NOR-MAN. Final Report. Sponsored by the Workplace Prior Learning Assessment and Recognition Committee (WPLAR)

NOR-MAN Research into Innovative Recruitment in Psychiatric/Mental Health Nursing Practice Final Report Sponsored by the Workplace Prior Learning Assessment and Recognition Committee (WPLAR) Authored by Project Consultant Marlene Gogal, RPN

NOR-MAN RESEARCH INTO INNOVATIVE RECRUITMENT IN PSYCHIATRIC/MENTAL HEALTH NURSING PRACTICE July 31, 2007 Table of Contents Executive Summary... 3 Introduction/Background... 4 Definitions... 5 Partners... 5 Needs/Issues... 6 Objectives... 8 Assumptions... 9 Consultation... 9 Provincial and National Trends... 11 Assessment... 14 Scope of Practice and the Nursing Act... 15 Education Comparative... 16 Standards of Practice... 17 Competency Mapping... 18 LPN Survey... 21 Postgraduate Psychiatric/Mental Health Programs for LPNs... 22 Nursing Articulation Pathways... 23 Limitations... 25 Results... 26 References... 28 Appendix A: Tables... 31 Appendix B: LPN Survey Highlights... 90 2 Final Report

NOR-MAN RESEARCH INTO INNOVATIVE RECRUITMENT IN PSYCHIATRIC/MENTAL HEALTH NURSING PRACTICE July 31, 2007 Executive Summary A labour shortage of health care professionals to provide quality Psychiatric/Mental Health services in the NOR-MAN Health Region has driven the need for innovative recruitment research. The primary focus has been the exploration of the potential to establish and deliver an Advanced Practice Licensed Practical Nurse credential in Psychiatry/Mental Health as part of a broad recruitment and retention strategy. To this end, research was conducted to ascertain if Licensed Practical Nurses have the foundation to develop the specialized skills required to practice in this extended area of practice, as well as to identify gaps and explore solutions and pathways of delivery to address these gaps. The practices of Prior Learning and Recognition and career laddering are considered throughout the process. Attention is also drawn to the need to develop meaningful education and employment opportunities in the North through a collaborative approach, thereby fostering the growth and optimal utilization of our invaluable human resources. There is a decided absence of clearly defined processes of analysis that have limited the outcomes of this research. Despite these limitations, there is the possibility of establishing and delivering an Advanced Practice Licensed Practical Nurse credential in Psychiatry/Mental Health to meet the identified needs. The key recommendation of this research is ongoing collaboration to explore and develop this potential. 3 Final Report

NOR-MAN RESEARCH INTO INNOVATIVE RECRUITMENT IN PSYCHIATRIC/MENTAL HEALTH NURSING PRACTICE July 31, 2007 Introduction/Background The NOR-MAN Health Region is a vast and diverse area. It has a population of approximately 26,000 residents, encompasses a geographical area of 72,000 square kilometres, and includes the communities of Flin Flon, Cranberry Portage, Sherridon/Cold Lake, Wanless, The Pas/Opaskwayak Cree Nation, Snow Lake, Moose Lake/Mosakahiken Cree Nation, Cormorant, Easterville/Chemawawin First Nation, Grand Rapids/Misipawistik Cree Nation, and Pukatawagan/Mathias Colomb Cree Nation. (NOR-MAN Regional Health Authority, 2007) The NOR-MAN Regional Health Authority has the capacity to provide a full continuum of Psychiatric/Mental Health services to its residents. An eight bed Psychiatric Unit opened in 2001 in The Pas Health Complex. It has a staffing compliment of 1.0 EFT Psychiatrist, 1.0 EFT Nurse Manager, 8.4 EFT General Duty Nurses, 2.0 EFT Psychiatric Nursing Assistants, 0.6 EFT Activity Aide and 0.5 EFT Ward Clerk. The Community Mental Health program, under the umbrella of Primary Health Care Teams, delivers community-based services to adults, children, adolescents and the elderly. There are five Community Mental Health Clinicians located in The Pas and seven in Flin Flon, who respectively serve these and the outlying communities. In addition, there is a Regional 1.0 EFT Psychologist and 1.0 EFT Occupational Therapist who provide in-patient and community-based services. The Occupational Therapist position is currently vacant. Community-based psychiatric services are enhanced by the employment of itinerant Psychiatrists who travel to the Region on a regular basis. Unfortunately, due to an acute labour shortage, the Region has been restricted in its ability to deliver the Psychiatric/Mental Health services it is mandated to provide. When this project was conceived, there were 4.4 EFT General Duty Nurse Positions vacant on the Psychiatric Unit. The Region was forced to staff on an overtime basis and to draw nursing resources from the Community Mental Health program to operate the Unit in a minimal capacity. This was certainly not a sustainable solution, and the Region responded by initiating the practice of under filling nursing positions that would typically be held by Registered Psychiatric Nurses (RPNs) and Registered Nurses (RNs) with Licensed Practical Nurses (LPNs). LPNs were hired on an indefinite term basis and were not able to occupy permanent positions. They were consistently paired with an experienced RPN or RN. This practice permitted the Region to maintain a bed availability of five spaces. However, services were curtailed as the LPNs were not able to be in a charge position and were not left alone on the Unit. This meant that the demands of the RPN or RN on duty were increased, as they were not able to leave the Unit for the duration of the 12-hour shift. It also generated a gap in the consultative services available to other units in The Pas Health Complex. The effects were felt in community-based Mental Health services as well. Initially, staff were seconded to the Psychiatric Unit to maintain acute services, 4 Final Report

