory and c l i n i c a l  time v a r i e s from 45.5% to 7&% o f the t o t a l  programs i n schools o f nursing.  The question a r i s e s as t o whether t h i s  variance has a major e f f e c t on the f i n a l product, the graduate, and whether or not i t i s s u f f i c i e n t when looking a t needs f o r continuing education. Entrance requirements  f o r diploma nursing programs vary with the  i n s t i t u t i o n p r o v i d i n g the education.  A l l schools except Douglas College  require a minimum o f grade twelve education, but subject requirements i n grade twelve vary from c o l l e g e t o c o l l e g e . Funding  f o r these  programs  i s provided  i n s t i t u t i o n s through the Department o f Education. t r a t i o n fee which colleges.  by  the sponsoring  Students pay a r e g i s -  i s i n l i n e with that paid by other students i n the  Most funding i s from the government.  Nursing schools are  expensive because o f the low r a t i o o f p u p i l to teacher when students are l e a r n i n g c l i n i c a l s k i l l s or p r a c t i s i n g i n the c l i n i c a l areas.  .13. C.  Degree Programs 1.  Bachelor's Programs The U n i v e r s i t y of B r i t i s h Columbia i n s t i t u t e d the f i r s t degree  program f o r nurses i n 1923.  Since then, the program has undergone many  r e v i s i o n s , the l a t e s t being i n 1980.  Students w i l l complete a four year  baccalaureate program before entering p r a c t i c e .  This, i n essence, adds  a f i f t h type of basic education program. In 1976, the U n i v e r s i t y of V i c t o r i a began i t s two year Bachelor o f Science i n Nursing degree program f o r r e g i s t e r e d nurses. The  o v e r a l l objectives of both B.S.N, programs are s i m i l a r ;  to  broaden and enhance knowledge and s k i l l s , p a r t i c u l a r l y i n r e l a t i o n to problem  s o l v i n g or s c i e n t i f i c method and  to develop new  skills;  to  provide nursing care to i n d i v i d u a l s , f a m i l i e s and community groups; to function w i t h i n a v a r i e t y increase  ability  to  of s e t t i n g s w i t h i n  function  the community and  interdependently with  other  to  health  professionals. The scheduled time spent i n c l i n i c a l 50%.  p r a c t i c e v a r i e s from 25% to  Students have some choice i n the s e l e c t i o n o f c l i n i c a l areas w i t h i n  broad s e t t i n g s . At both u n i v e r s i t i e s , nursing courses predominate, but courses i n p h y s i c a l and/or s o c i a l sciences are a l s o required.  Basic s t a t i s t i c s and  research methodology are included i n both programs. opportunity  to choose e l e c t i v e  courses and/or  Students have the  independent  directed  studies i n a selected area. The UBC Bachelor Degree must meet the requirements f o r approval of schools o f nursing by the RNABC. Then students are e l i g i b l e to write the n a t i o n a l r e g i s t r a t i o n exam w r i t t e n by other basic students.  Students  from both u n i v e r s i t i e s graduate with a Bachelor of Science i n Nursing degree.  14. 2.  Master's Program The Master of Science i n Nursing program at UBC began i n 1968.  This program prepares graduates to give h i g h l y s k i l l e d care, u t i l i z e the s c i e n t i f i c method of i n q u i r y , e f f e c t change and assume leadership r o l e s . As w e l l , s p e c i a l courses i n f u n c t i o n a l areas of a d m i n i s t r a t i o n , teaching or research or i n c l i n i c a l s p e c i a l i z a t i o n are a v a i l a b l e , depending on the student's choice.  Graduates are expected  to assume upper l e v e l  p o s i t i o n s i n f u n c t i o n a l or c l i n i c a l r o l e s . The M.S.N, program i s two academic years i n length, and c o n s i s t s almost e n t i r e l y  of nursing  courses.  In  the  first  year,  concentrate on systematic approaches to p a t i e n t care and methodology.  Clinical  experience  students  on  research  with selected p a t i e n t s i s managed.  Students  study and work with i n d i v i d u a l s of a selected maturational  stage.  Students  clinical  i n the second year  s e l e c t from courses  related  to  nursing, nursing education, nursing s e r v i c e a d m i n i s t r a t i o n ,  c o n s u l t a t i o n and c l i n i c a l research.  C l i n i c a l experience i s planned with  some courses. Students graduate with a Master of Science i n Nursing.  Evaluation  of the program i s the same as the bachelor's programs. Funding f o r these programs i s a l l o c a t e d through U n i v e r s i t y senates. Nurses pay the same r e g i s t r a t i o n fee as the other u n i v e r s i t y students. D.  Continuing Education 1.  Continuing Education Programs Continuing  education,  as  describe a l l education which occurs qualification.  a  term, can  be  used broadly  f o l l o w i n g attainment  to  of a basic  For the purposes of t h i s d i s c u s s i o n i t i s defined as ad  hoc or informal workshops, conferences, seminars, night school  courses  of l i m i t e d duration or i n s e r v i c e education (that i s up to f o r t y hours of f u l l time study).  15.  During  the e a r l y  sixties,  RNABC  staff  presented  e d u c a t i o n workshops f o r nurses a c r o s s the p r o v i n c e . expensive undertaking.  T h i s became a v e r y  I n 1966, the RNABC changed i t s p o l i c y and began  to work t o f a c i l i t a t e programs r a t h e r than p r o v i d e them. hospitals,  community  continuing  c o l l e g e s and u n i v e r s i t i e s  I t involved  i n presenting  these  programs t o n u r s e s f o r a reasonable f e e which u s u a l l y covered the c o s t s o f expenses. In 1967, t h e RNABC f a c i l i t a t e d t h e l i n k i n g o f n u r s i n g c o n t i n u i n g e d u c a t i o n w i t h an e s t a b l i s h e d , p o w e r f u l U n i v e r s i t y o f B r i t i s h Columbia Continuing  Medical  Education  body.  I t s recommendation  was, t h a t  " c o l l a b o r a t i o n be undertaken w i t h t h e Department o f C o n t i n u i n g M e d i c a l E d u c a t i o n t o send a nurse w i t h d o c t o r s p r e s e n t i n g M e d i c a l  Continuing  E d u c a t i o n programs, t o p r o v i d e r e l a t e d n u r s i n g i n s e r v i c e " (104). was  This  implemented i n t h e next year when f o u r c o u r s e s were p r e s e n t e d by  d o c t o r s and n u r s e s . A f u r t h e r stop i n d e v e l o p i n g c o n t i n u i n g e d u c a t i o n f o r n u r s i n g was taken i n 1968 i n response t o an Annual Meeting R e s o l u t i o n i n 1967 (104, 105).  The r e s o l u t i o n passed by the membership read a s f o l l o w s : That the RNABC o f f e r t o c o n t r i b u t e $5,000.00 per y e a r t o UBC f o r a p e r i o d o f f i v e y e a r s , t o a p p o i n t a f u l l time n u r s i n g f a c u l t y member t o the S c h o o l o f N u r s i n g , s a i d f a c u l t y member t o be seconded t o the Department o f C o n t i n u i n g M e d i c a l E d u c a t i o n t o a s s e s s the needs and r e s o u r c e s f o r c o n t i n u i n g e d u c a t i o n f o r nurses and t o p l a n , develop, implement and c o o r d i n a t e p r o j e c t s f o r c o n t i n u i n g e d u c a t i o n purposes. N e g o t i a t i o n s ensued w i t h UBC and a f t e r i n i t i a l d i f f i c u l t i e s , an  a p p r o p r i a t e appointment was made. f u n c t i o n s now b e i n g  performed  The RNABC o b v i o u s l y thought the  by nurses  could not continue  safely  w i t h o u t i n c r e a s e d e d u c a t i o n b u t i t had n o t been s u c c e s s f u l i n making t h i s need known t o the f u n d i n g b o d i e s , so i t p r o v i d e d the f u n d i n g . c o n t i n u e d t o fund t h i s p o s i t i o n u n t i l 1977.  The RNABC  16.  There has  been considerable development w i t h i n the province i n  continuing education w i t h i n the l a s t ten yers.  The  UBC  D i v i s i o n of  Continuing Education has provided most courses to nurses, followed by the U n i v e r s i t y of V i c t o r i a , BCIT and some of the community c o l l e g e s , but entrepreneurial groups and s p e c i a l i n t e r e s t groups w i t h i n nursing have a l s o undertaken a number of courses. In  general, continuing education  programs f o r nurses  funded through r e g i s t r a t i o n fees of p a r t i c i p a n t s .  are  self  I f i n d i v i d u a l nurses  or i n s t i t u t i o n s do not see these programs as meeting t h e i r needs, the attendance w i l l be low. Although there are areas of concern to be resolved i n developing continuing education programs f o r nurses, such as standards, to most people with i n f l u e n c e i n planning nurse education, t h i s i s not an area of major concern at t h i s time. In important  general,  continuing  i f specific  education  evaluations of  purpose of r e - r e g i s t r a t i o n are to be E.  programs nurses'  will  become  competencies  more  for  the  undertaken.  Post-Basic C l i n i c a l S p e c i a l t y Courses i)  A v a i l a b i l i t y and Adequacy of E x i s t i n g Programs During the 70's a number of b r i e f s and studies concerning the  need f o r post-basic c l i n i c a l s p e c i a l t y courses i n B.C. were c a r r i e d out. (See  Appendix D f o r complete l i s t i n g )  recommended that t h i s c u r r e n t l y  Although  they  a l l strongly  l a c k i n g area of nursing t r a i n i n g  be  provided, there was a l o t of motion but very l i t t l e productive a c t i v i t y . The RNABC was very concerned about the lack of post-basic c l i n i c a l s p e c i a l t y courses, so i t decided that i t had a r e s p o n s i b i l i t y to ensure that nurses received t h i s education.  17. By Division  1973 the RNABC had met with the f o l l o w i n g bodies; the UBC of Continuing Nursing Education, the Royal  Paul's, and Vancouver  General H o s p i t a l s ,  Intensive and Coronary Care Course.  Columbian, S t .  to develop and sponsor an  B r i t i s h Columbia H o s p i t a l Insurance  provided f i n a n c i a l support f o r program development and implementation; W.K.  Kellogg Foundation p a r t i c i p a t e d i n the developmental funding. The  UBC School of Nursing funded the evaluation of t h i s course. was  This course  repeated twice, s u c c e s s f u l l y , i n 1975 but further courses were  cancelled because of the lack of funding. The inadequate supply of nurses prepared t o work i n c r i t i c a l care areas became a serious issue i n e a r l y 1980. Health attempted  t o i d e n t i f y immediate  The p r o v i n c i a l M i n i s t r y of  needs so that crash programs  could be developed, but the problem was too complex and involved more than simply a numbers i d e n t i f i c a t i o n .  This attempt was not u s e f u l i n  i d e n t i f y i n g immediate need. In  a paper  Nursing Education  entitled (1980)"  "RNABC Views on Continuing Basic C l i n i c a l (100)  the RNABC i d e n t i f i e d current programming  a c t i v i t y as f o l l o w s : As of February, 198O, there are programs e i t h e r operating or proposed f o r a l l the known high need c l i n i c a l areas except neonatal i n t e n s i v e care. There i s almost no information to suggest how many nurses require t r a i n i n g i n each category. While there i s evidence that the number o f nurses r e q u i r i n g t r a i n i n g are considerable, the numbers which can be immediately t r a i n e d w i l l be l i m i t e d by a number of f a c t o r s , i n c l u d i n g a v a i l a b i l i t y of qualified instructional personnel, a b i l i t y of agencies to replace s t a f f that can be released f o r t r a i n i n g , the u n c e r t a i n t i e s connected with new and u n t r i e d course o f f e r i n g s , a v a i l a b i l i t y of funds to compensate nurses f o r s a l a r y l o s s during t r a i n i n g , and a v a i l a b i l i t y of funds f o r course development and operation. I t appears that the most c a r e f u l a l B e i t o p t i m i s t i c , estimates of numbers of nurses that could be t r a i n e d have been made by providers i n t h e i r course p r o j e c t i o n s . U n t i l there i s a d d i t i o n a l and better information which could a l t e r these  18. estimates, RNABC should support these as immediate post-basic t r a i n i n g goals and should caution against o v e r l y o p t i m i s t i c planning o f "crash programs." The Association should also support the e a r l y development o f a program f o r neonatal i n t e n s i v e care. This same paper also i d e n t i f i e s post-basic programs c u r r e n t l y being presented or i n the planning stages. In  a Post-Basic Nursing Programs Discussion Paper o f March, 1980  (121) Dr. Sheilah Thompson, Coordinator o f Health and Human Services Programs, M i n i s t r y o f Education, l i s t s post-basic courses and adds some courses i n the planning stages. These t r a i n i n g programs themselves vary i n length and l e v e l o f specialization.  For example, the Post-Basic Operating  Room Nursing  Course a t S t . Paul's H o s p i t a l i s 24 weeks i n length and includes m a t e r i a l on a l l major O.R. s e r v i c e s , post-anesthetic recovery  room and some  managerial information. The Okanagan College provides a program of 12 to 16 weeks to educate non-specialized Operating Room s t a f f . Most o f the programs do provide some form o f c e r t i f i c a t e f o r t h e i r graduates and e f f o r t s are underway to standardize the c e r t i f i c a t i o n . Although most o f these post-basic programs now must submit t h e i r curriculum to the RNABC Continuing Nursing Education Approval Program, t h i s i s a voluntary a c t i v i t y , so programs can be taught without e x t e r n a l evaluation mechanisms.  ^  Although curriculum approach v a r i e s according to the group which i s presenting the program, as w e l l as what s p e c i a l t y the program i s about, one thing i n common to a l l c l i n i c a l s p e c i a l t y post-basic courses i s that c l i n i c a l p r a c t i c e i s seen t o be as important as the t h e o r e t i c a l aspects of the course. Nurses who complete c l i n i c a l s p e c i a l t y courses are accepted by the employing agencies to work i n the s p e c i a l t y area f o r which they have been  19.  trained.  However, there i s a problem  f o r employing  agencies because  nurses from these courses i n B.C., and others i n Canada, may have been prepared to f u n c t i o n at d i f f e r e n t l e v e l s , therefore, s t a f f o r i e n t a t i o n programs have t o d i f f e r s i g n i f i c a n t l y - both w i t h i n the i n s t i t u t i o n s and between the i n s t i t u t i o n s . ii)  Funding Issues Most post-basic courses are expensive.  cost $25.00  t o $40.00  per day per student,  They are estimated to or from  $50,000.00 to  $60,000.00 per course. Funding f o r post-basic courses i s v a r i a b l e . *  The courses can be  paid f o r through student r e g i s t r a t i o n fees, through h o s p i t a l funding, or by the M i n i s t r i e s of Education, U n i v e r s i t i e s Science and Communication or Health.  In general, continuing education has been paid f o r by  students but c l i n i c a l s p e c i a l t y courses have sometimes been funded from other sources. Hospitals do provide a few post-basic courses, u s u a l l y out of d i r e need. In some h o s p i t a l s the student has been expected to provide service to the i n s t i t u t i o n during the post-basic course period as a means of c o n t r i b u t i n g t o the cost of the course, but t h i s type of payment f o r education  i s on the decline.  Education  f o r Nurses,  According  to L i s t i n g  published by the RNABC i n October,  post-basic courses i n the province are funded Columbia h o s p i t a l  of Continuing  p r o v i d i n g courses,  t h i s way.  1979, no  Any B r i t i s h  i s presently supporting  courses by s p e c i a l grants or out of general h o s p i t a l budgets.  these  (Appendix  A)  *This information has been taken from published documents. The current s i t u a t i o n may be d i f f e r e n t , since documents were consulted only up to June, 1980.  20. In  educational  institutions,  the funding  problem  i s further  compounded by the manner i n which funding i s a l l o c a t e d to community college nursing departments, BCIT and the UBC Department o f Continuing Education. Most  community  c o l l e g e s with  nursing  departments are u s u a l l y  organized i n such a way that a l l nursing education o f f e r i n g s stem from that  department.  I f short  term  continuing education  programs or  post-basic nursing programs are to be presented, the resources a v a i l a b l e are those from w i t h i n the department o f nursing.  Financially,  these  departments can submit proposals f o r post-basic courses (through t h e i r i n t e r n a l approval bodies) to the M i n i s t r y o f Education who w i l l approve or not approve funding.  The d i f f i c u l t y i s two-fold.  One, the i n i t i a l  developmental work to present the courses f o r approval must be provided by  the department's educators.  These  persons  already  have  major  r e s p o n s i b i l i t i e s for ensuring the adequacy o f basic education programs and have l i t t l e , i f any, time f o r other a c t i v i t i e s .  This problem has  been overcome by the RNABC Board o f D i r e c t o r s . In January, 1980, they approved  a policy  o f providing developmental  c l i n i c a l s p e c i a l t y programs.  funds  f o r post-basic  Funds have since been made a v a i l a b l e and  a l l o c a t e d f o r t h i s purpose. The second d i f f i c u l t y i s that there are no set c r i t e r i a to determine whether or not they might receive funding from the M i n i s t r y o f Education. This approval process i s an extensive one which can take up to two years to complete.  (See Appendix B) By that time, others may have already met  the i d e n t i f i e d needs, or other resources such as f a c u l t y or c l i n i c a l space may no longer be a v a i l a b l e . BCIT d i f f e r s from community c o l l e g e s i n that i t has a s p e c i f i c department whose purpose i s t o provide continuing educational o f f e r i n g s .  21. Therefore funding  the  resources  sources  are  department's budget.  f o r basic planning are more a v a i l a b l e ,  more  readily  accessible  from  within  and that  I f funding must be obtained from the M i n i s t r y of  Education the same process i s engaged i n as the community c o l l e g e s with one exception.  P r i o r to the l e t t e r of intent being sent to the M i n i s t e r ,  the proposal has to be f u l l y formulated and the proposed programs must be approved i n t e r n a l l y . UBC's Continuing d i f f e r e n t manner.  Education  i n Health  Sciences  i s funded  The d i v i s i o n i s composed o f an Executive D i r e c t o r of  the d i v i s i o n , D i r e c t o r s for each health science d i s c i p l i n e and staff.  in a  Each Health Science  Discipline  i n the  Continuing  support  Education  D i v i s i o n provides s a l a r y funding f o r i t s respective D i r e c t o r and  one  secretary.  The  salary  The School of Nursing a l s o funds an A s s i s t a n t D i r e c t o r .  of the  Executive D i r e c t o r and  other  support  s t a f f plus  any  operating costs are funded from charges to p a r t i c i p a n t s i n the various continuing education presentations, which must be s e l f - s u p p o r t i n g . Therefore, each p a r t i c i p a n t i n a continuing educational program presented by the D i v i s i o n pays f o r the costs of the course plus a p o r t i o n of the a d m i n i s t r a t i v e and operating overhead.  To sum up, funding for  post-basic courses i n nursing i s haphazard, because p r i o r i t i e s i n need f o r programs f o r c l i n i c a l s p e c i a l t i e s have not been i d e n t i f i e d . With the lack of i d e n t i f i c a t i o n of program need, the Department of 'Education cannot budget f o r programs on an ongoing b a s i s , even i f the department were to accept the r e s p o n s i b i l i t y f o r funding them as part of t o t a l nursing education p o l i c y .  Nor can i t provide g u i d e l i n e s to the  Academic Council as to the p r i o r i t i e s of nursing education over other educational needs.  Consequently, the energy expended i n procuring these  funds on an ad hoc b a s i s , makes these courses very expensive.  Teaching  22. material  cannot  be  planned  f o r continuing education courses but i s  c o n t i n u a l l y being s t a r t e d from "scratch" which i s not cost e f f e c t i v e . Post-basic courses are expensive to develop and operate, since s t a f f are required  f o r development,  supervision.  formal i n s t r u c t i o n ,  and  on-site  clinical  How much more expensive are they when each course begins at  the beginning to r e c r u i t and o r i e n t a t e s t a f f who w i l l have to experience problems that might have been solved by previous s t a f f had they continued to teach the course the second and t h i r d time? i i i ) C l i n i c a l and Class Room Resources Shortage of c l i n i c a l p r a c t i c e area and classroom resources i s a problem  i n presenting post-basic nursing education, p a r t i c u l a r l y i n  the lower mainland where the c l i n i c a l f a c i l i t i e s which might provide s u f f i c i e n t experience f o r the students are located. agencies already have d i f f i c u l t y current basic courses.  The lower mainland  i n providing c l i n i c a l spaces f o r the  Classroom space a v a i l a b i l i t y  may create f u r t h e r  problems but these are not as d i f f i c u l t to solve. iv)  Issues i n Locating Courses The  l o c a t i o n of courses provides added problems f o r nurses  l i v i n g outside the d i s t r i c t who must pay extra f o r board and room as w e l l as l o s i n g pay.  This i s d i f f i c u l t to accept when a nurse knows that she  w i l l not be f i n a n c i a l l y rewarded  f o r her e f f o r t s unless she wishes to  acquire geographic m o b i l i t y . v)  A v a i l a b i l i t y of Teaching Expertise Another major problem i s the recruitment of teachers with the  c l i n i c a l e x p e r t i s e necessary to i n s t r u c t i n post-basic programs.  Since  there i s not a c l i n i c a l education career ladder, c o l l e g e s must choose from educators who do not have c l i n i c a l e x p e r t i s e or p r a c t i t i o n e r s lack teaching and programming s k i l l s .  who  This becomes even more d i f f i c u l t  23. when programs are  offered on an ad hoc  basis because nurses do  not  prepare themselves f o r t h i s l e v e l of teaching and job s e c u r i t y i s l a c k i n g f o r anyone who might be prepared and interested to teach because of the nature o f the vi)  planning.  A v a i l a b i l i t y of Students P o t e n t i a l students f o r s p e c i a l t y courses are  working i n s p e c i a l care areas. life.  often  already  This i s not d e s i r a b l e , but a f a c t of  Hospitals would have d i f f i c u l t y r e p l a c i n g these s t a f f members f o r  the period of post-basic courses because they are already short o f nurses i n the s p e c i a l t y areas. F.  Pressures to Improve Continuing Education S p e c i a l t i e s : Who i s Concerned? As the confusion described i n the previous sections must i n d i c a t e ,  there are a number of d i f f e r e n t i n d i v i d u a l s and groups concerned about basic and  continuing education for nurses.  Their reasons f o r concern  d i f f e r and w i l l be discussed below. The nurses themselves are concerned about t h e i r education i n a society where q u a l i f i c a t i o n s are more and  more  educational  important  for  opportunities  opportunities.  a t t a i n i n g economic  are  This i s discussed  so  closely  becoming  rewards and  linked  with  where social  in F ( i ) .  The second section of the discussion F ( i i ) i s concerned with professional association's attitudes. e f f e c t i v e i n planning,  the  Since other groups have not been  the nurses' p r o f e s s i o n a l a s s o c i a t i o n has  much of the i n i t i a t i v e i n educational development.  