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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 THE FACULTY OF GRADUATE STUDIES (Department of Health Care and Epidemiology) We accept t h i s t h e s i s as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA October, 1980 (c^Lorea Amolea Ytterberg, 1980 MASTER OF SCIENCE (HEALTH SERVICES PLANNING) i n In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of Brit ish 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 thesis for 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 Brit ish Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1WS October, 1980 Date i i ABSTRACT A study was undertaken to determine how the planning process for post-basic c l i n i c a l specialty courses for nurses in Br i t i s h Columbia could be more effective. In order to answer this question, i t was decided f i r s t to examine the present planning process in i t s complexities. In so doing, the complexities in educational planning were described. The following agencies are involved: the basic nursing education programs, the university schools of nursing, continuing education providers, (the com-munity colleges, the University of Bri t i s h Columbia Division of Continuing Education, Br i t i s h Columbia Institute of Technology), the British Columbia Health Association, acute care hospitals, the Nursing Administrators' Association, the Registered Nurses' Association of British Columbia, the British Columbia Medical Association, the British Columbia Ministry of Health, the Br i t i s h Columbia Ministry of Education. In order to discover why a l l these agencies became involved, the nursing education issues in Br i t i s h Columbia are considered. The appropriateness of education and training for present day nursing functions was reviewed and the importance of c l i n i c a l specialty training in a developed medical-technological situation discussed. From time to time since the Second World War the "shortage" of nursing manpower has been a matter of concern to policy makers and planners whether groups of nurses, employers, educational bodies or governments. Nurse manpower planning as i t now exists is described. It i s argued that manpower planning and planning for education and training of nurses can be improved only i f the range of social roles and the behaviour of i i i i n d i v i d u a l nurses i n balancing these roles i s taken into consideration. Understanding where nursing roles 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 i n B r i t i s h Columbia have been making p a r t i c u l a r demands upon employers, represented by the Directors of Nursing of h o s p i t a l s , namely demands for positions with greater decision making autonomy and more l i f e style advantages, to f i t more cl 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 structure which offers v e r t i c a l mobility. Horizontal mobility at the l e v e l of "bedside" nursing care seems to be more a t t r a c t i v e . However, i n order to be attracted into and kept i n jobs i n bedside nursing care, nurses need to be provided with better preparation than at present, through more adequate c l i n i c a l s k i l l s based on a comprehensive knowledge ba.se. Recognition of the changing a c t i v i t i e s of nurses and the implications of the changes should lead to r e v i s i o n of planners' views about accepted patterns i n education, t r a i n i n g and work organization. This r e v i s i o n of views could form the basis for: a) more r a t i o n a l planning of education, t r a i n i n g and manpower deployment b) reconsideration of the importance of handling bureaucratic planning f a i l u r e s more e f f e c t i v e l y and c) more attention being given to the growing interest of nurses in trade union bargaining i n order to express t h e i r demands more f o r c i b l y . TABLE OF CONTENTS PAGE ABSTRACT i i - i i i LIST OF APPENDICES v LIST OF TABLES v i ACKNOWLEDGEMENTS v i i PART I INTRODUCTION 1 A. A Note on Method 5 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 5 PART I I PLANNING FOR NURSESEDUCATION AND TRAINING IN BRITISH COLUMBIA 7 A. D e f i n i t i o n s . 7 B. B a s i c Nursing Education Programs 10 C. Degree Programs 13 Bache 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 Issues 19 C l i n i c a l and C l a s s Room Resources 22 Issues i n L o c a t i n g the Courses 22 A v a i l a b i l i t y o f Teaching E x p e r t i s e 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 Planning 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 to Make D e c i s i o n s R e l a t i n g to Nursing Education 34 PART I I I HISTORY OF THE NURSING FUNCTION IN THE CONTEXT OF CHANGING WOMEN'S ROLES 37 A. The Beginnings 37 B. The Depression Years 41 C. The War Years and A f t e r 41 V TABLE OF CONTENTS (cont'd) PAGE D. The Last Two Decades 44 E. Development of C l i n i c a l Specialty Units 45 F. Unionization 49 G. Implications of Changing Attitudes For Nurse Manpower Training 50 PART IV HOW CAN THE PLANNING PROCESS BE MADE MORE EFFECTIVE? 52 A. From Sectoral Educational Concerns to Comprehensive Manpower Planning A c t i v i t i e s 52 B. Nursing Manpower i n B.C 56 C. Ineffective Cooperation between Sectoral Groups i n B.C 63 D. Possible Reasons for Ineffective Planning 65 PART V TOWARDS MORE EFFECTIVE PLANNING 72 A. Rational Planning 72 B. Bureaucratic Planning 76 C. Negotiation Planning 76 D. Conclusions 77 E. Recommendations 78 REFERENCES AND BIBLIOGRAPHY 80 APPENDICES 90 Appendix A Post-Basic Nursing Programs 90 Appendix B Process for Course Approval and Funding i n the Province of B r i t i s h Columbia 98 Appendix C Nursing Administrators' Reaction Paper to Nursing Education: Study Report (Kermacks' Report), (1979) . . 111 Appendix D 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 for Nurses 114 Appendix E Th e o r i t i c a l Way to Determine Manpower Needs 125 v i LIST OF TABLES TABLE PAGE 1. Number of F u l l Time Equivalent Graduate Nurses i n Spe c i a l i z e d Units i n B.C. Hospitals and as Proportion of Total Employed Graduate Nurses 1976 78 v i i ACKNOWLEDGEMENTS T h i s study i n v o l v e d the e f f o r t s o f many people. My thanks go to those people who c o n t r i b u t e d to t h i s study by o f f e r i n g t h e i r knowledge and experience p e r s p e c t i v e s i n numerous c o n v e r s a t i o n s , meetings and i n t e r v i e w s . I would l i k e to thank my committee members; D r . Anne C r i c h t o n , D r . Annette S t a r k , and Ms. S h i r l e y Brandt f o r t h e i r a s s i s t a n c e and v a l u a b l e support and a d v i c e . I am most g r a t e f u l to my n u r s i n g c o l l e a g u e s , who over the years have shared t h e i r concerns about n u r s i n g with me and helped to i n c r e a s e my p e r s p e c t i v e s o f n u r s i n g . My a p p r e c i a t i o n extends to my f e l l o w students i n Health S e r v i c e s P l a n n i n g , who have added to my understanding o f n u r s i n g i n the context o f the h e a l t h care system. A s p e c i a l thanks to Mr. K e i t h L o u g h l i n . I would l i k e to thank John Pousette, S e c r e t a r y - T r e a s u r e r o f the K i t i m a t Regional D i s t r i c t f o r h i s support and encouragement. I am indebted to Evangeline Kereluk whose e f f o r t s a s s i s t e d me i n completing t h i s study. F i n a l l y , I would l i k e to express my s i n c e r e g r a t i t u d e to Bob and my mother, who were always understanding, encouraging and s u p p o r t i v e . PART I PART 1 INTRODUCTION As C l i n i c a l Director of Medical Nursing at Vancouver General Hospital, i t became evident to the author that there were some new d i f f i c u l t i e s i n nurses' education emerging i n the 1980's. Nurses, with special c l i n i c a l s k i l l s , were not available i n s u f f i c i e n t numbers to s t a f f special c l i n i c a l units. Discussions with other nursing admin-i s t r a t o r s indicated that t h i s was a general problem and, further, l i t t l e t r a i n i n g was currently available, i n B r i t i s h Columbia, to prepare nurses to function i n special 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 action was being taken to solve t h i s problem. This s i t u a t i o n led 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 for post-basic c l i n i c a l specialty courses become more effective? 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 following agencies seemed to be involved: basic nursing education schools (the community colleges, and the B r i t i s h Columbia In s t i t u t e of Technology), the University of B r i t i s h Columbia Division of Continuing Nursing Education, the B r i t i s h Columbia Health Association, acute care hospitals, the Nursing Administrators' Association of B r i t i s h Columbia, 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 i e s of Health and Education. 2. Then, to understand why a l l these agencies became involved, i t seemed to be necessary to look at the nursing educational issues in Bri t i s h Columbia, and consider the confusion in planning. This aspect is examined in Part II. Because there were a number of different objectives being pursued by the educational planners — raising the level of basic education and building upon i t in order to train administrators, educators, researchers and c l i n i c a l specialists in nursing — i t seemed to be important to examine two further questions. Were the objectives of educational planners closely related to nursing functioning? Were education and training plans likely to cope with nursing 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 in recent years has been increasing in British Columbia. During the last few summers, in 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 is a shortage of registered nurses or only a shortage of nurses willing to come into the labour market. The author, in her capacity as administrator and employer's repre-sentative, began to consider why the shortage was regarded as a matter for educational planning. Why did the planners and administrators look to education of new recruits to resolve the shortages? The reaction of the Nursing Administrators' Association of the Lower Mainland, at a meeting in February 1980, had been to look to training 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 agreeing to stay i n a job, the nurses present t h e i r demands to the Directors of Nursing of s p e c i f i c h o s p i t a l s . These employment demands appear to be greater for basic bedside care nursing positions than f o r administrative p o s i t i o n s or for positions i n which coordinating of the work of the l e s s well trained a s s i s t a n t s i s to be done. However, basic care nurses (and, more p a r t i c u l a r l y , c l i n i c a l technological s p e c i a l i s t s among basic care nurses) need to believe themselves to be well trained and competent to take the r e s p o n s i b i l i t i e s which have to be handled i n these jobs. The t r a d i t i o n a l model of a nursing career structure i s pyramidal, 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 l o g i c which r e l a t e to t h e i r view of present day nursing functions and t h e i r perception of how these can best be f i t t e d i n with t h e i r other s o c i a l r o l e s . They have made Directors of Nursing aware that they prefer h o r i z o n t a l career structures. I t seems that there may be misunderstandings about these employment demands and time lags i n responding to them among manpower and educational planners. A number of other questions occurred to the author but only the f i r s t two of these were educational planning questions. What competencies or standards should a nurse have i n order 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 confident to perform the functions which they are being asked to do? Others were more general employment/manpower planning questions. Have the nursing manpower planners c l e a r d e f i n i t i o n s of nursing functions f o r s p e c i a l care areas? What e f f e c t does the f a c t that the majority of 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? Have the planners incorporated adequate demographic information about nurses i n t o t h e i r planning? Many nurses today seem to be "leaving" nursing for 4. jobs i n other areas. Have either the employers or planners considered the work environment and i t s relationship to other roles i n a t t r a c t i n g and keeping nurses on the job? Is i t clear what the nurses who actually provide nursing care want? Why are nurses leaving nursing? What effects to organizational structures and career prospects have on the nursing manpower situation? On further thought, questions about the relationship between nursing manpower planning and nursing education were raised. Why are so few post-basic c l i n i c a l courses available i n B r i t i s h Columbia? Have the nurse manpower planners not been able to be sp e c i f i c i n iden t i f y i n g needs? Why are so many separate groups involved i n th i s issue? How do they work together to develop the area of manpower planning and education? Who coordinates the i r a c t i v i t i e s ? Do recommendations from the interested groups get implemented? I f not, why not? Are resources available to provide the training needed to meet the manpower require-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 ove r a l l problem rather than only a segment of i t . This was begun by reviewing the evolution of nursing roles and women's positions i n Canadian society and by r a i s i n g questions about nurses' needs as women with other s o c i a l r o l e s . The techniques of nurse manpower planning and application to B r i t i s h Columbia are described i n Part IV. In a f i n a l section after following through the questions and analyzing documentary evidence, prospects for improving nurse manpower planning (and educational planning as part of that) are reviewed, and recommendations made. 5. Since the focus i s upon c l i n i c a l s p e c i a l t i e s i n nursing, s p e c i a l t i e s p r a ctised i n h o s p i t a l s , l i t t l e a t t ention w i l l be given to other nursing a c t i v i t i e s such as public health and mental health i n the discussion which follows. Beginning with an i n t e r e s t i n post-basic c l i n i c a l s p e c i a l t y courses fo r nurses, the focus changed to manpower issues since i t seemed that one could not be corrected without the other being dealt with. A Note on Method This i s a study of planning i n the f i e l d of nursing. The following methods were used: a) analysis of documents - primary and secondary source materials, b) discussion of the issues with planners i n the nursing f i e l d , c) discussion of issues with administrators i n the nursing 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 i n planning approaches. D e f i n i t i o n s and Abbreviations For the purposes of t h i s study the following terms are defined as follows: Basic Nursing Education Programs - prepare students to enter the p r a c t i c e of nursing i n a g e n e r a l i s t r o l e i n a supervised s e t t i n g and q u a l i f i e s them for r e g i s t r a t i o n . These may be diploma or baccalaureate degree program Continuing Education - as a term, can be used broadly to describe a l l education which occurs following attainment of a basic q u a l i f i c a t i o n . For the purposes of t h i s discussion i t i s defined as ad hoc or informal 6. workshops, conferences, seminars, night school courses of l i m i t e d duration or in 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). I t i s designed to develop or maintain nurses' currency or competency i n any area of p r a c t i c e . Post-Basic C l i n i c a l Specialty Programs (Part of Continuing Education) - prepare nurses for positi o n s beyond the basic l e v e l , focus on a c l i n i c a l s p e c i a l t y r o l e , and are of longer duration than f o r t y hours ( f u l l time). Post R.N. Baccalaureate Degree, Master's and Doctoral Degree - prepare nurses for upper l e v e l positions i n c l i n i c a l , administrative, or educational r o l e s . The following abbreviations are used: R.N. - Registered Nurse RNABC - Registered Nurses' Association of B r i t i s h Columbia RPNABC - Registered P s y c h i a t r i c Nurses' Association of B r i t i s h Columbia BCHA - B r i t i s h Columbia Health Association UBC - University of B r i t i s h Columbia BCIT - B r i t i s h Columbia I n s t i t u t e of Technology CNA - Canadian Nurses' Association BCMC - B r i t i s h Columbia Medical Center BCMA - B r i t i s h Columbia Medical Association CMA - Canadian Medical Association HMRU - Health Manpower Research Unit at UBC Direct quotes and references are numbered i n the text and l i s t e d a l p h a b e t i c a l l y at the end of the narr a t i v e . Appendices include several sections which support the narrative but do not need to be included i n the argument. Appendices w i l l be referred to by l e t t e r , when appropriate i n the na r r a t i v e . PART I I PLANNING FOR NURSES' EDUCATION AND TRAINING IN BRITISH COLUMBIA PART I I 7. PLANNING FOR NURSES' EDUCATION AND TRAINING IN BRITISH COLUMBIA The problem which presented i t s e l f t o the author was the shortage o f nurses with 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 to 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 to be a ge n e r a l agreement among n u r s i n g planners and n u r s i n g a d m i n i s t r a t o r s that 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 to the inadequacies o f p r o v i s i o n f o r c o n t i n u i n g e d u c a t i o n 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 focus o f the study i t seemed to be necessary to 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 education i n order 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 are now and what are the problems a s s o c i a t e d with t h e i r development or l a c k o f development. A. D e f i n i t i o n s The d i s c u s s i o n o f present 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 begin with a c l a r i f i c a t i o n o f the uses o f the words "education" and " t r a i n i n g " f o r there are semantic problems. In g e n e r a l use, "education" i s a broader term which i m p l i e s i n t e l -l e c t u a l l e a r n i n g . In Canada today i t o f t e n r e f e r s to a minimum o f c o l l e g e or u n i v e r s i t y e d u c a t i o n . "to develop mentally and mo 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 or l e a r n i n g o f a t e c h n i c a l nature. I t does not mean simply r o t e l e a r n i n g o f ta s k s , but encompasses conceptual t h i n k i n g r e l a t e d to the p r o f i c i e n c y a c h i e v e d . 8. "to form by instruction, 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 Director of the CNA d i f f e r e n t -iates between tr a i n i n g and educating the nurse. She says that educating a nurse equips her mentally to work far beyond the role of a technician and develops a nurse's a b i l i t y to function at a policy-making and at an administrative l e v e l . T r a d i t i o n a l l y , i t has been CNA policy to encourage more emphasis on education of nurses, a policy strongly supported by the provincial nursing association. But the majority of nurses do not function at t h i s l e v e l , although every nurse makes many decisions every working day. Does th i s then imply that basic beginning l e v e l nurses are trained but not well educated? Nurses do not l i k e the word training applied to the i r profession. I t has a negative connotation since i t i s often equated by nurses with the apprenticeship system of learning, or the rote system of learning to perform s k i l l s without knowing the conceptual reasons behind them. Today's nurses are engaged i n strong discussion about minimum entry q u a l i f i c a t i o n s to practice 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 dictionary 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. Training used i n t h i s way has a very positive connotation. Possibly too much attention has been given to education rather than trai n i n g i n recent years for there has been a recent surge of concern about the adequacy of t r a i n i n g for these c l i n i c a l nurses, and the numbers available to provide technological nursing services i n B r i t i s h Columbia. 