NOR-MAN RESEARCH INTO INNOVATIVE RECRUITMENT IN PSYCHIATRIC/MENTAL HEALTH NURSING PRACTICE July 31, 2007 which to a degree disabled the community program s ability to provide a full scope of services. The inherent challenges of recruiting experienced staff to the community program were also compounded by the inability to follow the natural pathway of transitioning experienced staff from in-patient to community services. In addition, professional opportunities for nursing staff were limited and had implications for employee satisfaction. Definitions For the purpose of this document, the following definitions have been adopted: Prior Learning and Recognition: a process that recognizes that adults acquire skills, knowledge and attitudes through formal and informal learning, and evaluates and recognizes this prior learning as it relates to performance standards. Scope of Practice: the range of activities on which a Nurse is educated and authorized to perform. Standards of Practice: statements that guide Nurses in the delivery of competent, ethical and safe practice. Competency: the integrated knowledge, skills, abilities, judgements, attitudes and values required of an entry-level Nurse. Entry Level Nurse: a Nurse at the point of registration or licensure following the completion of an approved nursing education program. Advanced Practice Licensed Practical Nurse: a Practical Nurse who has gained additional specialized knowledge, competence and experience through a Board-approved postgraduate program, and is registered by the College of Licensed Practical Nurses of Manitoba to practice at an advanced nursing level (CLPNM, 2004). Collaborative Practice: a cooperative approach used to attain the common goal of providing quality nursing care that is founded in professional mutual respect and understanding. Partners This project is a joint initiative of the Workplace Prior Learning and Recognition Committee (WPLAR), as funded by the Employment Manitoba Department of Competitiveness, Training 5 Final Report

NOR-MAN RESEARCH INTO INNOVATIVE RECRUITMENT IN PSYCHIATRIC/MENTAL HEALTH NURSING PRACTICE July 31, 2007 and Trade and the NOR-MAN Regional Health Authority. It was administered by an Advisory Committee comprised of representatives from these organizations. Needs/Issues Presently, the Psychiatric Unit has a full 8.0EFT Nursing contingent consisting of RPNs and RNs. This leaves vacant a 0.4EFT which is regularly filled by a casual RPN. The Unit is fully operational to its eight bed capacity. The community program is fully staffed, but has two vacant term positions in lieu of maternity leaves (one of which is filled on a short-term basis). It is, however, recognized that this is not the result of a carefully executed strategic plan as opposed to a fortunate series of events. Given the trends in nursing in this Region, which are reflective of the national trends, it is expected that there will be ongoing labour challenges. A review of the NOR-MAN nursing profile demonstrates that the highest percentage of Nurses (all designations and areas of practice) fall into the 35 to 49 and over 50 age range. Of the 21% remaining that are under 35 years, 16% are currently on maternity leave (please refer to Diagrams 1.1 and 1.2). With a high percentage of Nurses approaching retirement and a significant contingent being of child-bearing age, labour challenges will continue to impact the delivery of health care services, including Psychiatry/Mental Health. Although acute care in-patient services is the area in most critical need of human resource development at present, there are other areas which fall under the scope of Psychiatric/Mental Health service delivery which also require attention. The need to provide training opportunities to better prepare Nurses to deliver comprehensive Psychiatric/Mental Health care to the geriatric population has been flagged as a priority. There is a rising prevalence of Psychiatric/Mental Health issues in the elderly demographic, which is concentrated in the Personal Care Home (PCH) setting, and this is expected to continue to increase. According to the Manitoba Center for Health Policy (2004), 83% of Personal Care Home residents and 75% of new admissions had some mental health diagnosis within five years. This is consistent with the findings reported by The Alliance on Mental Illness and Mental Health (2007), who reported that 83% of Personal Care Home residents in Manitoba are diagnosed with a mental illness. The cumulative physical and mental health needs of the elderly present unique challenges and increasing demands for Nurses. Attention has been focused on the delivery of physical care, and must also be drawn to the provision of training and support for Nurses in order for them to provide for the holistic needs of the elderly patient. 6 Final Report

NOR-MAN RESEARCH INTO INNOVATIVE RECRUITMENT IN PSYCHIATRIC/MENTAL HEALTH NURSING PRACTICE July 31, 2007 Diagram 1.1 NOR-MAN RHA Nursing Profile by Age Diagram 1.2 % of Nurses on Maternity Leave per Age Group 100 90 80 70 60 50 40 30 20 10 0 16 0 0 < 35 years 35-49 years > 50 years 7 Final Report