taken  Their spokeswomen i n  the p r o f e s s i o n a l a s s o c i a t i o n and unions have struggled to help nurses to attain  greater  recognition  as  a  group,  firstly,  through  pursuing  p r o f e s s i o n a l objectives and more r e c e n t l y through union a c t i o n . On  the  other hand, the employers of nurses are  standards and  cost-effectiveness  and  efficiency.  The  concerned about third  section  24.  F(iii)  considers  education. are  the  employers'  attitudes  to  clinical  specialty  I t must be pointed out that i n B.C. the employers concerned  the h o s p i t a l s a c t i n g as a consortium (the BCHA), or i n d i v i d u a l l y ; the  Nursing Administrators' A s s o c i a t i o n speaks on behalf of the D i r e c t o r s of Nursing  of  the h o s p i t a l s  who  are  the p r i n c i p a l  concerned with the deployment of nursing s t a f f s . this  discussion of employers*  executive o f f i c e r s  The BCMA i s included i n  a t t i t u d e s , f o r w h i l s t doctors are not  employers of nurses they are much concerned about the q u a l i t y of help provided by the nurses working with them. The fourth s e c t i o n F(iv)  i s concerned with government planning. I t  has to be recognized that government has been entering the planning scene gradually as more demands have begun to be made f o r funding of programs rather than i n s t i t u t i o n s . 1.)  Nurses' Concerns about C l i n i c a l S p e c i a l t y Courses Post-graduate c l i n i c a l s p e c i a l t y courses o f f e r both advantages  and  disadvantages  f o r nurses.  Geographic  career m o b i l i t y  i s one  possible outcome f o r those nurses taking post-basic courses.  Nurses  w i l l be able to work i n c l i n i c a l s p e c i a l t y areas i n nursing and can then t r a n s f e r to a r e l a t e d c l i n i c a l s p e c i a l t y i n a way that nurses without post-basic education cannot do. to  another town w i l l  A nurse who must move with her husband  become immediately sought  after  by  the  local  hospital. Another  example of w i t h i n  institutional  mobility  i s the nurse  educated i n Coronary Care Nursing who i s more e a s i l y able to t r a n s f e r to a general i n t e n s i v e care u n i t , a post-anesthetic recovery room, or a burn u n i t than a nurse without such post-basic t r a i n i n g .  Unfortunately,  however, once orientated i n t o a s p e c i a l u n i t , a nurse does not have the same upward career m o b i l i t y as nurses taking post-basic a d m i n i s t r a t i v e  25. courses since c l i n i c a l career ladders are rare or non-existent i n the province. The current c o l l e c t i v e agreement between the Health Labor Relations A s s o c i a t i o n of B r i t i s h  Columbia and RNABC, Labor Relations D i v i s i o n ,  does not e i t h e r encourage or recognize a c l i n i c a l career ladder. 52:01  Clause  of the current contract does give f i n a n c i a l reward f o r s p e c i a l  c l i n i c a l preparation, but only i f the nurse has attended a course, of not l e s s than s i x months, approved by the RNABC, and i s employed i n the s p e c i a l s e r v i c e f o r which she/he has q u a l i f i e d .  These nurses w i l l be  paid an a d d i t i o n a l twenty-five d o l l a r s a month i f they have u t i l i z e d the course w i t h i n four years p r i o r to employment. At the present time, only nurses who have completed courses i n Operating Room Nursing at St. Paul's and the Registered P s y c h i a t r i c Nursing Course a t BCIT q u a l i f y f o r t h i s extra  remuneration. No other post-basic course offered i n B.C. q u a l i f i e s the graduates  to receive t h i s extra monthly stipend. In operating rooms, therefore, nurses who have taken  post-basic  courses other than a t S t . Paul's H o s p i t a l , work f o r l e s s money even though  they  may  perform  the  same  functions,  accept  the same  r e s p o n s i b i l i t y and have the same s o r t o f post-basic c e r t i f i c a t e from a B.C. course. level  Further, t h i s same contract does not recognize any other  of p r a c t i t i o n e r  than general  staff  nurses.  Other p o s i t i o n s  i d e n t i f i e d i n the wage schedule c l a s s i f i c a i t d n are e i t h e r non-registered general s t a f f nurses or a d m i n i s t r a t i v e personnel. T" erefore,  i n terms of upward career  m o b i l i t y , the post-basic  courses presently offered do not contribute i n a concrete way towards nurses'  career  mobility.  They o f f e r  the nurse f u r t h e r educational  26.  challenge i n s p e c i a l u n i t s , or s p e c i a l status i n the general duty nurse hierarchy, but nurses are not f i n a n c i a l l y rewarded f o r t h i s . 2.) Peer Group Concerns  —  Competency  The RNABC has long been a c t i v e l y involved i n nursing education and sees i t as a p r o f e s s i o n a l a s s o c i a t i o n ' s r e s p o n s i b i l i t y to be so. In the l a t e f i f t i e s the Association's concerns s h i f t e d from concentration on basic education to the r e c o g n i t i o n that continuing education was essential  f o r nurses.  I t became the f i r s t  provider of continuing  education i n the province, a r o l e which was f i l l e d u n t i l i t s p o l i c i e s changed i n the e a r l y 1970's.  A f t e r that time, the A s s o c i a t i o n saw i t s  r o l e as the f a c i l i t a t o r of educational developments f o r nurses rather than being the provider.  During the 80's, the RNABC has continued to  i n t e n s i f y i t s e f f o r t s i n pushing f o r continuing education f o r nurses. The nominating  RNABC has f a c i l i t a t e d members to serve  post-basic courses.  planning of continuing education by  on committees and planning bodies f o r  I t has continued to lobby governments f o r p r o v i s i o n  of post-basic courses f o r nurses and a s s i s t s i n developing these courses i n any other way i t can. At the January, 1980 meeting of the Board i t was decided that the remainder o f the $100,000.00 unspent f o r educational loans i n 1979 would be  made  courses.  available  f o r development  of post-basic c l i n i c a l  nursing  A maximum of $5,000.00 i s a v a i l a b l e f o r each course.  Courses  r e c e i v i n g the development funding are the C r i t i c a l Care Level I I f o r ICU, PAR,  and Emergency Nursing  being  provided  by UBC, and O b s t e t r i c a l  Nursing Level I I course and General Operating Room Course sponsored by Okanagan College, an Emergency Nursing  Course sponsored  by Douglas  College/Royal Columbian, a P s y c h i a t r i c course sponsored by UBC, a Long  27.  Term Care Course sponsored by UBC, and an Occupational sponsored by Douglas College/Royal Columbian.  Health  Course  Most of these courses are  planned to s t a r t i n l a t e 1980 or e a r l y 1981. At that same Board Meeting, a f u r t h e r d e c i s i o n was made that the RNABC would  undertake a study  to i d e n t i f y  required i n a number of c l i n i c a l  nursing  competencies and s k i l l s  specialties,  viz; critical  care, maternity, psychiatry, operating room, recovery room, long term care,  emergency,  Information planners planning  gathered  pediatrics,  and  neonatal  nursing.  by the committee from nursing education  i n d i c a t e d that a l i s t new  palliative  post-basic  program  of competencies would be u s e f u l i n  nursing  courses  to  standardization i n various educational s e t t i n g s . d e c i s i o n , a paper was developed i n A p r i l , 1980.  ensure  greater  As a r e s u l t of t h i s  I t was c a l l e d " C l i n i c a l  S p e c i a l t i e s Competencies Report" (99). The terms of reference were: to i d e n t i f y major s p e c i a l t i e s and s u b - s p e c i a l t i e s w i t h i n the p r a c t i c e of nursing, to s p e c i f y the competencies required f o r t h e i r safe p r a c t i c e , and to i n d i c a t e the type of s p e c i a l t y preparation required f o r p r a c t i c e i n the major s p e c i a l patient care u n i t s and s e r v i c e s which e x i s t i n B.C. Early i n the spring of 1980, the RNABC published a paper c a l l e d "RNABC Views on Post-Basic  Clinical  Nursing  Education"  (108).  It  reviewed the state of post-basic courses f o r nurses and then stated what was seen as the RNABC's primary r o l e / r e s p o n s i b i l i t y as f o l l o w s : As the professional organization and r e g i s t e r i n g body, RNABC i s v i t a l l y concerned with the competencies of R.N.s and hence with the q u a l i t y and content of t h e i r continued professional education. 1) Required competencies f o r the various c l i n i c a l s p e c i a l t y areas should be s e t up and r e g u l a r l y reviewed f o r currency by the p r o f e s s i o n a l organization, using consultation with other concerned groups. -  28.  2) A l l p o s t - b a s i c c l i n i c a l c o u r s e s be reviewed v i a t h e C o n t i n u i n g E d u c a t i o n a l A p p r o v a l Program, and one c r i t e r i o n f o r c o n t i n u e d f u n d i n g s h o u l d be CEAP approval. Decisions r e continued funding should a l s o r e s t on r e s u l t s o f post-program e v a l u a t i o n . T h i s a p p r o v a l c o u l d be b u i l t i n t o t h e CEAP p r o c e s s . In  January,  1979, a  consultant  was  hired  to evaluate  the  e f f e c t i v e n e s s o f CEAP and i n September, 1979 t h e board r e f e r r e d h e r r e p o r t t o the J o i n t C o n t i n u i n g E d u c a t i o n A p p r o v a l Committee a s k i n g f o r i t s recommendations. In January,  1980 the Board d e c i d e d t h a t the C o n t i n u i n g E d u c a t i o n  A p p r o v a l Program would c o n t i n u e , t h a t i t be w i d e l y a d v e r t i s e d t h a t the consultation  s e r v i c e was  s t a n d a r d s be developed  a v a i l a b l e , and  that  simplified  f o r s h o r t c o u r s e s which do n o t o f f e r  approval clinical  i n s t r u c t i o n o r award c r e d e n t i a l s . 3.)  Employer's Concerns - E f f e c t i v e n e s s and E f f i c i e n c y a)  B.C.H.A. The BCHA as a r e p r e s e n t a t i v e o f employers o f h e a l t h c a r e  workers has been concerned  about  t h e manpower i s s u e s p a r t i c u l a r l y i n  h o s p i t a l c a r e i n B.C. As  a  result,  a  Standing  Manpower  Committee  was  e s t a b l i s h e d i n l a t e 1979 t o address manpower i s s u e s on an ongoing b a s i s , to s e t p r i o r i t i e s f o r the A s s o c i a t i o n and t o develop t h e r o l e o f the A s s o c i a t i o n i n manpower p l a n n i n g . i s t o ensure t h a t employers  The primary mandate o f t h i s committee  a r e i n v o l v e d i n the d e f i n i t i o n o f manpower  needs. The f i r s t a c t i o n was t o i n v e n t o r y r e s e a r c h e f f o r t s o f the BCHA, the H e a l t h Manpower Research U n i t , p r o f e s s i o n a l a s s o c i a t i o n s and M a n a g e r i a l E n g i n e e r i n g U n i t s i n o r d e r t o i d e n f i t y what had t o be done and by whom and t o a s c e r t a i n any areas o f manpower p l a n n i n g n o t c u r r e n t l y  29.  being addressed.  In May,  Research Inventory  1980 the committee published i t s Manpower and  of A c t i v i t i e s and Reports.  (20)  Included  l i s t i n g are a number of nursing manpower reports and s t u d i e s . is  working  with  the  Health  Manpower Research  d i f f i c u l t - t o - f i l l p o s i t i o n s survey. b)  Unit  of  in this The BCHA  UBC  on  the  (13)  Hospital A c t i v i t i e s I n d i v i d u a l h o s p i t a l s or groups of h o s p i t a l s have lobbied  the  Health  M i n i s t r y re the  particular, clinical  nurses  areas.  questionnaire  . As  with  shortage of general  post-basic  a result,  the  i n the spring of 1980  preparation M i n i s t r y of  duty nurses and to  work  Health  in  in special  circulated a  (19) to attempt to discover what  urgent needs might be, with the hope of e s t a b l i s h i n g some crash courses for  those p a r t i c u l a r s p e c i a l t i e s . Since  hospitals  have  had  to  rely  on  recruiting  inexperienced nurses and providing good o r i e n t a t i o n , they are discussing providing t h e i r own  s p e c i a l t y courses with support and  funding  requested from the M i n i s t r i e s of Health and Education. Paul's  to  be  Currently St.  H o s p i t a l i n Vancouver i s providing some post-basic  courses i n  Operating Room and Enterostomal Therapy. A major discussion point  i n h o s p i t a l s i s "who  c o n t r o l educational a c t i v i t i e s f o r post-basic courses?"  should  Some comments  i n d i c a t e that respondents see t h i s as a r o l e f o r h o s p i t a l s to develop with seconded assistance from the community colleges and u n i v e r s i t i e s . c)  Nursing Administrators' A s s o c i a t i o n of B r i t i s h Columbia This organization encompasses other than h o s p i t a l nursing  administrators  but  the  majority  of  the  administrators who are employed i n h o s p i t a l s .  membership  is  nursing  I t has not been a strong  organization but i s presently re-organizing i t s forces.  30. The nursing administrators presented a "Reaction Paper to the Nursing Education Study Report."  (1979)  (Appendix  C)  The Nursing  Administrators' A s s o c i a t i o n s t r o n g l y supported recommendations r e l a t i n g to improving basic standard educational and degree programs and making degree programs a c c e s s i b l e f o r nurses i n other parts of the province. Recommendations which dealt with post-basic education supported  by  the  Association.  recommendtions which c l i n i c a l nursing.  suggest  The  Association  the development  were s t r o n g l y also  of career  supported streams i n  Recommendations which dealt with planning f o r needs  for nursing were a l s o endorsed. In  October,  the M i n i s t e r of Health British  Columbia:  An  1979, the A s s o c i a t i o n presented a b r i e f to  entitled  "The Registered Nurse Shortage  Increasing  Problem  for British  H o s p i t a l s . " (88) The recommendations from t h i s b r i e f are as f o l l o w s : The Nurse Administrators urge the M i n i s t r i e s of Education and Health to combine e f f o r t s f o r implementation o f the f o l l o w i n g recommendations: I. To provide s u f f i c i e n t separate funding to meet nursing s t a f f o r i e n t a t i o n and continuing education f o r job requirements. II. To immediately increase the number of seats a v a i l a b l e to refresher courses. I I I . To continue funding of the U n i v e r s i t y of B r i t i s h Columbia/Vancouver C i t y College Level I C r i t i c a l Care Course. IV. To provide funding f o r the f o l l o w i n g postbasic courses: Cardiothoracic Care Coronary Care Emergency Care Gerontology Level I and I I Intensive Care Neurological Care  in  Columbia  31. Neurosurgical Care O b s t e t r i c a l Care Operating Room Care Post-Anesthetic Recovery Care Renal Care S p i n a l Cord I n j u r y Care V. To increase the number o f seats f o r basic nursing programs. The Nursing A d m i n i s t r a t o r s invited  Mr.  Professional  R.E.  McDermitt,  and I n s t i t u t i o n a l  Senior  group o f the Lower Mainland  1  Assistant  Services,  Deputy  Minister,  M i n i s t r y o f Health,  to a  s p e c i a l meeting i n March 1980, t o discuss with him t h e i r concerns about the shortage o f s p e c i a l t y t r a i n e d nurses and lack o f post-basic courses to  train  nurses  i n special c l i n i c a l  areas.  In meeting  with Mr.  McDermitt, t h i s was t h e i r attempt to make c l e a r t h e i r consensus to the M i n i s t r y o f Health. d)  Colleagues' Concern - Doctors' A t t i t u d e s Re E f f e c t i v e n e s s The BCMA has long been i n t e r e s t e d i n nursing  Until  education.  r e c e n t l y , i t was h i g h l y involved i n p a r t i c i p a t i n g i n nursing  education,  i t s members  often  giving  nurses  lectures  physiology, disease pathology and medical treatments.  i n anatomy,  More important to  the physicians o f B.C. i s that graduates o f nursing programs, i n c a r i n g f o r p a t i e n t s , work c l o s e l y with physicians. Therefore,  the physicians are d i r e c t l y a f f e c t e d by the  outcomes o f nursing programs. In December, 1979, i t was brought to the a t t e n t i o n o f the Board o f the BCMA that a serious shortage o f nurses was developing and a l s o that nursing needed support i n obtaining funding from e i t h e r the M i n i s t r y o f Health or M i n i s t r y of Education  f o r post-basic  courses.  There had also been concerns expressed by physicians as to the competence  32.  of nurses educated i n the two year programs.  As a r e s u l t , the BCMA  Hospitals Committee was asked to study the e f f e c t i v e n e s s o f nursing education i n the province and to report back to the board. Dr. D. MacPherson, who c h a i r s the Hospitals Committee, wrote to the RNABC and several d i r e c t o r s of nursing t o t r y to a s c e r t a i n the scope o f the problem. that  there  obtained.  E s s e n t i a l l y , answers he received i n d i c a t e d  was a problem but that  adequate data had not yet been  I t was i n d i c a t e d that attempts a t c o r r e c t i v e a c t i o n were being  taken through the Health Manpower Research Unit, the RNABC and the BCHA. The  Hospitals  Committee  presented  the  following  recommendations to the Board of D i r e c t o r s of the BCMA i n January, 1980 (15): 1) That the M i n i s t r y o f Education give immediate and serious consideration to the dangerously neglected area of post-basic c l i n i c a l nursing education i n c r i t i c a l care areas. 2) That the M i n i s t r y o f Education respond to the need f o r an ongoing dependable source of funding to be u t i l i z e d f o r the development and implementation o f q u a l i t y post-basic nursing courses. 3) That a source o f revenue f o r c o n s i s t e n t l y a s s i s t i n g h o s p i t a l s with the cost o f s t a f f replacement f o r nurses attending post-basic courses be i d e n t i f i e d . H)  Government Involvements i n Planning C l i n i c a l S p e c i a l t y Courses  Post-Basic  Since d e l i v e r y o f h o s p i t a l services i s not a d i r e c t government  responsibility  themselves, the Health  but delegated  to the h o s p i t a l s  M i n i s t r i e s d i d not become  directly  involved i n the nurse manpower planning u n t i l the seventies (The development o f t h i s involvement a f t e r the i n t r o d u c t i o n of National  Health  Insurance  i s discussed  i n Part  V.)  33.  Equally, the involvement of the M i n i s t r i e s of Education grew slowly, as was  described  earlier  in  this  chapter.  Consequently,  until  very  r e c e n t l y , governments were not involved i n supporting post-basic nursing c l i n i c a l s p e c i a l t y courses.  A p o l i c y f o r funding t h i s area of nursing  education on an ongoing basis did not e x i s t , nor had the governments taken leadership i n coordinating inputs from i n t e r e s t e d groups so that ongoing needs could be i d e n t i f i e d .  Instead they had moved i n and out of  the planning process as the pressures from the i n t e r e s t e d groups had demanded t h e i r a t t e n t i o n or f a l l e n o f f . The planning focus had only been on the s t r o n g l y i d e n t i f i e d program needs not on an o v e r a l l assessment of needs. Further, governments had not c l e a r l y i d e n t i f i e d what the r o l e s of i n s t i t u t i o n s should be i n presenting post-basic c l i n i c a l courses, so a competition of s o r t s had developed  i n terms of who would  get the ad hoc i n d i v i d u a l program funding which was In 1977,  specialty  available.  i n B.C. a mechanism to review requests f o r a d d i t i o n a l  funding f o r c l i n i c a l s p e c i a l t y programs was set up, but n e i t h e r on-going need f o r programs nor program p r i o r i t i e s was to be on a one time b a s i s . As a r e s u l t , funding f o r a program might be approved on a one time b a s i s . Continuing to present the program meant reapplying through the mechanism requests f o r a d d i t i o n a l courses, f o r f u r t h e r one time funding. not  only  time  consuming  but  often  resources  unavailable by the time the second approval was As  demands have been  were  This was  dispersed  or  granted.  i n c r e a s i n g f o r nurses  with  special  c l i n i c a l preparation, the government has begun to be more involved with the planning process  through  attempts  to i d e n t i f y needs and,  through  funding and guiding the HMRU, i t has begun to play a coordinating r o l e .  34. 5.  Discussion: Who Has the Power to Make Decisions R e l a t i n g to Nursing Education? The  l a s t two decades were the time when most e a r l i e r  regarding nursing education were implemented. came  under  the c o n t r o l  departments. quantity.  and funding  Baccalaureate  nursing  Basic education programs  of the p r o v i n c i a l courses  plans  increased  education  q u a l i t y and  Masters' programs were s t a r t e d i n many u n i v e r s i t i e s .  Yet  education f o r s p e c i a l i z a t i o n i n nursing i s s t i l l i n the e a r l y planning and implementation stages despite the f a c t that these two decades were characterized by i n c r e a s i n g technology and s p e c i a l i z a t i o n i n nursing. There i s s t i l l d i s c u s s i o n w i t h i n the profession today about nursing education needs - about the d i f f e r e n c e between " s e r v i c e " and "education." nursing.  This may w e l l be r e l a t e d to the lack of c l i n i c a l models i n  Because the p r a c t i t i o n e r i s not h i g h l y regarded or rewarded  w i t h i n the nursing profession even today, the question of who decides what nursing p r a c t i c e i s and what education i s needed t o f u l f i l t h i s r o l e i s an important one. The status i n the nursing profession has not been with those people  who  provide  nursing  service,  but, r a t h e r , with  administer the s e r v i c e and those who educate f o r i t .  who  To advance i n  nursing, one had t o s p e c i a l i z e i n education or a d m i n i s t r a t i o n . l a s t few years, the educators have had the most power.  those  U n t i l the  Many nurses who  gained t h e i r higher education chose the teaching r o l e because teachers tended  t o have b e t t e r working  nursing a d m i n i s t r a t o r s .  c o n d i t i o n s , s a l a r i e s and status than  They had more freedom to c o n t r o l and make  decisions about the educational environment.  They were a l s o i n an  environment where new ideas and concepts are expected.  The educators  35. were able to advance i n t h e i r thoughts about what nursing should be and what various e d u c a t i o n a l l y prepared l e v e l s of nurses should do. The nursing administrators were looking f o r nurses who could perform the e s t a b l i s h e d nursing p r a c t i c e s w e l l , not nurses who had new ideas  t h t the nursing administrators could not p o s s i b l y implement.  Within the h o s p i t a l s , many nurse administrators themselves were not given r e a l power but were often delegated tasks to carry out.  They had  little  hospital  control  administrators  over  their  controlled  working  environment  because  the budget and physicians c o n t r o l l e d the  quantity and q u a l i t y of workload.  As a r e s u l t , they were often unable to  do much more than f o l l o w orders while t r y i n g to advance nursing as best they could. But educators?  who  should  determine  The administrators?  what  nursing  really  is?  The  Or the p r a c t i t i o n e r s who provide d a i l y  care f o r patients? Attempts were made by the p r o f e s s i o n a l a s s o c i a t i o n s to p u l l together  varying views about  the o b j e c t i v e s of nursing  education.  