9. Who, then, i s responsible for planning education and tra 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$ of the t o t a l number of nurses i t needs i n the work force. I t has depended on immigration from other countries and transfers from other provinces to provide s u f f i c i e n t numbers of nurses. As other provinces are reducing the numbers of students i n the 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 trai n i n g programs i n u n i v e r s i t i e s and community colleges. More recently, the Open Learning Institute has begun to offer some courses to students i n isolated areas. Funding for nursing education continues to be a problem for some potential r e c r u i t s . Whilst the RNABC set aside some money for bursaries 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 reiterated the continuing need i d e n t i f i e d i n the Weir Report (125) i n 1934 for nurses educated at the university l e v e l . The second report (93) reviewed the f a c i l i t i e s available for post-basic education (only UBC School of Nursing) and suggested ways in which more candidates could be admitted to programs and how nurses could gain degree credits before entering UBC. I t recommended a collaborative approach by Canadian u n i v e r s i t i e s to developing nursing Master's programs and also recognized the need for doctoral programs in Canada. The educational planning process i n confused and there has grown up a complexity of bodies responsible for different aspects of providing 10. education and tra i n i n g or providing funding for the purpose of evaluating and influencing education and tra i n i n g a c t i v i t i e s . The des-c r i p t i o n of present day curriculum and course planning which following i s concerned with explaining these inputs into education and t r a i n i n g policy making and the gaps and overlaps i n the process of planning programs. B. Basic Nursing Education Programs Entry into the practice of nursing i n B r i t i s h Columbia i s provided by four kinds of basic education programs. These are: (1) general nursing programs (diploma or degree)*, (2) psychiatric nursing (diploma), (3) p r a c t i c a l nursing**, (4) nursing aide***. Basic nursing programs are offered primarily in post-secondary i n s t i t u t i o n s * except for general nursing diploma programs at the Vancouver, Royal Jubilee and V i c t o r i a General Hospitals. General and Psychiatric Nursing Programs General and psychiatric programs do not d i f f e r greatly i n objectives for the i r graduates except i n making them competent i n the c l i n i c a l areas i n which they are prepared to function. Both types of programs expect graduates to assess, plan, implement and evaluate nursing care for individuals 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 similar to the diploma years, but t h i s program has now been revised 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 practice and write the r e g i s t r a t i o n examinations. Nurses graduating from diploma programs are accepted for further 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 further 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 psychiatric patients. Psychiatric nursing programs emphasize the care of patients with psychiatric i l l n e s s and mental retardation. There are ten general nursing diploma courses and two psychiatric nursing programs. Programs vary from two to three years. The current trend i s for programs to be longer to provide more c l i n i c a l experience i n various forms for the students. Graduates of these programs receive a diploma and are e l i g i b l e to write national r e g i s t r a t i o n examinations. Responsibility for the control of education rests with the provinces i n Canada; therefore, a l l educational programs for the preparation of health manpower must be approved by the p r o v i n c i a l autho-r i t i e s . 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 certain standards i n regard to length of program, curriculum, faculty, and other aspects of educational administration. Under the health practitioner acts, authority to control healing arts has been delegated i n most cases to the respective professional associations in the provinces which have established c r i t e r i a . The associations set forth minimum requirements for the conduct of schools to prepare the 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 write standardized exam-inations for the purpose of r e g i s t r a t i o n . These are nationally set examinations, but allow for r e g i s t r a t i o n only within the province i n which the graduate i s writing the exam. 12. Curricula of diploma programs are structured i n a variety of patterns, the most common being a s i x semester program i n two years. The major part of the f i n a l semester i s usually concentrated c l i n i c a l practice to consolidate s k i l l s p r i o r to graduation. A l l diploma programs include instruction i n nursing, the physical and s o c i a l sciences and most include general education subjects. Courses i n the physical and s o c i a l sciences and other f i e l d s are usually taught by faculty i n other d i s c i p l i n e s . Nursing students rarely share common classes with other students because of scheduling complications, content needs not shared by other programs and i n s t i t u t i o n a l organization of separate programs i n self-contained units. Nursing i s the major component of a l l programs, compromising 72% to 93% of the content of each program. There are s i g n i f i c a n t variations i n the amount of time spent i n nursing theory and practice from program to program. Laboratory and c l i n i c a l time varies from 45.5% to 7&% of the t o t a l programs i n schools of nursing. The question arises as to whether t h i s variance has a major effect 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 at needs for continuing education. Entrance requirements for diploma nursing programs vary with the i n s t i t u t i o n providing the education. A l l schools except Douglas College require a minimum of grade twelve education, but subject requirements i n grade twelve vary from college to college. Funding for these programs i s provided by the sponsoring i n s t i t u t i o n s through the Department of Education. Students pay a regis-t r a t i o n fee which i s i n l i n e with that paid by other students i n the colleges. Most funding i s from the government. Nursing schools are expensive because of the low r a t i o of pupil to teacher when students are learning c l i n i c a l s k i l l s or practising i n the c l i n i c a l areas. .13. C. Degree Programs 1. Bachelor's Programs The University 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 for nurses in 1923. Since then, the program has undergone many revisions, the l a t e s t being i n 1980. Students w i l l complete a four year baccalaureate program before entering practice. This, i n essence, adds a f i f t h type of basic education program. In 1976, the University of V i c t o r i a began i t s two year Bachelor of Science i n Nursing degree program for registered nurses. The ov 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 solving or s c i e n t i f i c method and to develop new s k i l l s ; to provide nursing care to individuals, families and community groups; to function within a variety of settings within the community and to increase a b i l i t y to function interdependently with other health professionals. The scheduled time spent i n c l i n i c a l practice varies from 25% to 50%. Students have some choice i n the selection of c l i n i c a l areas within broad settings. At both u n i v e r s i t i e s , nursing courses predominate, but courses i n physical and/or s o c i a l sciences are also required. Basic s t a t i s t i c s and research methodology are included i n both programs. Students have the opportunity to choose elective courses and/or independent directed studies i n a selected area. The UBC Bachelor Degree must meet the requirements for approval of schools of nursing by the RNABC. Then students are e l i g i b l e to write the national r e g i s t r a t i o n exam written 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 highly 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 inquiry, effect change and assume leadership roles. As w e l l , special courses i n functional areas of administration, teaching or research or in c l i n i c a l s p e c i a l i z a t i o n are available, depending on the student's choice. Graduates are expected to assume upper l e v e l positions i n functional or c l i n i c a l roles. The M.S.N, program i s two academic years i n length, and consists almost e n t i r e l y of nursing courses. In the f i r s t year, students concentrate on systematic approaches to patient care and on research methodology. C l i n i c a l experience with selected patients i s managed. Students study and work with individuals of a selected maturational stage. Students i n the second year select from courses related to c l i n i c a l nursing, nursing education, nursing service administration, consultation 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 for these programs i s allocated through University senates. Nurses pay the same re g i s t r a t i o n fee as the other university students. D. Continuing Education 1. Continuing Education Programs Continuing education, as a term, can be used broadly to describe a l l education which occurs following attainment of a basic q u a l i f i c a t i o n . For the purposes of t h i s discussion i t i s defined as ad hoc or informal workshops, conferences, seminars, night school courses of limited duration or inservice education (that i s up to forty hours of f u l l time study). 15. During the e a r l y s i x t i e s , RNABC s t a f f presented c o n t i n u i n g 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 . T h i s became a very expensive undertaking. In 1966, the RNABC changed i t s p o l i c y and began to work to 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. I t i n v o l v e d h o s p i t a l s , community c o l l e g e s and u n i v e r s i t i e s i n p r e s e n t i n g these programs t o nurses f o r a reasonable fee which u s u a l l y covered the c o s t s o f expenses. In 1967, the RNABC f a c i l i t a t e d the 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 , powerful U n i v e r s i t y o f B r i t i s h Columbia C o n t i n u i n g M e d i c a l 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 with the Department o f Con t i n u i n g Medical E d u c a t i o n to send a nurse with 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 Education programs, to provide r e l a t e d n u r s i n g i n s e r v i c e " (104). T h i s was implemented i n the next year when four courses were presented by doc t o r s and nurses. A f u r t h e r stop i n developing 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 as 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 year to UBC f o r a p e r i o d o f f i v e y e a r s , to appoint a f u l l time n u r s i n g f a c u l t y member to the School o f Nursing, s a i d f a c u l t y member to be seconded t o the Department o f Con t i n u i n g M e d i c a l Education to assess the needs and re s o u r c e s f o r c o n t i n u i n g education f o r nurses and to p l a n , develop, implement and coordinate 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 with 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. The RNABC o b v i o u s l y thought the f u n c t i o n s now being performed by nurses could not continue s a f e l y without i n c r e a s e d e d u c a t i o n but i t had not been s u c c e s s f u l i n making t h i s need known to the funding bodies, so i t provided the funding. The RNABC continued to fund t h i s p o s i t i o n u n t i l 1977. 16. There has been considerable development within the province i n continuing education within the l a s t ten yers. The UBC Division of Continuing Education has provided most courses to nurses, followed by the University of V i c t o r i a , BCIT and some of the community colleges, but entrepreneurial groups and special interest groups within nursing have also undertaken a number of courses. In general, continuing education programs for nurses are s e l f funded through r e g i s t r a t i o n fees of participants. I f ind 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 thei 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 for nurses, such as standards, to most people with influence i n planning nurse education, t h i s i s not an area of major concern at t h i s time. In general, continuing education programs w i l l become more important i f s p e c i f i c evaluations of nurses' competencies for the purpose of re-registration are to be undertaken. E. Post-Basic C l i n i c a l Specialty Courses i ) A v a i l a b i l i t y and Adequacy of Existing Programs During the 70's a number of b r i e f s and studies concerning the need for post-basic c l i n i c a l specialty courses i n B.C. were carried out. (See Appendix D for complete l i s t i n g ) Although they a l l strongly recommended that t h i s currently lacking area of nursing training 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 specialty 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 1973 the RNABC had met with the following bodies; the UBC Division of Continuing Nursing Education, the Royal Columbian, St. Paul's, and Vancouver General Hospitals, to develop and sponsor an Intensive and Coronary Care Course. B r i t i s h Columbia Hospital Insurance provided f i n a n c i a l support for program development and implementation; W.K. Kellogg Foundation participated i n the developmental funding. The UBC School of Nursing funded the evaluation of th i s course. This course was repeated twice, successfully, i n 1975 but further courses were cancelled because of the lack of funding. The inadequate supply of nurses prepared to work i n c r i t i c a l care areas became a serious issue i n early 1980. The provincial Ministry of Health attempted to id e n t i f y immediate 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 useful i n ide n t i f y i n g immediate need. In a paper e n t i t l e d "RNABC Views on Continuing Basic C l i n i c a l Nursing Education ( 1 9 8 0 ) " ( 1 0 0 ) the RNABC i d e n t i f i e d current programming a c t i v i t y as follows: As of February, 198O, there are programs either operating or proposed for a l l the known high need c l i n i c a l areas except neonatal intensive care. There i s almost no information to suggest how many nurses require tra i n i n g i n each category. While there i s evidence that the number of nurses requiring training are considerable, the numbers which can be immediately trained w i l l be limited by a number of factors, including a v a i l a b i l i t y of qu a l i f i e d i n s t r u c t i o n a l personnel, a b i l i t y of agencies to replace s t a f f that can be released for t r a i n i n g , the uncertainties connected with new and untried course offerings, a v a i l a b i l i t y of funds to compensate nurses for salary loss during t r a i n i n g , and a v a i l a b i l i t y of funds for course development and operation. I t appears that the most careful a l B e i t o p timistic, estimates of numbers of nurses that could be trained have been made by providers i n the i r course projections. U n t i l there i s additional and better information which could a l t e r these 18. estimates, RNABC should support these as immediate post-basic tra i n i n g goals and should caution against overly optimistic planning of "crash programs." The Association should also support the early development of a program for neonatal intensive care. This same paper also i d e n t i f i e s post-basic programs currently being presented or i n the planning stages. In a Post-Basic Nursing Programs Discussion Paper of March, 1980 (121) Dr. Sheilah Thompson, Coordinator of Health and Human Services Programs, Ministry of Education, l i s t s post-basic courses and adds some courses i n the planning stages. These tr a i n i n g programs themselves vary i n length and l e v e l of sp e c i a l i z a t i o n . For example, the Post-Basic Operating Room Nursing Course at St. Paul's Hospital i s 24 weeks in length and includes material on a l l major O.R. services, 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 of the programs do provide some form of c e r t i f i c a t e for 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 of these post-basic programs now must submit thei 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 external evaluation mechanisms. ^ Although curriculum approach varies according to the group which i s presenting the program, as well as what specialty the program i s about, one thing i n common to a l l c l i n i c a l specialty post-basic courses i s that c l i n i c a l practice i s seen to be as important as the theoretical aspects of the course. Nurses who complete c l i n i c a l specialty courses are accepted by the employing agencies to work i n the specialty area for which they have been 19. trained. However, there i s a problem for employing agencies because nurses from these courses i n B.C., and others i n Canada, may have been prepared to function at different l e v e l s , therefore, s t a f f orientation programs have to d i f f e r s i g n i f i c a n t l y - both within 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 . i i ) Funding Issues Most post-basic courses are expensive. They are estimated to cost $25.00 to $40.00 per day per student, or from $50,000.00 to $60,000.00 per course. Funding for post-basic courses i s variable.* The courses can be paid for through student r e g i s t r a t i o n fees, through hospital funding, or by the M i n i s t r i e s of Education, Universities Science and Communication or Health. In general, continuing education has been paid for by students but c l i n i c a l specialty courses have sometimes been funded from other sources. Hospitals do provide a few post-basic courses, usually out of dire need. In some hospitals 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 contributing to the cost of the course, but t h i s type of payment for education i s on the decline. According to L i s t i n g of Continuing Education for Nurses, published by the RNABC i n October, 1979, no post-basic courses i n the province are funded t h i s way. Any B r i t i s h Columbia hospital providing courses, i s presently supporting these courses by special grants or out of general hospital budgets. (Appendix A) *This information has been taken from published documents. The current si t u a t i o n may be diff e r e n t , since documents were consulted only up to June, 1980. 20. In educational i n s t i t u t i o n s , the funding problem i s further compounded by the manner i n which funding i s allocated to community college nursing departments, BCIT and the UBC Department of Continuing Education. Most community colleges with nursing departments are usually organized i n such a way that a l l nursing education offerings stem from that department. I f short term continuing education programs or post-basic nursing programs are to be presented, the resources available are those from within the department of nursing. F i n a n c i a l l y , these departments can submit proposals for post-basic courses (through their internal approval bodies) to the Ministry of 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 for 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 of basic education programs and have l i t t l e , i f any, time for other a c t i v i t i e s . This problem has been overcome by the RNABC Board of Directors. In January, 1980, they approved a policy of providing developmental funds for post-basic c l i n i c a l specialty programs. Funds have since been made available and allocated for 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 Ministry of 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 faculty or c l i n i c a l space may no longer be available. BCIT d i f f e r s from community colleges i n that i t has a s p e c i f i c department whose purpose i s to provide continuing educational offerings. 21. Therefore the resources for basic planning are more available, and funding sources are more readily accessible from within that department's budget. I f funding must be obtained from the Ministry of Education the same process i s engaged i n as the community colleges with one exception. P r i o r to the l e t t e r of intent being sent to the Minister, 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 Education i n Health Sciences i s funded i n a different manner. The d i v i s i o n i s composed of an Executive Director of the d i v i s i o n , Directors for each health science d i s c i p l i n e and support s t a f f . Each Health Science Dis c i p l i n e i n the Continuing Education Division provides salary funding for i t s respective Director and one secretary. The School of Nursing also funds an Assistant Director. The salary of the Executive Director and other support s t a f f plus any operating costs are funded from charges to participants i n the various continuing education presentations, which must be self-supporting. Therefore, each participant i n a continuing educational program presented by the Division pays for the costs of the course plus a portion of the administrative 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 for programs for 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 for programs on an ongoing basis, even i f the department were to accept the r e s p o n s i b i l i t y for funding them as part of t o t a l nursing education policy. Nor can i t provide guidelines 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 basis, makes these courses very expensive. Teaching 22. material cannot be planned for continuing education courses but i s continually being started 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 for development, formal in s t r u c t i o n , and on-site c l i n i c a l supervision. How much more expensive are they when each course begins at the beginning to r e c r u i t and orientate 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 practice 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 for the students are located. The lower mainland agencies already have d i f f i c u l t y i n providing c l i n i c a l spaces for the current basic courses. Classroom space a v a i l a b i l i t y may create further problems but these are not as d i f f i c u l t to solve. iv) Issues i n Locating Courses The location of courses provides added problems for nurses l i v i n g outside the d i s t r i c t who must pay extra for board and room as well as losing 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 for her e f f o r t s unless she wishes to acquire geographic mobility. 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 expertise necessary to instruct i n post-basic programs. Since there i s not a c l i n i c a l education career ladder, colleges must choose from educators who do not have c l i n i c a l expertise or practitioners who lack teaching and programming s k i l l s . 