Nursing Strategies For Better Workforce Performance

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2 Letter of Transmittal Honourable Don McMorris Minister of Health Room 302 Legislative Building Regina SK S4S 0B3 April 2009 Dear Minister McMorris: I am pleased to submit the report, Commitment to Care: Nurse Retention and Recruitment in Saskatchewan. This comprehensive report is the culmination of 15 months spent studying nursing shortage issues, as directed by the Mandate you assigned in March For more than a year, I have enjoyed the privilege of meeting and working with literally thousands of nurses in the province, learning firsthand about the impact the nursing shortage has on their careers and lives. My research took me to recruitment fairs across Canada and overseas to understand best practices so that we can take steps to implement them here. Saskatchewan nurses expressed great appreciation for this Legislative Secretary role, and willingly participated to help improve workplace conditions and patient care. They have been engaged by the Government s show of commitment to this issue. I trust this report and its recommendations for action will provide you with the information and framework you need to move forward to resolve the nursing shortage. Thank you for the opportunity to complete this study, and for providing the resources necessary. Laura Ross, MLA Regina Qu Appelle Valley

3 Acknowledgements I wish to acknowledge the contributions of many, without whose help this project would not have succeeded. First of all, thank you to the more than 3000 Saskatchewan nurses who participated in the project. You shared your opinions, experiences and ideas with my project team, and I assure you that your voices have been heard loud and clear. I trust the recommendations you read here meet the concerns you expressed. Thanks also to representatives of various professional nursing associations and unions for your encouragement and engagement. Your professional opinions have proven invaluable to this project. Special thanks go to Ron Knaus, Executive Director of Workforce Planning Branch, Lynn Digney-Davis, Chief Nursing Officer of Saskatchewan, and Cathy Jeffery, who served as Acting Chief Nursing Officer of Saskatchewan for many months of this project. All of you provided outstanding support and advice throughout this project. Thank you for sharing your knowledge and friendship throughout these months. Thank you to the staff of the Workforce Planning Branch for the Ministry of Health. You were particularly co-operative, patient and considerate, sharing with me and the

4 research team great passion and commitment for your programs and initiatives. Thank you for your wise counsel and patience to answer endless questions. The fine research methodology and implementation was developed and delivered by two highly skilled professional lead researchers, Susan Bazylewski and Robert Berthiaume. Susan s relevant background in nursing and strong research skills proved invaluable, while Bob s human resources and change management consulting expertise ensured he served as project manager with grace and intelligence. Both Bob and Susan actively participated in the preparation of this report. In addition to the two lead researchers, Kandace Hennenfent and Rivi Seaberg provided additional research and writing support, while Cheryl Olson provided project administrative support, including organizing consultations, the Expert Panel and Best Practices Symposium. Finally, I extend sincere thanks to the Honourable Don McMorris, Minister of Health, for ensuring I had access to the resources required to complete this project and report. Your support throughout the project is greatly appreciated.

5 Table of Contents Letter of Transmittal Acknowledgements Executive Summary 1 Mandate and Project Methodology 12 Nursing Literature Review 34 The Saskatchewan Response to the Challenges 91 Voices of Concern and Hope: Consultations with Nurses 138 Themes for Change 170 Nursing Leadership/Management 172 Nursing Practice 178 Relationships 181 Learning 184 Workplace Transformation 187 Enabling Information and Technologies 190 Workforce Development Strategies 192 Key Levers of Success 199 Conclusion 202 Appendix A Consultation List 205 Appendix B Consultation Questionnaires 213 Appendix C Consultation Comments 239 Appendix D - The Saskatchewan Health Workforce 259 Appendix E Reference List 289 Appendix F List of Tables 325 Appendix G List of Commonly Used Acronyms 327

6 Executive Summary After extensively studying nursing in Saskatchewan over the past 15 months, I am confident in pronouncing that we cannot afford to ignore the challenges nurses are facing. Saskatchewan, similar to other jurisdictions, is facing a nursing shortage. Many nurses are stressed with too much work, leading to burnout which in turn can effect patient care, safety and outcomes. Many nurses, recognizing that remaining in a stressed workplace takes a toll on their physical and mental health, have opted to leave the province or in many cases, leave the profession altogether. Without a skilled and dedicated nursing force, quality health care delivery is impossible. The urgency of the nurse shortage cannot be overstated. Evidence continues to demonstrate that nursing shortages result in increased nursing workloads, increased risk of errors, spread of infections, nursing turnover, perception of unsafe working conditions, and rates of injury to nurses due to work related incidents. As members of interdisciplinary teams, nurses do not act in isolation, so addressing the current issues of recruitment and retention in our province offers direct benefits for other occupational groups. 1