NOR-MAN RESEARCH INTO INNOVATIVE RECRUITMENT IN PSYCHIATRIC/MENTAL HEALTH NURSING PRACTICE July 31, 2007 Objectives This project has a multifaceted scope of objectives and desirable outcomes. The primary objective is to research the possibility of employing an innovative recruitment strategy to address the need for skilled health care professionals to deliver Psychiatric/Mental Health services in the NOR-MAN Health Region. The practices of Prior Learning and Recognition (PLAR) and career laddering are considered throughout the process. The utilization of LPNs played a critical role in the delivery of acute Psychiatric/Mental Health services in response to a critical labour shortage. It has been proposed that they may play an ongoing legitimate role in this area of practice, one that they are not traditionally employed in. The primary focus of this project has thus been to examine the feasibility of this proposal through several activities that include, but are not limited to, identifying the competencies required, identifying gaps, and identifying the gap training solutions and pathways required to deliver these services. Although acute care, in-patient services is the most immediate area of need, LPNs are often employed in PCHs. This is a setting where mental health issues are concentrated, and it is reasonable to extend the project scope to exploring additional training opportunities for LPNs in this area as part of the process. It is important to qualify that this solution is not intended to be exclusive, but rather part of a broad health care strategy that aims to sustain the integrity and optimum delivery of Psychiatric/Mental Health services in the Region. The delivery of competent and quality services is the foremost guiding principle. On a broader scope is the recognized need to support and develop regional human resources. It could also be said that there is a need to facilitate opportunities in the North for the North. This is not isolated to health care, and there are several presenting dynamics that undermine the stability and growth of our human resources in all sectors. There is an established pattern of emerging professionals relocating to northern areas to draw from the diverse professional development opportunities, and then transplanting back to more southern, often urban locales as experienced professionals. A parallel pattern is the need for individuals who wish to pursue professional careers to have to relocate to larger, southern centers to obtain their education. Often individuals who have left the North to pursue an education lose ties with their home communities and do not return. For many others, the option of relocating for educational purposes is simply not feasible for a variety of reasons, and hence they are not able to attain the education or career they desire. The advances in distance education and emerging virtual classrooms have certainly minimized this gap; however, there is an ongoing need to develop innovative solutions and opportunities for our residents. Assiniboine Community College s Practical Nursing rotating site program is one such example having a direct causal relationship to this project. The delivery of that program in the Region generated a contingent of LPNs that 8 Final Report

NOR-MAN RESEARCH INTO INNOVATIVE RECRUITMENT IN PSYCHIATRIC/MENTAL HEALTH NURSING PRACTICE July 31, 2007 were available to provide the skilled labour required to sustain acute Psychiatric/Mental Health services. The availability of meaningful training and employment opportunities in the Region has the capacity to stabilize our human resource pool, while also attending to the unique cultural and social needs of the area. In addition, it would also provide professionals who are committed to practicing in the North with professional development opportunities, which may have an impact on overall professional satisfaction and retention. Systemically, the development of a collaborative and interdependent partnership between employment, education and employers one that is knowledgeable and responsive to the collective needs and issues of the Region provides an opportunity to develop meaningful strategies to foster the growth and optimal utilization of our human resources. Consultation and collaboration with other stakeholders would serve to define, guide and enhance these partnerships and broaden their capacities. Assumptions The project proceeded based on several assumptions which guided the exploration and qualification of the research. These included, but were not limited to, the following assumptions: There are areas of commonality in Entry-Level Competencies and Standards of Practice between RPNs, RNs and LPNs. LPNs have a foundation in Psychiatry/Mental Health from which to pursue an Advanced Practice Licensed Practical Nurse in Psychiatry/Mental Health credential. LPNs in the Region have an interest in postgraduate education and to work in an extended area of practice. The infrastructure required to deliver and support an Advanced Practice Licensed Practical Nurse in Psychiatry/Mental Health program exists in the Region. There are existing programs that may meet the educational requirements for the development of an Advanced Practice Licensed Practical Nurse in Psychiatry/Mental Health credential. There is a need for meaningful education and employment processes in the North to develop and sustain our human resources. Consultation Various stakeholders were consulted throughout the research process, including but not limited to: Nursing Colleges, Unions, Educational Institutions, and Health Regions in Manitoba and in other Provinces. 9 Final Report

NOR-MAN RESEARCH INTO INNOVATIVE RECRUITMENT IN PSYCHIATRIC/MENTAL HEALTH NURSING PRACTICE July 31, 2007 The College of Licensed Practical Nurses of Manitoba (CLPNM) has supported this preliminary exploration into an extended area of practice and an advanced practice educational component in Psychiatry/Mental Health as it relates to their scope of practice. It is notable that the Competency Profile for Licensed Practical Nurses in Manitoba was released in May 2007 and entails a comprehensive mental health component (College of Licensed Practical Nurses of Manitoba and Alberta Health and Wellness, 2007). The profile is responsive to changes in the Practical Nursing curriculum, which introduced enhanced mental health content in 2006/07 (depending on the delivery site). The College of Registered Psychiatric Nurses of Manitoba (CRPNM) has expressed some concern regarding the practice of LPNs in Psychiatry/Mental Health. It is their position that despite the high quality of the LPN program in Manitoba, that LPNs do not have a solid foundation in Psychiatry/Mental health from which to build an Advanced Practice. They similarly expressed concern about Diploma-prepared Registered Psychiatric Nurses who practice in very independent and autonomous community settings. The need for a strong professional support network for new graduates and even experienced Nurses practicing in such settings was identified and presented as a valuable recruitment and retention incentive. The CRPNM suggested that a comprehensive recruitment and retention strategy to draw RPNs to the Region would be an appropriate short-term approach, with the delivery of the Bachelors of Science of Psychiatric Nursing program in the North being a long-term objective. They offered assistance in developing and facilitating a strategic plan of this nature. The CRPNM also encourages employers to specify their needs for Registered Psychiatric Nurses when advocating for human resources, as Provincial Departments respond to employer demand when developing resources. The College of Registered Nurses of Manitoba (CRNM) likewise expressed concern regarding an Advanced Practice designation for LPNs in the absence of a strong foundation of theoretical and practical experience in Psychiatry/Mental Health. It was suggested that practicing LPNs should be consulted in the process to determine if they, as a nursing body, are interested in employment in an extended practice area. Preliminary contact with the Manitoba Nurses Union (MNU), Regional Representative, revealed support for an extended LPN practice in Psychiatry/Mental Health and encouraged organizational recognition and utilization of LPNs to their full scope of practice. Emphasis was placed on the development of a sustainable and legitimate employment strategy as opposed to a stop gap intervention. 10 Final Report