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 for t h i s l e v e l of teaching and job security i s lacking for anyone who might be prepared and interested to teach because of the nature of the planning. v i ) A v a i l a b i l i t y of Students Potential students for specialty courses are often already working i n special care areas. This i s not desirable, but a fact of l i f e . Hospitals would have d i f f i c u l t y replacing these s t a f f members for the period of post-basic courses because they are already short of nurses in the specialty areas. F. Pressures to Improve Continuing Education Sp e c i a l t i e s : Who i s Concerned?  As the confusion described i n the previous sections must indicate, there are a number of different individuals and groups concerned about basic and continuing education for nurses. Their reasons for 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 becoming more and more important for attaining economic rewards and where educational opportunities are so closely linked with s o c i a l opportunities. This i s discussed i n F ( i ) . The second section of the discussion F ( i i ) i s concerned with the professional association's attitudes. Since other groups have not been eff e c t i v e i n planning, the nurses' professional association has taken much of the i n i t i a t i v e i n educational development. Their spokeswomen in the professional association and unions have struggled to help nurses to a t t a i n greater recognition as a group, f i r s t l y , through pursuing professional objectives and more recently through union action. On the other hand, the employers of nurses are concerned about standards and cost-effectiveness and e f f i c i e n c y . The t h i r d section 24. F ( i i i ) considers the employers' attitudes to c l i n i c a l specialty education. I t must be pointed out that i n B.C. the employers concerned are the hospitals acting as a consortium (the BCHA), or i n d i v i d u a l l y ; the Nursing Administrators' Association speaks on behalf of the Directors of Nursing of the hospitals who are the p r i n c i p a l executive o f f i c e r s concerned with the deployment of nursing s t a f f s . The BCMA i s included i n t h i s discussion of employers* attitudes, for whilst doctors are not employers of nurses they are much concerned about the quality of help provided by the nurses working with them. The fourth section 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 for 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 Specialty Courses Post-graduate c l i n i c a l specialty courses offer both advantages and disadvantages for nurses. Geographic career mobility i s one possible outcome for 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 specialty areas i n nursing and can then transfer to a related c l i n i c a l specialty i n a way that nurses without post-basic education cannot do. A nurse who must move with her husband to another town w i l l become immediately sought after by the l o c a l h o s p i t a l . Another example of within i n s t i t u t i o n a l mobility i s the nurse educated i n Coronary Care Nursing who i s more eas i l y able to transfer to a general intensive care unit, a post-anesthetic recovery room, or a burn unit than a nurse without such post-basic t r a i n i n g . Unfortunately, however, once orientated into a special unit, a nurse does not have the same upward career mobility as nurses taking post-basic administrative 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 Association of B r i t i s h Columbia and RNABC, Labor Relations Division, does not either encourage or recognize a c l i n i c a l career ladder. Clause 52:01 of the current contract does give f i n a n c i a l reward for special c l i n i c a l preparation, but only i f the nurse has attended a course, of not less than s i x months, approved by the RNABC, and i s employed i n the special service for which she/he has q u a l i f i e d . These nurses w i l l be paid an additional twenty-five dollars a month i f they have u t i l i z e d the course within four years prior to employment. At the present time, only nurses who have completed courses i n Operating Room Nursing at St. Paul's and the Registered Psychiatric Nursing Course at BCIT qualify for th 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 at St. Paul's Hospital, work for less money even though they may perform the same functions, accept the same re s p o n s i b i l i t y and have the same sort of post-basic c e r t i f i c a t e from a B.C. course. Further, t h i s same contract does not recognize any other l e v e l of practitioner than general s t a f f nurses. Other positions 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 either non-registered general s t a f f nurses or administrative personnel. T" erefore, i n terms of upward career mobility, the post-basic courses presently offered do not contribute i n a concrete way towards nurses' career mobility. They offer the nurse further educational 26. challenge i n special units, or special status i n the general duty nurse hierarchy, but nurses are not f i n a n c i a l l y rewarded for t h i s . 2.) Peer Group Concerns — Competency The RNABC has long been acti v e l y involved i n nursing education and sees i t as a professional association'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 shifted from concentration on basic education to the recognition that continuing education was essential for nurses. I t became the f i r s t provider of continuing education i n the province, a role 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 early 1970's. After that time, the Association saw i t s role as the f a c i l i t a t o r of educational developments for nurses rather than being the provider. During the 80's, the RNABC has continued to int e n s i f y i t s e f f o r t s i n pushing for continuing education for nurses. The RNABC has f a c i l i t a t e d planning of continuing education by nominating members to serve on committees and planning bodies for post-basic courses. I t has continued to lobby governments for provision of post-basic courses for nurses and assists 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 of the $100,000.00 unspent for educational loans i n 1979 would be made available for development of post-basic c l i n i c a l nursing courses. A maximum of $5,000.00 i s available for each course. Courses receiving the development funding are the C r i t i c a l Care Level I I for ICU, PAR, and Emergency Nursing being provided by UBC, and Obstetrical 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 Psychiatric course sponsored by UBC, a Long 27. Term Care Course sponsored by UBC, and an Occupational Health Course sponsored by Douglas College/Royal Columbian. Most of these courses are planned to start i n late 1980 or early 1981. At that same Board Meeting, a further decision was made that the RNABC would undertake a study to id e n t i f y competencies and s k i l l s required i n a number of c l i n i c a l nursing s p e c i a l t i e s , v i z ; c r i t i c a l care, maternity, psychiatry, operating room, recovery room, long term care, emergency, pediatrics, p a l l i a t i v e and neonatal nursing. Information gathered by the committee from nursing education program planners indicated that a l i s t of competencies would be useful i n planning new post-basic nursing courses to ensure greater standardization i n various educational settings. As a resul t of t h i s decision, a paper was developed i n A p r i l , 1980. I t was call e d " C l i n i c a l Specialties Competencies Report" (99). The terms of reference were: to id e n t i f y major sp e c i a l t i e s and sub-specialties within the practice of nursing, to specify the competencies required for the i r safe practice, and to indicate the type of specialty preparation required for practice i n the major special patient care units and services which exist i n B.C. Early i n the spring of 1980, the RNABC published a paper called "RNABC Views on Post-Basic C l i n i c a l Nursing Education" (108). I t reviewed the state of post-basic courses for 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 follows: As the professional organization and registering body, RNABC i s v i t a l l y concerned with the competencies of R.N.s and hence with the quality and content of th e i r continued professional education. 1) Required competencies for the various c l i n i c a l specialty areas should be set up and regularly reviewed for currency by the professional 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 courses be reviewed v i a the Continuing E d u c a t i o n a l Approval Program, and one c r i t e r i o n f o r continued funding should be CEAP ap p r o v a l . D e c i s i o n s 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 approval c o u l d be b u i l t i n t o the CEAP process. In January, 1979, a c o n s u l t a n t was h i r e d to evaluate the e f f e c t i v e n e s s o f CEAP and i n September, 1979 the board r e f e r r e d her r e p o r t to the J o i n t Continuing Education Approval Committee as k i n g f o r i t s recommendations. In January, 1980 the Board decided that the Continuing Education Approval Program would continue, t h a t i t be widely a d v e r t i s e d t h a t the c o n s u l t a t i o n s e r v i c e was a v a i l a b l e , and that s i m p l i f i e d approval standards be developed f o r s h o r t courses which do not o f f e r c l i n i c a l i n s t r u c t i o n or 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 care workers has been concerned about the 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 care i n B.C. As a r e s u l t , a Standing Manpower Committee was e s t a b l i s h e d i n l a t e 1979 to 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 to develop the 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 . The primary mandate o f t h i s committee i s to ensure that employers are 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 to 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 Health 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 Managerial E n g i n e e r i n g U n i t s i n order to i d e n f i t y what had to be done and by whom and to a s c e r t a i n any areas o f manpower p l a n n i n g not c u r r e n t l y 29. being addressed. In May, 1980 the committee published i t s Manpower and Research Inventory of A c t i v i t i e s and Reports. (20) Included i n t h i s l i s t i n g are a number of nursing manpower reports and studies. The BCHA i s working with the Health Manpower Research Unit of UBC on the d i f f i c u l t - t o - f i l l positions survey. (13) b) Hospital A c t i v i t i e s Individual hospitals or groups of hospitals have lobbied the Health Ministry re the shortage of general duty nurses and i n p a r t i c u l a r , nurses with post-basic preparation to work i n special c l i n i c a l areas. . As a r e s u l t , the Ministry of Health circulated a questionnaire i n the spring of 1980 (19) to attempt to discover what urgent needs might be, with the hope of establishing 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 r e c r u i t i n g inexperienced nurses and providing good orientation, they are discussing providing t h e i r own specialty courses with support and funding to be requested from the M i n i s t r i e s of Health and Education. Currently St. Paul's Hospital i n Vancouver i s providing some post-basic courses i n Operating Room and Enterostomal Therapy. A major discussion point i n hospitals i s "who should control educational a c t i v i t i e s for post-basic courses?" Some comments indicate that respondents see t h i s as a role f o r hospitals 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' Association of B r i t i s h Columbia This organization encompasses other than hospital nursing administrators but the majority of the membership i s nursing administrators who are employed i n hospitals. 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' Association strongly supported recommendations r e l a t i n g to improving basic standard educational and degree programs and making degree programs accessible for nurses i n other parts of the province. Recommendations which dealt with post-basic education were strongly supported by the Association. The Association also supported recommendtions which suggest the development of career streams i n c l i n i c a l nursing. Recommendations which dealt with planning for needs for nursing were also endorsed. In October, 1979, the Association presented a b r i e f to the Minister of Health e n t i t l e d "The Registered Nurse Shortage i n B r i t i s h Columbia: An Increasing Problem for B r i t i s h Columbia Hospitals." (88) The recommendations from t h i s b r i e f are as follows: 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 for implementation of the following recommendations: I. To provide s u f f i c i e n t separate funding to meet nursing s t a f f orientation and continuing education for job requirements. I I . To immediately increase the number of seats available to refresher courses. I I I . To continue funding of the University of B r i t i s h Columbia/Vancouver City College Level I C r i t i c a l Care Course. IV. To provide funding for the following post-basic courses: Cardiothoracic Care Coronary Care Emergency Care Gerontology Level I and I I Intensive Care Neurological Care 31. Neurosurgical Care Obstetrical Care Operating Room Care Post-Anesthetic Recovery Care Renal Care Spinal Cord Injury Care V. To increase the number of seats for basic nursing programs. The Nursing Administrators 1 group of the Lower Mainland invited Mr. R.E. McDermitt, Senior Assistant Deputy Minister, Professional and I n s t i t u t i o n a l Services, Ministry of Health, to a special meeting i n March 1980, to discuss with him t h e i r concerns about the shortage of specialty trained nurses and lack of post-basic courses to t r a i n nurses i n special c l i n i c a l areas. In meeting with Mr. McDermitt, t h i s was their attempt to make clear t h e i r consensus to the Ministry of Health. d) Colleagues' Concern - Doctors' Attitudes Re Effectiveness The BCMA has long been interested i n nursing education. U n t i l recently, i t was highly involved i n pa r t i c i p a t i n g i n nursing education, i t s members often giving nurses lectures i n anatomy, physiology, disease pathology and medical treatments. More important to the physicians of B.C. i s that graduates of nursing programs, i n caring for patients, work closely with physicians. Therefore, the physicians are d i r e c t l y affected by the outcomes of nursing programs. In December, 1979, i t was brought to the attention of the Board of the BCMA that a serious shortage of nurses was developing and also that nursing needed support i n obtaining funding from either the Ministry of Health or Ministry of Education for 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 re s u l t , the BCMA Hospitals Committee was asked to study the effectiveness of nursing education i n the province and to report back to the board. Dr. D. MacPherson, who chairs the Hospitals Committee, wrote to the RNABC and several directors of nursing to try to ascertain the scope of the problem. E s s e n t i a l l y , answers he received indicated that there was a problem but that adequate data had not yet been obtained. I t was indicated that attempts at corrective action 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 Directors of the BCMA i n January, 1980 (15): 1) That the Ministry of 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 Ministry of Education respond to the need for an ongoing dependable source of funding to be u t i l i z e d for the development and implementation of quality post-basic nursing courses. 3) That a source of revenue for consistently a s s i s t i n g hospitals with the cost of s t a f f replacement for nurses attending post-basic courses be i d e n t i f i e d . H) Government Involvements i n Planning Post-Basic C l i n i c a l Specialty Courses  Since delivery of hospital services i s not a direct government r e s p o n s i b i l i t y but delegated to the hospitals themselves, the Health M i n i s t r i e s did not become d i r e c t l y involved i n the nurse manpower planning u n t i l the seventies (The development of th i s involvement after the introduction 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 e a r l i e r i n t h i s chapter. Consequently, u n t i l very recently, governments were not involved i n supporting post-basic nursing c l i n i c a l specialty courses. A policy for 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 interested 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 interested groups had demanded thei r attention or f a l l e n off. The planning focus had only been on the strongly 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 roles 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 specialty courses, so a competition of sorts had developed i n terms of who would get the ad hoc ind i v i d u a l program funding which was available. In 1977, i n B.C. a mechanism to review requests for additional funding for c l i n i c a l specialty programs was set up, but neither on-going need for programs nor program p r i o r i t i e s was to be on a one time basis. As a r e s u l t , funding for a program might be approved on a one time basis. Continuing to present the program meant reapplying through the mechanism requests for additional courses, for further one time funding. This was not only time consuming but often resources were dispersed or unavailable by the time the second approval was granted. As demands have been increasing for 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 Relating to Nursing Education?  The l a s t two decades were the time when most e a r l i e r plans regarding nursing education were implemented. Basic education programs came under the control and funding of the pro v i n c i a l education departments. Baccalaureate nursing courses increased quality and quantity. Masters' programs were started i n many u n i v e r s i t i e s . Yet education for spe c i a l i z a t i o n i n nursing i s s t i l l i n the early planning and implementation stages despite the fact that these two decades were characterized by increasing technology and spe c i a l i z a t i o n i n nursing. There i s s t i l l discussion within the profession today about nursing education needs - about the difference between "service" and "education." This may well be related to the lack of c l i n i c a l models i n nursing. Because the practitioner i s not highly regarded or rewarded within the nursing profession even today, the question of who decides what nursing practice i s and what education i s needed to f u l f i l t h i s role i s an important one. The status i n the nursing profession has not been with those people who provide nursing service, but, rather, with those who administer the service and those who educate for i t . To advance i n nursing, one had to specialize i n education or administration. U n t i l the l a s t few years, the educators have had the most power. Many nurses who gained t h e i r higher education chose the teaching role because teachers tended to have better working conditions, salaries and status than nursing administrators. They had more freedom to control and make decisions about the educational environment. They were also i n an environment where new ideas and concepts are expected. The educators 35. were able to advance i n thei r thoughts about what nursing should be and what various educationally prepared levels of nurses should do. The nursing administrators were looking for nurses who could perform the established nursing practices w e l l , not nurses who had new ideas tht the nursing administrators could not possibly implement. Within the hospitals, many nurse administrators themselves were not given r e a l power but were often delegated tasks to carry out. They had l i t t l e control over the i r working environment because hospital administrators controlled the budget and physicians controlled the quantity and quality of workload. As a r e s u l t , they were often unable to do much more than follow orders while trying to advance nursing as best they could. But who should determine what nursing r e a l l y i s ? The educators? The administrators? Or the practitioners who provide daily care for patients? Attempts were made by the professional associations to p u l l together varying views about the objectives of nursing education. Mussalem (85) for long the Executive Director of the CNA, has put forward her interpretation of the reasons for slow progress i n attaining the objectives i d e n t i f i e d by the professional association by quoting King (76): Throughout the f i r s t part of the century, organized groups closely associated with health care, for one reason or another, appeared to favour maintaining the narrow custodial image of the nurse. This coupled with the apparent i n a b i l i t y or unwillingness of nurses to interpret developments i n both education and service, further 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 university nursing education has always depended on funds channeled through the provincial government, i t i s essential that the needs of nursing be 36. interpreted c l e a r l y to their l e v e l of government. I t was inevitable that through the lack of clear interpretation of the need f o r , and the role 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 university degree programs. The question may well be asked why, i f the general public was confused, nurses were content to accept t h i s s i t u a t i o n . Over the same period other professional groups successfully recognized the need for involving new educational approaches and interpreting these changes to the public. Unfortunately, the mass of nurses were apathetic and lacked understanding of both the need for, and the character of the change i n basic nursing education controlled by the university. Is t h i s a useful interpretation of the present nursing situation? Certainly i t focusses attention on the ind i v i d u a l nurse's reactions to thei r general s i t u a t i o n i n society though these reactions may well have changed i n recent years. In the next section the development of nursing functions i n hospitals and womens' roles i n society are considered, as a basis for making an assessment of the appropriateness of education and train i n g i n nursing today and i n interpretation of reasons for the "shortage" of nurses. 