7 Executive Summary When Saskatchewan people are asked to cite their biggest concerns, access to high quality, timely health care is at the top of the list. The Government of Saskatchewan understands how important health care is to the people of our province, and has committed to fill 600 nurse vacancies and hire an additional 200 nurses during the first term of government. To meet this goal, an innovative partnership agreement with Saskatchewan Union of Nurses (SUN) was struck in Moreover, the Government of Saskatchewan has moved to increase nursing education seats, and implement a number of incentive programs for nurses, encouraging relocation to rural and northern communities, and providing opportunities for experienced nurses to mentor new nurses. One of the strongest signals of the will for change was the appointment of a Legislative Secretary to the Minister of Health dedicated to nurse recruitment and retention. The Nurse Recruitment and Retention project operated under the mandate of examining the current state of nursing in our province, and outlining steps to ensure quality health care delivery for Saskatchewan residents. We utilized a methodological approach that included learning firsthand the perspectives of over 3,000 Saskatchewan nurses through interviews, questionnaires, meetings, presentations, and focus groups. The methodology included researching existing evidence from published and unpublished sources, touring health care facilities, and consulting with experts. Consultations included researchers, educators, front-line nurses, managers, and interdisciplinary team members. Nurses across the province told us actions must not be superficial but rather transformative and sustainable. They told us that Saskatchewan needs more nurse plus a process to better utilize and support those we have. The report points to both shortand long-term solutions embedded in a culture of collaboration and partnership with all stakeholders. It is recognized that financial and human resources are required to implement some of the recommendations. For other actions it will mean changing the systems and methods of how the work is being done within existing resources. In an Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 2

8 Executive Summary already challenged system, careful attention needs to be paid to implementation supports and capacity. Building on the successes of work previously implemented since Saskatchewan s Health Workforce Action Plan (2005), and the Pan Canadian Health Human Resources Planning Framework (2005), the report references the SUN Government Partnership Agreement (2008), and work completed by national and provincial nursing organizations, associations and unions across Canada. There are many innovative and practical local solutions already underway in our province and this project attempted to examine the impact of these initiatives on nurses. The report describes the current situation of nursing in Saskatchewan and identifies themes and recommendations for future action. The following is a summary of recommendations, formulated thematically with desired goals, and the actions necessary to reach them. Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 3

9 Executive Summary Summary of Recommendations by Theme Themes: Nursing Management and Leadership Nursing Practice Relationships Learning Workplace Transformation Enabling Information and Technologies Workforce Development Strategies Nursing Management Goal: Positively impact nurse recruitment and retention and patient outcomes by providing nurse managers with a sufficient and manageable control that enables reasonable levels of contact with nurses in each setting. Proposed actions: Facilitate collaboration between government and with all regional health authorities and the Saskatchewan Cancer Agency to assemble existing evidence on the current span of control for nurse managers in health regions/saskatchewan Cancer Agency. Develop criteria to implement guidelines regarding the number of staff a nurse manager can effectively manage and lead, based on Saskatchewan needs. Invest in organizational supports for nurse managers and leaders to provide for enhanced patient care through support for decision-making and clinical practice for nurses as interdisciplinary team members. Identify and inventory optimal practices in workplaces that have made significant progress on this front. Nursing Leadership Goal: Create a coordinated body of nurse leaders, to advise the Ministry on policy, innovation, and research for nurse recruitment and retention in Saskatchewan. Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 4

10 Executive Summary Proposed actions: Establish a Provincial Nursing Council as an over-arching coordinating body to advise government on nursing issues and to research, and evaluate initiatives to support nursing recruitment and retention in the province. Work with all regional health authorities to review organizational structures and placement of nursing leadership/management positions. Nurse Manager positions should be in senior levels of all health regions and have the authority, accountability and responsibility for nursing services in health regions. Nursing Leadership Goal: Recruit and retain nurses to and in management and leadership positions. Proposed actions: Support nurse leadership development by implementing educational programs and mentorship to prepare and support nurses for management and leadership positions. Develop and implement programs for succession planning, such as orientation and mentorship programs for new managers, and a provincial nurse manager exchange program. Promote movement between educator, clinician, manager and administrator roles within organizations and throughout the province. Nursing Practice Goal: Retain nurses through the appropriate utilization of all nursing health care providers. Proposed actions: Develop understanding among educators, unions, employers and professional associations of the role of each designation. Provide Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 5