NOR-MAN RESEARCH INTO INNOVATIVE RECRUITMENT IN PSYCHIATRIC/MENTAL HEALTH NURSING PRACTICE July 31, 2007 Contact with representation from the Brandon University, Psychiatric Nursing programs, recollected that efforts had been made to expand the program into the North; however, the infrastructure to support this initiative was not viable at that time. Presently, the first year is deliverable through distance education. There is an expressed willingness to respond to the labour needs by delivering an increased number of psychiatric nursing courses through distance education. However, the Baccalaureate program is not attainable solely via distance education, and students would be required to relocate to Brandon or Winnipeg to complete their degree. Preliminary contact with University College of the North (UCN) revealed a strong interest in partnering in this process to deliver postgraduate programming for LPNs. UCN has a fundamental interest in expanding their delivery of nursing education. Their Blueprint for Health Careers Education in Northern Manitoba: A Discussion Paper (Gregory and Gardiner, 2005) outlined recommendations for the delivery of a broad continuum of health care programming in the North. The document highlighted among other things the need for maximum articulation and credit transfer between nursing programs, and proposed the development of a foundational year from which to deliver a continuum of nursing education. UCN has expressed a commitment to partnering in subsequent phases of this process. The Office of Rural and Northern Health (ORNH) was developed in response to the need for recruitment and retention of health care professionals in the rural and northern areas of the Province. It represents the interests of the Northern Regional Health Authorities, which include Parklands, NOR-MAN and Burntwood. Preliminary conversation with this organization revealed a significant interest in partnering in this initiative as it is in line with their objective of facilitating training opportunities in the North. Provincial and National Trends We need only refer to works such as The Nursing Strategy for Canada (2000) and the Manitoba Nursing Strategy (2000), and to the establishment of organizations like the Office of Rural and Northern Health and the Northern Sector Council, to realize that significant national, provincial and regional concern exists with respect to health human resources. The Health Human Resources in Collaborative Mental Health Care report (2005) refers to the recruitment and retention of mental health care professionals as a significant challenge, and identifies the maldistribution of mental health care providers in rural and remote areas as a compounding issue. 11 Final Report

NOR-MAN RESEARCH INTO INNOVATIVE RECRUITMENT IN PSYCHIATRIC/MENTAL HEALTH NURSING PRACTICE July 31, 2007 In order to develop a grassroots, comprehensive understanding of the labour challenges, needs and potential solutions as they pertain specifically to Psychiatric/Mental Health nursing, research comprised of a literature search and personal contacts was completed. What was confirmed is that the challenges experienced in NOR-MAN are not unique or isolated. Health regions throughout the Province and across Canada are experiencing difficulty recruiting and retaining Nurses in all areas of practice, including Psychiatry/Mental Health. The following information details this exploration. In Burntwood Health Region, the ten bed Psychiatric Unit has endured similar bed closures as the result of nursing labour shortages. They have resorted to hiring Agency Nurses in order to maintain minimal services. This is a costly financial undertaking and has implications for the consistency of care due to the transitional staffing patterns. Burntwood has not adopted the practice of hiring LPNs to underfill vacancies. This was presented as not being a considerable option due to a lack of LPNs to employ in this manner. The Parklands Regional Health Authority (PRHA) is also in the process of recruiting to their Psychiatric Unit. It is their practice to employ only RPNs in this area. Although they have historically had little difficulty recruiting and retaining Nurses, this is not the current circumstance. An additional challenge encountered is with respect to remuneration, as the PRHA is not able to offer the Northern Living Allowance. They do offer a bursary for nursing students, with a work-back agreement to draw Graduates to their area. A similar natural transitioning process of experienced staff occurs between their in-patient and community-based Psychiatric/Mental Health programs. To address Psychiatric/Mental Health service delivery needs for the geriatric population, the PRHA added Mental Health Resource Nurse positions to support the General Duty Nurses in long-term care to manage mental health issues with their residents. The Selkirk Mental Health Center (SMHC) experienced an acute nursing shortage in 2001/02. SMHC opted to employ LPNs on a permanent basis to a maximum of 10% of their staffing compliment, or 12 positions. LPNs were subjected to the same hiring process as other Nurses. Their duties were primarily related to direct care and they did not complete mental health assessments or assume charge responsibilities. LPNs were encouraged to advance their education through the provision of an incentive opportunity to work on a part-time basis, with a work-back agreement, to accommodate part-time study. A number of LPNs did respond to this opportunity. Currently, SMHC s contingent of LPNs is to full capacity, and the practice of recruiting LPNs has declined as there are more RPNs and RNs available. 12 Final Report