Mussalem (85) f o r long the Executive D i r e c t o r of the CNA, has put forward her i n t e r p r e t a t i o n of the reasons f o r slow progress i n a t t a i n i n g the o b j e c t i v e s i d e n t i f i e d by the p r o f e s s i o n a l a s s o c i a t i o n by quoting King (76): Throughout the f i r s t part of the century, organized groups c l o s e l y associated with health care, f o r one reason or another, appeared to favour maintaining the narrow c u s t o d i a l image of the nurse. This coupled with the apparent i n a b i l i t y or unwillingness of nurses to i n t e r p r e t developments i n both education and s e r v i c e , f u r t h e r strengthened the accepted image of the nurse. The s i t u a t i o n was a l l the more unfortunate when translated from public confusion to government bewilderment. Since u n i v e r s i t y nursing education has always depended on funds channeled through the p r o v i n c i a l government, i t i s e s s e n t i a l that the needs of nursing be  36.  i n t e r p r e t e d c l e a r l y to t h e i r l e v e l of government. I t was i n e v i t a b l e that through the lack of c l e a r i n t e r p r e t a t i o n of the need f o r , and the r o l e of the baccalaureate prepared nurses, there would be f i n a n c i a l d i f f i c u l t i e s for u n i v e r s i t y degree programs. The question may w e l l be asked why, i f the general p u b l i c was confused, nurses were content t o accept t h i s s i t u a t i o n . Over the same period other p r o f e s s i o n a l groups s u c c e s s f u l l y recognized the need f o r i n v o l v i n g new educational approaches and i n t e r p r e t i n g these changes to the p u b l i c . Unfortunately, the mass of nurses were apathetic and lacked understanding of both the need f o r , and the character of the change i n basic nursing education c o n t r o l l e d by the university. Is situation?  this  a useful interpretation  of the present  nursing  C e r t a i n l y i t focusses a t t e n t i o n on the i n d i v i d u a l  nurse's  reactions to t h e i r general s i t u a t i o n i n s o c i e t y though these reactions may w e l l have changed i n recent years. In  the next s e c t i o n the development of nursing functions i n  h o s p i t a l s and womens' r o l e s i n s o c i e t y are considered, as a b a s i s f o r making an assessment of the appropriateness of education and t r a i n i n g i n nursing today and i n i n t e r p r e t a t i o n of reasons nurses.  f o r the "shortage" of  PART I I I HISTORY OF NURSING FUNCTIONS IN THE CONTEXT OF CHANGING WOMEN'S ROLES IN CANADA  37.  PART I I I  HISTORY OF NURSING FUNCTION IN THE CONTEXT OF CHANGING WOMEN'S ROLES IN CANADA I t would appear that i n d i v i d u a l nurses i n B r i t i s h been making  particular  demands upon employers,  Columbia have  represented  by the  D i r e c t o r s of Nursing of h o s p i t a l s , namely demands f o r p o s i t i o n s with greater d e c i s i o n making autonomy and more l i f e s t y l e advantages to f i t more c l o s e l y with t h e i r other s o c i a l r o l e s . Nursing i s a women's profession. In manpower d i s c u s s i o n s , t h i s i s i d e n t i f i e d as a c h a r a c t e r i s t i c of the nursing p r o f e s s i o n . To explore the problem of nursing shortages, womens' r o l e s must be examined to understand any impact  t h i s c h a r a c t e r i s t i c may have on the a v a i l a b i l i t y of  nurses f o r the labour market. A.  The Beginnings Nursing functions today have evolved as a r e s u l t of many f a c t o r s .  Increasing knowledge and technology are obvious i n themselves.  Less  obvious, but very important, are changes i n the values on which nursing i s based, changes i n r o l e s of women i n our s o c i e t y , and the development of our s o c i e t y .  E x t e r n a l , economic and s o c i a l pressures as w e l l as  i n t e r n a l searchings to adapt to the changes has created a s t a t e of uncertainty i n nursing as to what i s the scope and f u n c t i o n of nursing. For the perceptions of nursing today have been determined t r a d i t i o n s as w e l l as more recent i n f l u e n c e s : Uprichard has i d e n t i f i e d heritages from the past that have tended to i n h i b i t progress i n nursing as a profession. These are: the f o l k images of the nurse brought forward from the p r i m i t i v e times, the r e l i g i o u s image of the nurse i n h e r i t e d from the medieval period, and the servant image of the nurse created by the Protestant C a p i t a l i s t i c e t h i c of the 16th to 19th c e n t u r i e s .  by i t s  38.  These images, while appealing to the humanistic side of man's nature, show nursing i n a subordinate p o s i t i o n to a l l other professions, omni-present and uncomplainingly dedicated, with l i t t l e thought of personal gain. (78) The values of the nursing profession are c l o s e l y intertwined with those thought  t o be a part of the woman's r o l e .  I t i s , therefore,  d i f f i c u l t to separate the two, so they w i l l be discussed together as the changing values i n nursing are i d e n t i f i e d . During the period from the e a r l y settlements i n Canada u n t i l the 1920's the values i n nursing were simple.  Nursing was a servant's r o l e  and thus a duty. Canadian nursing began i n the early years as a "labor of love" f o r the  religious  orders  i n Canada, family members or neighbours  volunteered t h e i r s e r v i c e s .  who  These nurses were untrained and d i d what  they could f o r the comfort of t h e i r p a t i e n t s .  Rewards f o r nurses were  based on the value of the dedication to p a t i e n t s .  They a l s o valued  praise from the physicians f o r t h e i r work. In t h i s period i n Canada's h i s t o r y , the normal r o l e s of women were to be wives and mothers staying a t home.  Women were seen as needing  p r o t e c t i o n and therefore dependent on men.  Their status was much l e s s  than men's and they were not welcome or accepted when working i n s o c i e t y i n competition with men. However, they were accepted i n jobs as teachers or as nurses because these were seen to be extensions of the "woman's role."  Nursing as an occupation was a l s o valued by women, as a way of  p u t t i n g t i n time, h o e p f u l l y , u n t i l they were married. As Canada became more s e t t l e d , h o s p i t a l s were set up and the l a r g e r ones opened schools of nursing.  Since women had very  few career  o p p o r t u n i t i e s , nursing was a popular choice, and many women considered themselves fortunate t o have been accepted i n t o a t r a i n i n g school.  39.  At  this  time, nursing care was  aimed at c l e a n l i n e s s ,  maintenance of n u t r i t i o n ,  and  easing  Medical  and  often treatments  care  remedies.  was  minimal  of  symptoms f o r the p a t i e n t . consisted of family  Very l i t t l e nursing care during t h i s period was  i l l n e s s prevention or health maintenance.  comfort,  Most care was  aimed at  d i r e c t e d at  those already i l l . Since most nursing care was  provided on an i n d i v i d u a l basis to  p a t i e n t s i n t h e i r homes, nurses, besides providing i l l n e s s care, a l s o d i d the c l e a n i n g , cooking and family might need.  g e n e r a l l y provided the extra care  the  They tended to l i v e i n when they were with a family  and provided care on a twenty four hour b a s i s . During most of t h i s period, many nurses entrepreneurs.  They  were  self-employed  and  worked as accountable  independent to  their  employers f o r the q u a l i t y of care they provided, although the physicians might oversee some of t h e i r work.  As independent p r a c t i t i o n e r s , they  assumed r e s p o n s i b i l i t y and a c c o u n t a b i l i t y f o r t h e i r p r a c t i c e and continued  their  l e a r n i n g to keep s k i l l s up to date, even though there  was  minimal increase i n knowledge i n t h i s period. I f one were to review the criteria  used  to  designate  an  occupation  as  a  self-regulating  profession, nursing at t h i s time probably most c l e a r l y approximates  the  d e s c r i p t i o n of a true p r o f e s s i o n a l group. A few nurses worked as administrators of h o s p i t a l s and as u s u a l l y assumed t o t a l r e s p o n s i b i l i t y hospitals.  These administrators may  such,  f o r the i n t e r n a l management of have had an a s s i s t a n t who  helped  them with business and finance matters on behalf of the board, but they were d e f i n i t e l y i n c o n t r o l . they were often expected  As w e l l as t h e i r a d m i n i s t r a t i v e f u n c t i o n s ,  to teach the students how  to provide nursing  40.  care.  Living-in,  they  were  responsible  f o r the twenty-four  operation of the h o s p i t a l and were often c a l l e d upon to a s s i s t d i r e c t care  to to provide  hour with  "expert advice" to the student nurses who  provided most o f the nursing care.  They were very attuned to the " r e a l  world" o f nursing. Because the h o s p i t a l s were s t a f f e d mainly  by apprentices, most  t r a i n e d nurses were i s o l a t e d i n p r i v a t e duty nursing and i n the e a r l y 1900's t h i s stimulated the graduates of the t r a i n i n g programs to band together i n alumni a s s o c i a t i o n s to support one another i n whatever ways they  could,  including socializing  and sharing c l i n i c a l  information.  This was t h e i r form of continuing education, and u l t i m a t e l y p r o t e c t i o n . I t was i n these groups that nurses began to t a l k about organizing themselves, and e s t a b l i s h i n g basic standards  f o r nursing  education.  They were not g r e a t l y concerned with l e v e l s of renumeration.  Although  nurses might ask f o r s p e c i f i c amounts f o r payment f o r t h e i r s e r v i c e s , they often would work f o r l i t t l e or nothing because "they were needed." The leaders i n the nursing a s s o c i a t i o n s were concerned that anyone could o f f e r h e r s e l f f o r h i r e as a nurse, whether she was t r a i n e d or not. Although  many nurses were concerned with  the c o n t r o l of q u a l i t y of  nursing care, others were concerned with the competition f o r jobs that the untrained nurses created. Whatever the reason, most nurses became i n t e r e s t e d i n developing some form o f c o n t r o l over non-trained  nurses.  I t became important to  nurses to have formal r e c o g n i t i o n f o r t h e i r t r a i n i n g and they  valued  nursing r e g i s t r a t i o n as a way to gain t h i s r e c o g n i t i o n . So they began to value the need to be l i n k e d together i n p r o f e s s i o n a l a s s o c i a t i o n s and they began to work f o r e f f e c t i v e p r o f e s s i o n a l o r g a n i z a t i o n .  41. B.  The Depression  Years  In the period from 1920 to 1940 there were few changes i n womens' and  nurses'  values  and  i n nursing  functions except  that, i n the  depression years, i t became more acceptable f o r women to work outside the home i n order to add to family income. However, l e s s home nursing care was c a r r i e d out because, with the depression, people were unable to a f f o r d to pay nurses and they t r u s t e d h o s p i t a l s more because of the improved i n f e c t i o n c o n t r o l  (2).  More  people went to h o s p i t a l s when they were i l l , but, there was very l i t t l e money to pay more nurses f o r t h e i r s e r v i c e s .  This sometimes r e s u l t e d i n  more students being taken on or sometimes those that were there had to work harder.  Some h o s p i t a l s began to f i n d students expensive and d i d  h i r e a few more t r a i n e d nurses f o r h o s p i t a l work, but, not many were able to do t h i s because of s c a r c i t y of funds. Provincial  a s s o c i a t i o n s had  formed  across  Canada  and  were  s t r u g g l i n g to set and improve standards of basic t r a i n i n g programs and to develop higher education programs f o r nurses.  For the f i r s t time the  a s s o c i a t i o n s were given c o n t r o l over nursing r e g i s t r a t i o n by the e a r l y twenties.  They a l s o began to work to develop p u b l i c funding f o r nurses'  t r a i n i n g and thus remove i t from the apprenticeship system.  More nurses  were unemployed and could concentrate on f u r t h e r education as a way of keeping up t h e i r s k i l l s while w a i t i n g f o r employment. C.  The War Years and A f t e r Towards the end of t h i s depression period, as war began i n Europe,  many nurses  were sent to nurse  soldiers  i n combat, others sent to  organize nursing s e r v i c e s f o r other c o u n t r i e s . This l e f t a shortage of nurses on the domestic scene.  To increase t h i s shortage, many i n j u r e d  42. servicemen were sent home f o r treatment i n government h o s p i t a l s .  The  need f o r nurses, i n Europe as w e l l as a t home, increased f a s t e r than nurses could be t r a i n e d . overcome t h i s shortage.  Auxiliary  nurses were introduced t o help  The impact of introducing p r a c t i c a l and other  a u x i l i a r i e s was that registered nurses began to p r a c t i c e i n a d i f f e r e n t way.  Besides being a bedside nurse, the R.N. was now expected to guide  and supervise another category of nurse. Doctors were a l s o i n short supply a t home.  Nurses began to take  over procedures which had previously been performed only by doctors. As w e l l , the development of new medical technologies, new drugs, such as the sulphonamides,  meant  that  more  severely i l l  patients  survived and  required t o be nursed through i n t e n s i v e i l l n e s s e s as they had not before. The increased duties of nursing more patients who were i n t e n s i v e l y  ill,  and taking on more medical functions, increased the nursing shortage. In 19^3, the Heagarty Committee, set up by the f e d e r a l government, (69) proposed  that Canada should adopt  a National  Health  Insurance  Scheme. Although i t took t h i r t y years f o r a l l the programs i n the scheme to be introduced, i t was made c l e a r i n the National Health Survey of 1943 (29) that 90,292 more h o s p i t a l beds were b u i l t and gradually as the National Health Scheme was implemented  (33), the demand f o r nurses  increased. Despite the increase i n the numbers and s i z e of h o s p i t a l s and changes  i n their  technological  activities,  nursing  s t r u c t u r e s i n h o s p i t a l s d i d not change a t t h i s time.  organization  C l i n i c a l models of  advancement were not introduced as s p e c i a l t i e s began t o develop.  Post-  basic s p e c i a l t y courses d i d allow nurses h o r i z o n t a l m o b i l i t y but upward career  mobility  still  consisted  of moving  into  administration or  43.  education.  However, nurses a c q u i r e d i n c r e a s e d geographic  they had taken a course. nursing  m o b i l i t y once  To summarize, d u r i n g the 1940's to 1960's,  f u n c t i o n s i n Canada changed d r a s t i c a l l y .  From g i v i n g  simple  tender l o v i n g c a r e as t h e i r o n l y f u n c t i o n , nurses were r e q u i r e d to engage in  other  tasks.  F i r s t , many became i n v o l v e d i n h i g h l y complex  t e c h n i c a l d i a g n o s t i c and t h e r a p e u t i c procedures.  and  They a l s o moved away  from s p e n d i n g time with p a t i e n t s as another c a t e g o r y o f employees began to  a s s i s t them  on  the  wards.  The  second  major  change  was  the  f i n a l i z a t i o n o f the move away from i n d i v i d u a l i z e d home n u r s i n g c a r e to i n s t i t u t i o n a l i z e d c a r e f o r groups o f p a t i e n t s . for  increased  numbers  of  registered  nurses  There was a g r e a t demand to  take  on  these  new  functions. Nurses s t i l l saw themselves as d e d i c a t e d to s e r v i n g o t h e r s but they a l s o began to be aware t h a t they were important system.  to the h e a l t h  They began to r e a l i z e t h a t more e d u c a t i o n  was  care  required  and  should be p a i d f o r the s o c i e t y which wanted t h e i r s e r v i c e s and t h a t they should be p a i d more a p p r o p r i a t e l y f o r t h e i r work. W i l s t the o l d e r forms o f r e c o g n i t i o n were s t i l l valued, new rewards began to be  appreciated,  namely, 'reasonable' monetary renumeration, h i g h e r s t a t u s i n s u p e r v i s i o n o f o t h e r s who took over some o f t h e i r t a s k s and p l e a s u r e i n l e a r n i n g  new  t e c h n i q u e s and working more c l o s e l y with o t h e r p r o f e s s i o n a l s . Whilst  the  professional  o b j e c t i v e s and n u r s i n g standards beginning  groups  still  emphasized  educational  as t h e i r p r i n c i p a l concern,  t o become i n t e r e s t e d i n c o l l e c t i v e b a r g a i n i n g .  they were  In 1946,  for  example, the RNABC s e t i t s e l f up as the b a r g a i n i n g body f o r i t s members. The r o l e o f women changed d r a s t i c a l l y d u r i n g t h i s p e r i o d . were i n the l a b o u r f o r c e and expected to be.  Women  They now d i d many jobs t h a t  44.  previously  had only  been  o p p o r t u n i t i e s expanded.  done  by men.  Educational  and career  The expectation that women who married  q u i t work, and stay i n the home faded. with p u b l i c l i f e a t every l e v e l .  should  Women began to be more involved  The status o f women was s t i l l below  that o f men, but the gap was l e s s wide than i t had been. D.  The Last Two Decades The  1960's  and 1970's  r e v o l u t i o n i n Canada.  were  characterized  by a major  social  The p r o s p e r i t y a f t e r the war, the explosions i n  knowledge and technology,  the i n c r e a s i n g educational o p p o r t u n i t i e s and  the demands o f minority groups f o r t h e i r r i g h t s a l l combined to create t h i s r e v o l u t i o n . The Women's Movement stimulated discussions of women's r o l e s i n s o c i e t y and because of the Women's Movement, a l l sectors of s o c i e t y have attempted to begin to move towards greater e q u a l i t y of the sexes. for  Women have gained status and i f nothing e l s e , are no longer taken  granted as automatically belonging i n the "homemaker r o l e . " Educational  o p p o r t u n i t i e s are now more open  to women who are  attending u n i v e r s i t y i n greater numbers than ever before, because of the s o c i a l value now attached t o being a u n i v e r s i t y  graduate.  In Canada 9856 of nurses are female, so nurses have been able to echo women's general goals w i t h i n t h e i r own p r o f e s s i o n . As w e l l , nurses have become more a s s e r t i v e and v o c a l .  Gradually they began to see nursing  education and t r a i n i n g as an expectation rather than a p r i v i l e g e and were no longer w i l l i n g to pay f o r t h i s with s e r v i c e . Nurses have begun to set great value on u n i v e r s i t y education. a way to increase s o c i a l m o b i l i t y and to meet young men.  It is  I t provides  o p p o r t u n i t i e s o f moving out o f nursing i n t o other occpuations.  Nurses  have become u n w i l l i n g to work i n r e s t r i c t i v e , a u t h o r i t a r i a n i n s t i t u t i o n s and they have begun t o value r e c o g n i t i o n o f t h e i r knowledge and s k i l l s .  45.  Nursing  administrators gained strength i n t h i s time period.  and more they are beginning with  nursing  decisions.  More  to be seen as i n s t i t u t i o n a l administrators  backgrounds becoming  involved  i n top  administrative  This i s not yet the norm throughout the industry, but the  precedents have been set and i t may now be necessary f o r more nurses i n senior  p o s i t i o n s to prove that  they are capable of taking  broader  responsibilities. During the seventies, several changes i n health care d e l i v e r y have intensified  s p e c i a l i z a t i o n i n nursing.  A few of these  significant  trends are: 1)  more patients are being treated on an outpatient or day  care b a s i s .  Those patients that are admitted to h o s p i t a l are more  s e r i o u s l y i l l than they have been i n the past. 2)  There  i s increasing  specialization resulting  from  expanding knowledge and technology, r a d i c a l i n t r u s i o n i n t o the human body and treatments which have been developed f o r severe trauma. 3)  S h i f t s i n the population structure with more emphasis on  the e l d e r l y and the r a m i f i c a t i o n s of the aging E.  process.  Development of C l i n i c a l S p e c i a l t y Units Nurses  valued  for) technological  a b i l i t i e s rather than basic bedside nursing care.  The s p e c i a l t y areas  evolved  began  gradually  developed.  to value  (and to be  i n hospitals  as  new  information  and  technology  As new machines came i n t o use, places were found f o r them to  be set up i n h o s p i t a l s and nurses were t r a i n e d to operate them.  These  areas gradually became recognized as " s p e c i a l care areas" or " i n t e n s i v e care areas" where the s i c k e s t p a t i e n t s were gathered f o r concentrated nursing care.  46. The equipment and personnel i n these s p e c i a l t y areas were expensive to fund.  The t e c h n o l o g i c a l advances might not have come so q u i c k l y had  not governments f i r s t taken over payment of c a p i t a l and operating  costs  of h o s p i t a l s and then s a l a r i e s of physicians. The  1957  H o s p i t a l Insurance Scheme and the 1966 Medicare programs  (33) provided funding f o r doctors to spend more f o r " e s o t e r i c " areas of health care.  Since  the patient no longer had  to "foot the b i l l "  for  these expensive s e r v i c e s , "nothing was spared" to provide p a t i e n t s with l i f e - s a v i n g care. governments, had  Physicians with regular payments being received from to "donate" l e s s free care to indigent p a t i e n t s  could a f f o r d more time f o r explore new The  Nursing  Administrators'  and  techniques.  Association  of  British  Columbia  presented a p o s i t i o n paper on budget r e s t r a i n t s to the M i n i s t r y of Health i n November, 1979.  (86)  Although t h i s paper was mainly concerned with  f i n a n c i n g , the group described the changed function of nursing. The l e v e l of s o p h i s t i c a t i o n of patient care i n health care f a c i l i t i e s continues to r i s e . This l e v e l of s o p h i s t i c a t i o n and increased technology, as w e l l as the continuing " t r a n s f e r of medical functions" to nursing, increases the workload and demands on nursing. Physician s p e c i a l i s t s i n most communities are demanding more and more highly s o p h i s t i c a t e d diagnostic and treatment procedures which require increased costs i n equipment and supplies, and highly s k i l l e d nursing personnel. The nursing r o l e has a l s o expanded i n the areas of patient and family teaching with increased emphasis on ambulatory care and health promotion. Also as w e l l as more s o p h i s t i c a t e d patient care, the handling and care of expensive diagnostic and treatment equipment must be taught, i . e . c i r c u l a r - e l e c t r i c beds, endoscopes, r e s p i r a t o r s , monitors. Today the function of nursing i s extremely complex.  Few  patients  today have the nursing needs as simple as those provided by nurses p r i o r to 1950.  Even the patients on the general wards have numerous needs that  are complex and those i n s p e c i a l care areas may need two or more highly  47.  