11 Executive Summary guidance to employers on effective integration of each member in patient care teams. Implement modules in educational and work settings to teach and articulate the roles of all nurses (RN/LPN/RPN) to build congruency in understanding of these roles in both practice and educational settings. Implement provincial strategies to promote full employer utilization of all nurses to work to their full scope of practice. Nursing Practice Goal: Increase access to quality care through the integration of advanced practice nurses into health care settings in Saskatchewan. Proposed actions: Develop and implement a provincial strategy that addresses the role and utilization of advanced practice nurses such as Clinical Nurse Specialists and Nurse Practitioners. Explore the implementation of the role of the acute care nurse practitioner in areas such as Psychiatry, Emergency, Geriatrics and other acute care areas as identified by Health Regions and the Saskatchewan Cancer Agency. Relationships Goal: Develop a collaborative practice model to enhance the recruitment and retention of nurses. Proposed actions: Implement guidelines and processes developed for ongoing collaborative work between professional associations, unions, employers and individual nurses. Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 6

12 Executive Summary Adapt educational curricula for nursing students to include core education and training on collaborative practice. Continue the collaborative work with the Saskatchewan Union of Nurses (SUN) to identify and develop strategies to address nurse shortages throughout the province. Explore the expansion of this collaboration to involve other unions so as to build stronger collaboration between government, employers and unions. Invest in collaborative strategies to support the building of interdisciplinary teams of health professionals who work together to provide patient care. Learning Goal: Increase recruitment and retention of nurses by creating stronger links between education and practice. Proposed actions: Continue to support the transition of new nurses entering the workforce by maintaining and expanding the Nursing Mentorship and New Graduate Job program to include Licensed Practical Nurses. Support the transition to nursing management through mentorship. Implement a project to explore development of a cooperative learning program in Saskatchewan that employs undergraduate nurses throughout their student years, with those employee/undergraduate hours contributing to clinical hours for specific courses. Invest in processes that transfer knowledge to action for nurses that focus on best practices in our province, demonstrates linkages between initiatives, and offers practical steps for the implementation of these practices. Develop a nursing education strategy for the province that meets both geographic and demographic needs of nursing education. Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 7

13 Executive Summary Increase the use of distributive nursing education to rural and remote Saskatchewan to enhance nursing recruitment and retention initiatives. Increase learning about roles and practice of team members in curriculum of undergraduate nurses. Develop mechanisms to communicate theoretical and practical aspects of nursing curriculum among the educational institutions and employers as a method of enhancing clinical experience for students and employers. Implement professional development programs about lateral and horizontal violence in all Health Regions/Saskatchewan Cancer Agency Enhance the positive role of the nursing profession by sharing stories of success and celebrating excellence in patient care. Workplace Transformation Goal: Create quality workplaces that attract and retain nurses. Proposed actions: Slow the rate of experienced nurses (RN, LPN, RPN) leaving the workforce by implementing alternative work arrangements that provide increased opportunities for work/life balance. Survey the experienced nurses to determine what areas and projects they have interest in, what is working, and what is not as methods to inform policy development and practical solutions. Invest in the implementation of staffing models that transform, attract and keep nurses working in Saskatchewan, as determined by the application of key criteria developed through the Provincial Nursing Council. Key criteria include nursing leadership, commitment, staff engagement, collaborative frameworks, clearly defined roles and scope of practice, decision-making processes, evaluation and measurement of results. Use the Provincial Nursing Council as a mechanism to align provincial nursing initiatives with key provincial workplace initiatives to ensure congruence with overall vision and directions for patient care. Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 8

14 Executive Summary Initiate a framework for quality of care and cost analysis of major initiatives as they impact nursing recruitment and retention, such as Releasing Time to Care, to inform future workplace solutions. Ensure that all nurses most affected by changes in a workplace are involved, informed and engaged in creating the solutions. Enabling Information and Technologies Goal: Increase recruitment and retention through the use of technology and equipment. Proposed actions: Increase access to, and utilization of, technology for communication and the clinical resources required for patient care through strategic investments throughout the province that focus on areas of core business to the nursing process. Evaluate the technology needs for rural/northern nurses and implement solutions that improve access to educational materials as well as support for the use of technology currently being utilized. Evaluate existing technology solutions, such as scheduling systems, from the perspective of support for nurse users. Use the information from the evaluation to guide the implementation of additional technological solutions in the province. Workforce Development Strategies Goals: Develop capacity for long-term workforce planning as a strong foundation for policy development and workforce planning. Proposed actions: Research, implement and evaluate a health human resource (HHR) information system. This will assist in forecasting future system needs and direct recruitment and retention efforts. Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 9