NOR-MAN RESEARCH INTO INNOVATIVE RECRUITMENT IN PSYCHIATRIC/MENTAL HEALTH NURSING PRACTICE July 31, 2007 According to the College of Licensed Practical Nurses, LPNs are similarly employed in Psychiatric/Mental Health settings throughout the Province, including the Manitoba Developmental Center, Rideau Park Personal Care Home, St. Amant Center, and St. Judes Group Home. The Saskatchewan Hospital in North Battleford, Saskatchewan, is a Psychiatric facility comprised of seven in-patient units. They are similarly challenged by a nursing labour shortage, and in addition to other strategies have adopted the ongoing practice of employing LPNs. LPNs are subjected to the same interview and orientation process as other Nurses. The extensive orientation program includes information regarding the continuum of mental illnesses and employs a buddy system that pairs new Nurses to the facility with experienced ones. LPNs are not tasked with Charge Nurse responsibilities, but instead fulfil all other nursing duties. It is expected that Saskatchewan Hospital will increase the practice of employing LPNs as the nursing shortage intensifies. The practice of employing LPNs in Psychiatry/Mental Health is gaining momentum in Alberta. According the College of Licensed Practical Nurses of Alberta, LPNs are working to full scope of practice in a number of Psychiatric/Mental Health settings throughout the Province. Considerable attention has been focused on a collaborative nursing model and interprofessional education. The Claresholm Center for Mental Health and Addictions is a 100-bed facility that employs LPNs to full scope of practice on all units, including their Methadone Clinic. The Alberta Hospital in Edmonton, a 400-bed psychiatric facility, received funding in 2006/07 to super numerate their nursing workforce, and commenced the practice of employing LPNs in Rehabilitation and Psychogeriatric Units to their full scope of practice. Similar initiatives that utilize the services of LPNs in the delivery of Psychiatric/Mental Health services are underway in Medicine Hat and Red Deer as well. Enhanced Psychiatry/Mental Health education programming for LPNs has been developed to support this employment practice. According to the College of Licensed Practical Nurses of British Columbia, the practice of employing LPNs in Psychiatry/Mental Health settings is expanding in their Province. This is thought to be a response to a nursing shortage, as well as a commitment to the better utilization of nursing resources. It is noted that their LPN training entails a very basic mental health education, and additional education in this area of practice is encouraged and supported by the availability of enhanced training opportunities. Considerable emphasis has been placed on the education of employers regarding the role that LPNs can play and the supports they require to practice competently and within their legislated scope of practice. Riverside Psychiatric Center provides acute-tertiary psychiatric care for adults and geriatrics, and also houses a 13 Final Report

NOR-MAN RESEARCH INTO INNOVATIVE RECRUITMENT IN PSYCHIATRIC/MENTAL HEALTH NURSING PRACTICE July 31, 2007 Neuropsychiatric Unit. LPNs are employed on the Neuropsychiatric Unit, providing direct care for patients who are relatively stable and have been oriented to the Unit. Being a new facility (a product of a decentralization process in the Province), a substantial amount of attention was attributed in the development phase to the client profile and needs when formulating the desired nursing mix. It was determined that LPNs had a role to play in the delivery of services. However, their psychiatric education base was limited. In collaboration with Douglas College, the Mental Health Certificate for RNs was adapted for LPN delivery. Based on the individual Nurse s training and experience at the time of hire, a condition of employment may include the completion of identified Psychiatric/Mental Health courses. This applies to both LPNs and RNs. The Center for Nursing Studies located in St. John s, Newfoundland, delivers a Licensed Practical Nursing program, a Bachelor of Nursing (Collaborative) program, and the Nurse Practitioner program, as well as a number of continuing education programs and workshops for Registered Nurses and Licensed Practical Nurses. Approximately two years ago the nursing labour shortage demanded an enhanced training program to equip LPNs to practice in the area of Psychiatry/ Mental Health. The Center for Nursing Studies subsequently developed an LPN Post-Basic Mental Health program, and has generated approximately 80 graduates, meeting the need for qualified health care professionals to deliver Psychiatric/Mental Health care. This exploration revealed some common themes within the Province and Nationally. In the developmental stages, it is critical to involve stakeholders in the process. It is also important to consider staff mix in response to client needs. The biggest challenge encountered when LPNs were introduced to extended practice areas was the reticence of other Nurses to accept their presence. Issues regarding territorial boundaries and the fear of being displaced prevailed. Placing the emphasis on serving client needs and teamwork helped to foster acceptance. The delivery of inter-professional education was instrumental in assisting Nurses to understand the roles that each designation could play. Well-defined roles and support networks are essential, and using a collaborative nursing model that considers the client, the Nurse and environmental factors in nursing utilization assisted in meeting these needs. LPNs employed in Psychiatric/Mental Health settings were consistently reported to be meeting organizational expectations. Assessment In order to respond to the needs identified in the Region, meet the objectives of this project and attend to the assumptions, it is necessary to develop a comprehensive understanding of the existing processes and the opportunities for development through an assessment-focused approach. 14 Final Report