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 ind i v i d u a l nurses i n B r i t i s h Columbia have been making particular demands upon employers, represented by the Directors of Nursing of hospitals, namely demands for positions with greater decision making autonomy and more l i f e style advantages to f i t more closely with the i r other s o c i a l roles. Nursing i s a women's profession. In manpower discussions, t h i s i s i d e n t i f i e d as a chara c t e r i s t i c of the nursing profession. To explore the problem of nursing shortages, womens' roles must be examined to under-stand 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 for the labour market. A. The Beginnings Nursing functions today have evolved as a result of many factors. 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 roles of women i n our society, and the development of our society. External, economic and s o c i a l pressures as well as int e r n a l searchings to adapt to the changes has created a state of uncertainty i n nursing as to what i s the scope and function of nursing. For the perceptions of nursing today have been determined by i t s t r a d i t i o n s as well as more recent influences: 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 folk images of the nurse brought forward from the primitive times, the re l i g i o u s image of the nurse inherited 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 ethic of the 16th to 19th centuries. 38. These images, while appealing to the humanistic side of man's nature, show nursing i n a subordinate position 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 closely intertwined with those thought to be a part of the woman's rol 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 early settlements i n Canada u n t i l the 1920's the values i n nursing were simple. Nursing was a servant's role and thus a duty. Canadian nursing began i n the early years as a "labor of love" for the r e l i g i o u s orders i n Canada, family members or neighbours who volunteered t h e i r services. These nurses were untrained and did what they could for the comfort of their patients. Rewards for nurses were based on the value of the dedication to patients. They also valued praise from the physicians for thei r work. In t h i s period i n Canada's history, the normal roles of women were to be wives and mothers staying at home. Women were seen as needing protection and therefore dependent on men. Their status was much less than men's and they were not welcome or accepted when working i n society 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 ro l e . " Nursing as an occupation was also valued by women, as a way of putting t i n time, hoepfully, u n t i l they were married. As Canada became more settled, hospitals were set up and the larger ones opened schools of nursing. Since women had very few career opportunities, nursing was a popular choice, and many women considered themselves fortunate to have been accepted into a train i n g school. 39. At t h i s time, nursing care was aimed at cleanliness, comfort, maintenance of n u t r i t i o n , and easing of symptoms for the patient. Medical care was minimal and often treatments consisted of family remedies. Very l i t t l e nursing care during t h i s period was aimed at i l l n e s s prevention or health maintenance. Most care was directed at those already i l l . Since most nursing care was provided on an ind i v i d u a l basis to patients i n the i r homes, nurses, besides providing i l l n e s s care, also did the cleaning, cooking and generally provided the extra care the family might need. They tended to l i v e i n when they were with a family and provided care on a twenty four hour basis. During most of t h i s period, many nurses worked as independent entrepreneurs. They were self-employed and accountable to the i r employers for the quality of care they provided, although the physicians might oversee some of the i r work. As independent practitioners, they assumed r e s p o n s i b i l i t y and accountability for t h e i r practice and t h e i r continued learning 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 c r i t e r i a 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 description of a true professional group. A few nurses worked as administrators of hospitals and as such, usually assumed t o t a l r e s p o n s i b i l i t y for the internal management of hospitals. These administrators may have had an assistant 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 control. As well as t h e i r administrative functions, they were often expected to teach the students how to provide nursing 40. care. L i v i n g - i n , they were responsible for the twenty-four hour operation of the hospital and were often called upon to a s s i s t with direct care to to provide "expert advice" to the student nurses who provided most of the nursing care. They were very attuned to the "real world" of nursing. Because the hospitals were staffed mainly by apprentices, most trained nurses were isolated i n private duty nursing and i n the early 1900's th i s stimulated the graduates of the training programs to band together i n alumni associations to support one another i n whatever ways they could, including s o c i a l i z i n g and sharing c l i n i c a l information. This was t h e i r form of continuing education, and ultimately protection. I t was i n these groups that nurses began to talk about organizing themselves, and establishing basic standards for nursing education. They were not greatly concerned with levels of renumeration. Although nurses might ask for s p e c i f i c amounts for payment for thei r services, they often would work for l i t t l e or nothing because "they were needed." The leaders i n the nursing associations were concerned that anyone could offer herself for hire as a nurse, whether she was trained or not. Although many nurses were concerned with the control of quality of nursing care, others were concerned with the competition for jobs that the untrained nurses created. Whatever the reason, most nurses became interested i n developing some form of control over non-trained nurses. I t became important to nurses to have formal recognition for thei 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 recognition. So they began to value the need to be linked together i n professional associations and they began to work for effective professional organization. 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 for women to work outside the home i n order to add to family income. However, less home nursing care was carried out because, with the depression, people were unable to afford to pay nurses and they trusted hospitals more because of the improved infection control (2). More people went to hospitals when they were i l l , but, there was very l i t t l e money to pay more nurses for thei r services. This sometimes resulted i n more students being taken on or sometimes those that were there had to work harder. Some hospitals began to find students expensive and did hire a few more trained nurses for hospital work, but, not many were able to do t h i s because of scarcity of funds. P r o v i n c i a l associations had formed across Canada and were struggling to set and improve standards of basic tra i n i n g programs and to develop higher education programs for nurses. For the f i r s t time the associations were given control over nursing r e g i s t r a t i o n by the early twenties. They also began to work to develop public funding for 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 further education as a way of keeping up t h e i r s k i l l s while waiting for employment. C. The War Years and After Towards the end of th 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 services for other countries. This l e f t a shortage of nurses on the domestic scene. To increase t h i s shortage, many injured 42. servicemen were sent home for treatment i n government hospitals. The need for nurses, i n Europe as well as at home, increased faster than nurses could be trained. A u x i l i a r y nurses were introduced to help overcome t h i s shortage. 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 practice i n a different way. Besides being a bedside nurse, the R.N. was now expected to guide and supervise another category of nurse. Doctors were also i n short supply at home. Nurses began to take over procedures which had previously been performed only by doctors. As wel l , the development of new medical technologies, new drugs, such as the sulphonamides, meant that more severely i l l patients survived and required to be nursed through intensive i l l n e s s e s as they had not before. The increased duties of nursing more patients who were intensively i l l , and taking on more medical functions, increased the nursing shortage. In 19^3, the Heagarty Committee, set up by the federal government, (69) proposed that Canada should adopt a National Health Insurance Scheme. Although i t took t h i r t y years for a l l the programs i n the scheme to be introduced, i t was made clear i n the National Health Survey of 1943 (29) that 90,292 more hospital beds were b u i l t and gradually as the National Health Scheme was implemented (33), the demand for nurses increased. Despite the increase i n the numbers and size of hospitals and changes i n th e i r technological a c t i v i t i e s , nursing organization structures i n hospitals did not change at th i s time. 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 to develop. Post-basic specialty courses did allow nurses horizontal mobility but upward career mobility s t i l l consisted of moving into administration or 43. e d u c a t i o n . However, nurses a c q u i r e d i n c r e a s e d geographic m o b i l i t y once they had taken a course. To summarize, during the 1940's to 1960's, n u r s i n g 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 care as t h e i r only f u n c t i o n , nurses were r e q u i r e d to engage i n other t a s k s . F i r s t , many became i n v o l v e d i n h i g h l y complex and 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. They a l s o moved away from spending time with p a t i e n t s as another category of 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 care to i n s t i t u t i o n a l i z e d care f o r groups o f p a t i e n t s . There was a g r e a t demand f o r i n c r e a s e d numbers o f r e g i s t e r e d nurses to take on these new f u n c t i o n s . 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 others but they a l s o began to be aware t h a t they were important to the h e a l t h care system. They began to r e a l i z e that more education was r e q u i r e d 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 that 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 a p p r e c i a t e d , namely, 'reasonable' monetary renumeration, higher 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 tasks and p l e a s u r e i n l e a r n i n g new techniques and working more c l o s e l y with other p r o f e s s i o n a l s . W h i l s t the p r o f e s s i o n a l groups s t i l l emphasized e d u c a t i o n a l o b j e c t i v e s and n u r s i n g standards as t h e i r p r i n c i p a l concern, they were beginning to 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 . In 1946, f o r example, the RNABC se 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 . Women were i n the labour f o r c e and expected to be. They now d i d many jobs t h a t 44. previously had only been done by men. Educational and career opportunities expanded. The expectation that women who married should quit work, and stay i n the home faded. Women began to be more involved with public l i f e at every l e v e l . The status of women was s t i l l below that of men, but the gap was less wide than i t had been. D. The Last Two Decades The 1960's and 1970's were characterized by a major s o c i a l revolution i n Canada. The prosperity after the war, the explosions i n knowledge and technology, the increasing educational opportunities and the demands of minority groups for t h e i r rights a l l combined to create t h i s revolution. The Women's Movement stimulated discussions of women's roles i n society and because of the Women's Movement, a l l sectors of society have attempted to begin to move towards greater equality of the sexes. Women have gained status and i f nothing else, are no longer taken for granted as automatically belonging i n the "homemaker r o l e . " Educational opportunities are now more open to women who are attending university i n greater numbers than ever before, because of the s o c i a l value now attached to being a university graduate. In Canada 9856 of nurses are female, so nurses have been able to echo women's general goals within t h e i r own profession. As we l l , nurses have become more assertive and vocal. Gradually they began to see nursing education and trai n i n g as an expectation rather than a pri v i l e g e and were no longer w i l l i n g to pay for th i s with service. Nurses have begun to set great value on university education. I t i s a way to increase s o c i a l mobility and to meet young men. I t provides opportunities of moving out of nursing into other occpuations. Nurses have become unwilling to work i n r e s t r i c t i v e , authoritarian i n s t i t u t i o n s and they have begun to value recognition of th e i r knowledge and s k i l l s . 45. Nursing administrators gained strength i n t h i s time period. More and more they are beginning to be seen as i n s t i t u t i o n a l administrators with nursing backgrounds becoming involved i n top administrative decisions. This i s not yet the norm throughout the industry, but the precedents have been set and i t may now be necessary for more nurses i n senior positions to prove that they are capable of taking broader r e s p o n s i b i l i t i e s . During the seventies, several changes i n health care delivery have i n t e n s i f i e d s p e c i a l i z a t i o n i n nursing. A few of these s i g n i f i c a n t trends are: 1) more patients are being treated on an outpatient or day care basis. Those patients that are admitted to hospital are more seriously i l l than they have been i n the past. 2) There i s increasing s p e c i a l i z a t i o n resulting from expanding knowledge and technology, r a d i c a l intrusion into the human body and treatments which have been developed for severe trauma. 3) S h i f t s i n the population structure with more emphasis on the elderly and the ramifications of the aging process. E. Development of C l i n i c a l Specialty Units Nurses began to value (and to be valued for) technological a b i l i t i e s rather than basic bedside nursing care. The specialty areas evolved gradually i n hospitals as new information and technology developed. As new machines came into use, places were found for them to be set up i n hospitals and nurses were trained to operate them. These areas gradually became recognized as "special care areas" or "intensive care areas" where the sickest patients were gathered for concentrated nursing care. 46. The equipment and personnel i n these specialty areas were expensive to fund. The technological advances might not have come so quickly had not governments f i r s t taken over payment of c a p i t a l and operating costs of hospitals and then salaries of physicians. The 1957 Hospital Insurance Scheme and the 1966 Medicare programs (33) provided funding for doctors to spend more for "esoteric" areas of health care. Since the patient no longer had to "foot the b i l l " for these expensive services, "nothing was spared" to provide patients with l i f e - s a v i n g care. Physicians with regular payments being received from governments, had to "donate" less free care to indigent patients and could afford more time for explore new techniques. The Nursing Administrators' Association of B r i t i s h Columbia presented a position paper on budget restraints to the Ministry of Health i n November, 1979. (86) Although t h i s paper was mainly concerned with financing, the group described the changed function of nursing. The l e v e l of sophistication 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 sophistication and increased technology, as well as the continuing "transfer 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 sophisticated 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 role has also expanded i n the areas of patient and family teaching with increased emphasis on ambulatory care and health promotion. Also as well as more sophisticated 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, respirators, monitors. Today the function of nursing i s extremely complex. Few patients today have the nursing needs as simple as those provided by nurses prior to 1950. Even the patients on the general wards have numerous needs that are complex and those i n special 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. Specialized units are increasing i n numbers and si z e . A Ministry of Education Sub-Committee on Nursing Education, Kermacks' (1979) (73) reported that: an examination of the positions i n which R.N.s are employed indicated that approximately 30% of those positions require preparation beyond the diploma l e v e l . Most of these positions would require a preparation at least 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, counselling, administration, consultative and research ) not provided i n diploma programs. The S t a t i s t i c Canada data indicated that at least twenty percent of the f u l l time equivalent positions for graduate and registered nurses i n hospitals are i n specialized areas. Few nurses have or can obtain t h i s preparation. TABLE 2 Number of Full-Time Equivalent Graduate Nurses Employed i n Specialized Units i n B.C. Hospitals and as Proportion of Total Employed Graduate Nurses, 1976 Full-Time ^ Percentage of Specialized Units Equivalents Total F.T.E. Intensive Care 367.0 H.k% Labour and Delivery 187.7 2.256 Operating Room including PAR 810.0 9.7? Emergency Department 275.6 3•3% Total Employed 8,389.5 19.6$ 1 Other specialized units i n medical - s u r g i c a l , psychiatric, 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 registered 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 different rewards. Conditions of work and salar i e s are now far more important to nurses. As w e l l , the age of technology has affected nurses. Understanding machines — thei r operations and effects — has become very important to nurses. Those nurses who work i n special care areas have a higher status among nurses and physicians than do other nurses, although i t i s not because of extra monetary rewards. One can look at the reward system to attempt one explanation of the phenomenon. Physicians have more power, make more money, are more independent i n functioning than nurses. Nurses seeking to gain some status with the higher status physician group can do so more easily through understanding the technology (machines) than i n any other way. The Age of Specialization i s highly organized i n the physician group. Many physicians do not understand the i n t r i c a c i e s of the technology i n the special care areas. They usually refer t h e i r patients to physicians specialized i n these areas, who are minimal i n numbers and considered the e l i t e of the profession. Those who a s s i s t these specialized physicians are the nurses who work i n these areas. The nurses are not rewarded for the tender loving care they give the patients i n special care units, but, rather for thei r a b i l i t y to understand and operate the technological 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 recognition 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 physicians. C l i n i c a l specialty 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 for these nurses as the 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 we l l , to some older nurses, the "younger" nurses do not seem to be as dedicated to nursing. This i s suggested, for example, when these nurses are said to "leave right on time." This may be a way i n which the older nurses describe change i n nursing which they find d i f f i c u l t to accept or more correctly, i s at odds with their values. In today's society, l e i s u r e or non-work time i s highly valued. To most nurses, nursing i s only one role among their many varied roles. F. Unionization I t took over t h i r t y years for many nurses to accept the idea of building a strong union for bargaining purposes because of the strong "vocational" ethic which Nightingale had b u i l t into the idea of nursing. In B r i t i s h Columbia, around the mid-seventies many nurses would not admit that they belonged to a union. They did admit to having a professional labour organization. The idea of professionalism for many nurses was not i n harmony with the concept of unions and therefore, unionism was denied. However, the Labour Relations Division of the RNABC has recently become very strong. In a s t r i k e vote, taken by nurses i n over eighty hospitals i n the province, i n 1979, over 90% of the nurses voted to s t r i k e . This i s a major change i n values by nurses i n the province within the l a s t few years. Union a c t i v i t y i s evolving i n another dire 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. vehicle for advancing professional concerns of nurses as well as socio-economic interests. Nurses, as professionals, 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 quality of services has to be assured. Where the r e s p o n s i b i l t i e s of employment and professional standards are i n c o n f l i c t , nurses have a righ t and a duty to point out the c o n f l i c t . To negotiate disputes of t h i s nature, c o l l e c t i v e bargaining can be the instrument which should be used by nursing. In fact, nurses can be the agency nurses use to promote t h e i r professional values. G. Implications of Changing Attitudes The United States i s i n the midst of a major nursing s t a f f i n g problem. In a study done by the University 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 cause for widespread shortage (8). The reasons cited by nurses for job d i s s a t i s f a c t i o n included lack of support by hospital and nursing administration, lack of autonomy, i n f l e x i b i l i t y of working hours, being "pulled" from a f a m i l i a r unit to work on short staffed units, need for c h i l d care, c o n f l i c t with family schedules, frequent overtime with no additional compensation, lim i t e d help i n keeping up professional s k i l l s , i n d i f f e r e n t or inadequate personnel and low sa l a r i e s . Texas nurses are refusing to work for hospitals f u l l time because hospitals decide the number of hours, s h i f t s and days which the nurses w i l l work. An alternative has been provided for 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 dire s t r a i t s and are being forced to offer the nurses remaining on s t a f f many concessions to retain them. The aspirations of individual 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 necessarily those who know the most about and give the best personal care or, rather, those who play a handmaiden role i n promoting the technological aspects of caring for the patients? Has thi s implications for the future nursing structures and reward systems i n Canada? Are nurses going to continue to seek indi v i d u a l solutions or contract solutions for 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 national 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 Sectoral Educational Concerns to Comprehensive Manpower Planning^ A c t i v i t i e s  The present confused si t u a t i o n i n educational planning was outlined at the beginning of th i s paper and the reasons for the confusions have been explored, at least 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 relationships to nurses' changing roles i n society. 