Nursing Education in Canada: Historical Review and Current Capacity

This report is part of an overall project entitled Building the Future: An integrated strategy for nursing human resources in Canada. Nursing Education in Canada: Historical Review and Current Capacity 2004 The work in this publication was provided to The Nursing Sector Study Corporation courtesy of/or under licence from the respective authors. Publisher Authors Editor Designer Cover The Nursing Sector Study Corporation Dorothy Pringle PhD, MS, BScN Linda Green EdD (c), MEd, BA Stacey Johnson, BScN Maude Downey Maude Downey Zed Communications Project The Nursing Sector Study Corporation Management 99 Fifth Avenue, Suite 10 Ottawa, Ontario K1S 5K4 Phone (613) 233-1950 E-mail info@buildingthefuture.ca Website www.buildingthefuture.ca Nursing Education in Canada: Historical Review and Current Capacity (English, PDF) ISBN 0-9734932-8-3 Également disponible en français sous le titre: L'enseignement des soins infirmiers au Canada : historique et capacité actuelle (document en français, PDF). ISBN 0-9734932-9-1 This project is funded in part by the Government of Canada. The opinions and interpretation in this publication are those of the author(s) and do not necessarily reflect those of the Government of Canada.

Table of Contents Preface...v Executive Summary...1 1. Introduction...7 2. Methods...8 2.1. Consultations with Stakeholders History of Nursing...8 2.2. Surveys of Schools of Nursing Capacity of Schools...9 Table 1. Response Rates for RNs, LPNs, and RPNs...11 2.3. Literature Review Educational Capacity and Trends...11 2.4. Focus Groups Under-represented Groups...12 2.4.1. Target Group...12 2.4.2. Data Collection...12 2.4.3. Recruitment...12 2.4.4. Participants...13 2.4.5. Data Analysis...14 3. History of Nursing Education in Canada...15 3.1. History of RN Education in Canada...15 3.1.1. Origins in English and French Canada...15 3.1.2. University-based nursing education...15 3.1.3. From Hospitals to Education Sector...16 3.1.4. The Development of the Entry to Practice Initiative...17 3.1.4.a. British Columbia...17 3.1.4.b. New Brunswick...20 3.1.4.c. Prince Edward Island...21 3.1.4.d. Ontario...22 3.1.4.e. Quebec...23 3.1.4.f. Other Provinces/territories...23 3.2. History of LPN Education in Canada...24 3.2.1. Phase 1: The Establishment of Educational Programs...24 3.2.2. Phase 2: The Evolution of Educational Programs...27 3.2.3. Phase 3: Expansion of Practical Nurses Scope of Practice (1990 and onward)...28 3.3. History of RPN Education in Canada...31 3.3.1. The Pre-nursing Phase, 1886 1920...31 3.3.2. The Developmental Phase, 1920 1960...32 3.3.3. The Transition Phase, 1960 2000...33 3.3.4. The Educational Options Phase, 2000...35 4. Nursing Education in Canada and Key Source Countries...39 Table 2. Overview of RN Programs, in Canada and Source Countries...40 Table 3. Overview of LPN Programs, in Canada and Source Countries...41 Table 4. Overview of RPN Programs, in Canada and Source Countries...41 5. RN Education and Capacity Survey Findings...42 Table 5. Regional Response Rates to Survey Questionnaire, RNs...42 5.1. Types of Programs That Prepare RNs...42 5.2. Student Admission and Enrolment, RNs...43 5.2.1. Admissions, 2002, 2003...43 5.2.2. Gender Profile of Admitted Students...44 5.2.3. Admission Targets...44 Table 6. Admission Targets and Success in Meeting Them, 2001 2003, RNs...44 Building the Future: An integrated strategy for nursing human resources Page i