knowledgeable and  s k i l l e d nurses around the clock to care  for their  needs. S p e c i a l i z e d u n i t s are increasing i n numbers and s i z e . Education Sub-Committee on  Nursing  Education,  A M i n i s t r y of  Kermacks'  (1979)  (73)  reported that: an examination of the p o s i t i o n s i n which R.N.s are employed i n d i c a t e d that approximately 30% of those p o s i t i o n s require preparation beyond the diploma l e v e l . Most of these p o s i t i o n s would require a preparation at l e a s t at the baccalaureate l e v e l because they demand a broader scope of nursing knowledge and a range of complex s k i l l s (teaching, c o u n s e l l i n g , a d m i n i s t r a t i o n , c o n s u l t a t i v e and research ) not provided i n diploma programs. The S t a t i s t i c Canada data i n d i c a t e d that at l e a s t twenty percent of the f u l l time equivalent p o s i t i o n s f o r graduate and r e g i s t e r e d nurses i n h o s p i t a l s are i n s p e c i a l i z e d areas. Few nurses have or can obtain t h i s preparation.  TABLE 2 Number of Full-Time Equivalent Graduate Nurses Employed i n S p e c i a l i z e d Units i n B.C. Hospitals and as Proportion of T o t a l Employed Graduate Nurses, 1976  S p e c i a l i z e d Units  Full-Time ^ Equivalents  Percentage of Total F.T.E.  Intensive Care  367.0  H.k%  Labour and Delivery  187.7  2.256  i n c l u d i n g PAR  810.0  9.7?  Emergency Department  275.6  3•3%  Operating Room  T o t a l Employed 8,389.5 19.6$ 1 Other s p e c i a l i z e d u n i t s i n medical - s u r g i c a l , p s y c h i a t r i c , nursery and other areas could not be i d e n t i f i e d from data. 2 Full-Time Equivalent - graduate or r e g i s t e r e d nurses - One F.T.E. i s based on 1,950 hours worked per year (37.5/wk/52 weeks/yr).  48. Nurses  today  value d i f f e r e n t  rewards.  Conditions of work and  s a l a r i e s are now f a r more important to nurses. technology  has affected  operations and e f f e c t s —  nurses.  Understanding  As w e l l , the age of machines  —  their  has become very important to nurses.  Those  nurses who work i n s p e c i a l care areas have a higher status among nurses and physicians than do other nurses, although i t i s not because o f extra monetary rewards. One can look at the reward system to attempt one explanation of the phenomenon. independent  Physicians have more power, make more money, are more i n f u n c t i o n i n g than nurses.  Nurses seeking to gain some  status with the higher status p h y s i c i a n group can do so more e a s i l y through understanding the technology (machines) than i n any other way. The group.  Age of S p e c i a l i z a t i o n i s highly organized i n the p h y s i c i a n Many physicians do not understand  technology i n the s p e c i a l care areas.  the i n t r i c a c i e s  of the  They u s u a l l y r e f e r t h e i r p a t i e n t s  to physicians s p e c i a l i z e d i n these areas, who are minimal i n numbers and considered  the e l i t e  of the profession.  Those who  assist  s p e c i a l i z e d physicians are the nurses who work i n these areas.  these The  nurses are not rewarded f o r the tender l o v i n g care they give the p a t i e n t s i n s p e c i a l care u n i t s , but, rather f o r t h e i r a b i l i t y to understand and operate the t e c h n o l o g i c a l equipment and thus support the s p e c i a l i s t physician.  In developing a partnership with s p e c i a l i s t physicians these  nurses gain r e c o g n i t i o n and respect that i s not evident i n other nursing areas.  Thus, status i s increased i n the eyes of physicians generally and  p a r t i c u l a r l y with the s p e c i a l i s t p h y s i c i a n s . C l i n i c a l s p e c i a l t y nurses are able to work i n a much more independent manner and have more s o c i a l power than non-technical nurses who are not educators or administrators.  49.  The rewards are greater f o r these nurses as t h e i r s e l f worth i s enhanced on the job. There are some concerns i n the profession about whether nurses' proper functions are to nurse patients or to nurse machines.  As w e l l , to  some older nurses, the "younger" nurses do not seem to be as dedicated to nursing.  This i s suggested, f o r example, when these nurses are s a i d to  "leave r i g h t on time."  This may  be a way  i n which the older nurses  describe change i n nursing which they f i n d d i f f i c u l t to accept or more c o r r e c t l y , i s at odds with t h e i r values. In today's s o c i e t y , l e i s u r e or non-work time i s highly valued. To most nurses, nursing i s only one r o l e among t h e i r many varied r o l e s . F.  Unionization I t took over t h i r t y years f o r many nurses to accept the idea of  b u i l d i n g a strong union f o r bargaining purposes because of the strong " v o c a t i o n a l " e t h i c which Nightingale had b u i l t i n t o the idea of nursing. In B r i t i s h  Columbia, around  admit  they belonged  that  the mid-seventies many nurses would  to a union.  p r o f e s s i o n a l labour organization. nurses was  They did admit  not  to having a  The idea of professionalism f o r many  not i n harmony with the concept of unions and  therefore,  unionism was denied. However, the Labour Relations D i v i s i o n of the RNABC has recently become very strong.  In a s t r i k e vote, taken by nurses i n over eighty  h o s p i t a l s i n the province, i n 1979, over 9 0 % of the nurses voted to strike.  This i s a major change i n values by nurses i n the province  w i t h i n the l a s t few years. Union a c t i v i t y  i s evolving i n another d i r e c t i o n .  Baumgart (8)  suggests that c o l l e c t i v e bargaining i s beginning to and should, become a  50.  v e h i c l e f o r advancing p r o f e s s i o n a l concerns of nurses as w e l l as socioeconomic i n t e r e s t s .  Nurses, as p r o f e s s i o n a l s , have a r e s p o n s i b i l i t y to  safeguard human l i v e s .  To accomplish t h i s , the q u a l i t y of s e r v i c e s has  to be assured. Where the r e s p o n s i b i l t i e s of employment and p r o f e s s i o n a l standards are i n c o n f l i c t , nurses have a r i g h t and a duty to point out the  conflict.  To  negotiate disputes of  this  nature,  collective  bargaining can be the instrument which should be used by nursing.  In  f a c t , nurses can be the agency nurses use to promote t h e i r p r o f e s s i o n a l values. G.  Implications of Changing A t t i t u d e s The  United States i s i n the midst of a major  problem.  nursing s t a f f i n g  In a study done by the U n i v e r s i t y of Texas at Austin (1980),  prompted by the acute shortage of nurses i n Texas, i t was found that undesirable working  conditions were the major  shortage ( 8 ) .  reasons c i t e d  The  cause  f o r widespread  by nurses f o r job  dissatisfaction  included lack of support by h o s p i t a l and nursing a d m i n i s t r a t i o n , lack of autonomy, i n f l e x i b i l i t y of working hours, being " p u l l e d " from a f a m i l i a r u n i t to work on short s t a f f e d u n i t s , need f o r c h i l d care, c o n f l i c t with family limited  schedules, frequent overtime with no a d d i t i o n a l help  in  keeping  up  professional  skills,  compensation,  indifferent  or  inadequate personnel and low s a l a r i e s . Texas nurses are r e f u s i n g to work f o r h o s p i t a l s f u l l time because h o s p i t a l s decide the number of hours, s h i f t s and days which the nurses w i l l work.  An a l t e r n a t i v e has been provided f o r the nurses by nurse  s t a f f i n g companies.  A nurse can sign up to work with a company and she  w i l l then be able to decide how many hours, what s h i f t s and what days she wishes to work.  Nurses have flocked to these companies.  Hospitals are  51.  i n d i r e s t r a i t s and are being forced to o f f e r the nurses remaining on s t a f f many concessions to r e t a i n them. The  aspirations  of i n d i v i d u a l  nurses  i n the profession  are a  challenge to the previous e l i t e groups of educators and administrators. Are these new-style nurses n e c e s s a r i l y those who know the most about and give the best personal care or, rather, those who play a handmaiden r o l e i n promoting the technological aspects of caring f o r the patients? t h i s i m p l i c a t i o n s f o r the future nursing structures and reward i n Canada?  Has  systems  Are nurses going to continue to seek i n d i v i d u a l s o l u t i o n s or  contract s o l u t i o n s f o r t h e i r employment conditions? I t i s important now to consider whether the nurse manpower planners have recognized and addressed themselves to these changes.  The next  chapter w i l l explore n a t i o n a l and l o c a l nurse manpower planning e f f o r t s .  PART IV  HOW CAN THE PLANNING PROCESS BE MADE MORE EFFECTIVE?  52.  PART IV HOW CAN THE PLANNING PROCESS BE MADE MORE EFFECTIVE? A.  From S e c t o r a l Educational Planning^ A c t i v i t i e s  Concerns  to Comprehensive  Manpower  The present confused s i t u a t i o n i n educational planning was o u t l i n e d at  the beginning of t h i s paper and the reasons f o r the confusions have  been explored, a t l e a s t to some extent, through considering f i r s t the issues i n nursing  education  and second, the development of nursing  functions and t h e i r r e l a t i o n s h i p s to nurses' changing r o l e s i n s o c i e t y . The shortage of nurses, now having become a p o l i t i c a l problem the administrators i n government have, as t h e i r f i r s t step, gone back to the nursing manpower planners to t r y to j u s t i f y the need and determine the scope of the problem,  provide  the means o f r a t i o n a l i z i n g  preparation and the use of nursing s k i l l s .  nursing  But who are the manpower  planners? A l f o r d , i n Health Care P o l i t i c s , (1) has suggested  that there are  three groups of planners involved i n h o s p i t a l planning i n New York — the entrepreneurs,  the corporate planners and,advocacy planners.  This way  of d i v i d i n g planning i n t e r e s t s provides a h e l p f u l i n d i c a t i o n of how s e c t o r a l planning approaches i n nursing i n Canada may be viewed.  In  manpower planning i n Canada and B r i t i s h Columbia we can i d e n t i f y : 1) set  the "entrepreneurs" who were a t f i r s t the t r a i n e d nurses who  up i n p r i v a t e p r a c t i c e from the e a r l i e s t days u n t i l  1940.  Thereafter, t h i s group disappeared.  became employees and began  They, or t h e i r successors,  to be represented  a s s o c i a t i o n speaking on t h e i r behalf.  approximately  by the p r o f e s s i o n a l  Although the nurses are no longer  self-employed, the a s s o c i a t i o n s t i l l represents the nurses' i n t e r e s t .  53.  Because of the heavy 'vocational' overload, these representatives of nurses concerned themselves with  discussions about education  and  t r a i n i n g more often than about rewards i n the period up to the mid seventies.  Now that nurses have become unionized, and are beginning to  push  strongly  more  f o r improved  between p r o f e s s i o n a l (standards)  economic  standards,  the r e l a t i o n s  and union (economic) a c t i v i t i e s has  become a r e a l issue f o r the a s s o c i a t i o n s to manage. 2)  the corporate planners who have been c o n s o r t i a of employers,  i n s t i t u t i o n a l i n t e r e s t groups or government sponsored groups i n Canada and i n B r i t i s h Columbia.  The a c t i v i t i e s of corporate planners have been  sporadic and ad hoc u n t i l very r e c e n t l y .  For example, the shortage of  nurses i n World War I I , l e d the f e d e r a l government i n 1946, to set up the " J o i n t Commission of Nursing" (30) with representation from the Canadian Hospital  Council, Canadian Mental Health  A s s o c i a t i o n , Department of  National Health and Welfare and the Department of Veterans'  A f f a i r s to  consider the acute shortage of h o s p i t a l personnel. Much of the planning by i n s t i t u t i o n a l i n t e r e s t groups or employers' representatives has continued, as was shown i n the n a r r a t i v e above, but i t has not been very e f f e c t i v e since the p r i n c i p a l l o y a l t y of committee members has been to t h e i r sponsoring organizations and not to the ad hoc planning groups. Corporate  planning  was  given  a  major  government deciding to fund health s e r v i c e s .  boost  by  the f e d e r a l  In 1948, the p r o v i n c i a l  governments had to produce h o s p i t a l plans before  they could tap the  n a t i o n a l health grant funds and a t about t h i s time they a l s o reviewed t h e i r p u b l i c health and mental health programs and developed plans. But at that time there were no strong administrators who were employed by the  54.  provincial  governments  (available  to  implement  plans)  except i n  Saskatchewan, and outside consultants' plans tended to be pushed aside by p r o v i n c i a l p o l i t i c i a n s who had d i f f e r e n t objectives than the v i s i t i n g planners. The National  Health  Grant Program  (1948) provided  f o r hospital  construction grants which greatly expanded the number of h o s p i t a l beds. This i n turn, created great problems i n r a i s i n g enough funds to keep these  hospitals operating.  Services  Act (1957)  further  The Hospital increased  Insurance  access  to health  Canadians and u t i l i z a t i o n of hospitals continued to r i s e . the  Medical  Care  Act (1966) continued  funding health care.  Before  and Diagnostic  government's  care f o r  The passage of involvement i n  t h i s act could be implemented, costs had  r i s e n alarmingly and the governments became concerned. The Task Force on the Costs of Health Care i n Canada (32) was established i n 1969. This committee made recommendations which can be summarized as: 1)  change  the f e d e r a l - p r o v i n c i a l funding  system to close the  open-ended "funding of health care" system. 2)  t r y to move away from treating so many persons i n hospitals by  closing beds and moving towards more outpatient care. 3)  investigate other methods of organizing health care systems.  The main d i f f i c u l t y with government planning i s that the delivery of services i s usually delegated to groups authorized by l e g i s l a t i o n and funded  by government  to provide  services  - groups which  are only  indirectly controlled. Judge (1978) (71) was distinguished between f i n a n c i a l and service rationing.  Governments can only control the l e g i s l a t i o n and funding of  d i r e c t services, although  they have been trying to find ways of making  55. the i n d i r e c t service d e l i v e r e r s more accountable.  However, the service  d e l i v e r e r s have been r e s i s t a n t to these c o n t r o l s . Consequently, the Task Force recommendations were very threatening. Obviously, for  nursing  the f i r s t two recommendations had s p e c i a l i m p l i c a t i o n s and  they  were  strongly  supported  by  allied  health  professionals. The  medical establishment  and h o s p i t a l s r e s i s t e d both of these  recommendations as i t would mean a major change i n a s t r u c t u r e with which they were  comfortable. A l f o r d (1) s t a t e s : Groups are u s u a l l y r e l u c t a n t to y i e l d r i g h t s and p r i v i l e g e s that they have exercised, and w i l l resist significant restructuring unless i t appears that there i s something i n i t f o r them.  Closing  h o s p i t a l beds was not conducive to the status  of the  h o s p i t a l s , nor to the p r a c t i c e p o t e n t i a l of the physicians, who had become used to t r e a t i n g t h e i r patients i n the now-sophisticated  hospital  environment. The  third  recommendation l e d to other  activities.  The f e d e r a l  government c a l l e d two Health Manpower Conferences i n 1969 and 1971 (24). up  (23)  Following t h i s , f e d e r a l - p r o v i n c i a l manpower committees were set  i n 1972 and gradually, i n v e n t o r i e s of health personnel and t h e i r  d i s t r i b u t i o n were b u i l t up. As w e l l , the government began to look at ways of u t i l i z i n g current health  care  manpower more  effectively,  nursing  manpower  included.  Physicians wished to remain the primary contact with t h e i r patients and work on a f e e - f o r - s e r v i c e b a s i s .  Ambulatory care was not a t t r a c t i v e  since the physicians have had f a i r l y ready access to more convenient  .56.  h o s p i t a l beds.  The Community Health Centres Concept i s at odds with  concepts of physician c o n t r o l over the work s i t u a t i o n .  Although some of  the physicians seemed to support the recommendations of the Boudreau Report to develop nurse p r a c t i t i o n e r s , i n general the medical profession has  strongly  resisted  this  concept  and  after  demonstrations  had  succeeded, no more was done to develop the p o s i t i o n except i n the f a r north. 3)  advocacy  groups  are groups  because of s p e c i f i c concerns. cause changes.  of consumers who  come together  They attempt to u t i l i z e p u b l i c support to  In the health care system i n B r i t i s h Columbia the S o c i a l  Planning and Review Committee performs t h i s r o l e but i t has not been i n t e r e s t e d i n nursing problems.  P r o f e s s i o n a l i n t e r e s t groups may  seek p u b l i c support f o r t h e i r concerns. General H o s p i t a l i n 1978,  also  The nurses from the Vancouver  played t h i s r o l e .  They s u c c e s s f u l l y  used  p u b l i c support to gain changes at the Vancouver General H o s p i t a l . Generally though, the public i s asked to support so many d i f f e r e n t causes and issues that the r o l e of advocates i n planning i s e f f e c t i v e u s u a l l y only i n " c r i s i s " types of s i t u a t i o n s .  On an ongoing long term  planning basis they have l i t t l e e f f e c t i n B r i t i s h Columbia. B.  Nursing Manpower Planning i n B r i t i s h  Columbia  In B r i t i s h Columbia, manpower planning began i n 19^9 with studies by Hamilton and E l l i o t (65) (18). The government d i d not implement these studies immediately because i t d i d not have a strong c i v i l service to f o l l o w through and p o l i t i c a l decisions were incremental decisions rather than planned d e c i s i o n s . In  1959  - 60, Dr. J . McCreary, Dean of Medicine, managed to f i n d  resources to finance the Metropolitan H o s p i t a l Planning Council and two  57. epidemiologists Epidemiology  working  out of the Department  of Health  prepared reports on h o s p i t a l u t i l i z a t i o n .  that the M i n i s t e r of H o s p i t a l Insurance  Care and  I t was hoped  would pick up t h i s  activity  ( a f t e r i t had shown i t s e l f to be u s e f u l ) , and provide funding to c a r r y on with i t , but there was no help forthcoming and the Council went out of existence.  The government moved more ' e f f e c t i v e l y  into  health  care  planning i n 1966 when the Regional D i s t r i c t s Act was passed together with a Regional H o s p i t a l D i s t r i c t s Act to c o n t r o l h o s p i t a l f a c i l i t y planning. In  1966,  Dr. McCreary  persuaded  the Honourable  Judy  LaMarsh,  Federal M i n i s t e r of Health of the necessity to set aside some funding f o r the  development  of health  manpower  training  facilities.  Columbia was slow to pick up i t s share of the money.  British  The p r o v i n c i a l  government showed a great reluctance to get i n t o planning so voluntary planning bodies continued to a c t .  In 1968, the RNABC joined the B r i t i s h  Columbia Medical A s s o c i a t i o n , the B r i t i s h Columbia Pharmacy A s s o c i a t i o n and the B r i t i s h Columbia Dental A s s o c i a t i o n to form the Council on Health Resources and Manpower.  Subsequently,  the RNABC supported a study by  Williamson c a l l e d the "Nursing Manpower Study i n the Province of B r i t i s h Columbia" (126).  The goal was to attempt  manpower was a v a i l a b l e .  The other  to i d e n t i f y what nursing  d i s c i p l i n e s were studying  profession's manpower a v a i l a b i l i t y a t the same time. council  was  subsequently  Resources Council.  changed  to the B r i t i s h  their  The name of the Columbia  Health  I t was c l o s e l y r e l a t e d to the Department of Health  Care and Epidemiology  and l a t e r  to the D i v i s i o n of Health Services  Research and Development at UBC which was headed by Dr. D.O. Anderson. (The D i v i s i o n of Health Services Research and Development i s the s i t e of the current Health Manpower Research  Unit.)  Although not i n any way  58.  e f f e c t i v e i n introducing changes, the c o u n c i l had made people aware of the i s s u e s . Dr.  Anderson  continued  t o research  health  manpower issues on  research grant funding from the f e d e r a l government, and e s t a b l i s h e d the Health Manpower Research Unit (HMRU) i n the D i v i s i o n . government  became  involved  i n health  manpower  When the f e d e r a l  planning  i n 1972  ( f o l l o w i n g the two n a t i o n a l conferences i n 1969 and 1971), they involved the p r o v i n c i a l government as w e l l .  The Federal government formed four  continuing committees, one o f which was the F e d e r a l / P r o v i n c i a l Health Manpower Committee, t o advise the Council o f M i n i s t e r s , and Conference of Deputy M i n i s t e r s of Health f o r Canada. Dr.  Anderson  was  asked  to represent  the province  on the  F e d e r a l / P r o v i n c i a l Health Manpower Committee. When the NDP government came i n t o power i n 1973, they set up the BCMC  which  was meant  to do teaching  hospital f a c i l i t y  planning  p r i m a r i l y , but i t got involved i n s o r t i n g out the students'  practicum  placements and therefore i n t o manpower planning. The D i v i s i o n o f Health Services Research and Development under Dr. D.O.  Anderson, then became involved with the BCMC i n a formal way.  F i r s t the P r o v i n c i a l Council, responsible f o r a d v i s i n g the M i n i s t r i e s of Health  and Education  on f a c i l i t i e s  and programs f o r health manpower  production, was established under the l e g i s l a t i o n which created BCMC. Second, officials  the Health  Manpower  Working  Group,  c o n s i s t i n g of senior  i n the M i n i s t r i e s of Health and Education,  was created to  advise the M i n i s t e r s on health manpower requirements f o r the p r o v i n c i a l health care system. Each of these bodies has a s p e c i a l research and development u n i t . The  P r o v i n c i a l Council was supported  by the D i v i s i o n of Educational  59.  Planning r e p o r t i n g to the Council through an Educational Conimittee of Deans and Academic D i r e c t o r s . supported by the HMRU at UBC. production and  requirements  The Health Manpower Working Group  was  These two u n i t s , dealing r e s p e c t i v e l y with were l i n k e d by  cross appointments.  The  D i r e c t o r of Health Research and Development played an o f f i c i a l r o l e ; i t s d i r e c t o r Dr. D.O.  Anderson, was secretary to the Health Manpower Working  Group, the representative of health o f f i c i a l s on the Education Committee of the BCMC, and the p r o v i n c i a l representative to the F e d e r a l / P r o v i n c i a l Health Manpower Committee ( 3 ) .  Thus the d i r e c t o r became the corporate  planner f o r the manpower s e c t i o n . The D i v i s i o n of Health Services Research and Development was given the r e s p o n s i b i l i t y to study and model nursing manpower requirements all  types  of nurses,  of  t a k i n g i n t o account population needs, nursing  functions and categories, p o s i t i o n s a v a i l a b l e , vacancies, unemployment rates and labour force p a r t i c i p a t i o n .  The goal was to advise on l o c a t i o n  and s i z e of new schools of nursing ( 3 ) . Meanwhile  the  RNABC had  published  "Registered Nurse Manpower i n B r i t i s h  a  report  i n 1973  Columbia" (110).  entitled  This was  in  response to p u b l i c concern i n 1970 and 1971 that there was an oversupply of nurses r e s u l t i n g i n unemployment f o r nurses. and  In the summer of  1973 the press again were concerned with the supply of nurses  t h i s time, there was a shortage. This reports states i n summary: The data presented i d e n t i f y current needs i n r e l a t i o n to the present health care system and as such should provide a s t a r t i n g point f o r manpower planning to meet future needs as the system begins to change.  