NOR-MAN RESEARCH INTO INNOVATIVE RECRUITMENT IN PSYCHIATRIC/MENTAL HEALTH NURSING PRACTICE July 31, 2007 Scope of Practice and the Nursing Act The Licensed Practical Nursing Scope of Practice is defined in Part 2 of The Licensed Practical Nurses Act (2001) as: The practice of practical nursing is the provision of nursing services for the purpose of assessing and treating health conditions, promoting health, preventing illness, and assisting individuals, families and groups to achieve an optimal state of health. Nursing Acts as legislated in Manitoba give nursing regulatory bodies the authority to define and regulate the practice of their membership. Neither the Licensed Practical Nurses Act nor the College of Licensed Practical Nurses clearly identifies any restricted areas of practice for LPNs. According to the College of Licensed Practical Nurses Regulatory Bulletin (2005), the parameters of Scope of Practice are established through basic entry-level, postgraduate and/or advanced education. Scope of Practice can be a seemingly vague and ambiguous term, but establishes a basis from which regulatory bodies establish Standards of Practice, educational institutions develop curriculum, employers develop job descriptions, and consumers know what to expect of the profession. It sets the outer limits of practice; however, the individual Nurse s scope of practice will be influenced by the practice setting, employer requirements and client needs (Canadian Nurses Association, 1993). For the purpose of this exercise, it is necessary to understand the process through which an Advanced Practice Licensed Practical Nurse credential is established. According to Section 7 Part 51(1) of the Licensed Practical Nurses Act (2001), the CLPNM Board may (d) make regulations defining areas of general or specialized Practical Nursing practice as related to education, experience or otherwise and (I) with respect to standards for educational programs including advanced practical nursing education programs. A Licensed Practical Nurse may be registered as an Advanced Licensed Practical Nurse as per Regulation 14(1) and (2) of the Act (2002). In essence, if the CLPNM Board approves a training program that meets their criteria for an Advanced Practice Licensed Practical Nurse credential, the Nurses completing the training and practicing in these areas would be practicing within the parameters of their licensure. The CLPNM has to date established Advanced Practice credentials in the specialized areas of operating room, dialysis and foot care. It is commonly reported in the literature that Nurses are restricted from practising to full Scope of Practice. This may be particularly true with respect to LPNs as suggested in the work of 15 Final Report

NOR-MAN RESEARCH INTO INNOVATIVE RECRUITMENT IN PSYCHIATRIC/MENTAL HEALTH NURSING PRACTICE July 31, 2007 Besner et al. (2005) on maximizing nursing scopes of practice. According to Bosco (2005), a lack of understanding regarding Scope of Practice parameters and boundaries is a primary cause of health care professionals not working to the full extent of their training. This results in confusion and conflict over roles and responsibilities amongst providers. This work in collaborative mental health care recommended that strategies be developed to promote the maximum utilization of the skills and competencies of all mental health care providers. Building the Future: An integrated strategy for nursing human resources in Canada, Phase I Final Report (2005), recommended that the ability of Nurses to work to their full Scope of Practice needs to be maximized. The Phase II Final Report (2006) proceeded to identify that, There is a need to move away from the language of scope of practice and focus on developing management policy to facilitate nurses to practice to their level of competency in various clinical settings. Education Comparative As was previously highlighted, Scope of Practice is defined by basic entry-level preparation and postgraduate and/or advanced education. Central to this process is an understanding of the foundational elements upon which an Advanced Practice Licensed Practical Nurse in Psychiatry/Mental Health could be established. It also begs the question of what the difference in the preparation of an LPN to other Nurses as it pertains to entry- level practice in Psychiatry/Mental Health entails. Appendix A - Table 1.0 provides an overview of curricular elements of the Practical Nursing program, the Diploma Nursing (Accelerated) program and a Bachelors of Nursing program specific to Psychiatry/Mental Health. The curriculum content of the Psychiatric Nursing education was not included in this exercise, given that it is dedicated to this area of practice. The Practical Nursing curriculum includes the enhanced mental health content introduced in 2006/07. It is observed that the Practical Nursing and Diploma Nursing (Accelerated) programs are most relatively comparable and contain an equivalent number of theoretical credit hours dedicated to Psychiatry/Mental Health. Of course, the challenges of drawing definitive conclusions about equivalency based on credits is that educational institutions do not necessarily utilize a standardized system of measurement, and it does not account for how the material is delivered. Nonetheless, a review of the course objectives/syllabus for each program respectively does support a reasonable comparison of Psychiatric/Mental Health content. The primary, most observable difference between the two programs is the lack of emphasis on the elements of skill development and implementation in the Practical Nursing program. This is noted throughout 16 Final Report

NOR-MAN RESEARCH INTO INNOVATIVE RECRUITMENT IN PSYCHIATRIC/MENTAL HEALTH NURSING PRACTICE July 31, 2007 the content delivery and in the critical absence of a Psychiatric/Mental Health specific practicum, and would suggest a degree of equivalency in the knowledge base of the graduate PN and DNA, but with a gap in the area of practical skill development. Although Practical Nurses would have had some exposure to Mental Health processes in their practicum rotations, it can be expected that this does not provide adequate opportunity to develop the broad range of skills specific to practice in a Psychiatric/Mental Health setting. Standards of Practice Standards of Practice provide direction for professional practice in the delivery of services that are competent, ethical and safe. Standards provide information regarding what the public can expect of Nurses in any practice setting or role. Each nursing College in Manitoba has the legislated authority though their respective Acts to establish Standards of Practice that guide the practice of their membership. Nurses are accountable to ensure that they are practicing in accordance with their Standards of Practice. Diagram 2.0 Standards of Practice Universally Valued Principles Appendix A - Table 2.0 outlines the Standards of Practice adopted by each of the Nursing Colleges in Manitoba, CRPNM (1993), CLPNM (2004) and CRNM (2004). It also includes the Standards of Practice of the Canadian Federation of Mental Health Nurses (2006). The Canadian 17 Final Report