15 Executive Summary Increase capacity to link workforce planning needs with population health needs and service demands. Develop consistent definitions for key workforce indicators to inform workforce planning and measure the impact of changes to nursing recruitment and retention. Develop a systematic approach to collect and monitor key indicators for nursing HHR needs. Build the capacity for nursing health human resource planning. This will require improving existing HR information systems to allow for timely information about the nursing workforce and assist in proactive planning and resource allocation for recruitment and retention. Workforce Development Strategies Goal: Enhance Regional Health Authority recruitment and retention strategies. Proposed actions: Develop a provincial framework and guidelines for the ethical recruitment of internationally educated nurses (IENs). Determine the need for international recruitment each year. Continue to support and enhance workplace transition (i.e. cooperative learning programs for nursing students) and peer support programs (i.e. Nursing the Future) that prepare new graduates for the realities of practice. Continue to support the current recruitment incentives provided to nurses to seek employment in the province. Conduct a review of the types of grants currently provided to determine ongoing need. Continue to communicate with all Saskatchewan nursing students and expatriate nurses about nursing careers in Saskatchewan. Develop workplace transformation and retention strategies to support the engagement of employees. Support organizations to build a collaborative culture that fosters respect, involvement and personal growth. Encourage the evolution of organizations to become employers of choice where the Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 10

16 Executive Summary attraction, retention and energizing of staff are key business strategies leading to sustainable health care service excellence. Workforce Development Strategies Goal: Increase the number of Aboriginal nurses in the health care workforce. Proposed actions: Increase the recruitment and retention of Aboriginal nurses in Saskatchewan by through the development of a centre of excellence for Aboriginal education in the health professions. Support targeted recruitment efforts for Aboriginal students, building on existing successes like bridging programs from high school to university. Support recommendations from the Northern Health Strategy that address issues of nursing recruitment and retention. Recommendations are directed at many levels: government, managers, employers, educators, researchers, front line nurses, unions and professional associations. Each level has a stake in the outcomes of the recommended actions. Implementation will require coordination, collaboration, partnership and strong leadership at all levels. The time frame for recommended action begins immediately and extends over the next 18 months. It is important to move forward with a sense of urgency, leadership and commitment. To sum up, the appointment of a Legislative Secretary to study nurse recruitment and retention was welcomed by nursing stakeholders across the province. The Government of Saskatchewan has shown it places the utmost importance on resolving the nursing shortage. Now that the nursing community has been engaged and so generously shared their ideas and experiences in good faith, it is imperative to prove the commitment by moving forward with the recommendations. Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 11

17 Mandate and Methodology Mandate from the Minister of Health On March 27, 2008, the Minister of Health provided a letter to Laura Ross, MLA Regina Qu Appelle Valley, to outline her mandate as the appointed Legislative Secretary, Nurse Recruitment and Retention. Summarize the current nursing recruitment and retention practices and challenges in the health regions Review current provincial incentive programs (Relocation and Rural/Northern/Hard to Recruit Grant Program Analyze the need to recruit internationally, including settlement and integration capacity in Saskatchewan Review the labour market and potential challenges related to recruiting and retaining expatriate nurses, and engaging the Aboriginal community in the nursing workforce Explore the best approach to communicate and profile Saskatchewan opportunities and incentives with Saskatchewan nursing students (LPN, RPN, RN) 12

18 Mandate and Methodology Provide recommendations for recruiting nurses to Saskatchewan that will ensure our government mandate can be met Specific attention to these mandate requirements is provided in The Saskatchewan Response to the Challenges section. Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 13

19 Mandate and Methodology Project Approach and Methodology Project Assumptions and Guiding Principles A comprehensive literature review was undertaken before the project scope was developed. This provided not only an understanding of the issues, but also a framework of assumptions about the very nature of the role and practice of nurses within the health care system. The following underlying assumptions were developed to guide the project: The report will be inclusive of all categories of nurses in our province: RN, LPN, RPN and will reflect a province-wide perspective covering all Regional Health Authorities and the Cancer Agency. Urgent action is required, primarily due to the demographic realities of the aging workforce but also due to the seriousness of the impact of the nurse shortage on patient care and on the health and well-being of the nurses themselves. Safe, high-quality patient care is the result of addressing the ongoing issues in nursing recruitment and retention. Primary Health Care will continue to be a major focus in the province but the health care needs of Saskatchewan residents will be different tomorrow than they have been in the past. Nurses are valued members of interdisciplinary teams and support collaborative patient centred practice. The report supports the provision of safe and healthy workplaces. Retaining nurses is as critical to workforce planning as is recruitment efforts. Effective workforce planning takes the long-term view. Strategies in recruitment and retention may not have demonstrable impact until many years into the future. The planned 10 year health human resources plan will assist with building the workforce of the future. Workforce development strategies must include a representative workforce (i.e. Aboriginal nurses). Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 14