1972 and  60. The problems i d e n t i f i e d by t h i s examination of the r e g i s t e r e d nurse manpower s i t u a t i o n i n B.C. emphasize the need f o r f u r t h e r study i n the context of t o t a l health manpower and t o t a l health care f o r the people of the province. This recommendation from the RNABC had not y e t been c a r r i e d out. The RNABC became involved i n p r o v i n c i a l manpower planning through the BCMC. The past president of the a s s o c i a t i o n , Margaret Neylan, became an employee of BCMC. The a s s o c i a t i o n was asked to send a representative to the f i r s t planning meeting and other nurses sat on planning committees for s p e c i a l t y areas. But  i n 1975 the government changed, BCMC was dissolved and the  manpower planning process was considerably diminished i n scope. nursing study was not completed although  The  some information was u s e f u l  l a t e r on to determine school of nursing l o c a t i o n s . The D i r e c t o r of Health Services Research and Development D i v i s i o n of UBC resigned and the u n i t took some time to be reorganized. The concern with shortages of nursing personnel  continued.  The Kermacks Report (73) s t a t e s : As was discussed e a r l i e r , the demand f o r R.N.s i s i n c r e a s i n g . Cycles of very short supply and then adequate supply seem to c h a r a c t e r i z e t h i s work force. I n d i c a t i o n s are that the province i s now moving toward another short supply period. Two cycles have occurred since 1970. These f i n d i n g s d e f i n i t e l y i n d i c a t e the need f o r serious manpower planning as r e g i s t e r e d nurses represent a large p o r t i o n of the health care workers. Their absence creates a c r i s i s i n health care. The number of nurses prepared f o r a d m i n i s t r a t i v e , teaching and s p e c i a l i z e d c l i n i c a l p o s i t i o n s presents an even greater problem. The l a c k of q u a l i f i e d nurses f o r these p o s i t i o n s has been a p e r s i s t e n t concern of nurses and employers f o r years. An immediate and defined course of a c t i o n i s required.  61. Shortages of nurses have obviously affected the health care system. The  e f f e c t I s most obvious during the summer months when f u l l  time  nursing s t a f f are taking vacations and when many nurses tend to t r a n s f e r to other p o s i t i o n s .  For the past several summers, beds have had to be  closed i n h o s p i t a l s i n B.C.  This has been most noticeable on the Lower  Mainland. The current 1980 s i t u a t i o n i n B.C. i s that there i s concentration at t h i s time on nursing requirements and supplies.  This concern i s with  quantity but a l s o with q u a l i t y of nurses needed and a v a i l a b l e . Many groups have made t h e i r concerns known to the M i n i s t r y of Health through reports, b r i e f s and meetings. Experience i n the current summer has only supported these concerns as h o s p i t a l s throughout the province have closed beds f o r the summer or u n t i l they have s u f f i c i e n t nursing s t a f f to re-open these areas. areas have not closed beds but have encouraged  Some  t h e i r medical s t a f f to  admit only urgent cases as they are "working short", which means they are s t r e t c h i n g t h e i r nursing s t a f f t o dangerous l i m i t s . H o s p i t a l , the major  Vancouver  General  t e r t i a r y care r e f e r r a l h o s p i t a l i n the province,  closed 200 patient care beds from June 1 to September 15, 1980. As w e l l , s p e c i a l areas have reduced some of t h e i r s e r v i c e s .  The heart surgery  u n i t has reduced beds and some of the O.R.s are not open f o r the summer. Dr. M. Petreman, President of the BCMA, i n the a s s o c i a t i o n ' s b r i e f to the H a l l Commission, March 11, 1980 stated: that the BCMA i s aware of inadequate h o s p i t a l funding with i t s r e s u l t a n t d e t e r i o r a t i o n of care. He maintained that whenever h o s p i t a l budgets get 'clamped on' there i s an immediate  cut-back  on  nurses.  He  claimed  there  i s inadequate  remuneration f o r nurses i n B.C. and a shortage of nurses i s developing.  62. In the same b r i e f the BCMA a l s o recommended a review of current nursing t r a i n i n g and continuing education programs; reasonable  working  conditions and compensation f o r nurses. These n o t i f i c a t i o n s of problems with manpower supply of nurses are u s e f u l to help i d e n t i f y and focus on the problem.  They are not u s e f u l to  help solve the problem because o b j e c t i v e data i s not provided i n the submission. I t has not yet been i d e n t i f i e d how many nurses with what e x p e r t i s e , knowledge and s k i l l s are needed where i n the province. Not only has t h i s current need not been i d e n t i f i e d , but p r e d i c t o r s for future needs are only beginning.  Since considerable time i s required  to plan and provide nursing education programs, current trends may  be  i n d i c a t i v e of future c r i s i s . Recent development i n manpower planning fronts.  The  have occurred  S o c i a l C r e d i t government, concerned with  cost  on  three saving,  i n i t i a t e d a study on physician manpower which was c a r r i e d out by the Hon. W.  Black (former M i n i s t e r of Health), (11) recommending cut-backs  training  of physicians.  Communication, the  Hon.  developing technology. divided  The Dr.  M i n i s t e r of U n i v e r s i t i e s , Science P.  McGeer, i s extremely  in and  interested i n  As M i n i s t e r of Education before the M i n i s t r y was  (See Appendix B), he recommended i n c r e a s i n g the s i z e of  the  medical school at UBC to provide more physicians. In the l a s t few years, the M i n i s t r y of Education manpower development. Thompson, coordinator  has become i n c r e a s i n g l y involved i n health  The M i n i s t r y of Education, through Dr. Sheilah of  the  D i v i s i o n of  Health  and  Human Service  Programs, has begun to s o r t out the nursing care system, by i d e n t i f y i n g the various l e v e l s of nurses and the competencies which these l e v e l s must  63. have.  Major  concentration  to t h i s  point  i n the d e f i n i t i o n of  competencies has been on nursing aides and p r a c t i c a l nurses, although as mentioned p r e v i o u s l y , funding i s now being sought to work on post-basic c l i n i c a l s p e c i a l t y courses f o r r e g i s t e r e d nurses. The  post-basic  s p e c i a l t y courses have become an issue because o f  demands by entrepreneural  groups  that  something  be done  to solve  problems i n t h i s area and the HMRU f o r the Health Manpower Working Group has  been delegated  related  to c l i n i c a l  activities. (13).  the task o f s o r t i n g out nursing specialties.  The group  manpower issues  has begun  two major  The f i r s t i s the Health Manpower Vacancy Monitoring Project  This p r o j e c t i s being undertaken by the BCHA and the HMRU. A  monthly survey i s conducted which c o l l e c t s data on the positions. more.  difficult-to-fill  These are p o s i t i o n s which have been vacant f o r t h i r t y days or  The purpose o f t h i s survey i s to i d e n t i f y the s h o r t f a l l on a  monthly basis of R.N.s and other settings.  occupational  groups i n acute  care  This i s a beginning attempt to determine what current demands  are f o r r e g i s t e r e d nurses and others. The  second a c t i v i t y  i s being  c a r r i e d out by the HMRU f o r the  Manpower Working Group. I t i s a project to review the post-basic problems i n the province (123).  nursing  A Steering Committee has been set up and  a preliminary questionnaire designed t o a s c e r t a i n the numbers of R.N.'s providing s p e c i a l care services i n acute care h o s p i t a l s i s i n the process of t a b u l a t i o n . C.  I n e f f e c t i v e Cooperation Between S e c t o r a l Groups i n B r i t i s h Columbia A l f o r d (1) has argued that the ideologies of the s e c t o r a l i n t e r e s t  groups i n New York H o s p i t a l Planning were so much i n c o n f l i c t that the planning which went on was "dynamics without change."  I t seems that i n  64. B.C., i n t e r e s t groups were prepared to get together from time to time to pursue common o b j e c t i v e s .  But planning of nursing manpower i n B r i t i s h  Columbia has never r e a l l y evolved to s a t i s f a c t o r y l e v e l s . hand  models  f o r nursing  manpower  planning  have  On the one  not been  clearly  i d e n t i f i e d , or i f i d e n t i f i e d , not c l e a r l y shown to f i t the circumstances of B r i t i s h Columbia.  In nursing manpower there has not been a c l e a r  i d e n t i f i c a t i o n of the need f o r numbers and l e v e l s of nurses required f o r B r i t i s h Columbia.  Part of the problem i s the lack of standards f o r the  various l e v e l s of nurse and the various employment areas. Another  reason  why  nursing  manpower  planning  i s not  highly  developed i n B r i t i s h Columbia may have been the lack of commitment by the government  to u t i l i z e  the data  generated,  possibly  because  those  concerned have not seen where best t o . I t has been pointed out to the p r o v i n c i a l government i n many b r i e f s over s e v e r a l years that t h i s province only graduates f o r t y per cent of the  nurses r e g i s t e r e d i n B r i t i s h  Columbia because i t i s an intake  province, but no one has determined what the requirements a c t u a l l y are. As w e l l , nurses with post-basic c l i n i c a l expertise have been i d e n t i f i e d as scarce i n t h i s province. Very l i t t l e has been done to date about e i t h e r s i t u a t i o n . not be p o l i t i c a l l y  expedient  I t may  to promote nursing manpower planning i n  B r i t i s h Columbia or the funding may not be a v a i l a b l e to u t i l i z e the data. The educational  bodies  involved have not sorted out who  should  be  providing e i t h e r education or t r a i n i n g or when, how and where t h i s should be provided.  These groups are part of the corporate government group but  have not been properly incorporated i n t o the planning a c t i v i t i e s .  Nor  has a coordinated approach been developed e i t h e r i n long term planning or  65.  in  those  involved i n the  planning.  Plans,  to now,  developed, over a period of time i n an orderly way.  have not  been  Rather there have  been " s t a r t s and stops" or ad hoc plans developed, often i n i s o l a t i o n from what has gone before or i n r e l a t i o n to future needs. Interested  groups remain uncoordinated.  groups, e n t r e p r e n e u r i a l , corporate  and  There are  still  advocacy, t r y i n g to solve  nursing manpower planning program i n t h e i r own  ways or from t h e i r  many the own  i n t e r e s t bases, but up to now they have been i n e f f e c t i v e . D.  P o s s i b l e Reasons f o r I n e f f e c t i v e Planning Marmor (83) i n the " P o l i t i c s of Medicare", suggests another model  f o r planning.  He suggests that timing i s important and at a s p e c i f i c  time, one of three d e c i s i o n making methods may be most appropriate.  He  describes the three methods as Rational Inputs, Bureaucratic Adjustments and Negotiation Adjustments.  Rational Inputs are obvious - as pointed  out above, there i s a lack of models, standards, c l e a r o b j e c t i v e s i n nurse manpower planning.  Rational planning i m p l i e s i d e n t i f i c a t i o n of  goals and purposes, because decisions regarding which actions should be undertaken are r e l a t e d to the optimal means i n reaching those goals and purposes.  Are the purposes and goals of entrepreneurs,  advocate groups the same f o r nursing manpower planning? been c l e a r l y i d e n t i f i e d by any or a l l of the groups?  corporate  and  Have they ever Can they be  and  should they be the same? Can some goals and purposes be the same and yet others d i f f e r ? differ?  W i l l short term and long term goals of various groups  Further involved i n r a t i o n a l planning i s a c h a r a c t e r i s t i c model  of d e s c r i p t i o n , explanation, p r e d i c t i o n and evaluation. Are these areas i n which a l l three i n t e r e s t groups can agree on these a c t i v i t i e s so that nursing manpower planning can proceed?  66. Before r a t i o n a l planning can develop basic f a c t s and data must be available.  Are these data a v a i l a b l e now?  Can the Rational Inputs,  Bureaucratic Adjustments and Negotiation Adjustments groups cooperate i n developing t h i s data base? Do they want to develop a s i m i l a r or the same data base? The concern with adequate numbers and q u a l i t i e s of nurses i s a North American problem a t t h i s time. Nursing,  An a r t i c l e i n the American Journal o f  March 1979 ( 5 ) , states loudly and c l e a r l y  serious shortage  that there i s a  o f both quantity and q u a l i t y o f nurses.  I t further  states that enrolments i n schools o f nursing i s d e c l i n i n g . The a r t i c l e l i s t s four d i s t i n c t problem areas: 1)  there i s a geographic m a l d i s t r i b u t i o n of nurses  2)  expanding  health  care  operations  have created  a need f o r  r e g i s t e r e d nurses with a d d i t i o n a l education 3)  c e r t a i n p o s i t i o n s remain u n f i l l e d (those i n which there have  always been l e s s than d e s i r a b l e working conditions) 4)  the number of v o l u n t a r i l y i n a c t i v e nurses i s high.  These same problems are present  i n the B r i t i s h  Columbia nursing  scene. These are negative statements.  P o s i t i v e models are l e s s frequently  discussed but one which has had considerable currency i s the pyramidal model considered by the WHO/ICS/MCU (128) group as the r i g h t model. In B r i t a i n and i n A u s t r a l i a , a r a t i o n a l plan f o r d e l i v e r y o f nursing care has been developed.  I t involves the use of equivalents of p r a c t i c a l  nurses f o r a great deal of nursing care d e l i v e r y . In Canada, nurses have not accepted  t h i s delegation r o l e and have not been forced to do so  because the government funds h o s p i t a l s by g l o b a l budgets and does not  67. determine what l e v e l of nurse the h o s p i t a l must h i r e .  Further, the  government has not had a r a t i o n a l plan f o r i t s i n t r o d u c t i o n .  Do  the  "entrepreneurs" - the p r o f e s s i o n a l a s s o c i a t i o n planners -understand  and  accept the i m p l i c a t i o n s of asking f o r a r a t i o n a l plan? Since a l l three groups have a d i f f e r e n t i n t e r e s t base, do any of these groups r e a l l y want r a t i o n a l planning?  The  "entrepreneurs"  have  been t r y i n g to i n i t i a t e or develop a manpower plan f o r years.  I f there  were a surplus of nurses  rational  planning?  would they  still  be  committed to  Would a r a t i o n a l plan remove f l e x i b i l i t y of the profession's  development? The  bureaucratic  planning model i s concerned with  the  present  s i t u a t i o n over which any planning group has c o n t r o l and ways of moving incrementally towards change w h i l s t making the best use of i t s e x i s t i n g departments or s e c t o r s . The bureaucratic planners have to consider what i m p l i c a t i o n s a r a t i o n a l plan would have i n nurse manpower planning. Shortages i n nursing, p a r t i c u l a r l y c l i n i c a l s p e c i a l t y prepared exists.  nurses  I f the bureaucratic planners were to develop a r a t i o n a l plan  adjusted to f i t e x i s t i n g i n s t i t u t i o n s would they have to commit the resources and/or would they be able t o , to implement the plan? corporate  planners  disadvantage  involved  in  nurse  manpower  planning  are  The at  a  because no one group has attained the power to provide an  overview of the s i t u a t i o n and to pursue i t . The M i n i s t r y of Health, through the Health Manpower Working Group can i d e n t i f y s e r v i c e needs f o r nurses, but the M i n i s t r y of Education have d i f f e r e n t p r i o r i t i e s f o r spending the budget f o r educating for  these  services.  The  M i n i s t r y of Health  may  nurses  c o n t r o l s the manpower  deployment i n operating i n s t i t u t i o n s only through the budget and use of  68.  consultancy advice. ability  Therefore, the Health M i n i s t r y i s l i m i t e d i n i t s  to pursue manpower planning and implement recommendations.  The  Ministry  institutions, clarified,  of  Education,  whose r o l e s  through  i n nursing  various  education  educational  have not yet been  may i d e n t i f y and plan f o r educational needs f o r nurses but i f  these do not meet the p r i o r i t i e s of the M i n i s t r y of Health approval w i l l not be given. C i r c l e s run i n c i r c l e s .  The confusion which e x i s t s today r e s u l t s i n  large part because of the vested i n t e r e s t s of these corporate planners and the lack of an o v e r a l l coordinating mechanism which has the power to force them to plan together.  The negotiations adjustments  model i s  concerned with seeking bargained s o l u t i o n s between p a r t i e s with power to plan. The bureaucratic planning model i n B.C. seems to be almost more of a  negotiations adjustment  model,  f o r the corporate  planners  have  developed mechanisms w i t h i n t h e i r groups f o r n e g o t i a t i o n and d i s c u s s i o n . An example i s the Health Manpower Working Group which has representation from the M i n i s t r y of Education and the M i n i s t r y of Labour.  Members of  t h i s group have worked reasonably w e l l together to t r y to solve nursing manpower problems. By contrast, i n the Education M i n i s t r y , approval f o r funding of programs i s through the Academic Council, which i s not part of the c i v i l s e r v i c e , reports only to the M i n i s t e r of Education and i s not represented on the Health Manpower Working Group (although there i s some attempt at cross referencing d i s c u s s i o n since the chairman of the Health Manpower Working Group attends the Education Health Committee of the Academic C o u n c i l ) . But the Health Manpower Working Group can not be sure that i t s recommendations w i l l be c a r r i e d out by that M i n i s t r y . The e f f e c t i v e n e s s of t h i s  inter-Ministry  group i s questionable  o v e r a l l because i t s members do not have c o n t r o l of the i n s t i t u t i o n a l or  69.  p r o f e s s i o n a l resources and have not set up a formal n e g o t i a t i o n system with the " e n t r e p r e n e u r i a l " ( p r o f e s s i o n a l a s s o c i a t i o n ) groups. Marmor (83) power  of  the  says that t h i s model develops from the p o s i t i o n and principals  and  focuses  on  the  understandings  and  misunderstandings which determine the outcome of the games. In planning power?  f o r nursing manpower, which group has  the  greatest  Since advocacy groups are not a c t i v e i n supporting nursing man-  power, they have only p o t e n t i a l power at t h i s time. The "entrepreneurs" - the p r o f e s s i o n a l a s s o c i a t i o n - have attempted to i d e n t i f y the needs and to lobby f o r nursing manpower planning since 1973, has  but up to now have not been very e f f e c t i v e . been s u c c e s s f u l i n r a i s i n g consciousness  However, t h i s group  about the issue and  in  focusing the current i n t e r e s t on post-basic c l i n i c a l s p e c i a l t y courses. Apart from t h e i r general concern about r a i s i n g the general educational standards  of t h e i r members, p r o f e s s i o n a l organizations, have i n the  past, tended to react to e x t e r n a l pressures.  As a r e s u l t , they have  planned on a short term basis f o r immediate c r i s i s needs. overall  d i r e c t i o n s i n which  c l e a r l y been determined.  they  see  nursing  Therefore  progressing  have  the not  To develop a plan f o r nursing manpower, the  i n t e r e s t of a l l l e v e l s and groups of nurses must be considered, which i s d i f f i c u l t to do i f the current c r i s i s r e l a t e s to only one area of nursing (the  R.N.'s).  The  vested  interests,  then  of  the  professional  a s s o c i a t i o n , being focused on c r i s e s , have l e s s force i n nursing manpower planning.  This group does gain strength i n the short term because  i t can concentrate  i t s energies i n a bounded area of concern, but i t s  long term s e l f i n t e r e s t s may be compromised. The  government corporate  planning group, sometimes working with  employers' organizations (or HMRU), i s the most powerful group since i t  70.  controls  the funding  and the approval  mechanisms.  But government  i n t e r e s t has not, u n t i l r e c e n t l y , focused on nursing manpower.  This  government corporate planning group i s made up of a t l e a s t two separate p r o v i n c i a l m i n i s t r i e s , each of which has i n t e r e s t s other than nursing manpower planning. grasp  manpower  This group has never been sure that i t wanted to  planning  until  d i s c u s s i o n w i t h i n the ranks.  r e c e n t l y and there  are s t i l l  many  The Health Manpower Working Group has not  been unduly concerned with nursing manpower u n t i l 1980 and therefore i t s resources have not been focused i n t h i s area. Since corporate planning i n B.C. must be concerned with bargaining with the "entrepreneurs" what mechanisms have been set up to f a c i l i t a t e this  activity  f o r manpower  planning?  Have  they  been  effective  mechanisms? There has not been a formal mechanism set between the professions and the corporate planners to deal with nursing manpower.  The RNABC  meets with the M i n i s t e r of Health on a regular b a s i s , but to discuss a l l concerns r e l a t e d  to nursing  not j u s t  the manpower planning  issue;  however through t h i s mechanism the a s s o c i a t i o n has been able to b r i n g the manpower issue forward as a concern.  The RNABC i s now represented on  s e v e r a l planning groups, but tends to act as a consultant about needs and standards rather than as a p o l i c y s e t t e r because i t does not c o n t r o l resources.  The RNABC i s the agency which keeps the r e g i s t e r of nurses,  thus i t has a v a i l a b l e some of the information about the supply of nurses which i t w i l l i n g l y c o n t r i b u t e s . Because the RNABC has decided that standard s e t t i n g i s i t s respons i b l i t y (approval o f programs f o r continuing education), and t h i s seems to be accepted by corporate planners, i t has a subtle power to shape the  71.  planning, and to determine i t s e f f e c t i v e n e s s or i n e f f e c t i v e n e s s . In 1980,  the UBC Health Manpower Research Unit was delegated  nursing manpower planning f o r post-basic nursing.  the task of  A s t e e r i n g committee  for t h i s group has been set up. The RNABC has appointed two members to t h i s s t e e r i n g committee.  This group provides a mechanism f o r formal  d i s c u s s i o n among d i f f e r e n t planning i n t e r e s t s but i s j u s t beginning i t s task. The n e g o t i a t i o n adjustments between the groups i s i n i t s infancy. Although the corporate planners should be able to lead n e g o t i a t i o n s , i t has been hampered because of i t s i n t e r n a l competing i n t e r e s t s . To be e f f e c t i v e ,  these  groups must be aware of t h e i r  relative  powers, and become p o l i t i c a l l y astute re t h e i r bargaining bases.  They  must a l s o recognize each other as actors i n t h i s a c t i v i t y and s e t up formal mechanisms, with d e c i s i o n making powers, to begin progress i n manpower planning.  PART V  TOWARDS MORE EFFECTIVE PLANNING  72.  