NOR-MAN RESEARCH INTO INNOVATIVE RECRUITMENT IN PSYCHIATRIC/MENTAL HEALTH NURSING PRACTICE July 31, 2007 Standards for Psychiatric-Mental Health Nursing are included as a baseline reference in lieu of this project s specific focus on the delivery of Psychiatric/Mental Health nursing care and the adoption of these standards by the Region, as per their accreditation process, to guide delivery of Psychiatric/Mental Health services. The CFMHN is a national body and the Canadian Standards for Psychiatric-Mental Health Nursing 3rd Edition involved consumers of Psychiatric/Mental health nursing services in the process of improving the standards as part of their ongoing quality improvement initiatives. Please note that the standards are not represented in their entirety in Table 2.0, in that qualifying statements that outline the specific activities of each standard are not included. For a full description of all Nursing Standards referred to in this document, please refer to their respective websites. A review of these Standards of Practice reveals that there are central principles that are universally valued amongst all nursing designations, and that are fundamentally consistent with standards that are specific to practice in Psychiatry/Mental Health. Diagram 2.0 demonstrates the interconnectedness of nursing designations based on these principles. Appendix A - Tables 3.1 and 3.2 demonstrate the correlation between the Psychiatric/Mental Health curriculum content of the Practical Nursing program and the Canadian Standards for Psychiatric-Mental Health Nursing. The purpose of this exercise was to determine if this content provides a basis for the practising LPN to be able meet Standards of Practice specific to this practice area. The conclusion that a basis exists can be drawn. Competency Mapping Competency profiles provide a framework from which it is reasonable to develop expectations with respect to what an entry-level Nurse can do. They are not, however, static or exhaustive documents. It is important to recognize that entry-level competencies do not reflect the additional competencies that the individual Nurse may acquire through postgraduate education, employment or experience (College of Licensed Practical Nurses of Manitoba, 2002). It also does not reflect the Nurse s individual aptitudes, strengths, and informal life learning and experiences. All competencies may not relate to all areas of practice, and as the Nurse s practice evolves, he or she may become more proficient in some competency areas and less in others (College of Registered Nurses of Manitoba, 2005). Each nursing profession has expectations around continuing competency that guide the Nurse s efforts to remain current in his/her ability to provide quality, competent nursing care. A task of this project was the identification of skills and abilities commonly shared by nursing designations. This exercised is aimed at developing a base understanding of the competencies required by LPNs to practice in Psychiatry/Mental Health by comparing their competencies with those of nursing designations that typically practice in this area. It may also be utilized to 18 Final Report

NOR-MAN RESEARCH INTO INNOVATIVE RECRUITMENT IN PSYCHIATRIC/MENTAL HEALTH NURSING PRACTICE July 31, 2007 determine the commonalities across competencies between professions, and allow for the analysis of PLAR or credit transfer opportunities against further education and training. As the practice of nursing is holistic in its orientation, competencies are examined from this perspective. It was not possible to directly correlate competency profiles as they currently exist. Competency profiles are not standardized in their language, construction or delivery. This conclusion was similarly drawn by Basford (2005) in their work on competency mapping. A mapping process that groups competency statements in thematic clusters was therefore utilized. This approach was based on work completed at The University of Lethbridge (Basford, 2005). A Competency Clusters Exercise was completed by a focus group comprised of seven Nurses. These participants were chosen from each of the nursing designations and represent diversity in educational preparation, experience and employment roles and settings. A forced choice format was adopted, and participants were asked to categorize each competency statement into the one thematic cluster that they thought best represented the intent of the statement. Conversely, many of the competency statements could be represented by more than one cluster. Based on the responses, each competency statement was then categorized and inferences drawn with respect to commonality. Appendix A-Table 4.0 highlights the proposed areas of competency commonality in each cluster. It is important to note that competencies that are not identified as being common may be represented in another cluster. In consideration of the limited number of Graduates who would have received the enhanced mental health content in the Practical Nursing program and the constitution of the regional contingent of LPNs, this exercise used the pre-existing, 2001 Scope of Practice Entry-Level Competencies (College of Licensed Practical Nurses of Manitoba, 2001). Definitive conclusions with respect to commonality between nursing designations could not be drawn through this process. The subtle differences in how the information and intent are presented make it difficult to comprehend the commonality and uniqueness between Nurses. Competency statements are highly interpretive. This was evidenced by the lack of consensus between participants as to which cluster best represented the intent of each competency statement, and through the process of trying to draw reasonable conclusions. Whereas the LPN and RN competency statements are similarly expressed and organized, they do not provide clarity around depth or breadth of scope. The RPN competencies are expressed and organized quite differently and are very specific to Psychiatry/Mental Health. The areas highlighted in the RPN competencies as being common with the LPN and RN competencies are based on an interpretation of how it relates to the practice of Nursing. For example, all Nurses are expected 19 Final Report