20 Mandate and Methodology Nursing leadership is a key managerial and organizational change function that must be provided throughout the health care system to champion and guide transformation. In the adoption of the project approach and the development of the methodologies for research, the following guiding principles were used: Research must recognize the complexity of the workforce: many providers in nursing, variety of roles, scopes and accountabilities in a variety of geographic locations. The project must be inclusive of all nurses: RN, LPN, RPN. Information guiding development of the actions will be evidence-based. Recommendations will be action-orientated. There will be active engagement of nurses, employers, educators, researchers, and providers in the consultation and planning process. Solutions will outline global principles and frameworks, with actions to be applied locally, and tailored to the specific population health needs and design and geography of each region, organization and the Cancer agency. Recommendations will be directed towards government, professional associations, unions, councils, employers, educators, researchers, and individual nurses. The Health System and Human Resources Planning Conceptual Framework developed by Linda Lee O Brien Pallas will guide HHR planning. Effective HHR requires timely and accurate information; as new information comes forward, models will need to be reassessed and adjusted. Effective HHR planning requires integration between the education system that prepares the providers and the health systems that employ them. Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 15

21 Mandate and Methodology Project Approach As the project scope was developed, it was identified that the Ministry of Health and the Regional Health Authorities were currently actively engaged in a variety of ongoing programs and initiatives in the areas of nurse recruitment and retention. Using a workforce planning approach as the basis for the project seemed to be the logical extension and application of the work of a number of researchers, but most recently expressed by Linda O Brien-Pallas and her co-authors (O'Brien-Pallas, L. & Baumann, A. (1997), O Brien-Pallas, L., Birch, S., Baumann, A., Tomblin Murphy, G. (2001), O Brien- Pallas, L., Duffield, C., Tomblin Murphy, G., Birch, S. & Meyer, R. (2005)). This conceptual model for HHR planning was also used as an underpinning for the Saskatchewan Workforce Action Plan (Saskatchewan Health, 2005b, 2007c). It is recognized that effective workforce planning is by nature a future-looking activity. The plans and actions of today will have their most significant impacts in the future. As the population health needs of Saskatchewan residents change, the health care delivery Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 16

22 Mandate and Methodology system will continue to evolve. As the most important component of health care delivery, the health human resource will change over time in response to, and sometimes in anticipation of, changes in delivery. The workforce planning approach used in this project is outlined below: Workforce Planning Approach ORGANIZATIONAL NEEDS SK Labour Market + Importation of Labour GAP GAP How do we prepare for the future of health care delivery? PRESENT EMPLOYMENT PROFILE How do we change our employment profile? FUTURE NEEDS FUTURE EMPLOYMENT PROFILE Program Initiatives Training Recruitment IEN, Expatriate Nurses, Aboriginal, New Nurse Graduates Retention Utilization Workplace change Technology Delivery Methods In the future, the HHR needs will certainly be different and may well be greater than they are today. A number of key workforce planning initiatives will need to be employed to build the nursing workforce of tomorrow. Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 17

23 Mandate and Methodology Project Methodology The following goals were identified for the project: identify the current state of nursing in Saskatchewan identify the gaps, impacts and challenges identify the future state identify the issues, thoughts, ideas of nurses and leaders identify the local solutions: what works, what needs to happen, urgency of change The project was conceptualized into three main phases: Literature Review, review of statistical reports and forecasts of future workforce needs (supply and demand) Research: consultations, facility tours, presentations, and questionnaires Synthesis of ideas; development of recommendations; validation with experts The first two phases are represented by the following diagram: DATA GATHERING PHASE Literature Review 1. Published Reports 2. Unpublished reports 3. Grey Literature Statistical Analysis Consultations and Interviews Forecasting Phase 1: Literature Review The purpose of the literature review phase of the project was to: identify statistics (current, valid, meaningful) identify trends in the literature examine jurisdictional comparisons describe issues and problems identify root causes, actions, and best practices. The research methodology used in this report was a descriptive review of the literature combined with a thematic content analysis, which served to provide an overview of what Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 18