PART V  TOWARDS MORE EFFECTIVE PLANNING  Marmor's t h e s i s ( 8 3 ) i s that a t c e r t a i n times one type o f plan i s more e f f e c t i v e than another. 1)  When i s the appropriate time, i f any, f o r r a t i o n a l d e c i s i o n  making to occur i n nurse manpower planning a c t i v i t i e s ?  A.  2)  Can bureaucratic planning be improved?  3)  What i s l i k e l y to be the future of negotiated planning?  R a t i o n a l Planning Should  nursing manpower planning continue without d i s c u s s i o n and  decisions r e l a t e d to r a t i o n a l planning? The customary way of making change i n democratic incrementalism.  s o c i e t i e s i s by  This may be shapeless and incoherent unless the p o l i c y  makers can draw upon a plan.  Donnison ( 5 6 ) has argued that i t i s h e l p f u l  f o r p o l i c y makers to know o f a standing r a t i o n a l plan. change or be implemented i n a d i f f e r e n t  That plan may  manner once the p r a c t i c a l  a p p l i c a t i o n i s begun but that can only happen i f there i s a basis of understanding.  In applying  this  to nursing  manpower planning, a  r a t i o n a l plan should be the, foundation f o r any decisions on trade o f f s . I f such a plan were developed  i t should be the s t a r t i n g point to  solve the confusions and d i s o r g a n i z a t i o n i n nursing manpower planning. Various models have been used i n the past to p r e d i c t nursing needs. (79) (See Appendix E) The measure of t h e i r lack o f success can be seen i n the current arguments about whether or not there i s a shortage of nursing personnel.  Although  t h e o r e t i c a l l y , many o f these models have  73.  i n d i c a t e d that there should not be a shortage, i n p r a c t i c e , D i r e c t o r s of Nursing who are not able to r e c r u i t nurses i n d i c a t e that there i s a severe shortage. Nursing manpower planning has been going on i n the province, but the r e s u l t s of t h i s work have not been d e f i n i t i v e  enough to f a c i l i t a t e  action. No c l e a r p i c t u r e of current or future supply has been i d e n t i f i e d f o r general or s p e c i a l c l i n i c a l areas.  This can be r e l a t e d to the f a c t that  s p e c i f i c d e f i n i t i o n s of l e v e l s of h o s p i t a l s and health care are not yet established.  Nevertheless there are some commonly accepted  areas where work could begin. current  Presently there i s no c l e a r p i c t u r e of  demand or predicted demand  p o s i t i o n s survey i s an attempt  specialty  f o r nurses.  to t r y to determine  The  hard-to-fill  what the current  nursing needs are i n general nursing areas as w e l l as i n s p e c i a l c l i n i c a l areas. The p r o v i n c i a l government provides operating costs f o r h o s p i t a l s i n the province.  I t should be p o s s i b l e to i d e n t i f y the number of f u l l time  equivalent p o s i t i o n s the province i s c u r r e n t l y supporting.  This could  then be broken down by nurses employed i n general nursing areas and those employed i n s p e c i a l c l i n i c a l areas.  In Canada, the average percentage of  nurses needing education f o r s p e c i a l c l i n i c a l areas i s 20%.  The B r i t i s h  Columbia average i s c u r r e n t l y unknown. Standards  of competency f o r nurses working i n s p e c i a l care areas  have not been determined.  Perhaps nurses could be provided f o r the lower  l e v e l s p e c i a l care areas more e a s i l y by means other than post-basic courses, were these standards set.  The demand f o r s p e c i a l t y c l i n i c a l l y  educated nurses might then be c l e a r e r .  74.  The p r o v i n c i a l government has developed a Bed Matrix Model f o r the province.^ (62) This i d e n t i f i e s the beds which are to be i n operation and the types of s e r v i c e s which are to be offered f o r 1981 and 1986 by provincial hospitals.  These data could provide a basis f o r estimates of  current and future demand f o r nurses.  To date these data have not been  used i n nurse manpower planning. The current supply of general duty and s p e c i a l c l i n i c a l nurses i s unknown. I f evaluations of competencies were to occur t h i s would provide a beginning base. The f o l l o w i n g information was taken from the Kermacks' Report ( 7 3 ) . The majority of nurses are women. employed i n 1978 were men. of 25 to 34 years. single.  Most  Only 1-6% of the r e g i s t e r e d nurses  The majority of nurses are between the ages  Most nurses are married.  married  R.N.s  Only 36.3% of the R.N.s are  are employed  on a  part  time  basis  p a r t i c u l a r l y between the ages of 30 and 39. The highest percentage of f u l l time employees are s i n g l e , between the ages of 20 to 24 and 55 to 64.  A t o t a l of 76.7% of a l l R.N.s are employed on a f u l l time b a s i s . Characteristics  supply  and  of nurses should  integrated  be considered  i n the planning  when discussing  information.  The  social  c h a r a c t e r i s t i c s of nurses have an impact on how, why, and where they remain i n the nursing work force or why they might be l e a v i n g nursing. By reviewing these c h a r a c t e r i s t i c s , s p e c i f i c f a c t o r s can be i d e n t i f i e d which  should  be  considered  i n manpower  planning,  particularly i n  i d e n t i f y i n g supplies of nurses. The new graduates provided by the education system are a part of supply  information.  The nursing  "places" f o r entry of students.  schools  have a c e r t a i n  number of  Should t h i s number be increased to make  75.  up f o r the high a t t r i t i o n rate ( 3 0 to H0%) of nursing students, so that schools designed to provide 100 graduates f o r the system are able to do so?  I s i t necessary to increase the "spaces" or merely to oversubscribe? Can t h i s province continue to count on others to provide "up to 60%"  of our nursing manpower?  The schools of nursing should be included i n  discussions on supply of nursing manpower. The preparation of nurses to work i n s p e c i a l t y c l i n i c a l u n i t s i s one area that has lacked concrete a t t e n t i o n . officially  recognized  The M i n i s t r y of Health has not  the need f o r i n c l u s i o n  of post-basic nursing  courses as a part of p u b l i c l y funded education.  This i s p a r t l y because  the s p e c i a l t y and have not  sub-specialty care u n i t s , where these nurses work,  yet been c l e a r l y  identified.  This w i l l  be  difficult  to  determine u n t i l the r o l e s of h o s p i t a l s , and the l e v e l of a c t i v i t y to be provided i n each, i s c l e a r l y defined. The government, i n a l l o c a t i n g funds to h o s p i t a l s , has neglected to consider the o r i e n t a t i o n and i n s e r v i c e costs f o r nurses i n h o s p i t a l s . Nurses i n s p e c i a l care u n i t s have often not had s u f f i c i e n t training  and  orientation  to  perform  required of them i n s p e c i a l care u n i t s .  effectively  the  on-the-job  competencies  As a r e s u l t , there i s not at the  present time a pool of knowledgeable and w e l l q u a l i f i e d nurses a v a i l a b l e to work i n these ares, nor i s there money a v a i l a b l e to prepare new nurses i n t h i s way f o r t h e i r r e s p o n s i b i l i t i e s . this activity, nurses.  i t may  Even i f money were a v a i l a b l e f o r  not be the most d e s i r a b l e method of preparing  Standards would vary g r e a t l y from one h o s p i t a l to another  and  cost e f f e c t i v e n e s s could be questioned. One other area of funding i s c u r r e n t l y l a c k i n g .  Support of nurses  to attend post-basic courses and costs of r e p l a c i n g s t a f f while they are f  76.  at courses has not yet been sorted out.  This i s an important  question  which needs to be addressed before planning f o r post-basic courses  can  proceed. B.  Bureaucratic Planning A number of problems i n bureaucratic nurse manpower planning i n  B r i t i s h Columbia were i d e n t i f i e d .  The  f i r s t i s that of commitment to  planning, the second j u r i s d i c t i o n a l boundaries and f a i l u r e s to resolve the d i f f i c u l t i e s associated with these. C.  Negotiation Planning Whilst government involvement i n nurse manpower planning i n B r i t i s h  Columbia can be c r i t i c i z e d f o r i t s i n e f f e c t i v e n e s s , i t can be applauded f o r i t s openness i n n e g o t i a t i n g with other i n t e r e s t groups. these  negotiations tend  to  be  ineffective,  because of  the  However, current  planning models and also because of the d i f f e r e n t  values that nursing  a d m i n i s t r a t o r s , nursing educators and p r a c t i t i o n e r s  have.  In the past,  educators were most powerful because they had the most education, time to think, time to develop support networks and the status given them by the nurses themselves.  Nursing administrators have begun to overtake  that  power, as they are now becoming more educated and are much c l o s e r to the r e a l world of nursing and the dispensation of d o l l a r s to provide nursing care.  Practitioners  submissive  have had  least,  i f any,  power because of  their  employee s t a t u s , but today they have begun to r e a l i z e that  they have a great deal more power, simply by withholding t h e i r work.  It  i s important to ask i f these three groups involved i n the negotiations have thought about or i d e n t i f i e d where the power l i e s or what t h e i r power base i s . I f so, have they c l e a r l y i d e n t i f i e d t h i s rather than working on assumptions which may have derived from t r a d i t i o n a l stereotyping?  77. D.  Conclusions The f a i l u r e of nurse manpower planning i n B r i t i s h Columbia can be  attributed  to  lack  of  a  rational  basis  against  which  to  measure  performance, bureaucratic ineptness, and f a i l u r e s i n n e g o t i a t i o n . Although care, nursing enough.  nursing i s regarded  as an important  a c t i v i t y i n health  i n B r i t i s h Columbia has not been considered  carefully  I n t e r n a t i o n a l models f o r nurse manpower planning may  be quite  inappropriate f o r planning here. Stereotyped writings  c h a r a c t e r i s t i c s of nurses are commonly described i n  about nursing manpower planning.  Rarely do authors  g r i p s with what e f f e c t s changing c h a r a c t e r i s t i c s of the  come to  occupational  group a c t u a l l y have on nursing manpower, because i t i s not easy to do so. What does i t mean to nursing manpower planning i n B r i t i s h Columbia that nursing i s almost t o t a l l y a woman's profession? most nurses being married have?  What e f f e c t does  What do the ages of nurses mean? I t i s  important to know about part time and f u l l time employees but what does t h i s mean i f we are t r y i n g to plan f o r nurses' manpower here? One of the concerns of nursing, described e a r l i e r i n t h i s paper, i s the d i f f e r e n t i n t e r p r e t a t i o n or d e f i n i t i o n of nursing made by nursing educators and nursing service people. and  teach  nursing  according  to one  The educators are seen to i d e n t i f y set of standards.  The  administrators and p r a c t i t i o n e r s seem to say "that's not how  nursing it is."  Does the same type of s i t u a t i o n e x i s t i n manpower planning? The p r a c t i t i o n e r s provide the majority of nursing manpower. we  examined  the  basic  value  system of  practitioners?  Since  Have most  p r a c t i t i o n e r s are women, and married, they often have competing r o l e s of wives and mothers.  Have we looked at commitments of p r a c t i t i o n e r s to  78. these varying r o l e s ? prepared  to give  Have we asked them what they want and what they are  i n nursing?  Have they  e f f e c t i v e l y enough with the planners?  been able  to communicate  Have we understood and been able  to u t i l i z e t h i s information i n manpower planning?  Would i t be valuable?  These questions remain to be answered. The p r a c t i s i n g nurse,  i n the past has had l i t t l e ,  power except to work or not to work — not make h e r s e l f heard.  i f any formal  she could vote with her f e e t but  Do the changing values and r o l e s of the nurses  who a c t u a l l y provide the care now begin to matter as they increase t h e i r formal power with the development of unions which no longer p u l l t h e i r punches f o r 'vocational* reasons? In the past the nursing p r a c t i t i o n e r has negotiated d i r e c t l y with the  hospital Directors  of  w i l l i n g n e s s to f i l l them.  Nursing  about  a v a i l a b l e jobs  and  her  She has made i t c l e a r that what she wants i s  not a pyramidal s t r u c t u r e of power with promotion upwards and delegation downwards.  She wants to be a primary care nurse i n charge of her own  p a t i e n t s with the p o t e n t i a l f o r h o r i z o n t a l movement w i t h i n the same h o s p i t a l or w i t h i n the l o c a l i t y (or i f her husband moves she wants to be able to pick up a job i n the l o c a l h o s p i t a l i n the new l o c a t i o n ) . wants  to know  she i s competent to do  this  work.  uncomfortable she w i l l move out i n t o some other sphere. this. E.  I f she  She feels  D i r e c t o r s know  Do health planners? Recommendations I t i s recommended that: A model of r a t i o n a l planning, that considers the current s i t u a t i o n  of  nurses  planning.  in British  Columbia,  be  identified  f o r nurse  manpower  79.  a.  A  rational  Columbia be developed  plan  f o r nurse  manpower  and implemented.  This  planning plan  i n British  should  include  a t t e n t i o n to post-basic c l i n i c a l s p e c i a l t y courses. b.  The bureaucratic negotiation process f o r nursing manpower i n  B r i t i s h Columbia be sorted out and a l l involved p a r t i e s be made aware. c. be  The negotiating process involved i n nursing manpower planning  continued,  but a l l p a r t i e s be aware that with  involvement t h i s process w i l l become more f i e r c e .  increasing  union  80.  References and Bibliography  1.  A l f o r d , Robert E., Health Care P o l i t i c s . of Chicago Press, 1975.  Chicago, The University  2.  Agnew, G. Harvey, Canadian Hospitals 1920 - 70. 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Registered Nurses' Association of B r i t i s h Columbia, Registered Nurse Manpower i n B r i t i s h Columbia, Vancouver, Registered Nurses' Association f o r B r i t i s h Columbia, 1973.  111.  Registered Nurses' Association of B r i t i s h Columbia, Statements on Certain Recommendations on the Report of the Royal Commission on Health Services, Vancouver, Registered Nurses' A s s o c i a t i o n of B r i t i s h Columbia, 1965.  88. 112.  Research Group, Metropolitan H o s p i t a l Planning Council, H o s p i t a l Use i n the Metropolitan Area of the Lower Mainland, Vancouver, Metropolitan H o s p i t a l Planning Council, 1 9 6 1 .  113.  Robertson, R. Rocke, Health Manpower Output o f Canadian Educational I n s t i t u t i o n s , Ottawa, A s s o c i a t i o n o f U n i v e r s i t i e s and Colleges of Canada, 1973.  114.  Roemer, Ruth and Roemer, M i l t o n , Health Manpower P o l i c y Under National Health Insurance - The Canadian Experience. 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Watchfires on the Mountains: The L i f e and Writings of E t h e l Johns, Toronto, U n i v e r s i t y o f Toronto Press, 1973.  121.  Thompson, S., Post Basic Nursing Programs Discussion Paper: Vancouver Health and Human Services Program, B r i t i s h Columbia M i n i s t r y of Education, pp 1 - 3 0 , 1976.  122.  U n i v e r s i t y o f B r i t i s h Columbia, Health Manpower Research Unit, R o l l C a l l , 1978, 79.  123.  U n i v e r s i t y o f B r i t i s h Columbia, Human Manpower Research Unit, Review o f Post Basic Nursing Problems i n the Province, ongoing 1980.  124.  Webster, M., Seventh New C o l l e g i a t e D i c t i o n a r y , Thomas A l l e n L i m i t e d , Toronto, 1963.  125.  Weir, G.M., Survey of Nursing Education i n Canada, Toronto, U n i v e r s i t y o f Toronto Press, 1932.  126.  Williamson, Eva. M., Nurse Manpower Study i n the Province of B r i t i s h Columbia, B r i t i s h Columbia Health Resources Council, 1970.  89.  127.  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APPENDIX A POST-BASIC NURSING PROGRAMS Table A:  Post-Basic Nursing Programs Based i n Education Institutions  Table B:  Post-Basic Nursing Programs Based i n Health Care Facilities  Table C:  Proposals f o r New Post-Basic Nursing Programs  Source:  Kermacks, C l a i r e ; A Report to the Health Education Advisory Council: Nursing Education Study; M i n i s t r y of Education, Science and Technology, Province of B r i t i s h Columbia, Vancouver, A p r i l , 1 9 7 9 .  TABLE A:  POST-BASIC NURSING PROGRAMS BASED IN EDUCATION INSTITUTIONS REPORT FOR BRITISH COLUMBIA, 1979  PROGRAM INTAKES R INTAKES or PER STU- ADMISSION LENGTH D YR DENT CRITERIA  NAME & DESCRIPTION  LOCATION  Advanced Nursing Care of H o s p i t a l i z e d C h i l d  VCC  14 wks (p.t.) & 4 wks full-time Clinical Practice  Diploma i n P s y c h i a t r i c Nursing  BCIT  34 wks min. a 17 wk preceptorship may be required  Program s p e c i a l l y designed f o r R.N.s Includes practicum i n acute and long term psych., Mental Retardation and Psychogeriatrics  R 1 12 Jan  SOURCE OF PROG. CERTIFICATE OPERATING ISSUED BY TUITION FUNDS  mos. acute care experience satis, clin. evaluation 6  P r i o r i t y B.C. 2 deJan pend Aug on seats  VCC  $200.00  VCC Ministry of Ed.  BCIT  $505.00  BCIT Ministry of Ed.  STUDENT FINANCIAL SUPPORT AVAILABLE  Remarks: Graudates e l i g i b l e f o r r e g i s t r a t i o n as p s y c h i a t r i c nurse (RPNABC)  TABLE A CONT'D  NAME & DESCRIPTION C r i t i c a l Care Nursing Level I  LOCATION VCC Lower Mainland UBC parts of prov. on request  PROGRAM INTAKES R INTAKES or PER STU- ADMISSION LENGTH D YR DENT CRITERIA 6 wks + 5 wks or approx 1 y r on p/t basis  R 3& 6 D  15  SOURCE OF PROG. CERTIFICATE OPERATING ISSUED BY TUITION FUNDS  Recent s a t i s . clinical evaluation.  VCC or UBC  STUDENT FINANCIAL SUPPORT AVAILABLE  $250.00 VCC Min. of Ed. UBC  C.P.R. certificate At l e a s t 1 y r recent exp. i n acute med/surg. unit.  OR Nursing to prepare beginning l e v e l R.N.s f o r OR's  BCIT (B'by)  10 wks F.T.  R 3 12 Oct Jan Apr  Recent C l i n , exp. Intent to work i n B.C. S a t i s med. exam  BCIT  BCIT Min. of Ed.  CEIC  TABLE A CONT'D PROGRAM INTAKES R INTAKES or PER STU- ADMISSION LENGTH D YR DENT CRITERIA  SOURCE OF PROG. CERTIFICATE OPERATING ISSUED BY TUITION FUNDS  NAME & DESCRIPTION  LOCATION  Health Care Management  BCIT (B'by)  3 yrs p/t 3 hrs/ wk 8 units  R 2 appr no r e s t r i c Sept 50 tions Jan  BCIT i n co-operat i o n with BCHA  $70 BCIT per u n i t  RCH/DC Ed Cent. New West  15 wks p/t 3 hr/wk  R 2  DC  $33  to develop & improve s k i l l s , o f department heads, supervisors, head nurses, a s s i s t , head nurses i n hosp. & other health care f a c i l i t e s Management i n Health Care I n s t i t u t i o n s  course designed f o r nurses & other health workers wanting to prepare f o r supervisory p o s i t i o n s . Includes theory & p r a c t i c e on fundamentals o f supervision  appr. p r i o r i t y 15 to B.C. residents  DC  STUDENT FINANCIAL SUPPORT AVAILABLE  TABLE B:  POST-BASIC NURSING PROGRAMS BASED IN HEALTH CARE FACILITIES REPORT FOR BRITISH COLUMBIA, 1979  NAME & DESCRIPTION  LOCATION  Enterostomal Therapy  SPH Van.  PROGRAM INTAKES R INTAKES or PER STU- ADMISSION LENGTH D YR DENT CRITERIA  SOURCE OF PROG. CERTIFICATE OPERATING ISSUED BY TUITION FUNDS  8 wks F.T.  R 5  1 y r exp. & confirm of f . t . job on completion Priority: 1. B.C. 2. Canada 3. USA  SPH  approx $1000  SPH  SPH OR Nursing Van to provide knowledge & s k i l l s so that optimum nursing care can be given to p a t i e n t s before, during and a f t e r surg. i n t e r v e n t i o n  6 mos f.t.  R 2 6 Sept Mar  1 yr nursing exp Priority: 1. B.C. 2. Canada 3. USA  SPH  $250  SPH  Radiotherapy Technology f o r Nurses  2 yrs  R 2 June Oct  to prepare R.N.s to f u n c t i o n as enterostomal therapists SPH: S t . Paul's H o s p i t a l  CCABC Van.  STUDENT FINANCIAL SUPPORT AVAILABLE  Bursaries available Remarks: Program lead to e l i g i b i l i t y to s i t n a t i o n a l exams f o r Canadian Assoc. of Medical Radiology Technologists  TABLE B CONT'D  NAME & DESCRIPTION Industrial F i r s t Aid Certificate  Industrial F i r s t Aid Theory & p r a c t i c e i n emergency care equipment & CPR  LOCATION  PROGRAM INTAKES R INTAKES or PER STU- ADMISSION LENGTH D YR DENT CRITERIA  St. John's 10 wks Amb. or i* wks p. t . 2 wks f.t. ABC Industrial Emerg. Training School Inc.  2 wks f.t. 10 wks p.t.  R 2 Sept Jan  SOURCE OF PROG. CERTIFICATE OPERATING ISSUED BY TUITION FUNDS  STUDENT FINANCIAL SUPPORT AVAILABLE  St. John's $135 Amb. Remarks: a week f u l l time f o r A & Ticket Holders only  R 20 wkly  19 yrs of age  WCB  $125  selffunding  Remarks: on completion of program students e l i g i b l e to s i t WCB exams R.N.s e l i g i b l e f o r B t i c k e t .  TABLE C:  PROPOSALS FOR NEW POST-BASIC NURSING PROGRAMS REPORT FOR BRITISH COLUMBIA, 1979  NAME & DESCRIPTION  LOCATION  C r i t i c a l Care Nursing Level I I  VCC & UBC  PROGRAM INTAKES R INTAKES or PER STUADMISSION LENGTH D YR DENT CRITERIA  3 mos.  2 6  advanced knowledge & s k i l l s common to specialized C r i t i c a l Care areas with courses i n specific specialized f i e l d s , e.g. cardiac, s p i n a l i n j u r y , emergency, e t c . Obs. Nursing Level I Normal mother & newborn with emphasis on intrapartum period  VCC 20 wks Van. p.t. + Distance 6-8 wks Educ. f.t.  1 16  Critical Care Course I or equiv.  SOURCE OF PROG. CERTIFICATE OPERATING ISSUED BY TUITION FUNDS  STUDENT FINANCIAL SUPPORT AVAILABLE  VCC or UBC  VCC Min. of Ed./UBC  VCC  VCC Min. Of Ed.  F i r s t Course Sept/80 or Jan/81  Remarks: F i r s t course Sept/80 Two courses at one time one l o c a l - one distance  TABLE C CONT'D  NAME & DESCRIPTION  Level I I  LOCATION  VCC  high r i s k mother & newborn with emphasis on intrapartum period  PROGRAM INTAKES R INTAKES or PER STU- ADMISSION LENGTH D YR DENT CRITERIA  as above  1 16  Obs Nrsg Level I or equiv.  SOURCE OF PROG. CERTIFICATE OPERATING ISSUED BY TUITION FUNDS  VCC  Remarks:  Psychiatric Nursing  BCIT Douglas  I n f e c t i o n Control  UBC  p.t.  C e r t i f i c a t e Program i n Gerontology  UBC  i-1 y r  Occupational Health Nrsg.  RCH/ DC Ed. Centre New West  12 mos. p.t. 6 parts of 10 wks  Emergency Nursing  RCH/ 16 wks DC Ed. f.t. Centre New West.  1 20-25  R.N.'s working i n occup. health  15-1st 2 y r s exp. course 30 thereafter  VCC Min. of Ed. F i r s t course Sept/81  DC  DC  STUDENT FINANCIAL SUPPORT AVAILABLE  DC F i r s t course Min. of Sept/80 Ed. $400  DC F i r s t course Min. of Sept/80 Ed. second course Jan/81.  APPENDIX B  PROCESS FOR COURSE APPROVAL AND FUNDING IN THE PROVINCE OF BRITISH COLUMBIA, 1980  99.  APPENDIX B  PROCESS FOR COURSE APPROVAL AND FUNDING IN THE PROVINCE OF BRITISH COLUMBIA, 1980  To begin to understand t h i s process, i t i s important generally to know the o r g a n i z a t i o n a l structures of the M i n i s t r y of Education and the M i n i s t r y of Health as they r e l a t e to the approval process and to know s p e c i f i c functions of bodies w i t h i n the m i n i s t r i e s . THE MINISTRY OF EDUCATION The  M i n i s t r y of Education i s headed by a M i n i s t e r of Education.  Reporting to him are three deputy ministers one i f whom i s the A s s i s t a n t Deputy of Post-Secondary Education.  The post-secondary department has  three d i v i s i o n s : programs s e r v i c e s , continuing education and management services.  Each provides support services f o r the c o u n c i l s i n a d d i t i o n to *  performing i n s p e c i f i c areas o u t l i n e d . The  program services d i v i s i o n p a r t i c i p a t e s i n the development of  new programs f o r colleges and i n s t i t u t i o n s .  