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 their f i r s t step, gone back to the nursing manpower planners to try to j u s t i f y the need and determine the scope of the problem, provide the means of r a t i o n a l i z i n g nursing preparation and the use of nursing s k i l l s . But who are the manpower planners? Alford, 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 hospital planning i n New York — the entrepreneurs, the corporate planners and,advocacy planners. This way of dividing planning interests provides a helpful indication of how sectoral 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 id e n t i f y : 1) the "entrepreneurs" who were at f i r s t the trained nurses who set up i n private practice from the e a r l i e s t days u n t i l approximately 1940. Thereafter, t h i s group disappeared. They, or their successors, became employees and began to be represented by the professional association speaking on their behalf. Although the nurses are no longer self-employed, the association s t i l l represents the nurses' interest. 53. Because of the heavy 'vocational' overload, these representatives of nurses concerned themselves with discussions about education and tra 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 more strongly for improved economic standards, the relations between professional (standards) and union (economic) a c t i v i t i e s has become a r e a l issue for the associations to manage. 2) the corporate planners who have been consortia of employers, i n s t i t u t i o n a l interest 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 recently. For example, the shortage of nurses i n World War I I , led the federal government i n 1946, to set up the "Joint Commission of Nursing" (30) with representation from the Canadian Hospital Council, Canadian Mental Health Association, Department of National Health and Welfare and the Department of Veterans' A f f a i r s to consider the acute shortage of hospital personnel. Much of the planning by i n s t i t u t i o n a l interest groups or employers' representatives has continued, as was shown i n the narrative above, but i t has not been very effective since the p r i n c i p a l l o y a l t y of committee members has been to thei r sponsoring organizations and not to the ad hoc planning groups. Corporate planning was given a major boost by the federal government deciding to fund health services. In 1948, the pro v i n c i a l governments had to produce hospital plans before they could tap the national health grant funds and at about t h i s time they also reviewed th e i r public 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 in Saskatchewan, and outside consultants' plans tended to be pushed aside by provincial politicians who had different objectives than the v i s i t i n g planners. The National Health Grant Program (1948) provided for hospital construction grants which greatly expanded the number of hospital beds. This in turn, created great problems in raising enough funds to keep these hospitals operating. The Hospital Insurance and Diagnostic Services Act (1957) further increased access to health care for Canadians and uti l i z a t i o n of hospitals continued to rise. The passage of the Medical Care Act (1966) continued government's involvement in funding health care. Before this act could be implemented, costs had risen alarmingly and the governments became concerned. The Task Force on the Costs of Health Care in Canada (32) was established in 1969. This committee made recommendations which can be summarized as: 1) change the federal-provincial funding system to close the open-ended "funding of health care" system. 2) try to move away from treating so many persons in 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 legislation and funded by government to provide services - groups which are only indirectly controlled. Judge (1978) (71) was distinguished between financial and service rationing. Governments can only control the legislation and funding of direct services, although they have been trying to find ways of making 55. the i n d i r e c t service deliverers more accountable. However, the service deliverers have been resistant to these controls. Consequently, the Task Force recommendations were very threatening. Obviously, the f i r s t two recommendations had special implications for nursing and they were strongly supported by a l l i e d health professionals. The medical establishment and hospitals resisted both of these recommendations as i t would mean a major change i n a structure with which they were comfortable. Alford (1) states: Groups are usually reluctant to y i e l d rights and privileges that they have exercised, and w i l l r e s i s t s i g n i f i c a n t restructuring unless i t appears that there i s something i n i t for them. Closing hospital beds was not conducive to the status of the hospitals, nor to the practice potential of the physicians, who had become used to treating th e i r patients i n the now-sophisticated hospital environment. The t h i r d recommendation led to other a c t i v i t i e s . The federal government ca l l e d two Health Manpower Conferences i n 1969 and 1971 (23) (24). Following t h i s , federal-provincial manpower committees were set up i n 1972 and gradually, inventories of health personnel and th 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 e f f e c t i v e l y , nursing manpower included. Physicians wished to remain the primary contact with th e i r patients and work on a fee-for-service basis. Ambulatory care was not at 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. hospital beds. The Community Health Centres Concept i s at odds with concepts of physician control 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 practitioners, i n general the medical profession has strongly resisted t h i s concept and after demonstrations had succeeded, no more was done to develop the position except i n the far north. 3) advocacy groups are groups of consumers who come together because of s p e c i f i c concerns. They attempt to u t i l i z e public support to cause changes. In the health care system i n B r i t i s h Columbia the Social Planning and Review Committee performs t h i s role but i t has not been interested i n nursing problems. Professional interest groups may also seek public support for the i r concerns. The nurses from the Vancouver General Hospital i n 1978, played t h i s role. They successfully used public support to gain changes at the Vancouver General Hospital. Generally though, the public i s asked to support so many different causes and issues that the role of advocates i n planning i s effective usually only i n " c r i s i s " types of situations. On an ongoing long term planning basis they have l i t t l e effect 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 did not implement these studies immediately because i t did not have a strong c i v i l service to follow through and p o l i t i c a l decisions were incremental decisions rather than planned decisions. In 1959 - 60, Dr. J. McCreary, Dean of Medicine, managed to find resources to finance the Metropolitan Hospital Planning Council and two 57. epidemiologists working out of the Department of Health Care and Epidemiology prepared reports on hospital u t i l i z a t i o n . I t was hoped that the Minister of Hospital Insurance would pick up th i s a c t i v i t y (after i t had shown i t s e l f to be useful), and provide funding to carry 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 Hospital D i s t r i c t s Act to control hospital f a c i l i t y planning. In 1966, Dr. McCreary persuaded the Honourable Judy LaMarsh, Federal Minister of Health of the necessity to set aside some funding for the development of health manpower training f a c i l i t i e s . B r i t i s h Columbia was slow to pick up i t s share of the money. The provincial government showed a great reluctance to get into planning so voluntary planning bodies continued to act. In 1968, the RNABC joined the B r i t i s h Columbia Medical Association, the B r i t i s h Columbia Pharmacy Association and the B r i t i s h Columbia Dental Association to form the Council on Health Resources and Manpower. Subsequently, the RNABC supported a study by Williamson ca 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 to id e n t i f y what nursing manpower was available. The other d i s c i p l i n e s were studying t h e i r profession's manpower a v a i l a b i l i t y at the same time. The name of the council was subsequently changed to the B r i t i s h Columbia Health Resources Council. I t was closely related to the Department of Health Care and Epidemiology and l a t e r to the Division of Health Services Research and Development at UBC which was headed by Dr. D.O. Anderson. (The Division 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. effective i n introducing changes, the council had made people aware of the issues. Dr. Anderson continued to research health manpower issues on research grant funding from the federal government, and established the Health Manpower Research Unit (HMRU) i n the Division. When the federal government became involved i n health manpower planning i n 1972 (following the two national conferences i n 1969 and 1971), they involved the p r o v i n c i a l government as wel l . The Federal government formed four continuing committees, one of which was the Federal/Provincial Health Manpower Committee, to advise the Council of Ministers, and Conference of Deputy Ministers of Health for Canada. Dr. Anderson was asked to represent the province on the Federal/Provincial Health Manpower Committee. When the NDP government came into 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 primarily, but i t got involved i n sorting out the students' practicum placements and therefore into manpower planning. The Division of 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 Pr o v i n c i a l Council, responsible for advising the Mi 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 for health manpower production, was established under the l e g i s l a t i o n which created BCMC. Second, the Health Manpower Working Group, consisting of senior o f f i c i a l s i n the Mi n i s t r i e s of Health and Education, was created to advise the Ministers on health manpower requirements for the pro v i n c i a l health care system. Each of these bodies has a special research and development unit. The P r o v i n c i a l Council was supported by the Division of Educational 59. Planning reporting to the Council through an Educational Conimittee of Deans and Academic Directors. The Health Manpower Working Group was supported by the HMRU at UBC. These two units, dealing respectively with production and requirements were linked by cross appointments. The Director of Health Research and Development played an o f f i c i a l r o l e ; i t s director 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 Federal/Provincial Health Manpower Committee (3). Thus the director became the corporate planner for the manpower section. The Division 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 of a l l types of nurses, taking into account population needs, nursing functions and categories, positions available, 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 location and size of new schools of nursing (3). Meanwhile the RNABC had published a report i n 1973 e n t i t l e d "Registered Nurse Manpower i n B r i t i s h Columbia" (110). This was i n response to public concern i n 1970 and 1971 that there was an oversupply of nurses re s u l t i n g i n unemployment for nurses. In the summer of 1972 and 1973 the press again were concerned with the supply of nurses and 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 st a r t i n g point for manpower planning to meet future needs as the system begins to change. 60. The problems i d e n t i f i e d by th i s examination of the registered nurse manpower si t u a t i o n i n B.C. emphasize the need for further study i n the context of t o t a l health manpower and t o t a l health care for the people of the province. This recommendation from the RNABC had not yet been carried out. The RNABC became involved i n provincial manpower planning through the BCMC. The past president of the association, Margaret Neylan, became an employee of BCMC. The association was asked to send a representative to the f i r s t planning meeting and other nurses sat on planning committees for specialty areas. But i n 1975 the government changed, BCMC was dissolved and the manpower planning process was considerably diminished i n scope. The nursing study was not completed although some information was useful l a t e r on to determine school of nursing locations. The Director of Health Services Research and Development Division of UBC resigned and the unit took some time to be reorganized. The concern with shortages of nursing personnel continued. The Kermacks Report (73) states: As was discussed e a r l i e r , the demand for R.N.s i s increasing. Cycles of very short supply and then adequate supply seem to characterize this work force. Indications are that the province i s now moving toward another short supply period. Two cycles have occurred since 1970. These findings d e f i n i t e l y indicate the need for serious manpower planning as registered nurses represent a large portion of the health care workers. Their absence creates a c r i s i s i n health care. The number of nurses prepared for administrative, teaching and specialized c l i n i c a l positions presents an even greater problem. The lack of q u a l i f i e d nurses for these positions has been a persistent concern of nurses and employers for years. An immediate and defined course of action i s required. 61. Shortages of nurses have obviously affected the health care system. The effect Is 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 transfer to other positions. For the past several summers, beds have had to be closed i n hospitals i n B.C. This has been most noticeable on the Lower Mainland. The current 1980 si t u a t i o n i n B.C. i s that there i s concentration at thi s time on nursing requirements and supplies. This concern i s with quantity but also with quality of nurses needed and available. Many groups have made th e i r concerns known to the Ministry of Health through reports, br i e f s and meetings. Experience i n the current summer has only supported these concerns as hospitals throughout the province have closed beds for 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. Some areas have not closed beds but have encouraged 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 stretching t h e i r nursing s t a f f to dangerous l i m i t s . Vancouver General Hospital, the major t e r t i a r y care r e f e r r a l hospital i n the province, closed 200 patient care beds from June 1 to September 15, 1980. As we l l , special areas have reduced some of their services. The heart surgery unit has reduced beds and some of the O.R.s are not open for the summer. Dr. M. Petreman, President of the BCMA, i n the association's b r i e f to the Hal l Commission, March 11, 1980 stated: that the BCMA i s aware of inadequate hospital funding with i t s resultant deterioration of care. He maintained that whenever hospital budgets get 'clamped on' there i s an immediate cut-back on nurses. He claimed there i s inadequate remuneration for nurses i n B.C. and a shortage of nurses i s developing. 62. In the same b r i e f the BCMA also recommended a review of current nursing tra i n i n g and continuing education programs; reasonable working conditions and compensation for nurses. These n o t i f i c a t i o n s of problems with manpower supply of nurses are useful to help i d e n t i f y and focus on the problem. They are not useful to help solve the problem because objective 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 expertise, 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 predictors for future needs are only beginning. Since considerable time i s required to plan and provide nursing education programs, current trends may be indicat i v e of future c r i s i s . Recent development i n manpower planning have occurred on three fronts. The Social Credit government, concerned with cost saving, i n i t i a t e d a study on physician manpower which was carried out by the Hon. W. Black (former Minister of Health), (11) recommending cut-backs i n training of physicians. The Minister of Universities, Science and Communication, the Hon. Dr. P. McGeer, i s extremely interested i n developing technology. As Minister of Education before the Ministry was divided (See Appendix B), he recommended increasing the size of the medical school at UBC to provide more physicians. In the l a s t few years, the Ministry of Education has become increasingly involved i n health manpower development. The Ministry of Education, through Dr. Sheilah Thompson, coordinator of the Division of Health and Human Service Programs, has begun to sort out the nursing care system, by i d e n t i f y i n g the various levels of nurses and the competencies which these levels must 63. have. Major concentration to th 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 previously, funding i s now being sought to work on post-basic c l i n i c a l specialty courses for registered nurses. The post-basic specialty courses have become an issue because of demands by entrepreneural groups that something be done to solve problems i n t h i s area and the HMRU for the Health Manpower Working Group has been delegated the task of sorting out nursing manpower issues related to c l i n i c a l s p e c i a l t i e s . The group has begun two major a c t i v i t i e s . The f i r s t i s the Health Manpower Vacancy Monitoring Project (13). This project 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 d i f f i c u l t - t o - f i l l positions. These are positions which have been vacant for t h i r t y days or more. The purpose of t h i s survey i s to id 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 occupational groups i n acute care settings. This i s a beginning attempt to determine what current demands are for registered nurses and others. The second a c t i v i t y i s being carried out by the HMRU for the Manpower Working Group. I t i s a project to review the post-basic nursing problems i n the province (123). A Steering Committee has been set up and a preliminary questionnaire designed to ascertain the numbers of R.N.'s providing special care services i n acute care hospitals i s i n the process of tabulation. C. Ineffective Cooperation Between Sectoral Groups i n B r i t i s h Columbia Alford (1) has argued that the ideologies of the sectoral interest groups i n New York Hospital 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., interest groups were prepared to get together from time to time to pursue common objectives. 