24 Mandate and Methodology is known about issues that effect nurses in Saskatchewan. To provide a comprehensive understanding about identified thematic issues that effect nurses, the literature review was conducted on professional and grey literature gathered from a wide variety of sources. In the analysis, themes were described along with some examples of what has done in terms of providing programming, services, and policies to address some of the impacts of these issues on nurses of Saskatchewan. Literature specific to nurses in Saskatchewan, in Canada, and around the world was relatively easy to locate because the nurse shortage has been widely studied. Professional journals, research reports, statistics, and nursing strategy reports from many organizations and jurisdictions were readily available and formed a rich information source. As well a number of pieces of grey literature were identified, which although lacking the academic rigour of published reports, would be useful for determining the extent of impacts and feelings of those most impacted by the nurse shortage. These documents included papers written by Nursing Education Program of Saskatchewan (NEPS) students, opinion pieces contributed by participants, and anecdotal materials from public sources and magazines. Much of the literature includes published documents available from government and non-government services and organizations across Canada and available from Internet sources. This literature includes: needs assessments, conference reports, position papers, evaluations, annual reports, and other nurse information. Some reports were of limited distribution and some were yet to be published. To be relevant to the study, the literature had to be Saskatchewan or Canada-specific, focused on nursing issues, published between in the last ten years, and discuss the research themes to be described later. However, relevant government and international documents and other seminal materials published before 2000 were included in the literature review. Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 19

25 Mandate and Methodology The collection and review of the documents contained in this report was necessarily selective rather than exhaustive. The attempt was to collect as much of the available literature as possible and to organize it for wider accessibility after the research project was complete. Approximately three hundred and sixty documents were gathered, reviewed and analyzed. Literature collected was accessed through networking with government and non-government agencies, Internet searches, library and professional journal reviews, and recommendations from experts across Canada. Reference sections of collected documents were also reviewed to identify other materials that could be relevant to the research. The literature collected was reviewed, themes/sub-themes identified and data entered into matrices. Information extracted from the documents included the objective of the report, issues that affect nurses, methodology used in the original study, the programs/policies in place that address the issues that effect nurses, and the findings and suggested recommendations. Content analysis was used to develop a descriptive framework for each of the themes. Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 20

26 Mandate and Methodology Phase 2 Consultations In the second phase of this project, extensive consultations were conducted to involve a maximum number of people in information sharing. Over 3,000 nurses and health care leaders were talked to, interviewed, consulted with, listened to, or engaged for information gathering. Appendix A provides a list of the consultations. The purpose of the consultation phase of the project was to: validate the literature and statistics understand local perspectives communicate and create relationships with stakeholders identify local solutions, best practices, and actions taken identify issues for future resolution The focus groups questions and individual participant questionnaires were carefully designed to capture as much information as possible from the respondents about their views of the nursing shortage and what should be done to change the impacts. The focus was a future-looking, optimistic tone. The research instruments asked questions relating to life as a nurse, issues faced by nurses in health care facilities, what could be changed to make things better, ideals for the future, and their reaction to specific questions around the identified theme areas. Prior to project administration the draft questionnaires were provided to a number of experienced nurses and health care professionals for their review and feedback on language and suitability. The draft questionnaires were then administered to a small group of nurses in pilot testing, with the respondents asked to provide feedback on both the questions and the administration process. The pilot testing also had the benefit of training the researchers on the use of the instruments. The comments offered were used to prepare the researchers for the actual interviews and focus groups. Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 21

27 Mandate and Methodology Focus groups Between August 29, 2008 and January 26, 2009, a total of 34 focus groups were held primarily with defined homogeneous groups of respondents. Several of the focus groups had respondents with mixed background characteristics (ie members of more than one nursing occupation in the same meeting; a new graduate RN together with more experienced RNs; an expatriate nurse together with RNs; or a rural nurse was with urban nurses) but front-line nurses were tested apart from nurse managers and administrators. A total of 593 participants attended the focus groups across the province. Appendix A contains a list of the focus groups with details such as dates, locations and groups consulted. Focus groups were conducted in one of three forms: face-to-face meeting, teleconference phone call, or Telehealth video-conference call. Groups were asked two pre-determined questions and gave individual and group responses. Responses were captured by the facilitator, a project administrative support person, or by a participant acting as a recorder at each table. Where possible, focus groups were provided the two questions a few days in advance of the meeting. Focus groups were conducted with various time periods of between 30 minutes and two hours, depending on the availability and number of the participants. From the outset, we recognized the importance of gathering information from a broad group of stakeholders during the consultation phase. Each of these groups had particular background characteristics that were considered vital to understanding the nursing situation in Saskatchewan. Questionnaires Throughout the project consultation phase there was a broad solicitation for individuals to participate in the data gathering through the completion of a questionnaire. As the Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 22