I t implements research i n t o  subject areas i n which new needs have been perceived appears d e s i r a b l e , proceeds to curriculum procedures  by which  institutions  develop  design.  and i f a program I t also  regulates  programs, monitors  their  e f f e c t i v e n e s s through regular reviews of the need of both students and employers, and i n i t i a t e s a f i v e - y e a r review of each i n s t i t u t i o n . programs services d i v i s i o n supplies Academic and Occupational Training d i v i s i o n , again,  selected Councils.  support service The programs  to the services  i s divided i n t o three areas of r e s p o n s i b i l i t y . The  Academic/Technical Directory i s the d i v i s i o n which deals with programs.  The  nursing  This d i v i s i o n has appointed a Coordinator of Health and Human  Services Programs who i s c u r r e n t l y Dr. S. Thompson.  100. One"other important group i n the Education M i n i s t r y relevant to the approval system i s the Councils Advisory to the M i n i s t r y .  These c o u n c i l s  are three i n number. The one of concern to post-basic nursing education i s c a l l e d the Academic Council. At the post-secondary  l e v e l , the governing boards of i n s t i t u t i o n s  have complete management a u t h o r i t y . delegated  responsibility  Provincial  f o r recommending  c o u n c i l s have been  levels  of  support  to  government and a l l o c a t i n g f i n a n c i a l resources. The  c o u n c i l s are funnels through which the f i n a n c i n g requests of  the i n s t i t u t i o n s flow i n t o the M i n i s t r y and to the government, which bear the ultimate f i n a n c i a l and l e g i s l a t i v e r e s p o n s i b i l i t y . These bodies are the U n i v e r s i t i e s ' Council of B r i t i s h Columbia, the Academic Council, the Occupational T r a i n i n g Council and the Management Advisory C o u n c i l . The i n t e n t of t h i s system i s to free a l l post-secondary institutions  education  from d i r e c t government c o n t r o l while at the same  providing the t o o l s to enable  everyone concerned  with  time  post-secondary  education t o meet two imperatives. The f i r s t i s the p r o v i s i o n of knowledge and s k i l l s to the people of the province to' enable them to l i v e enriched and u s e f u l l i v e s and earn s a t i s f a c t o r y compensation f o r t h e i r c o n t r i b u t i o n to s o c i e t y . The second i s to accomplish t h i s i d e a l a t a cost that i s reasonable i n r e l a t i o n to the t o t a l revenue a v a i l a b l e to the government and, at the same time, acceptable t o the taxpayers of the province. The appointment of members of the c o u n c i l s and members of the boards of p r o v i n c i a l i n s t i t u t e s i s the prerogative of the Lieutenant-Governor i n C o u n c i l , while the appointment of the members of the governing bodies  101.  of c o l l e g e s i s the prerogative of the M i n i s t e r and involved districts.  school  This ensures c i t i z e n involvement i n educational d e c i s i o n  making. The p r a c t i c e i s to appoint l a y people with managerial  experience  and a strong sense of f i s c a l r e s p o n s i b i l i t y , who have a t t a i n e d success i n their  own p a r t i c u l a r  fields,  and who have a broad i n t e r e s t i n , and  dedication'to, education and career t r a i n i n g . In 1963, a new U n i v e r s i t i e s Act established the Advisory Board to make recommendations to the government on the a l l o c a t i o n  of p u b l i c  monies among the u n i v e r s i t i e s and an Academic Board to advise on academic matters. In 1974, the functions of the two boards were combined i n t o a s i n g l e intermediary body, the U n i v e r s i t i e s Council of B r i t i s h Columbia.  This  recognized the need f o r an even stronger voice between the government's policy-making  and  directional  independently-operated authority  roles  universities.  and  yet be close  enough  three  public  but  A body with c l e a r l e g i s l a t i v e  was required, one that could  government  the  have the confidence  to the u n i v e r s i t i e s  of the  to d i s t i n g u i s h  between t h e i r needs and the needs of the province as a whole. It  could  also  serve  to eliminate  unnecessary  d u p l i c a t i o n of  s e r v i c e s among i n s t i t u t i o n s i n close p h y s i c a l proximity, and coordinate t h e i r a c t i v i t i e s on matters of common concern. Similar  reasoning  was  instrumental  i n the d e c i s i o n  of the  government i n 1977 t o set up three a d d i t i o n a l c o u n c i l s to l i a s e with the M i n i s t r y and the i n d i v i d u a l colleges and p r o v i n c i a l i n s t i t u t e s which complete the post-secondary spectrum. The U n i v e r s i t i e s Council of B r i t i s h Columbia c o n s i s t s of 11 members who are appointed by the p r o v i n c i a l government and employs a f u l l time  102.  d i r e c t o r and s t a f f . The  U n i v e r s i t i e s Council reviews the budget proposals  and other  requests f o r funds from the three u n i v e r s i t i e s , examines t h e i r f i n a n c i a l requirements, and advises the government on the t o t a l amount of money they need. The  Council d i s t r i b u t e s a l l operating  funds from the p r o v i n c i a l  governments t o the i n d i v i d u a l u n i v e r s i t i e s .  The U n i v e r s i t i e s Council  a l s o reviews the Academic Council recommmendations regarding  requests  f o r money from colleges and p r o v i n c i a l i n s t i t u t e s t o pay f o r programs f o r which the Academic Council i s responsible. Demands f o r c a p i t a l funds are assessed by the U n i v e r s i t i e s Council f o r the U n i v e r s i t i e s and reommendations are made to the M i n i s t r y . The U n i v e r s i t i e s Council a l s o examines plans f o r academic development, and approves the establishment  of new f a c u l t i e s and degree prog-  rams.  I t may require the u n i v e r s i t i e s to consult with each other to  avoid  unnecessary  duplication  pf f a c u l t i e s  and programs  and can  e s t a b l i s h procedures t o evaluate u n i v e r s i t y departments, f a c u l t i e s and programs. The U n i v e r s i t i e s Council and the Academic Council work together on questions  of program a r t i c u l a t i o n  and course  equivalencies  between  Academic Council c o n s i s t s of f i v e members appointed  by the  programs. The  p r o v i n c i a l government. The c o u n c i l i s responsible f o r coordination and funding of academic transfer offered  programs offered  by the c o l l e g e s ,  by BCIT and various  institutes.  other  career  technological  programs  programs at c o l l e g e s and  103.  The  programs  sciences.  related  Included  administrative, electronics,  to  are  the  career  secretarial,  aviation  humanities, programs  clerical,  technology  and  social in  the  health,  such  and  natural  managerial,  applied  service related  arts, aras  as  criminology, p o l i c e t r a i n i n g and a d m i n i s t r a t i o n , f i r e f i g h t i n g and l e g a l assistance. The  Academic  Council required i n s t i t u t i o n s  proposed budgets f o r the designated programs.  to provide  i t with  I t makes recommendations  to the u n i v e r s i t i e s Council and the M i n i s t r y concerning those requests and a l l o c a t e s funds provided to i t by government amongst the various institutions. The Council a l s o e s t a b l i s h e s Academic Advisory Committees to a s s i s t the Council and M i n i s t r y i n developing program content and standards. I t depends  upon  articulation  committees  to  provide  advice  on  the  equivalency of courses given at one i n s t i t u t i o n compared with another. The Council may require i n s t i t u t e s to accept equivalency d e c i s i o n s , and may recommend to u n i v e r s i t i e s ' senates that they be accepted by the universities.  The r e s u l t i n g i n t e r c h a n g e a b i l i t y of program c r e d i t s i s  designed to f a c i l i t a t e movement of students from c o l l e g e to c o l l e g e and from c o l l e g e to u n i v e r s i t y . i  The  Academic  Council has  a subcommittee c a l l e d  the Technical  Advisory Committee. Members of t h i s committee are appointed and they are s p e c i a l i s t s i n a given f i e l d .  The Education Health Advisory Committee  reports to the Technical Advisory Committee. When d i s c u s s i n g t h i s process, i t i s important to note that a change has occurrred i n the education f i e l d Government  i n British  News, Volume 24, Number 9,  Columbia.  The  B.C.  December 1979 reported  that  104.  Premier B i l l 1979.  Bennett announced major cabinet changes on November 23,  Among these were a d i v i s i o n i n the M i n i s t r y of Education i n t o two  ministries. The  M i n i s t r y of Education was to have r e s p o n s i b i l i t y f o r p u b l i c  schools from kindergarten t o Grade 12, c o l l e g e s , v o c a t i o n a l schools, the B.C.  I n s t i t u t e of Technology, and the Open Learning I n s t i t u t e . The  newly  created  Ministry  of  Universities,  Science  and  Communications was to have r e s p o n s i b i l i t y f o r the a d m i n i s t r a t i o n of the U n i v e r s i t y ' s Act and the promotion o f science and technology w i t h i n the province. In discussions about the funding process Co-Ordinator Education  of Health  and Human  Services  with Sheilah Thompson, Programs,  M i n i s t r y of  i n March, 1980, she i n d i c a t e d that j u r i s d i c t i o n a l  matters  between thee two m i n i s t r i e s were s t i l l being worked on and evolving. For that reason, very l i t t l e information i s provided about the M i n i s t r y of U n i v e r s i t i e s , Science and Communication.  MINISTRY OF EDUCATION STRUCTURES AS IT RELATES TO FUNDING OF ADDITONAL COURSES  MINISTRY OF EDUCATION M i n i s t e r of Education  Councils Advisory t o the M i n i s t e r  Deputy M i n i s t e r of Education Academic Council  Post-Secondary  K-12  I  Assistant Deputy M i n i s t e r Post-Secondary  (Nursing Courses)  Management Services Division  Program Services Division  Continuing Education Division  Research and Development Director  Technical/Trades Director  Academic/Technical Director  Occupational Training Council  Management Advisory Council  Health and Human Services Programs Coordinator Dr. Sheilah Thompson Coordinator of Health and Human Services Programs M i n i s t r y of Education March, 1980  o  106. THE MINISTRY OF HEALTH The M i n i s t e r of Health i s responsible f o r the work of the M i n i s t r y of Health.  A deput m i n i s t e r reports to the M i n i s t e r o f Health and i s  responsible f o r seven d i v i s i o n s of the M i n i s t r y . i s the Planning and Development Group.  One of these d i v i s i o n s  The Health Mannpower Working  Group i s an i n t r a - m i n i s t e r i a l committee of the M i n i s t r y which i s chaired by the Executive D i r e c t o r of Planning and Development and reports to the Deputy M i n i s t e r of Health. HEALTH MANPOWER WORKING GROUP Terms of Reference 1.  To recommend and advise on appropriate p o l i c y regarding the growth,  development and c o n t r o l o f health manpower i n the Province. 2.  To e s t a b l i s h p r i o r i t y areas f o r health mannpower research i n the  Province and arrange f o r t h i s research to be conducted. 3.  To advise the Deputy M i n i s t e r on appropriate a c t i o n regarding the  r e s u l t s of research conducted i n the area of health manpower. 4.  To address or respond to s p e c i f i c manpower concerns, c o n s u l t i n g  with expert committees, p r o f e s s i o n a l a s s o c i a t i o n s , the M i n i s t r i e s of Labour and Education, and other agencies or M i n i s t r i e s as necessary. 5.  To receive reports addressing  s p e c i f i c concerns and take a c t i o n  where necessary or advise the Deputy M i n i s t e r on appropriate a c t i o n with regard to these 6.  concerns.  To a c t as l i a i s o n with other M i n i s t r i e s and to discuss with and  recommend  action  through  the Deputy  Minister  on  matters  of  i n t e r - M i n i s t e r i a l concern regarding health manpower. 7.  Through  representation  the  chairman  on behalf  and/or  h i s appointees,  o f the P r o v i n c i a l  to  provide  M i n i s t r y of Health t o  107.  federal/provincial,  inter-provincial  and i n t r a - p r o v i n c i a l  concerned with health manpower, a d v i s i n g the M i n i s t r y  committees  o f Health on  matters of concern and appropriate a c t i o n . 8.  To review proposed health manpower l e g i s l a t i o n f o r i t s i m p l i c a t i o n s  regarding the d i s t r i b u t i o n , c o n t r o l and supply of health manpower stock and advise the Deputy M i n i s t e r of any concerns. 9.  To advise other M i n i s t r i e s , outside agencies, l i c e n s i n g bodies, and  a s s o c i a t i o n s o f e x i s t i n g p o l i c i e s regarding health manpower. 10.  To be aware of, and where necessary assess, proposed health care  programs f o r i m p l i c a t i o n s f o r health manpower and where  necessary,  advise the M i n i s t r y of Health of these i m p l i c a t i o n s . 11.  To review proposals regarding the establishment of new types of  health care workers and advise on p o l i c y with regard to the employment o f these new types of personnel.  MINISTRY OF HEALTH MINISTER OF HEALTH Hon. K.R. Mair  -Minister's O f f i c e  Deputy M i n i s t e r Dr. C. Key  Executive Director Health Promotion and Information  Executive Director Planning and  Senior Administrator Professional and Institutional Services  Development  R.E. McDermitt  -Deputy M i n i s t e r ' s O f f i c e  Senior Administrator Community Health Services  Administrator Support Services  Dr. G.W. Bonham  J. Bainbridge  Chairman Forensic Psychiatric Services Commission  Dr. F. Tucker C.B. Hoskins  C. Buckley  L. Chazottes Health Manpower Working Group  r Chariman Medical Services Comm. D. Weir  I  Emergency Health Services Dr. P. Ransford Source: C l a i r Buckley February, 1980  Chairman Alcohol and Drug Commission  I  I  Admin. Hospital Programs  Admin. Vancouver Bureau  D. Thompson  J . Smith  Admin. Direct Care Services I. Kelly  Admin. Preventative and S p e c i a l Community Services Dr. H. Richards  109. THE APPROVAL PROCESS OF ADDITIONAL NURSING PROGRAMS The sponsoring i n s t i t u t i o n s determines the need and f e a s i b i l i t y f o r a nursing course. procedures  The proposing department f o l l o w s whatever i n t e r n a l  are appropriate f o r that i n s t i t u t i o n .  Once the sponsoring  i n s t i t u t i o n has accepted the proposal, i t i n i t i a t e s the procedure f o r approval of government funding. First,  a letter  Services D i v i s i o n .  of i n t e n t  i s sent to the D i r e c t o r of Program  Information required i n a l e t t e r of i n t e n t i s s p e l l e d  out i n the statements of operating p o l i c y .  From here, i f i t i s deemed  reasonable by the D i r e c t o r of Program Services D i v i s i o n , i t i s sent to the Academic/Technical D i r e c t o r who delegates i t to the Health and Human Services Programs Coordinator f o r p r e l i m i n a r y i n v e s t i g a t i o n . The proposal i s assessed at t h i s point f o r d u p l i c a t i o n and need. Need i s determined w i l l determine  by reference to health Manpower Working Group which  whether or not there i s a need f o r t h i s program i n the  health care system.  The HMWG w i l l u t i l i z e the resources of the Health  Manpower Research Unit to l e g i t i m i z e the need f o r t h i s proposal. I f there i s a need f o r t h i s program and i t i s not already being presented, the proposing i n s t i t u t i o n i s n o t i f i e d and a d e t a i l e d proposal i s then prepared by the i n s t i t u t i o n . The process then begins again with the d e t a i l e d proposal sent to the D i r e c t o r of Program Services who delegates review of proposal to the Director  of  Academic/Technical  Programs.  Nursing  proposals  are  automatically r e f e r r e d to the Coordinator of Health and Human Services Programs who thoroughly i n v e s t i g a t e s the proposal.  At t h i s p o i n t , the  procedure has been adopted that the proposal i s automatically r e f e r r e d to the RNABC, RPNABC Continuing Education Approval Committee.  I f the  110. committee gives i t approval, a report i s submitted by the Coordinator of Health and Human Services Programs to the D i r e c t o r o f Program Services. The D i r e c t o r submits the proposal and accompanying report to a Monthly Program Services Review Committee.  Consideration o f f i n a n c i a l needs are  reviewed i n t h i s committee. When t h i s committee approves the proposal, t h e i r recommendations i s sent to the Academic Council. The Academic Council i s responsible f o r a l l o c a t i n g resources i f i t approves the proposal'. council,  I f f i n a n c i a l commitments are approved by the  the i n s t i t u t i o n i s n o t i f i e d  and planning can continue f o r  implementation o f the proposed program. This i s a very complex and time consuming process. approval  process  does  not have  stated  criteria  p r i o r i t i e s f o r any one proposal over any other.  Moreover, the  f o r determining  As a r e s u l t , decisions  approving funding f o r courses are not based on r a t i o n a l planning but i n the end are p o l i t i c a l d e c i s i o n s . Lack of r a t i o n a l i t y of t h i s process i s evident a t several p o i n t s , because, up t o t h i s p o i n t , p r i o r i t i e s f o r programs i n nursing have not been determined, p o l i c i e s have not been set by the M i n i s t e r of Education f o r a l l o c a t i o n of education d o l l a r s to health care and w i t h i n that to nursing programs.  The Academic Council members are responsible only to  the M i n i s t e r and therefore they do not have to answer to the p u b l i c or any p a r t i c u l a r sector, i f i t i s p o l i t i c a l l y loud enough, could a f f e c t the d e c i s i o n i n the M i n i s t r y of Education, M i n i s t r y of Health or a t the Academic Council.  111. APPENDIX C  NURSING ADMINISTRATORS' REACTION PAPER TO NURSING EDUCATION ( 1 9 7 9 ) STUDY REPORT (KERMACKS' REPORT)  RECOMMENDATIONS PERTINENT TO CONTINUING EDUCATION  SOURCE:  Kermacks, C l a i r e ; A Report to the Health Education Advisory Council Nursing Education Study; M i n i s t r y of Education, Science and Technology, Province of B r i t i s h Columbia, Vancouver, A p r i l , 1979.  112.  APPENDIX C RECOMMENDATIONS PERTINENT TO CONTINUING EDUCATION RECOMMENDATION 32 That highest p r i o r i t y i n nursing education development of post-basic c l i n i c a l courses.  be  given  to  the  We strongly support t h i s recommendation, as the need f o r nurses adequately prepared to work i n s p e c i a l t y areas i s acute i n t h i s province. We s i n c e r e l y hope that the funding w i l l be c o n s i s t e n t and immediately a v a i l a b l e , and that the courses w i l l be a c c e s s i b l e to nurses i n o u t l y i n g regions. RECOMMENDATION 33 That developmental work commence immediately on post-basic c l i n i c a l courses f o r r e g i s t e r e d nurses i n : c r i t i c a l care ( i n t e n s i v e and coronary care) emergency and trauma care long term care ( i n c l u d i n g extended care and gerontology) o b s t e t r i c a l care ( p a r t i c u l a r l y during labour and i n t e n s i v e care f o r newborns) operating room and post-anesthetic recovery room care p s y c h i a t r i c care Our a s s o c i a t i o n h e a r t i l y endorses t h i s recommendation. RECOMMENDATION 34 That innovative approaches be taken i n the development of post-basic courses based on the f o l l o w i n g p r i n c i p l e s , that courses be: developed on v a l i d a t e d competencies required i n the work setting made more accessible on a province wide basis designed to meet a v a r i e t y of learner needs i n various geographic areas evaluated through a b u i l t - i n evaluation process. We h e a r t i l y endorse t h i s recommendation. RECOMMENDATION 35 That the M i n i s t r y of Education award contracts to i n t e r e s t e d educational i n s t i t u t i o n s f o r the development of post-basic courses; and that coordination and c o n s u l t a t i v e services be a v a i l a b l e through the Ministry. We support t h i s recommendation.  113.  RECOMMENDATION 36 That employer and employee groups given serious consideration to the development o f career streams i n c l i n i c a l f i e l d s so that the career progession f o r c l i n i c a l nurses i s possible without having t o s h i f t a d m i n i s t r a t i o n or education. We agree with t h i s recommendation i n p r i n c i p l e as a method of rewarding c l i n i c a l l y competent nurses a t the bedside instead o f promoting them away from the bedside. Studies need to be c a r r i e d out regarding the f i n a n c i a l i m p l i c a t i o n s , labor r e l a t i o n s i m p l i c a t i o n s and impact on health team relationships. RECOMMENDATION 37  .  .  The J o i n t M i n i s t e r i a l Health Manpower Planning between the M i n i s t r i e s of Health and Education be examined; and that consideration be given to a s i n g l e o r g a n i z a t i o n a l structure i n v o l v i n g p o l i c y makers and planners who w i l l i d e n t i f y the supply and requirements, project future supply and requirements, and e f f e c t a balance between supply and requirements. Our A s s o c i a t i o n endorses t h i s recommendation. RECOMMENDATION 38 and 39 That the M i n i s t r y of Health (and Human Resources where indicated) i d e n t i f y the kind of health care workers required and areas o f s p e c i a l need and p r i o r i t y f o r manpower planning with input from employer groups, unions, p r o f e s s i o n a l / l i c e n s i n g bodies, consumers, etc. That the M i n i s t r y of Education i d e n t i f y needs f o r Health Education programs based on manpower planning and coordinate development, implementation, and evaluation of programs through cooperative planning with educational i n s t i t u t i o n s and organizations, p r o f e s s i o n a l / l i c e n s i n g bodies, consumers, etc. We endorse these recommendations but put emphasis on input from a l l groups a f f e c t e d .  APPENDIX D  ACTIVITIES IN THE 70 S IN BRITISH COLUMBIA TO SUPPORT f  CONTINUING EDUCATION FOR NURSES  115.  APPENDIX D  In  1973,  Development  the RNABC published a "Proposed Plan f o r the Orderly  of Nursing  Education  Continuing Nursing Education." review  of the problems  i n British  Columbia,  Part I I I :  This document provides a comprehensive  involved and the resources  i d e n t i f i e s a plan f o r continuing education i n B.C.  available.  It  w i t h i n the context of  the t o t a l nursing education system and recommends several actions which provided This  leadership f o r development i n continuing nursing  document c l e a r l y  identifies  education.  that the " p r o f e s s i o n a l a s s o c i a t i o n  (RNABC) assumes primary and o v e r a l l r e s p o n s i b i l i t y f o r planning t o meet the educational needs of nurses." the  post-secondary  educational  appropriate government agencies  I t goes on to i n d i c a t e that others, as institutions,  I t specificially  government  provide  should  care  agencies,  and the i n d i v i d u a l nurses should be  involved i n the planning. agencies  health  states that appropriate  supportive  s e r v i c e s plus  direct  f i n a n c i a l support f o r the development of continuing nursing education. This  plan  states  that  "implementation  of continuing  nursing  education i s l a r g e l y the business of the educational i n s t i t u t i o n s i n cooperation with appropriate sponsoring group." "The p r o f e s s i o n a l nurse must be w i l l i n g t o i n v e s t time, e f f o r t and money i n continuing education a c t i v i t i e s . " S h o r t l y before t h i s document was published, the government o f the province changed from S o c i a l Credit to NDP. the r o l e of the RNABC i n continuing education.  