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 satisfactory l e v e l s . On the one hand models for nursing manpower planning have not been c l e a r l y 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 clear i d e n t i f i c a t i o n of the need for numbers and levels of nurses required for B r i t i s h Columbia. Part of the problem i s the lack of standards for the various levels 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 to. I t has been pointed out to the provincial government i n many br i e f s over several years that t h i s province only graduates forty per cent of the nurses registered 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 actually 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 either s i t u a t i o n . I t may not be p o l i t i c a l l y expedient to promote nursing manpower planning i n B r i t i s h Columbia or the funding may not be available to u t i l i z e the data. The educational bodies involved have not sorted out who should be providing either education or training or when, how and where th i s should be provided. These groups are part of the corporate government group but have not been properly incorporated into the planning a c t i v i t i e s . Nor has a coordinated approach been developed either i n long term planning or 65. i n those involved i n the planning. Plans, to now, have not been developed, over a period of time i n an orderly way. Rather there have been "starts 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. There are s t i l l many groups, entrepreneurial, corporate and advocacy, trying to solve the nursing manpower planning program i n the i r own ways or from thei r own interest bases, but up to now they have been i n e f f e c t i v e . D. Possible Reasons for Ineffective Planning Marmor (83) i n the " P o l i t i c s of Medicare", suggests another model for planning. He suggests that timing i s important and at a s p e c i f i c time, one of three decision 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, clear objectives i n nurse manpower planning. Rational planning implies 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 related to the optimal means i n reaching those goals and purposes. Are the purposes and goals of entrepreneurs, corporate and advocate groups the same for nursing manpower planning? Have they ever 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? 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 ? W i l l short term and long term goals of various groups d i f f e r ? Further involved i n r a t i o n a l planning i s a cha r a c t e r i s t i c model of description, explanation, prediction and evaluation. Are these areas i n which a l l three interest 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 facts and data must be available. Are these data available 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 simi 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 at th i s time. An a r t i c l e i n the American Journal of Nursing, March 1979 (5), states loudly and cl e a r l y that there i s a serious shortage of both quantity and quality of nurses. I t further states that enrolments i n schools of nursing i s declining. 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 maldistribution of nurses 2) expanding health care operations have created a need for registered nurses with additional education 3) certain positions remain u n f i l l e d (those i n which there have always been less than desirable working conditions) 4) the number of volunt a r i l y inactive 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. Positive models are less frequently discussed but one which has had considerable currency i s the pyramidal model considered by the WHO/ICS/MCU (128) group as the right model. In B r i t a i n and i n Aust r a l i a , a ra t i o n a l plan for delivery of nursing care has been developed. I t involves the use of equivalents of p r a c t i c a l nurses for a great deal of nursing care delivery. In Canada, nurses have not accepted t h i s delegation role and have not been forced to do so because the government funds hospitals by global budgets and does not 67. determine what l e v e l of nurse the hospital must hir e . Further, the government has not had a r a t i o n a l plan for i t s introduction. Do the "entrepreneurs" - the professional association planners -understand and accept the implications of asking for a r a t i o n a l plan? Since a l l three groups have a different interest 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 trying to i n i t i a t e or develop a manpower plan for years. I f there were a surplus of nurses would they s t i l l be committed to r a t i o n a l planning? 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 si t u a t i o n over which any planning group has control and ways of moving incrementally towards change whilst making the best use of i t s existing departments or sectors. The bureaucratic planners have to consider what implications 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 specialty prepared nurses e x i s t s . I f the bureaucratic planners were to develop a r a t i o n a l plan adjusted to f i t existing 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 to, to implement the plan? The corporate planners involved i n nurse manpower planning are at a disadvantage because no one group has attained the power to provide an overview of the si t u a t i o n and to pursue i t . The Ministry of Health, through the Health Manpower Working Group can i d e n t i f y service needs for nurses, but the Ministry of Education may have different p r i o r i t i e s for spending the budget for educating nurses for these services. The Ministry of Health controls 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. Therefore, the Health Ministry i s limited i n i t s a b i l i t y to pursue manpower planning and implement recommendations. The Ministry of Education, through various educational i n s t i t u t i o n s , whose roles i n nursing education have not yet been c l a r i f i e d , may i d e n t i f y and plan for educational needs for nurses but i f these do not meet the p r i o r i t i e s of the Ministry 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 exists today results i n large part because of the vested interests of these corporate planners and the lack of an overall coordinating mechanism which has the power to force them to plan together. The negotiations adjustments model i s concerned with seeking bargained solutions between parties with power to plan. The bureaucratic planning model i n B.C. seems to be almost more of a negotiations adjustment model, for the corporate planners have developed mechanisms within t h e i r groups for negotiation and discussion. An example i s the Health Manpower Working Group which has representation from the Ministry of Education and the Ministry of Labour. Members of th i s group have worked reasonably well together to try to solve nursing manpower problems. By contrast, i n the Education Ministry, approval for funding of programs i s through the Academic Council, which i s not part of the c i v i l service, reports only to the Minister of Education and i s not represented on the Health Manpower Working Group (although there i s some attempt at cross referencing discussion since the chairman of the Health Manpower Working Group attends the Education Health Committee of the Academic Council). But the Health Manpower Working Group can not be sure that i t s recommendations w i l l be carried out by that Ministry. The effectiveness 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 control of the i n s t i t u t i o n a l or 69. professional resources and have not set up a formal negotiation system with the "entrepreneurial" (professional association) groups. Marmor (83) says that t h i s model develops from the position and power of the principals and focuses on the understandings and misunderstandings which determine the outcome of the games. In planning for nursing manpower, which group has the greatest power? Since advocacy groups are not active i n supporting nursing man-power, they have only potential power at t h i s time. The "entrepreneurs" - the professional association - have attempted to i d e n t i f y the needs and to lobby for nursing manpower planning since 1973, but up to now have not been very e f f e c t i v e . However, t h i s group has been successful i n r a i s i n g consciousness about the issue and i n focusing the current interest on post-basic c l i n i c a l specialty courses. Apart from t h e i r general concern about r a i s i n g the general educational standards of the i r members, professional organizations, have i n the past, tended to react to external pressures. As a r e s u l t , they have planned on a short term basis for immediate c r i s i s needs. Therefore the o v e r a l l directions i n which they see nursing progressing have not c l e a r l y been determined. To develop a plan for nursing manpower, the interest of a l l levels 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 relates to only one area of nursing (the R.N.'s). The vested int e r e s t s , then of the professional association, being focused on c r i s e s , have less force i n nursing man-power 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 interests 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 interest has not, u n t i l recently, focused on nursing manpower. This government corporate planning group i s made up of at least two separate pr o v i n c i a l m i n i s t r i e s , each of which has interests other than nursing manpower planning. This group has never been sure that i t wanted to grasp manpower planning u n t i l recently and there are s t i l l many discussion within the ranks. 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 th 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 t h i s a c t i v i t y for manpower planning? Have they been effec t i v e 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 Minister of Health on a regular basis, but to discuss a l l concerns related to nursing not just the manpower planning issue; however through t h i s mechanism the association has been able to bring the manpower issue forward as a concern. The RNABC i s now represented on several planning groups, but tends to act as a consultant about needs and standards rather than as a policy setter because i t does not control resources. The RNABC i s the agency which keeps the register of nurses, thus i t has available some of the information about the supply of nurses which i t w i l l i n g l y contributes. Because the RNABC has decided that standard setting i s i t s respon-s i b l i t y (approval of programs for continuing education), and th 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 effectiveness or ineffectiveness. In 1980, the UBC Health Manpower Research Unit was delegated the task of nursing manpower planning for post-basic nursing. A steering committee for t h i s group has been set up. The RNABC has appointed two members to t h i s steering committee. This group provides a mechanism for formal discussion among different planning interests but i s just beginning i t s task. The negotiation adjustments between the groups i s i n i t s infancy. Although the corporate planners should be able to lead negotiations, i t has been hampered because of i t s internal competing interests. To be e f f e c t i v e , these groups must be aware of th e i r r e l a t i v e powers, and become p o l i t i c a l l y astute re thei r bargaining bases. They must also recognize each other as actors i n t h i s a c t i v i t y and set up formal mechanisms, with decision making powers, to begin progress i n manpower planning. PART V TOWARDS MORE EFFECTIVE PLANNING 72. PART V TOWARDS MORE EFFECTIVE PLANNING Marmor's thesis (83) i s that at certain times one type of plan i s more effective than another. 1) When i s the appropriate time, i f any, for r a t i o n a l decision making to occur i n nurse manpower planning a c t i v i t i e s ? 2) Can bureaucratic planning be improved? 3) What i s l i k e l y to be the future of negotiated planning? A. Rational Planning Should nursing manpower planning continue without discussion and decisions related to ra t i o n a l planning? The customary way of making change i n democratic societies i s by incrementalism. This may be shapeless and incoherent unless the policy makers can draw upon a plan. Donnison (56) has argued that i t i s helpful for policy makers to know of a standing r a t i o n a l plan. That plan may change or be implemented i n a different manner once the p r a c t i c a l application i s begun but that can only happen i f there i s a basis of understanding. In applying t h i s to nursing manpower planning, a ra t i o n a l plan should be the, foundation for any decisions on trade o f f s . I f such a plan were developed i t should be the sta r t i n g point to solve the confusions and disorganization i n nursing manpower planning. Various models have been used i n the past to predict nursing needs. (79) (See Appendix E) The measure of their lack of 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 of these models have 73. indicated that there should not be a shortage, i n practice, Directors of Nursing who are not able to r e c r u i t nurses indicate that there i s a severe shortage. Nursing manpower planning has been going on i n the province, but the resu 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 clear picture of current or future supply has been i d e n t i f i e d for general or special c l i n i c a l areas. This can be related to the fact that s p e c i f i c d e f i n i t i o n s of levels of hospitals and health care are not yet established. Nevertheless there are some commonly accepted specialty areas where work could begin. Presently there i s no clear picture of current demand or predicted demand for nurses. The h a r d - t o - f i l l positions survey i s an attempt to try to determine what the current nursing needs are i n general nursing areas as well as i n special c l i n i c a l areas. The pro v i n c i a l government provides operating costs for hospitals i n the province. I t should be possible to id e n t i f y the number of f u l l time equivalent positions the province i s currently supporting. This could then be broken down by nurses employed i n general nursing areas and those employed i n special c l i n i c a l areas. In Canada, the average percentage of nurses needing education for special c l i n i c a l areas i s 20%. The B r i t i s h Columbia average i s currently unknown. Standards of competency for nurses working i n special care areas have not been determined. Perhaps nurses could be provided for the lower l e v e l special care areas more easily by means other than post-basic courses, were these standards set. The demand for specialty c l i n i c a l l y educated nurses might then be clearer. 74. The pro v i n c i a l government has developed a Bed Matrix Model for 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 services which are to be offered for 1981 and 1986 by pro v i n c i a l hospitals. These data could provide a basis for estimates of current and future demand for nurses. To date these data have not been used i n nurse manpower planning. The current supply of general duty and special 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 following information was taken from the Kermacks' Report (73). The majority of nurses are women. Only 1-6% of the registered nurses employed i n 1978 were men. The majority of nurses are between the ages of 25 to 34 years. Most nurses are married. Only 36.3% of the R.N.s are single. Most married R.N.s 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 single, 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 basis. Characteristics of nurses should be considered when discussing supply and integrated i n the planning information. The s o c i a l 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 leaving nursing. By reviewing these ch a r a c t e r i s t i c s , s p e c i f i c factors can be i d e n t i f i e d which should be considered i n manpower planning, p a r t i c u l a r l y i n ide 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 schools have a certain number of "places" for entry of students. Should t h i s number be increased to make 75. up for 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 for the system are able to do so? Is 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 specialty c l i n i c a l units i s one area that has lacked concrete attention. The Ministry of Health has not o f f i c i a l l y recognized the need for inclusion of post-basic nursing courses as a part of publicly funded education. This i s partly because the specialty and sub-specialty care units, where these nurses work, have not yet been c l e a r l y i d e n t i f i e d . This w i l l be d i f f i c u l t to determine u n t i l the roles of hospitals, 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 hospitals, has neglected to consider the orientation and inservice costs for nurses i n hospitals. Nurses i n special care units have often not had s u f f i c i e n t on-the-job tr a i n i n g and orientation to perform e f f e c t i v e l y the competencies required of them i n special care units. As a r e s u l t , there i s not at the present time a pool of knowledgeable and well q u a l i f i e d nurses available to work i n these ares, nor i s there money available to prepare new nurses i n t h i s way for t h e i r r e s p o n s i b i l i t i e s . Even i f money were available for t h i s a c t i v i t y , i t may not be the most desirable method of preparing nurses. Standards would vary greatly from one hospital to another and cost effectiveness could be questioned. One other area of funding i s currently lacking. Support of nurses to attend post-basic courses and costs of replacing 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 for 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 for i t s ineffectiveness, i t can be applauded for i t s openness i n negotiating with other interest groups. However, these negotiations tend to be i n e f f e c t i v e , because of the current planning models and also because of the different values that nursing administrators, nursing educators and practitioners 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 closer to the r e a l world of nursing and the dispensation of dollars to provide nursing care. Practitioners have had least, i f any, power because of the i r submissive employee status, 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. I t 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 th 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 r a t i o n a l basis against which to measure performance, bureaucratic ineptness, and f a i l u r e s i n negotiation. Although nursing i s regarded as an important a c t i v i t y i n health care, nursing i n B r i t i s h Columbia has not been considered c a r e f u l l y enough. International models for nurse manpower planning may be quite inappropriate for planning here. Stereotyped characteristics of nurses are commonly described i n writings about nursing manpower planning. Rarely do authors come to grips with what effects changing characteristics of the occupational group actually 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? What effect does most nurses being married have? 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 trying to plan for 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 different interpretation or d e f i n i t i o n of nursing made by nursing educators and nursing service people. The educators are seen to i d e n t i f y and teach nursing according to one set of standards. The nursing administrators and practitioners seem to say "that's not how i t i s . " Does the same type of si t u a t i o n exist i n manpower planning? The practitioners provide the majority of nursing manpower. Have we examined the basic value system of practitioners? Since most practitioners are women, and married, they often have competing roles of wives and mothers. Have we looked at commitments of practitioners to 78. these varying roles? Have we asked them what they want and what they are prepared to give i n nursing? Have they been able to communicate e f f e c t i v e l y enough with the planners? 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 practising nurse, i n the past has had l i t t l e , i f any formal power except to work or not to work — she could vote with her feet but not make herself heard. Do the changing values and roles of the nurses who actually 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 for 'vocational* reasons? In the past the nursing practitioner has negotiated d i r e c t l y with the hospital Directors of Nursing about available jobs and her willingness to f i l l them. She has made i t clear that what she wants i s not a pyramidal structure of power with promotion upwards and delegation downwards. She wants to be a primary care nurse i n charge of her own patients with the potential for horizontal movement within the same hospital or within 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 hospital i n the new location). She wants to know she i s competent to do th i s work. I f she feels uncomfortable she w i l l move out into some other sphere. Directors know t h i s . Do health planners? E. Recommendations I t i s recommended that: A model of r a t i o n a l planning, that considers the current si t u a t i o n of nurses i n B r i t i s h Columbia, be i d e n t i f i e d for nurse manpower planning. 79. a. A ra t i o n a l plan for nurse manpower planning i n B r i t i s h Columbia be developed and implemented. This plan should include attention to post-basic c l i n i c a l specialty courses. b. 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Zimmer, Marie J . , Rationale for a Ladder for C l i n i c a l Advancement i n Nursing Practice, Journal of Nursing  Administration, November/December, 1977. 