28 Mandate and Methodology project team traversed the province for presentations and meetings, project information was shared with potential respondents. Individuals were handed a postcard-sized information card referring them to the project web page. Moreover, the project web page address was advertised widely on project promotional materials and at the closing of each PowerPoint presentation. The web page provided project background information and a PowerPoint presentation for more details. Prospective respondents were invited to participate in the completion of a questionnaire. They were requested to complete a Participant Identification Form, return it to the project office via or fax and then a specialized questionnaire would be sent and returned via . Project administration support staff contacted participants to remind them to return their completed questionnaires. Questionnaires were developed for each of the identified groups under study in the project, including many stakeholders on the periphery of the central nursing groups. In addition to the standardized questionnaires, unique questionnaires were developed for respondents who possessed demographic backgrounds not fully covered in the above questionnaires. For example, a questionnaire was developed for an Aboriginal rural RN with more than 16 years of experience that combined the questions of the Aboriginal, rural and experienced RN questionnaires. The open call for focus group and questionnaire participants was an attempt to examine as broadly as possible the opinions of a wide sample of nurses and nurse leaders. However it was recognized that this methodology did not provide a fully representative, cross-sectional sampling. It was determined the information obtained through the consultations would be contrasted with that gleaned from the literature to find validation or difference. Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 23

29 Mandate and Methodology A total of 160 questionnaires were sent out to participants and 101 completed questionnaires were returned (a response rate of 63.1 per cent). Appendix A contains further information about the group demographics of the consultations and questionnaires returned. Appendix B contains a list of the questions for the focus groups and the questionnaires. Dialogue with the experts Throughout the Consultation Phase of the project it was recognized that we needed to speak to many of the leading-edge researchers and health care reformers who could share the latest research, describe best-practice and innovative solutions, and provide background to the nursing issues in Saskatchewan. Interviews and meetings were held with a wide audience at locations across Canada. The purpose of the interviews was to learn about nurses : issues, thoughts, ideas, feelings, impacts system capacity, span of control, HR management challenges, utilization and scope of practice, workplace local solutions and best practices strategic thinking, policy direction, and future setting Meetings were held with health care organizations throughout the province including regulatory bodies, unions, and employers. Appendix A contains a list of the key stakeholders and experts that were consulted with as part of the project. Tours of Facilities Nurses and health care leaders throughout the province had innovated important localized solutions and best practices to manage the nurse shortage. As well, various health regions and the Ministry of Health had implemented major nursing process and Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 24

30 Mandate and Methodology workplace transformation projects that showed promise for larger scale introduction. To study these initiatives first-hand, the project team toured four Saskatchewan hospitals and two outside the province: Ottawa General Hospital to review the Ottawa Hospital Model, and Vancouver General Hospital to review workplace and process improvement changes. We toured Regina General Hospital to review the 80:20 model of nursing practice, Cypress Regional Hospital to learn more about its implementation of the Ottawa Hospital Model, and All Nations Healing Hospital in Fort Qu Appelle to review primary health care in a First Nations community and the usage of Nurse Practitioners. SIAST Wascana Campus showcased its educational facilities and distance education capabilities. Conferences and Presentations The project team attended a number of conferences to hear about leading-edge research in nurse recruitment and retention and workforce planning. The conferences provided opportunities to communicate with others about the Saskatchewan project, to network with experts from across Canada, to understand best practices from other jurisdictions and to explore ideas about nursing issues. Laura Ross, MLA was invited to present at three of these conferences on the topic of Saskatchewan Health: Recruitment and Retention of Nurses. Each presentation provided opportunities for the Legislative Secretary to meet stakeholders firsthand, sharing and receiving vital information. Appendix A contains a list of the conferences attended. It is estimated that through these conferences the project team had the opportunity to meet with over 2,500 nurses and health care researchers and leaders. Nursing Education Program of Saskatchewan (NEPS) Starting in the spring of 2008, Laura Ross, MLA presented to fourth-year graduating classes of NEPS students in Regina, Saskatoon, and Prince Albert, gaining insight into Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 25

31 Mandate and Methodology the issues and expectations of the next generation of nurses. Moreover, one of the project researchers was a faculty member of the NEPS program at the University of Saskatchewan and she joined Chief Nursing Officer of Saskatchewan for a number of presentations to nursing students. Many of these students further participated in focus groups and in the completion of a questionnaire. Internationally Educated Nurses Laura Ross, MLA became involved in the recruitment of IENs in February 2008 when she accompanied a delegation of health care professionals to the Philippines on a major nurse recruiting initiative. Staff from five heath regions, including Regina Qu Appelle, Saskatoon, Prince Albert Parkland, Prairie North, and Sunrise, participated in the initiative, as did representatives from Health Careers in Sask., SRNA, University of Saskatchewan College of Nursing, SIAST Nursing Division and Citizenship and Immigration Canada. Upon returning to Canada, Laura Ross, MLA became closely involved with IEN recruitment issues throughout the province. She was also active in the development of government-to-government liaison, meeting with senior Filipino government officials and with the Canadian Ambassador to the Philippines. One of the researchers also met with the Honorary Consul to the Philippines, to discuss nursing recruiting in Sabo, a major population area of the Philippines. Website and Personal Contacts To support information dissemination and to act as a single point of contact for the project, a project web page was prepared and attached to the Ministry of Health Website. Information about the project including a PowerPoint presentation was provided on the website. Links were provided to addresses to encourage communication with the project team. Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 26