NOR-MAN RESEARCH INTO INNOVATIVE RECRUITMENT IN PSYCHIATRIC/MENTAL HEALTH NURSING PRACTICE July 31, 2007 to chart accordingly. There are competencies that suggested commonality between the RPN and RN only. These are concentrated in the areas of leadership/supervision of staff and on community consultation and collaboration. This exercise was intended to provide a base understanding of the commonality between entrylevel Nurses as defined by their knowledge, skills, abilities, attitudes, judgement, attributes and values. What it perhaps most effectively demonstrates is that a lack of definition makes it difficult to develop a clear understanding of roles and responsibilities of Nurses in their practice. This is particularly the case for the LPN and RN designations, whereas the RPN competencies are more defined by the nature of their specific practice orientation. In the process of trying to develop an understanding around competency, a considerable literature search was conducted to determine how this question of competency commonality has been addressed in other efforts. This produced little by way of work in the area. The aforementioned work by Basford (2005) was one such example; however, it was concluded in the study (Besner et al. 2005) that no definitive determinations could be drawn with respect to the degree of commonality. The only other work unearthed was the National Nursing Competency Project (Health Canada, 1997). This project in part examined the commonality and uniqueness of nursing competencies as they existed in 1996 and projected into 2001. It was concluded that of the entry-level competencies developed through their process (not existing competency profiles), 57.9% were shared by the three nursing groups in 1996, and that by 2001, 68.8% would be shared. Despite the limitations of this exercise, it is reasonable to determine that an entry-level LPN possesses the competencies from which to develop the specialized skills to practice in Psychiatry/Mental Health. The Theoretical Statement of Nursing Roles contained in the work of Besner et al. (2005) highlighted that there is a singular discipline of nursing, with distinct professional groups, that derive nursing knowledge from the same central body of knowledge. Although there are also differences or uniqueness between Nurses, LPNs possess the fundamental elements of nursing on which to build their practice. The matter of LPN competency in Psychiatry/Mental Health is further compounded by the recent evolution of the Practical Nursing program. In consideration of the enhanced mental health content and the extended competencies for LPNs, we must consider if there is a difference between older and new Graduates, with respect to the knowledge and skills required to deliver Psychiatric/Mental Health nursing care. The 2007 LPN Competency Profile identifies the LPN as being competent at an entry-level to provide comprehensive mental health nursing. 20 Final Report

NOR-MAN RESEARCH INTO INNOVATIVE RECRUITMENT IN PSYCHIATRIC/MENTAL HEALTH NURSING PRACTICE July 31, 2007 Any LPNs graduating prior to 2006/07 would not necessarily meet these competencies based on educational preparation solely, and would have had to develop them through experience and/or continuing education. The pre-existing Practical Nurse program did include mental health components. However, these related primarily to Gerontology. Hence, there is an obvious theoretical difference in the preparation of LPNs. To address this disparity, a PLAR process could be utilized to assess the knowledge and skills of an LPN who graduated prior to 2006/07, and if required, a bridging component could be delivered prior to entry into a Psychiatric/Mental Health postgraduate program. Nonetheless, there would remain a consistent gap in practical skill development that is facilitated through experiential learning. The development of leadership skills and the ability to collaborate with the greater communitybased system is also required. A postgraduate program would have to address these needs. LPN Survey Instrumental to moving through this process was developing some insight into the perceptions, experiences and desires of LPNs. To this end, ten LPNs who had been employed by the NOR- MAN RHA on the Psychiatric Unit were interviewed. Table 5.0 presents a general overview of the participants. The standardized interview addressed areas related to educational preparation, Scope of Practice, employment experience, and employment and educational goals. The resounding result of this exercise was the presentation by LPNs that they did not feel prepared or confident, based on their training, to practice in Psychiatry/Mental Health. However, they felt that they had the capacity to develop the skills required through further education, experience and support. Refer to Appendix B: LPN Survey Highlights. 21 Final Report

NOR-MAN RESEARCH INTO INNOVATIVE RECRUITMENT IN PSYCHIATRIC/MENTAL HEALTH NURSING PRACTICE July 31, 2007 Table 5.0 LPN Survey Participant Overview Median Age Gender Graduating Year Location Average Length of Employment on Psych Unit Current Employment Status Practice Setting Maternity Leave 38.3 2 Male 8 Female 1 2001 5 2003 4 2006 1 Brandon 5 Flin Flon 4 The Pas < 1 Year 8-1.0 EFT Perm 1-0.6 EFT Perm 1 DNA Student 6 PCH 1 Med/Peds 2 Float 2 Average Length of Employment on Psych Unit represents full-time to casual positions with a range of full-time to part-time hours. 3 LPNs who have permanent positions in long-term care have taken term positions in other areas, including Medical, Out-Patient Clinic and another PCH. Postgraduate Psychiatric/Mental Health Programs for LPNs In the process of exploring the feasibility of establishing an Advanced Practice Licensed Practical Nurse credential in Psychiatry/Mental Health, it was to be determined if programming exists or would need to be developed to meet the educational criteria. The research revealed that there are existing programs that have been developed to address similar needs and challenges experienced in other Provinces. Each of the Institutions identified through this process are well established and have worked in collaboration with their respective nursing regulatory bodies to develop resources to meet the needs of the evolving health care system. Appendix A- Table 6.0 presents for consideration the components of three programs that would appear to meet the comprehensive needs of the credentialing process and the Region. These programs are available through distance education, or have the potential to be brokered for direct delivery by an appropriate educational provider as deemed by the respective institution owning the program. As per UCN s expressed interest in delivering this programming, the most appropriate option to pursue would be to broker the selected program. This approach proposes several developmental opportunities. A program delivered by a regionally-based educational institution provides the opportunity to adapt it, in consultation and with the consent of the owner, to meet the unique needs of this Region. It may also set the stage for the development of recognition and transfer components that would foster a natural laddering process through the continuum of health care programming. 22 Final Report