This had a major impact on The NDP government w i t h i n  a matter of days of taking o f f i c e , through an Order i n Council, appointed Dr.  Richard G. Foulkes as a s p e c i a l consultant t o the M i n i s t r y of  116. Health.  H i s terms of reference were simply to "present recommendations  which could lead t o a r a t i o n a l i z a t i o n of the Health Care Services of the province."  The e f f e c t s of h i s report "Health  Security f o r B r i t i s h  Columbians" were widespread on nursing through h i s recommendations on nursing education but more so f o r t h i s recommendation of the c r e a t i o n of the B.C. Medical  Center.  The B.C. Medical Center was formed i n J u l y , 1973 to serve f o r the teaching of undergraduate and post-graduate including  nursing.  Foulkes  students i n a l l professions  i n d i c a t e d that m u l t i - d i s c i p l i n a r y  task  forces should be created and given s p e c i f i c o b j e c t i v e s r e l a t e d to the programs and to p r o v i n c i a l Education  Committee.  Sub-Committee. Essentially,  needs.  One of these  committees was an  A sub-committee was the Continuing  Education  The terms of reference f o r t h i s committee was appended.  the sub-committee  Committee on appropriate  was to recommend  to the Education  a d m i n i s t r a t i o n mechanisms and adequate and  appropriate educational resources i n continuing education a t the BCMC. The for  development of a formal government sponsored body responsible  organizing  continuing  nursing  education  allowed  the RNABC to  withdraw from the r o l e they had assumed because no one else had. The  RNABC as an a s s o c i a t i o n was a c t i v e i n BCMC Planning f o r  continuing education.  In J u l y i t prepared  a paper commenting on the  p r i n c i p l e s i d e n t i f i e d by the sub-committee, the terms of reference and the membership of that committee. I n essence, i t reaffirmed the plan and recommendations i d e n t i f i e d i n Part I I I of the Proposed Plan f o r the Orderly Development of Nursing Education i n B r i t i s h Columbia.  Standards  f o r nursing care must be stated;, manpower needs i d e n t i f i e d evaluation;  l e a r n i n g needs  identified  and met through  through  educational  .117.  programs and programs evaluated continued  and appropriate a c t i o n s taken.  to see continuing education  as a j o i n t  It  responsibility of  i n d i v i d u a l , health agencies, education i n s t i t u t i o n s , government and the association.  I t indicated  that consumers should be members o f the  planning committee.  \  In October of 1974, the RNABC presented a b r i e f to the sub-committee on Continuing Education, BCMC dealing with a d m i n i s t r a t i v e mechanisms w i t h i n the BCMC f o r continuing education planning. rational  approach  f o r identifying  needs  I t reviewed the  on an ongoing  providing appropriate continuing education programs.  basis and  Evaluation a t a l l  l e v e l s was a l s o recommended. The RNABC l i s t e d areas i n nursing r e q u i r i n g continuing  education  opportunities.  These included OR, Maternity,  Extended Care, P s y c h i a t r i c , C r i t i c a l Care and Primary Nursing. The BCMC joined with the Health Manpower Working Group to study and review the nursing education needs.  This j o i n t group was c a l l e d the  Advisory Committee on Nursing Manpower.  I n January of 1976 t h i s group  approved a number of recommendations f o r presentation to the BCMC Education  Committee and the Health  Manpower Working Group.  These  recommendations dealt with post-basic c l i n i c a l nursing education and suggested ways of r a t i o n a l i z i n g the system. Before any a c t i o n s could be taken on these recommendations, the BCMC suffered a p o l i t i c a l with the defeat of the NDP government.  demise  The newly elected S o c i a l C r e d i t  government discontinued the concept developed by B i l l 81 o f an o v e r a l l planning, Columbia.  organizing  and coordinating Medical  Center  for British  Planning f o r continuing education i n the province was not  ended but s e r i o u s l y set back.  118. With the change i n government and a new m i n i s t e r of education, a number of s t u d i e s were i n i t i a t e d which had a d i r e c t impact on nursing. These commissions were: 1.  The Winegard Commission to advise the M i n i s t e r of Education on  providing higher education i n non-metropolitan areas of the province. 2.  The Goard Commission to advise the M i n i s t e r s of Education and  Labor on v o c a t i o n a l , t e c h n i c a l and trade t r a i n i n g . 3.  The F a r i s Commission to advise the M i n i s t e r of Education on  a l l aspects of community education. 4.  The H a l l Commission to enquire i n t o the t r a i n i n g of p r a c t i c a l  nurses and r e l a t e d h o s p i t a l personnel. The RNABC presented b r i e f s to a l l these commissions.  One p o i n t ,  r e i n f o r c e d i n t h e i r b r i e f s to the f i r s t three commissions, was the urgent need to develop a system f o r post-basic nursing education programs i n the province. The Winegard Commission report was delivered i n September to  B.C.  Education M i n i s t e r P.L. McGeer.  This Commission developed a s e r i e s of  twenty-four  Addressing  recommendations.  the  overall  problem  of  providing higher education i n non-metropolitan areas, the commission report  recommends  that  SFU  i n s t i t u t i o n to serve the B.C.  became  multi-campus,  degree  granting  interior.  S p e c i f i c a l l y d i s c u s s i n g nursing, the report s t a t e s on page 26: "There i s no question about the demand outside of Vancouver and Victoria f o r degree-completion and post-basic courses i n nursing. Since nursing i s o f f e r e d by the UBC and U n i v e r s i t y of V i c t o r i a i t i s recommended that the u n i v e r s i t i e s cooperate i n the d e l i v e r y of necessary programs to the non-metropolitan areas. SFU can provide some A r t s and Science courses needed f o r the t r a i n i n g of nurses but the major load must be borne by the other two u n i v e r s i t i e s . "  119. The report makes no recommendation on continuing education "since t h i s matter i s before the committee chaired by Dr. R.L. F a r i s . "  A member  of the Winegard Commission, F a r i s was named i n J u l y to head a separate study of continuing education needs. The Goard Commission, i n i t s report, submitted i n January,  1977,  recognized the need f o r more c l i n i c a l experience f o r two year nursing graduates  and  post-clinical  courses,  but  recommendations r e l a t e d to these concerns.  there  were  I t was  no  specific  recommended that  consideration be given to providing a supporting grant to a s s i s t i n the operation of upgrading programs i n nursing but i t was not i d e n t i f i e d i n what way. It  may  be  commission was  important  to note  that the major  concern  of  the lack of o r g a n i z a t i o n and coordination and  c o n t r o l f o r planning these programs.  They were concerned  this  overall  about the  number of agencies and people that were involved before a course could proceed and the o v e r a l l lack of planning. This same s i t u a t i o n e x i s t s with the nursing education i n B r i t i s h Columbia.  There may  be  some i m p l i c a t i o n , from t h i s concern  of the  commission, that nursing does not have s p e c i a l problems but i s simply part of a problem  that a f f e c t s a l l of the education system  of the  province. The  Faris  Commission Report  Education i n December, 1976. adult  education  and  higher  was  presented  to the M i n i s t e r  of  The commission recommended more money f o r priority  for  community  and  continuing  education. While i t recommended f i s c a l c o n t r o l of continuing education by the provincial  government,  the  commission  sought  to  keep  control  of  120.  programming with l o c a l school d i s t r i c t s and community c o l l e g e regions. P r o v i n c i a l input would come with more education s t a f f and a p r o v i n c i a l or m i n i s t e r i a l c o u n c i l to provide leadership. In  assigning  priorities,  the  commission  report  placed  career  continuing education below three other v a r i e t i e s i t said have an impact on " f u n c t i o n a l i l l i t e r a c y " i n the province: below grade twelve  levels,  basic education f o r adults  language programs f o r Canadians who  have  d i f f i c u l t y with E n g l i s h , and teaching c i t i z e n s about t h e i r r o l e s i n public a f f a i r s .  The needs i n these areas were p a r t i c u l a r l y stressed f o r  the disadvantaged, the handicapped, women, the e l d e r l y and immigrants. P r o f e s s i o n a l a s s o c i a t i o n s should continue to be involved i n career continuing education, according to the commission, but funds f o r t h i s kind  of educational  activity  m i n i s t r i e s most involved, Two  separate  should  a l s o come from the  government  (e.g. Health)  commission recommendations  called for investigation  i n t o the p o s s i b i l i t y of paid educational leaves and i n t o funding f o r p r i v a t e organizations which provide educational programs. Reviewing educational needs outside major B.C. the  commission recommended government  population  areas,  i n v e s t i g a t i o n of a p r o v i n c i a l  "open c o l l e g e " that might use radio and t e l e v i s i o n as w e l l as development on a p r i o r i t y basis of other "distance educational methods" f o r sparsely populated The  areas. commission  recommended  that  institutions  that  provide  the  o r i g i n a l entry t r a i n i n g f o r the profession a l s o be the main provider of continuing education  i n cooperation with the p r o f e s s i o n a l a s s o c i a t i o n  and where appropriate with the community c o l l e g e s .  This recommendation  d i d not help i n s o r t i n g the r o l e s of continuing education departments at the UBC and BCIT from nursing departments i n community c o l l e g e s .  121.  Another a c t i v i t y at the p r o v i n c i a l l e v e l was important to nursing. B.C.  Education M i n i s t e r P.L.  Advisory  Council  McGeer e s t a b l i s h e d a Health  i n mid-September  (1976) to  continue  Education  some of  the  a c t i v i t i e s of the education committee of the now defunct BCMC. The seven member c o u n c i l was to advise Dr. McGeer on education i n nursing, medicine and health technologies, make recommendations on  new  programs, and study the requirements of a l l health occupations. In November, 1977, the B.C. M i n i s t r y of Education approved a study of nursing Council.  education  as  proposed  by  the Health  Education  Advisory  The s i x month study was to cover the education of r e g i s t e r e d  nurses, r e g i s t e r e d p s y c h i a t r i c nurses, licensed p r a c t i c a l nurses, other categories of nursing care workers.  and  I t s terms of reference were  e s t a b l i s h i n g with the M i n i s t r y of Health long term p r o j e c t i o n s of B.C.'s nursing needs. The  nursing community was assured when the M i n i s t r y of Education  released t h i s study.  The M i n i s t r y c a l l e d the study "A Discussion Paper:  Nursing Education Study Report."  This report was i n i t i a t e d by the Health  Education Advisory Council and funded by the M i n i s t r y of Education. report  listed  education.  forty-three  recommendations  The report attempted  dealing  with  The  nursing  to r a t i o n a l i z e the system of nursing  education by organizing a l l nursing personnel i n t o f i v e - p a r t f u n c t i o n a l classification psychiatric  system  nurse,  by  by  eliminating  introducing a  the student  category  of r e g i s t e r e d  competency  based  core  curriculum f o r basic nursing education, c l o s i n g h o s p i t a l schools of nursing,  developing  post-basic  continuing  education  at  specified  educational i n s t i t u t i o n s , and by providing baccalaureate l e v e l education for  nurses  outside  the  metropolitan  areas,  by  utilizing  manpower  122.  planning as a basis f o r i d e n t i f y i n g needs f o r educational programs and by supporting the post-basic educational needs f o r nursing. The majority of the recommendations, or the concepts involved i n them, can be supported i n part wholly by p o l i c y statements made by the CNA or the RNABC i n the l a s t ten to f i f t e e n years but the r e a c t i o n of the professional  body  was generally  not favorable.  The RNABC News  (April/May/June, 1979) page 7, describes the report as f o l l o w s : "Educational Bomb S h e l l " " C o n t r o v e r s i a l Nursing Study Released" " I t burst  a l l over  the B.C. nursing scene  l i k e a bombshell."  "Heated  Discussion" "The report by nursing consultant, C l a i r e Kermacks of North Vancouver  was  Education.  labelled  a  "discussion  paper"  by  the M i n i s t r y of  That i s p r e c i s e l y what has been generated, heated d i s c u s s i o n  with l i t t l e apparent middle ground between c r i t i c i s m and p r a i s e . " The nurses reacted mostly t o the methodology, the lack of precise supporting data f o r the recommendations, and the seeming encroachment on the a s s o c i a t i o n ' s l e g i s l a t e d a u t h o r i t y over basic nursing  educational  programs. The o v e r a l l e f f e c t of the document was p o s i t i v e , not so much i n what was  recommended,  but more  because  of the generated  i n t e r e s t and  d i s c u s s i o n about the nursing educational system. The long term e f f e c t s of t h i s document are yet t o be seen: The  RNABC has contributed i n other ways to continuing  education i n the province.  nursing  The RNABC L i b r a r y (1969) was improved f o r  membership use and a part time l i b r a r i a n was h i r e d . The a s s o c i a t i o n was providing f a c i l i t i e s f o r s e l f l e a r n i n g rather than providing l e a r n i n g experiences.  123. Beginning i n 1959, the RNABC provided y e a r l y loans/bursaries f o r nurses seeking t o continue t h e i r education.  These monies were a v a i l a b l e  f o r post-basic courses, c e r t i f i c a t e courses and u n i v e r s i t y education. They were w e l l u t i l i z e d by the membership. In 1979, the RNABC increased i t s loan fund f o r continuing education to $100,000.00. of B.C.  A non-profit s o c i e t y , the Registered Nurses Foundation  was being s e t up to promote nursing education and research i n  the province.  The loans funds have been t r a n s f e r r e d to t h i s foundation  which i s expected to administer the educational loan program and funding for c l i n i c a l l y oriented post-basic nursing programs. The purpose of RNF i s to promote the advancement and improvement of nursing care, p r a c t i c e and education. A joint  effort  by the RPNABC and RNABC i n i t i a t e d a voluntary  continuing nursing education approval program. program was f o u r f o l d .  The purpose of t h i s  I t was to provide g u i d e l i n e s f o r those developing  programs, provide a mechanism f o r evaluation of course plans, p a r t i c i p a n t s and/or employers i d e n t i f y  assist  programs most l i k e l y to meet  t h e i r needs and provide r e c o g n i t i o n and c r e d i b i l i t y f o r the programs approved and the p a r t i c i p a n t s i n them. This was an important move f o r the a s s o c i a t i o n . identified  one of i t s r o l e s  The RNABC had  i n continuing education  as providing  standards and t h i s was one way of doing so. I t i s a l s o important to note the cooperation between the a s s o c i a t i o n s . The Health Education Council created by Education M i n i s t e r P.L. McGeer  (1976) was to continue  some a c t i v i t i e s of the BCMC.  coordinator of continuing education was not included.  The  I n an attempt t o  pick up t h i s f u n c t i o n a group began to plan to e s t a b l i s h a B.C. Council  124.  for  Coordination of  Continuing  Education.  The  RNABC, RPNABC, the  Licensed P r a c t i c a l Nurses' A s s o c i a t i o n , the P a c i f i c Medical Technicians A s s o c i a t i o n and representatives of a number of educational i n s t i t u t i o n s and  agency  participants.  inservice  departments  were  involved  as  voluntary  They saw the goals of t h i s c o u n c i l as i d e n t i f y i n g l e a r n i n g  needs, s e t t i n g p r i o r i t i e s , a l l o c a t i n g resources, developing a resource bank and a c t i n g to c o n t r o l the q u a l i t y of continuing nursing education. The committee discontinued i n November, 1978, because i t could f i n d no new ways to attack basic problems.  The members did decide to ask the  RNABC to continue p u b l i s h i n g i t s l i s t of continuing nursing education programs, and to authorize an ad hoc committee to "maintain a watching brief"  of the  continuing education  situation,  and,  convene  another  conference at i t s d i s c r e t i o n . In March, 1977, the RNABC published a document t i t l e d "Competencies Required and Recommended f o r R e g i s t r a t i o n of Re-Entering Nurses." was  a comprehensive g u i d e l i n e f o r planners and sponsors  courses  f o r graduate  and  r e g i s t e r e d nurses and  This  of r e f r e s h e r  a basic standard f o r  nurses coming back i n t o the work f o r c e . The  RNABC Guideline f o r O r i e n t a t i o n of  Registered  Nurses  was  completed i n 1978. Continuing nursing education developed a great deal i n t h i s period, although post-basic c l i n i c a l programs are s t i l l not organized or funded. The RNABC, through  i t s various a c t i v i t i e s , provided strong leadership  because of the b e l i e f s of the need f o r continuing education and  the  a s s o c i a t i o n ' s r o l e i n s e t t i n g standards but most importantly because no other body was assuming t h i s r o l e .  Because of the a s s o c i a t i o n , organized  nurses  determining  were  very  powerful  in  continuing education i n B r i t i s h Columbia.  direction  for  nursing  APPENDIX E  THEORETICAL WAYS TO DETERMINE MANPOWER NEEDS  126. APPENDIX E  T h e o r e t i c a l Ways to Determine Manpower Needs Levine,  i n an  Requirements:  article  The  State  called of  "Measuring  Nursing  the A r t , " i n d i c a t e s  Supply  that  and  various  methodologies a v a i l a b l e have generally f a l l e n i n four types. F i r s t are those that r e l y onn comparative standards, or c r i t e r i a based on e x i s t i n g p r a c t i c e .  These methologies use medians, or averages  of state-nurse population r a t i o s or r a t i o s based on e x i s t i n g p r a c t i c e i n hospitals. Second,  methodologies  are i n e f f e c t ,  that  attempt  to develop  optimal r a t i o s or l e v e l s f o r use i n determining nursing requirements. These studies, while i n t e r e s t i n g have had d i f f i c u l t i e s a r r i v i n g a t c l e a r cut r e s u l t s . Third, models tend to i d e n t i f y requirements based on the supply and demand model u t i l i z e d by economists.  One a p p l i c a t i o n i s the counting up  of budgeted p o s i t i o n s , which can y i e l d a measure of demand. The problem i s that the budgeted p o s i t i o n s have to be l e g i t i m i z e d i n some fashion since the h o s p i t a l s may be over-budgeted safe nursing care.  or under-budgeted  to provide  Many times, these models i d e n t i f y how w e l l o f f or  poor an area i s rather than p r e d i c t i n g future needs of nurses. The fourth approach embraces comparative standards. I t uses demand and includes attempts to apply optimizing c r i t e r i a by using the r e s u l t s of c e r t a i n  research studies that measured the r e l a t i o n s h i p  nursing care and patient welfare. Eugene Levine says:  between  In the conclusion to t h i s a r t i c l e ,  127.  I t must be kept i n mind that determining supply and requirements f o r health manpower i s not a scientific exercise. Even the most precise q u a n t i t a t i v e model i n v o l v e s a c e r t a i n degree of subjective judgement and i s influenced by personal values. Many scenarios can be w r i t t e n of the future and i n the f i n a l a n a l y s i s each depends on one's view of the health care system and how nursing w i l l be utilized in i t . " What methodologies have been used i n the past to determine manpower needs and  what are  current proposals  for identifying  needs.  In  determining t h e o r e t i c a l models to determine manpower needs, supply of personnel i s u s u a l l y e a s i l y measured.  But the e s s e n t i a l component to  know whether or not there i s a problem i s to i d e n t i f y the requirements. Models are  currently  being  looked  at  to attempt  to i d e n t i f y  this  component. The D i v i s i o n of Nursing, U.S. P u b l i c Health S e r v i c e s , attempted to develop models f o r i d e n t i f y i n g requirements f o r nursing manpower.  They  are described as f o l l o w s i n an a r t i c l e by Eugene Levine and are described as f o l l o w s : 1)  System Dynamics Model This model was developed using a set of techniques known as  system dynamics.  The model i s concerned with changes taking place and  l i k e l y to take place i n nursing and i n health care g e n e r a l l y by the year 1990.  I t focuses on the impact those changes w i l l have on the supply,  demand and d i s t r i b u t i o n of nursing personnel and s e r v i c e s .  The model  produces simulations that are a sequence of c a l c u l a t i o n s d e s c r i b i n g how a system of r e l a t i v e f a c t o r s w i l l behave over time. 2)  Vector Requirement Model The purpose of t h i s model i s to assess the impact of three  a n t i c i p a t e d changes i n the health care system on the requirements f o r nurses.  128.  i)  The i n t r o d u c t i o n of n a t i o n a l health insurance (NHI)  ii)  the increased enrollment i n HMO's  iii)  the reformulation of nursing r o l e s  An overview of the model i s shown i n the f i g u r e .  Beginning with a base  of 1972, p r o j e c t i o n s of R.N. and L.P.N, requirements through 1985 were made using l i n e a r regression techniques. Similar  to the system dynamics model, various scenarios of the  future are postulated. The State Planning This concerning  method  Process c o n s i s t s of a procedure f o r a r r i v i n g at decisions  key elements i n current and future nursing resources  and  requirements and an integrated data base f o r a s s i s t i n g i n the d e c i s i o n making process. level.  The method has been developed f o r use at the state  In the requirement area the process c o n s i s t s of the f o l l o w i n g  steps: 1)  d i f f e r e n t i a t i n g the c l i e n t population  2)  assessing the health needs of the population  3)  formulating a health strategy  4)  choosing the l e v e l and mix of nursing s t a f f  5)  s t a f f i n g schools of nursing  The Micro Model This  p r o j e c t i s aimed at developing  incorporates  health  services u t i l i z a t i o n  and  testing  a model  factors affecting  that  nursing  demand and supply i n t o a framework determining shortages or surpluses. The model contains s p e c i f i c i n s t i t u t i o n a l c h a r a c t e r i s t i c s and i s capable of p r e d i c t i n g demand and supply f o r nursing manpower at country and state levels.  129.  These models used f o r manpower planning are examples of some of the l a t e s t techniques u t i l i z e d f o r manpower planning. models, the complexity of the problem i s obvious.  In reviewing these  I t w i l l not be an easy  task to determine what future nursing requirements w i l l be i n B.C. Nursing supply i s easier to i d e n t i f y but there are s t i l l problems r e l a t e d to t h i s because of the c h a r a c t e r i s t i c s  of nurses.  

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