32 Mandate and Methodology Many nurses from across Saskatchewan used the links to contact the project team or Laura Ross, MLA directly. Throughout the project and at every opportunity, individuals were handed an information card that referred them to the project web page. The project web page address was also promoted on project materials and at the closing of each PowerPoint presentation. Over 5,000 cards were distributed to people contacted at various events and gatherings. Thematic Development From the review of the literature, twelve themes were identified. To validate these themes, recognized nursing experts were asked whether these themes described the current state of nursing. The themes were used to guide the subsequent research into nursing issues in Saskatchewan. The twelve main themes were further divided into subthemes to expand the scope of research, and used to develop questions for the focus groups and questionnaires. The consultation processes generated an additional nine themes and related sub-themes as we attempted to summarize the responses. Through review, seven major theme areas emerged, as reflected in Table 1, and used to develop and organize the project recommendations. Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 27

33 Mandate and Methodology Table 1: Identification of Themes and Sub-themes. THEMES DESCRIPTION SUB-THEMES Nursing Leadership/ Management Nursing Practice Nursing leadership / management was seen as the foundation to support safe patient care through the provision support to front line nurses. Nursing practice was seen as a critical component to support safe patient care through the utilization of the best person performing the right task at the right time. Respondents expressed the need for nurses, employers and other health professions to respect the role and knowledge of all nurses. Nurses expect to work in supportive environments and to their full scope of practice. Leadership Vision Lack of Leadership Leading Change Leadership Role Management Span of Control Training/Orientation Selection Process Level of Authority Succession Planning Administrative Workload Support to Staff Support to Managers Scope of Practice Full Scope of Practice Barriers to Full Scope Employer Utilization Turf Protection Clinical Nurse Educator Role Respect & Employer Valuing Recognition Trust Involvement in Decisions Consultation Professionalism (Provider Image) Professional Presence/Image Articulation of Nurse Roles Professional Identity Professional Action Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 28

34 Mandate and Methodology Relationships Learning Effective nursing is based on strong communication skills, the development of interdisciplinary teams, and the collaboration relationships between health professionals. Many nurses commented on the link between education, recruitment and retention. Ideas included a more decentralized nursing education system, an education system that helps graduates become more practice ready, respects Aboriginal beliefs and culture and rural health care. Nurses expressed the need for enhanced professional development opportunities to keep pace with changes in practice and for greater emphasis on knowledge transfer. Team Building & Communications Interdisciplinary Work Interdisciplinary Conflict Collaboration Decision making/problem Solving Issue Conflict & Resolution Team Communications Organizational Collaboration Professional Bodies Collaboration Government Union Collaboration Professional Body to Union Collaboration Collaboration between regions Professional Development Opportunity Funding Knowledge Transfer Mentoring Coaching Release Time Funding Support to mentor/coach Training & Education Upgrading Specialized Training Entry to Practice Experience Recognition Funding Opportunity Credential Laddering, Portability, Transferability Workload & Staffing Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 29

35 Mandate and Methodology Workplace Transformation Enabling Information and technologies Many participants commented on the need to move towards a more efficient, quality and productive workplace where patients can expect to receive top rate nursing care. Generational differences exist in ideas around workplace transformation. The younger nurse is looking for support, consultation and ability to influence and participate. The older nurse wants to feel welcomed, accommodated, appreciated and effectively used. Many nurses commented on the need for information technology to enhance and support clinical decisionmaking, interdisciplinary communication and thus, safe patient care. Nurses noted the need for better high-speed internet access and support in rural and northern communities for education and communication needs, as well as the need to enhance cellular phone access in the province. Comments also included the need for a provincial electronic health record sooner than later. Overtime Flexibility of Assignment Nurses Performing Non- Nursing Duties Coverage for Nurses Nursing Processes Nursing Workflow Nurse/Patient Ratios Work Hours & Scheduling Work Hours Scheduling Flexibility of Hours (Shift Length) Safe Work Environment Stress Physical Hazards Workspace & Infrastructure Physical Spaces Child Care Workplace Transformation Process Improvement Supportive Environments Enabling Technologies & Equipment Communication/IT Nursing Tools Availability of Equipment Availability of Communication Commitment to Care: Nurse Recruitment and Retention in Saskatchewan 30