90. APPENDIX A POST-BASIC NURSING PROGRAMS Table A: Post-Basic Nursing Programs Based i n Education In s t i t u t i o n s Table B: Post-Basic Nursing Programs Based i n Health Care F a c i l i t i e s Table C: Proposals for New Post-Basic Nursing Programs Source: Kermacks, Clair e ; A Report to the Health Education Advisory Council: Nursing Education Study; Ministry 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 SOURCE STUDENT R INTAKES OF PROG. FINANCIAL or PER STU- ADMISSION CERTIFICATE OPERATING SUPPORT NAME & DESCRIPTION LOCATION LENGTH D YR DENT CRITERIA ISSUED BY TUITION FUNDS AVAILABLE Advanced Nursing Care of Hospitalized Child VCC 14 wks (p.t.) & 4 wks full-time C l i n i c a l Practice R 1 12 Jan 6 mos. acute care experience s a t i s , c l i n . evaluation VCC $200.00 VCC Ministry of Ed. Diploma i n Psychiatric Nursing BCIT Program spe c i a l l y designed for R.N.s Includes practicum i n acute and long term psych., Mental Retardation and Psycho-g e r i a t r i c s 34 wks min. a 17 wk pre-ceptorship may be required 2 de-Jan pend Aug on seats P r i o r i t y B.C. BCIT $505.00 BCIT Ministry of Ed. Remarks: Graudates e l i g i b l e for re g i s t r a t i o n as psychiatric nurse (RPNABC) TABLE A CONT'D PROGRAM INTAKES SOURCE STUDENT R INTAKES OF PROG. FINANCIAL or PER STU- ADMISSION CERTIFICATE OPERATING SUPPORT NAME & DESCRIPTION LOCATION LENGTH D YR DENT CRITERIA ISSUED BY TUITION FUNDS AVAILABLE C r i t i c a l Care Nursing Level I VCC Lower Mainland UBC parts of prov. on request 6 wks + 5 wks or approx 1 yr on p/t basis R 3- 15 Recent s a t i s . & 6 c l i n i c a l D evaluation. C.P.R. c e r t i f i c a t e VCC or UBC $250.00 VCC Min. of Ed. UBC At least 1 yr recent exp. i n acute med/surg. unit. OR Nursing to prepare beginning l e v e l R.N.s for 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. Satis med. exam BCIT BCIT Min. of Ed. CEIC TABLE A CONT'D PROGRAM INTAKES SOURCE STUDENT R INTAKES OF PROG. FINANCIAL or PER STU- ADMISSION CERTIFICATE OPERATING SUPPORT NAME & DESCRIPTION LOCATION LENGTH D YR DENT CRITERIA ISSUED BY TUITION FUNDS AVAILABLE Health Care Management to develop & improve s k i l l s , of 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 BCIT (B'by) RCH/DC Ed Cent. New West course designed for nurses & other health workers wanting to prepare for supervisory positions. Includes theory & practice on fundamentals of supervision 3 yrs p/t 3 hrs/ wk 8 units 15 wks p/t 3 hr/wk R 2 appr no r e s t r i c -Sept 50 tions Jan BCIT i n $70 BCIT co-opera- per unit tion with BCHA R 2 appr. p r i o r i t y 15 to B.C. residents DC $33 DC TABLE B: POST-BASIC NURSING PROGRAMS BASED IN HEALTH CARE FACILITIES REPORT FOR BRITISH COLUMBIA, 1979 PROGRAM INTAKES SOURCE STUDENT R INTAKES OF PROG. FINANCIAL or PER STU- ADMISSION CERTIFICATE OPERATING SUPPORT NAME & DESCRIPTION LOCATION LENGTH D YR DENT CRITERIA ISSUED BY TUITION FUNDS AVAILABLE Enterostomal Therapy to prepare R.N.s to function as enterostomal therapists SPH: St. Paul's Hospital OR Nursing SPH Van. SPH Van to provide knowledge & s k i l l s so that optimum nursing care can be given to patients before, during and after surg. intervention Radiotherapy Technology for Nurses CCABC Van. 8 wks F.T. R 5 6 mos f . t . 2 yrs R 2 6 Sept Mar R 2 June Oct 1 yr exp. & confirm of f . t . job on completion P r i o r i t y : 1. B.C. 2. Canada 3. USA 1 yr nursing exp P r i o r i t y : 1. B.C. 2. Canada 3. USA SPH approx SPH $1000 SPH $250 SPH Bursaries available Remarks: Program lead to e l i g i b i l i t y to s i t national exams for Canadian Assoc. of Medical Radiology Technologists TABLE B CONT'D PROGRAM INTAKES SOURCE STUDENT R INTAKES OF PROG. FINANCIAL or PER STU- ADMISSION CERTIFICATE OPERATING SUPPORT NAME & DESCRIPTION LOCATION LENGTH D YR DENT CRITERIA ISSUED BY TUITION FUNDS AVAILABLE In d u s t r i a l F i r s t Aid St. John's 10 wks R 2 St. John's $135 C e r t i f i c a t e Amb. or Sept Amb. i* wks Jan p. t. 2 wks Remarks: a week f u l l time for A & f . t . Ticket Holders only I n d u s t r i a l F i r s t Aid ABC 2 wks R 20 19 yrs WCB $125 s e l f -Indus- f . t . wkly of age funding t r i a l 10 wks Theory & practice Emerg. p.t. i n emergency care Training Remarks: on completion of program equipment & CPR School students e l i g i b l e to s i t WCB exams Inc. R.N.s e l i g i b l e for B t i c k e t . TABLE C: PROPOSALS FOR NEW POST-BASIC NURSING PROGRAMS REPORT FOR BRITISH COLUMBIA, 1979 PROGRAM INTAKES SOURCE STUDENT R INTAKES OF PROG. FINANCIAL or PER STU- ADMISSION CERTIFICATE OPERATING SUPPORT NAME & DESCRIPTION LOCATION LENGTH D YR DENT CRITERIA ISSUED BY TUITION FUNDS AVAILABLE C r i t i c a l Care Nursing Level I I VCC & UBC 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 s p e c i f i c specialized f i e l d s , e.g. cardiac, spinal injury, emergency, etc. Obs. Nursing Level I Normal mother & newborn with emphasis on intrapartum period 3 mos. VCC 20 wks Van. p.t. + Distance 6-8 wks Educ. f . t . 2 6 C r i t i c a l Care Course I or equiv. 1 16 VCC or UBC VCC VCC Min. of F i r s t Course Ed./UBC Sept/80 or Jan/81 VCC Min. Of Ed. 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 LOCATION PROGRAM INTAKES R INTAKES or PER STU- ADMISSION LENGTH D YR DENT CRITERIA SOURCE STUDENT OF PROG. FINANCIAL CERTIFICATE OPERATING SUPPORT ISSUED BY TUITION FUNDS AVAILABLE Level I I VCC high r i s k mother & newborn with emphasis on intrapartum period Psychiatric BCIT Nursing Douglas as above 1 16 Obs Nrsg Level I or equiv. VCC VCC Min. of Ed. Remarks: F i r s t course Sept/81 Infection Control C e r t i f i c a t e Program i n Gerontology Occupational Health Nrsg. UBC UBC RCH/ DC Ed. Centre New West p.t. i-1 yr 12 mos. p.t. 6 parts of 10 wks 1 20-25 R.N.'s working i n occup. health DC DC F i r s t course Min. of Sept/80 Ed. Emergency Nursing RCH/ DC Ed. Centre New West. 16 wks f . t . 15-1st course 30 there-after 2 yrs exp. DC $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 organizational structures of the Ministry of Education and the Ministry of Health as they relate to the approval process and to know s p e c i f i c functions of bodies within the mini s t r i e s . THE MINISTRY OF EDUCATION The Ministry of Education i s headed by a Minister of Education. Reporting to him are three deputy ministers one i f whom i s the Assistant Deputy of Post-Secondary Education. The post-secondary department has three d i v i s i o n s : programs services, continuing education and management services. Each provides support services for the councils i n addition to * performing i n s p e c i f i c areas outlined. The program services d i v i s i o n participates i n the development of new programs for colleges and i n s t i t u t i o n s . I t implements research into subject areas i n which new needs have been perceived and i f a program appears desirable, proceeds to curriculum design. I t also regulates procedures by which i n s t i t u t i o n s develop programs, monitors the i r effectiveness through regular reviews of the need of both students and employers, and i n i t i a t e s a five-year review of each i n s t i t u t i o n . The programs services d i v i s i o n supplies selected support service to the Academic and Occupational Training Councils. The programs services d i v i s i o n , again, i s divided into 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 nursing programs. This d i v i s i o n has appointed a Coordinator of Health and Human Services Programs who i s currently Dr. S. Thompson. 100. One"other important group i n the Education Ministry relevant to the approval system i s the Councils Advisory to the Ministry. These councils 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 authority. P r o v i n c i a l councils have been delegated r e s p o n s i b i l i t y for recommending levels of support to government and al l o c a t i n g f i n a n c i a l resources. The councils are funnels through which the financing requests of the i n s t i t u t i o n s flow into the Ministry 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 Universities' Council of B r i t i s h Columbia, the Academic Council, the Occupational Training Council and the Management Advisory Council. The intent of th i s system i s to free a l l post-secondary education i n s t i t u t i o n s from direct government control while at the same time providing the tools to enable everyone concerned with post-secondary education to meet two imperatives. The f i r s t i s the provision 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 useful l i v e s and earn satisfactory compensation for their contribution to society. The second i s to accomplish t h i s ideal at a cost that i s reasonable i n r e l a t i o n to the t o t a l revenue available to the government and, at the same time, acceptable to the taxpayers of the province. The appointment of members of the councils and members of the boards of pr 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 Council, while the appointment of the members of the governing bodies 101. of colleges i s the prerogative of the Minister and involved school d i s t r i c t s . This ensures c i t i z e n involvement i n educational decision making. The practice i s to appoint lay 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 attained success i n the i r own part i c u l a r f i e l d s , and who have a broad interest i n , and dedication'to, education and career t r a i n i n g . In 1963, a new Universities Act established the Advisory Board to make recommendations to the government on the al l o c a t i o n of public monies among the un 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 into a single intermediary body, the Universities Council of B r i t i s h Columbia. This recognized the need for an even stronger voice between the government's policy-making and di r e c t i o n a l roles and the three public but independently-operated u n i v e r s i t i e s . A body with clear l e g i s l a t i v e authority was required, one that could have the confidence of the government yet be close enough to the u n i v e r s i t i e s to distinguish between t h e i r needs and the needs of the province as a whole. I t could also serve to eliminate unnecessary duplication of services among i n s t i t u t i o n s i n close physical 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 decision of the government i n 1977 to set up three additional councils to l i a s e with the Ministry and the indiv i d u a l colleges and pro v i n c i a l i n s t i t u t e s which complete the post-secondary spectrum. The Universities Council of B r i t i s h Columbia consists of 11 members who are appointed by the pro v i n c i a l government and employs a f u l l time 102. director and s t a f f . The Universities Council reviews the budget proposals and other requests for funds from the three u n i v e r s i t i e s , examines thei 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 distributes a l l operating funds from the provincial governments to the indiv i d u a l u n i v e r s i t i e s . The Universities Council also reviews the Academic Council recommmendations regarding requests for money from colleges and provincial i n s t i t u t e s to pay for programs for which the Academic Council i s responsible. Demands for c a p i t a l funds are assessed by the Universities Council for the Universities and reommendations are made to the Ministry. The Universities Council also examines plans for academic develop-ment, and approves the establishment of new f a c u l t i e s and degree prog-rams. I t may require the un 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 establish procedures to evaluate university departments, f a c u l t i e s and programs. The Universities 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 programs. The Academic Council consists of f i v e members appointed by the prov i n c i a l government. The council i s responsible for coordination and funding of academic transfer programs offered by the colleges, technological programs offered by BCIT and various other career programs at colleges and i n s t i t u t e s . 103. The programs related to the humanities, s o c i a l and natural sciences. Included are career programs i n the managerial, administrative, s e c r e t a r i a l , c l e r i c a l , health, applied art s , electronics, aviation technology and such service related aras as criminology, police training and administration, f i r e f i g h t i n g and leg a l assistance. The Academic Council required i n s t i t u t i o n s to provide i t with proposed budgets for the designated programs. I t makes recommendations to the u n i v e r s i t i e s Council and the Ministry concerning those requests and allocates funds provided to i t by government amongst the various i n s t i t u t i o n s . The Council also establishes Academic Advisory Committees to as s i s t the Council and Ministry i n developing program content and standards. I t depends upon a r t i c u l a t i o n 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 decisions, and may recommend to u n i v e r s i t i e s ' senates that they be accepted by the u n i v e r s i t i e s . The resulting interchangeability of program credits i s designed to f a c i l i t a t e movement of students from college to college and from college to university. i The Academic Council has a subcommittee cal 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 discussing 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 i n B r i t i s h Columbia. The B.C. Government News, Volume 24, Number 9, December 1979 reported that 104. Premier B i l l Bennett announced major cabinet changes on November 23, 1979. Among these were a d i v i s i o n i n the Ministry of Education into two min i s t r i e s . The Ministry of Education was to have r e s p o n s i b i l i t y for public schools from kindergarten to Grade 12, colleges, vocational 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 Universi t i e s , Science and Communications was to have r e s p o n s i b i l i t y for the administration of the University's Act and the promotion of science and technology within the province. In discussions about the funding process with Sheilah Thompson, Co-Ordinator of Health and Human Services Programs, Ministry of Education i n March, 1980, she indicated that j u r i s d i c t i o n a l matters between thee two ministries 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 Ministry of Univ 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 K-12 Minister of Education Deputy Minister of Education Councils Advisory to the Minister Post-Secondary I Assistant Deputy Minister Post-Secondary Management Services Division Research and Development Director Academic Council (Nursing Courses) Program Services Division Technical/Trades Director Continuing Education Division 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 Ministry of Education March, 1980 o 106. THE MINISTRY OF HEALTH The Minister of Health i s responsible for the work of the Ministry of Health. A deput minister reports to the Minister of Health and i s responsible for seven divisions of the Ministry. One of these divisions i s the Planning and Development Group. 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 Ministry which i s chaired by the Executive Director of Planning and Development and reports to the Deputy Minister of Health. HEALTH MANPOWER WORKING GROUP  Terms of Reference 1. To recommend and advise on appropriate policy regarding the growth, development and control of health manpower i n the Province. 2. To establish p r i o r i t y areas for health mannpower research i n the Province and arrange for t h i s research to be conducted. 3. To advise the Deputy Minister on appropriate action regarding the results of research conducted i n the area of health manpower. 4. To address or respond to sp e c i f i c manpower concerns, consulting with expert committees, professional associations, the Mi n i s t r i e s of Labour and Education, and other agencies or Mi 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 action where necessary or advise the Deputy Minister on appropriate action with regard to these concerns. 6. To act 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 the chairman and/or his appointees, to provide representation on behalf of the Provincial Ministry of Health to 107. federal/provincial, i n t e r - p r o v i n c i a l and i n t r a - p r o v i n c i a l committees concerned with health manpower, advising the Ministry of Health on matters of concern and appropriate action. 8. To review proposed health manpower l e g i s l a t i o n for i t s implications regarding the d i s t r i b u t i o n , control and supply of health manpower stock and advise the Deputy Minister of any concerns. 9. To advise other M i n i s t r i e s , outside agencies, licensing bodies, and associations of existing p o l i c i e s regarding health manpower. 10. To be aware of, and where necessary assess, proposed health care programs for implications for health manpower and where necessary, advise the Ministry of Health of these implications. 11. To review proposals regarding the establishment of new types of health care workers and advise on policy with regard to the employment of these new types of personnel. MINISTRY OF HEALTH MINISTER OF HEALTH Hon. K.R. Mair -Minister's Office Deputy Minister Dr. C. Key -Deputy Minister's Office Executive Director Health Promotion and Information L. Chazottes Executive Director Planning and Development C. Buckley Senior Administrator Professional and I n s t i t u t i o n a l Services R.E. McDermitt Senior Administrator Administrator Chairman Chairman Community Health Services Dr. G.W. Bonham Health Manpower Working Group r Chariman Medical Services Comm. D. Weir I Emergency Health Services I Admin. Hospital Programs Support Forensic Alcohol Services Psychiatric and Drug Services Commission J. Bainbridge Commission Dr. F. Tucker C.B. Hoskins I Admin. Vancouver Bureau D. Thompson J. Smith Admin. Admin. Direct Preventative Care and Special Services Community Services I. Kelly Dr. H. Richards Dr. P. Ransford Source: C l a i r Buckley February, 1980 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 for a nursing course. The proposing department follows whatever int e r n a l procedures are appropriate for 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 for approval of government funding. F i r s t , a l e t t e r of intent i s sent to the Director of Program Services Division. Information required i n a l e t t e r of intent i s spelled out i n the statements of operating policy. From here, i f i t i s deemed reasonable by the Director of Program Services Division, i t i s sent to the Academic/Technical Director who delegates i t to the Health and Human Services Programs Coordinator for preliminary investigation. The proposal i s assessed at th i s point for duplication and need. Need i s determined by reference to health Manpower Working Group which w i l l determine whether or not there i s a need for th 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 legitimize the need for th i s proposal. I f there i s a need for 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 detailed 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 detailed proposal sent to the Director of Program Services who delegates review of proposal to the Director of Academic/Technical Programs. Nursing proposals are automatically referred to the Coordinator of Health and Human Services Programs who thoroughly investigates the proposal. At th i s point, the procedure has been adopted that the proposal i s automatically referred 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 Director of Program Services. The Director submits the proposal and accompanying report to a Monthly Program Services Review Committee. Consideration of f i n a n c i a l needs are reviewed i n t h i s committee. When th 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 for a l l o c a t i n g resources i f i t approves the proposal'. I f f i n a n c i a l commitments are approved by the council, 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 for implementation of the proposed program. This i s a very complex and time consuming process. Moreover, the approval process does not have stated c r i t e r i a for determining p r i o r i t i e s for any one proposal over any other. As a re s u l t , decisions approving funding for 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 decisions. Lack of r a t i o n a l i t y of t h i s process i s evident at several points, because, up to t h i s point, p r i o r i t i e s for programs i n nursing have not been determined, p o l i c i e s have not been set by the Minister of Education for a l l o c a t i o n of education dollars to health care and within that to nursing programs. The Academic Council members are responsible only to the Minister and therefore they do not have to answer to the public or any pa 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 affect the decision i n the Ministry of Education, Ministry of Health or at the Academic Council. 111. APPENDIX C NURSING ADMINISTRATORS' REACTION PAPER TO NURSING EDUCATION (1979) STUDY REPORT (KERMACKS' REPORT) RECOMMENDATIONS PERTINENT TO CONTINUING EDUCATION SOURCE: Kermacks, Cl a i r e ; A Report to the Health Education Advisory Council Nursing Education Study; Ministry 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 be given to the development of post-basic c l i n i c a l courses. We strongly support t h i s recommendation, as the need for nurses adequately prepared to work i n specialty areas i s acute i n t h i s province. We sincerely hope that the funding w i l l be consistent and immediately available, and that the courses w i l l be accessible to nurses i n outlying regions. RECOMMENDATION 33 That developmental work commence immediately on post-basic c l i n i c a l courses for registered nurses i n : c r i t i c a l care (intensive and coronary care) emergency and trauma care long term care (including 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 intensive care for newborns) operating room and post-anesthetic recovery room care psychiatric care Our association 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 following p r i n c i p l e s , that courses be: developed on validated competencies required i n the work setting made more accessible on a province wide basis designed to meet a variety 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 Ministry of Education award contracts to interested educational i n s t i t u t i o n s for the development of post-basic courses; and that coordination and consultative services be available through the Ministry. We support t h i s recommendation. 113. RECOMMENDATION 36 That employer and employee groups given serious consideration to the development of career streams i n c l i n i c a l f i e l d s so that the career progession for c l i n i c a l nurses i s possible without having to s h i f t administration 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 at the bedside instead of promoting them away from the bedside. Studies need to be carried out regarding the f i n a n c i a l implications, labor relations implications and impact on health team relationships. RECOMMENDATION 37 . . The Joint M i n i s t e r i a l Health Manpower Planning between the Min i s t r i e s of Health and Education be examined; and that consideration be given to a single organizational structure involving policy 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 effect a balance between supply and requirements. Our Association endorses t h i s recommendation. RECOMMENDATION 38 and 39 That the Ministry of Health (and Human Resources where indicated) i d e n t i f y the kind of health care workers required and areas of special need and p r i o r i t y for manpower planning with input from employer groups, unions, professional/licensing bodies, consumers, etc. That the Ministry of Education i d e n t i f y needs for 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, professional/licensing bodies, consumers, etc. We endorse these recommendations but put emphasis on input from a l l groups affected. APPENDIX D ACTIVITIES IN THE 70 fS IN BRITISH COLUMBIA TO SUPPORT CONTINUING EDUCATION FOR NURSES 115. APPENDIX D In 1973, the RNABC published a "Proposed Plan for the Orderly Development of Nursing Education i n B r i t i s h Columbia, Part I I I : Continuing Nursing Education." This document provides a comprehensive review of the problems involved and the resources available. I t i d e n t i f i e s a plan for continuing education i n B.C. within the context of the t o t a l nursing education system and recommends several actions which provided leadership for development i n continuing nursing education. This document c l e a r l y i d e n t i f i e s that the "professional association (RNABC) assumes primary and overall r e s p o n s i b i l i t y for planning to meet the educational needs of nurses." I t goes on to indicate that others, as the post-secondary educational i n s t i t u t i o n s , health care agencies, appropriate government agencies and the indiv i d u a l nurses should be involved i n the planning. I t s p e c i f i c i a l l y states that appropriate government agencies should provide supportive services plus direct f i n a n c i a l support for the development of continuing nursing education. This plan states that "implementation of continuing nursing education i s largely 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 professional nurse must be w i l l i n g to invest time, e f f o r t and money i n continuing education a c t i v i t i e s . " Shortly before t h i s document was published, the government of the province changed from Social Credit to NDP. This had a major impact on the role of the RNABC i n continuing education. The NDP government within 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 special consultant to the Ministry of 116. Health. His terms of reference were simply to "present recommendations which could lead to 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 effects of his report "Health Security for B r i t i s h Columbians" were widespread on nursing through his recommendations on nursing education but more so for this recommendation of the creation of the B.C. Medical Center. The B.C. Medical Center was formed i n July, 1973 to serve for the teaching of undergraduate and post-graduate students i n a l l professions including nursing. Foulkes indicated 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 objectives related to the programs and to provincial needs. One of these committees was an Education Committee. A sub-committee was the Continuing Education Sub-Committee. The terms of reference for t h i s committee was appended. Ess e n t i a l l y , the sub-committee was to recommend to the Education Committee on appropriate administration mechanisms and adequate and appropriate educational resources i n continuing education at the BCMC. The development of a formal government sponsored body responsible for organizing continuing nursing education allowed the RNABC to withdraw from the role they had assumed because no one else had. The RNABC as an association was active i n BCMC Planning for continuing education. In July i t prepared a paper commenting on the princi 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. In 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 for the Orderly Development of Nursing Education i n B r i t i s h Columbia. Standards for nursing care must be stated;, manpower needs i d e n t i f i e d through evaluation; learning needs i d e n t i f i e d and met through educational .117. programs and programs evaluated and appropriate actions taken. I t continued to see continuing education as a j o i n t r e s p o n s i b i l i t y of in 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 of 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 administrative mechanisms within the BCMC for continuing education planning. I t reviewed the rati o n a l approach for ident i f y i n g needs on an ongoing basis and providing appropriate continuing education programs. Evaluation at a l l levels was also recommended. The RNABC l i s t e d areas i n nursing requiring continuing education opportunities. These included OR, Maternity, Extended Care, Psychiatric, 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 call e d the Advisory Committee on Nursing Manpower. In January of 1976 thi s group approved a number of recommendations for 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 actions could be taken on these recommendations, the BCMC suffered a p o l i t i c a l demise with the defeat of the NDP government. The newly elected Social Credit government discontinued the concept developed by B i l l 81 of an ove r a l l planning, organizing and coordinating Medical Center for B r i t i s h Columbia. Planning for continuing education i n the province was not ended but seriously set back. 118. With the change i n government and a new minister of education, a number of studies were i n i t i a t e d which had a direct impact on nursing. These commissions were: 1. The Winegard Commission to advise the Minister of Education on providing higher education i n non-metropolitan areas of the province. 2. The Goard Commission to advise the Ministers of Education and Labor on vocational, technical and trade t r a i n i n g . 3. The Faris Commission to advise the Minister of Education on a l l aspects of community education. 4. The Ha l l Commission to enquire into the t r a i n i n g of p r a c t i c a l nurses and related hospital personnel. The RNABC presented b r i e f s to a l l these commissions. One point, reinforced 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 for post-basic nursing education programs i n the province. The Winegard Commission report was delivered i n September to B.C. Education Minister P.L. McGeer. This Commission developed a series of twenty-four recommendations. Addressing the o v e r a l l problem of providing higher education i n non-metropolitan areas, the commission report recommends that SFU became multi-campus, degree granting i n s t i t u t i o n to serve the B.C. i n t e r i o r . S p e c i f i c a l l y discussing nursing, the report states on page 26: "There i s no question about the demand outside of Vancouver and V i c t o r i a for degree-completion and post-basic courses i n nursing. Since nursing i s offered by the UBC and University 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 delivery of necessary programs to the non-metropolitan areas. SFU can provide some Arts and Science courses needed for the tr 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 th i s matter i s before the committee chaired by Dr. R.L. F a r i s . " A member of the Winegard Commission, Faris was named i n July 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 for more c l i n i c a l experience for two year nursing graduates and p o s t - c l i n i c a l courses, but there were no s p e c i f i c recommendations related to these concerns. I t was 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. I t may be important to note that the major concern of t h i s commission was the lack of organization and coordination and o v e r a l l control for planning these programs. They were concerned 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 si t u a t i o n exists with the nursing education i n B r i t i s h Columbia. There may be some implication, from t h i s concern of the commission, that nursing does not have special problems but i s simply part of a problem that affects a l l of the education system of the province. The Faris Commission Report was presented to the Minister of Education i n December, 1976. The commission recommended more money for adult education and higher p r i o r i t y for community and continuing education. While i t recommended f i s c a l control of continuing education by the pr o v i n c i a l 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 college regions. P r o v i n c i a l input would come with more education s t a f f and a pr o v i n c i a l or m i n i s t e r i a l council to provide leadership. In assigning p r i o r i t i e s , 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 "functional i l l i t e r a c y " i n the province: basic education for adults below grade twelve l e v e l s , language programs for Canadians who have d i f f i c u l t y with English, and teaching c i t i z e n s about t h e i r roles 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 for the disadvantaged, the handicapped, women, the elderly and immigrants. Professional associations should continue to be involved i n career continuing education, according to the commission, but funds for t h i s kind of educational a c t i v i t y should also come from the government ministr i e s most involved, (e.g. Health) Two separate commission recommendations called for investigation into the p o s s i b i l i t y of paid educational leaves and into funding for private organizations which provide educational programs. Reviewing educational needs outside major B.C. population areas, the commission recommended government investigation of a pr o v i n c i a l "open college" that might use radio and t e l e v i s i o n as well as development on a p r i o r i t y basis of other "distance educational methods" for sparsely populated areas. The commission recommended that i n s t i t u t i o n s that provide the o r i g i n a l entry t r a i n i n g for the profession also be the main provider of continuing education i n cooperation with the professional association and where appropriate with the community colleges. This recommendation did not help i n sorting the roles of continuing education departments at the UBC and BCIT from nursing departments i n community colleges. 121. Another a c t i v i t y at the provincial l e v e l was important to nursing. B.C. Education Minister P.L. McGeer established a Health Education Advisory Council i n mid-September (1976) to continue 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 council 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. Ministry of Education approved a study of nursing education as proposed by the Health Education Advisory Council. The s i x month study was to cover the education of registered nurses, registered psychiatric nurses, licensed p r a c t i c a l nurses, and other categories of nursing care workers. I t s terms of reference were establishing with the Ministry of Health long term projections of B.C.'s nursing needs. The nursing community was assured when the Ministry of Education released t h i s study. The Ministry called 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 Ministry of Education. The report l i s t e d forty-three recommendations dealing with nursing education. The report attempted to r a t i o n a l i z e the system of nursing education by organizing a l l nursing personnel into five-part functional c l a s s i f i c a t i o n system by eliminating the category of registered psychiatric nurse, by introducing a student competency based core curriculum for basic nursing education, closing hospital 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 u t i l i z i n g manpower 122. planning as a basis for ide n t i f y i n g needs for educational programs and by supporting the post-basic educational needs for nursing. The majority of the recommendations, or the concepts involved i n them, can be supported i n part wholly by policy 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 reaction of the professional body was generally not favorable. The RNABC News (April/May/June, 1979) page 7, describes the report as follows: "Educational Bomb S h e l l " "Controversial 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, Claire Kermacks of North Vancouver was labelled a "discussion paper" by the Ministry of Education. That i s precisely what has been generated, heated discussion with l i t t l e apparent middle ground between c r i t i c i s m and praise." The nurses reacted mostly to the methodology, the lack of precise supporting data for the recommendations, and the seeming encroachment on the association's l e g i s l a t e d authority over basic nursing educational programs. The ov e r a l l effect of the document was positive, not so much i n what was recommended, but more because of the generated interest and discussion about the nursing educational system. The long term effects of t h i s document are yet to be seen: The RNABC has contributed i n other ways to continuing nursing education i n the province. The RNABC Library (1969) was improved for membership use and a part time l i b r a r i a n was hired. The association was providing f a c i l i t i e s for s e l f learning rather than providing learning experiences. 123. Beginning i n 1959, the RNABC provided yearly loans/bursaries for nurses seeking to continue t h e i r education. These monies were available for post-basic courses, c e r t i f i c a t e courses and university education. They were well u t i l i z e d by the membership. In 1979, the RNABC increased i t s loan fund for continuing education to $100,000.00. A non-profit society, the Registered Nurses Foundation of B.C. was being set up to promote nursing education and research i n the province. The loans funds have been transferred 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, practice and education. A j o i n t e f f o r t by the RPNABC and RNABC i n i t i a t e d a voluntary continuing nursing education approval program. The purpose of th i s program was fourfold. I t was to provide guidelines for those developing programs, provide a mechanism for evaluation of course plans, a s s i s t participants and/or employers i d e n t i f y programs most l i k e l y to meet th e i r needs and provide recognition and c r e d i b i l i t y for the programs approved and the participants i n them. This was an important move for the association. The RNABC had i d e n t i f i e d one of i t s roles i n continuing education as providing standards and th i s was one way of doing so. I t i s also important to note the cooperation between the associations. The Health Education Council created by Education Minister P.L. McGeer (1976) was to continue some a c t i v i t i e s of the BCMC. The coordinator of continuing education was not included. In an attempt to pick up t h i s function a group began to plan to establish 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' Association, the P a c i f i c Medical Technicians Association and representatives of a number of educational i n s t i t u t i o n s and agency inservice departments were involved as voluntary participants. They saw the goals of t h i s council as i d e n t i f y i n g learning needs, setting 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 acting to control the quality 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 publishing i t s l i s t of continuing nursing education programs, and to authorize an ad hoc committee to "maintain a watching b r i e f " of the continuing education s i t u a t i o n , and, convene another conference at i t s discretion. In March, 1977, the RNABC published a document t i t l e d "Competencies Required and Recommended for Registration of Re-Entering Nurses." This was a comprehensive guideline for planners and sponsors of refresher courses for graduate and registered nurses and a basic standard for nurses coming back into the work force. The RNABC Guideline for Orientation 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 for continuing education and the association's role i n setting standards but most importantly because no other body was assuming t h i s r o l e . Because of the association, organized nurses were very powerful i n determining d i r e c t i o n for nursing continuing education i n B r i t i s h Columbia. APPENDIX E THEORETICAL WAYS TO DETERMINE MANPOWER NEEDS 126. APPENDIX E Theoretical Ways to Determine Manpower Needs Levine, i n an a r t i c l e c a l l e d "Measuring Nursing Supply and Requirements: The State of the Art," indicates that various methodologies available have generally f a l l e n i n four types. F i r s t are those that rely onn comparative standards, or c r i t e r i a based on exi s t i n g practice. These methologies use medians, or averages of state-nurse population r a t i o s or ratios based on existing practice i n hospitals. Second, methodologies are i n effect, that attempt to develop optimal r a t i o s or levels for use i n determining nursing requirements. These studies, while interesting have had d i f f i c u l t i e s a r r i v i n g at clear cut r e s u l t s . Third, models tend to ide n t i f y requirements based on the supply and demand model u t i l i z e d by economists. One application i s the counting up of budgeted positions, which can y i e l d a measure of demand. The problem i s that the budgeted positions have to be legitimized i n some fashion since the hospitals may be over-budgeted or under-budgeted to provide safe nursing care. Many times, these models i d e n t i f y how well o f f or poor an area i s rather than predicting 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 results of certain research studies that measured the relationship between nursing care and patient welfare. In the conclusion to th i s a r t i c l e , Eugene Levine says: 127. I t must be kept i n mind that determining supply and requirements for health manpower i s not a s c i e n t i f i c exercise. Even the most precise quantitative model involves a certain degree of subjective judgement and i s influenced by personal values. Many scenarios can be written of the future and i n the f i n a l analysis each depends on one's view of the health care system and how nursing w i l l be u t i l i z e d i n i t . " What methodologies have been used i n the past to determine manpower needs and what are current proposals for i d e n t i f y i n g needs. In determining theoretical models to determine manpower needs, supply of personnel i s usually easily measured. But the essential 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 t h i s component. The Division of Nursing, U.S. Public Health Services, attempted to develop models for i d e n t i f y i n g requirements for nursing manpower. They are described as follows i n an a r t i c l e by Eugene Levine and are described as follows: 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 generally 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 services. The model produces simulations that are a sequence of calculations describing how a system of r e l a t i v e factors w i l l behave over time. 2) Vector Requirement Model The purpose of this model i s to assess the impact of three anticipated changes i n the health care system on the requirements for nurses. 128. i ) The introduction of national health insurance (NHI) i i ) the increased enrollment i n HMO's i i i ) the reformulation of nursing roles An overview of the model i s shown i n the figure. Beginning with a base of 1972, projections 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 Process This method consists of a procedure for a r r i v i n g at decisions concerning key elements i n current and future nursing resources and requirements and an integrated data base for as s i s t i n g i n the decision making process. The method has been developed for use at the state l e v e l . In the requirement area the process consists of the following 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 project i s aimed at developing and testing a model that incorporates health services u t i l i z a t i o n factors affecting nursing demand and supply into 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 haracteristics and i s capable of predicting demand and supply for nursing manpower at country and state l e v e l s . 129. These models used for manpower planning are examples of some of the lat e s t techniques u t i l i z e d for manpower planning. In reviewing these models, the complexity of the problem i s obvious. 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 id e n t i f y but there are s t i l l problems related to t h i s because of the characteristics of nurses. 

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