5.2.4. Enrolment Targets...44 Table 7. Total Full-time Students Enrolments Across all Program Years, RNs...45 Table 8. Total Part-time Student Enrolments Across All Years, RNs...45 5.2.5. Aboriginal Students...45 5.2.6. Retention Rates...46 Table 9. Retention Rates for Classes Entering in 1998 and 1999, RNs...46 5.3. Resources to Maintain or Increase Enrolment, RNs...46 Table 10. Capacity of Schools to Maintain Current Enrolment, RNs...47 Table 11. Capacity of Schools to Increase Enrolment by 10%, RNs...49 Table 12. Capacity of Schools to Increase Enrolment by 25%, RNs...50 Table 13. Capacity of Schools to Increase Enrolment by 50%, RNs...51 Table 14. Capacity of Schools to Increase Enrolment by 100%, RNs...52 5.3.1. Summary of Capacity to Increase Enrolments...53 Table 15. Summary of Capacity of Schools to Expand by 10% 100%...53 5.3.2. Preferred Number of Students...53 5.4. Faculty Recruitment, RNs...54 Table 16. Number and Type of Faculty Positions Available in 2003...54 5.4.1. Full-time Tenure Stream/Permanent Positions...54 5.4.2. Full-time Contract Positions...55 5.4.3. Part-time Contractual Positions...55 5.5. Clinical Training Capacity of RN Schools...57 Table 17. Competition for Clinical Placements Faced by RN Schools...57 Table 18. Models of Clinical Practice in Each Year of RN Programs...58 Table 19. Reasons for Choice of Model of Clinical Practice...59 Table 20. Timeframes Used for Clinical Practice, RNs...59 5.5.1. Dependency on Preceptors, and Availability, RNs...59 Table 21. Dependency on Preceptors in Community Agencies...60 Table 22. Availability of Preceptors in Community Agencies...60 Table 23. Dependency on Preceptors in Acute Care Settings, RNs...60 Table 24. Availability of Preceptors in Acute Care Settings...61 Table 25. Incentives Offered to Preceptors...61 6. RN Education and Capacity Discussion...62 6.1. Educational Sector Capacity, RNs...62 6.1.1. Admissions and Trends in Admissions...62 Table 26. Admissions to Diploma and Baccalaureate Programs 1997 2001...62 Table 27. Enrolment in Diploma and Baccalaureate Schools of Nursing 1997 2001...63 6.1.2. Retention Rate...63 6.1.3. Resources to Support Capacity...65 6.1.3.a. Availability of Teachers...65 6.1.4. Capacity to Increase Enrolment...67 6.1.5. Enrolment of Aboriginal Students...67 6.2. Clinical Training Capacity and Models...68 6.2.1. Models of Clinical Practice...69 6.2.2. Dependence on and Availability of Preceptors...69 7. LPN Education and Capacity Survey Findings...71 Table 28. Regional Response Rates to Survey Questionnaire, LPNs...71 7.1. Types of Programs That Prepare LPNs...71 Table 29. Number of Sites per Program, LPNs...72 Table 30. Capacity at Permanent & Temporary Sites...72 Table 31. Hours of Theory and Practice in LPN Programs...73 7.1.1. Number of Classes Admitted per Year...73 7.1.2. Maintenance of Waiting Lists...73 7.2. Student Admission and Enrolment, LPNs...74 Building the Future: An integrated strategy for nursing human resources Page ii

7.2.1. Admissions, 2002, 2003...74 7.2.2. Gender Profile of Admitted Students...74 7.2.3. Admission Targets...74 Table 32. Admission Targets and Success in Meeting Them, 2001 2003, LPNs...75 7.2.4. Enrolment Targets...75 Table 33. Total Enrolment in October 2003...75 7.2.5. Aboriginal Students...76 7.2.6. Retention Rates...76 Table 34. Retention Rates for Classes Entering 1999 2002, LPNs...76 7.3. Resources to Maintain or Increase Enrolment, LPNs...77 Table 35. Capacity of Schools to Maintain Current Enrolment, LPNs...77 Table 36. Capacity of Schools to Increase Enrolment by 10%, LPNs...78 Table 37. Capacity of Schools to Increase Enrolment by 25%, LPNs...79 Table 38. Capacity of Schools to Increase Enrolment by 50%, LPNs...80 Table 39. Capacity of Schools to Increase Enrolment by 100%, LPNs...81 7.3.1. Summary of Capacity to Increase Enrolments...81 7.3.2. Preferred Number of Students...82 7.4. Faculty Recruitment, LPNs...82 Table 40. Number and Types of Positions Available in Schools, 2003...83 7.4.1. Full-time Tenure Stream/Permanent Positions...83 7.4.2. Full-time Contract Positions...83 7.4.3. Part-time Contractual Positions...84 7.5. Clinical Training Capacity of LPN Schools...85 Table 41. Competition for Clinical Placements Faced by LPN Schools...85 Table 42. Models of Clinical Practice in Each Year of LPN Programs...86 Table 43. Reasons for Choice of Model of Clinical Practice...86 Table 44. Timeframes Used for Clinical Practice...86 7.5.1. Dependency on Preceptors, and Availability, LPNs...86 Table 45. Dependency on Preceptors in Community Agencies...87 Table 46. Availability of Preceptors in Community Agencies...87 Table 47. Dependency on Preceptors in Acute Care Settings, LPNs...87 Table 48. Availability of Preceptors in Acute Care Settings, LPNs...87 Table 49. Incentives Offered to Preceptors...88 8. LPN Education and Capacity Discussion...89 8.1. Organization of Practical Nurse Education in Canada...89 8.2. Education Sector Capacity, LPNs...89 8.2.1. Admissions and Trends in Admissions...89 8.2.2. Retention Rate...90 8.2.3. Resources to Support Capacity...91 8.2.3.a. Availability of Teachers...92 8.2.4. Expanding Admissions Given Available Resources...92 8.2.5. Enrolment of Aboriginal Students...93 8.3. Clinical Training Capacity and Models...93 8.3.1. Models of Clinical Practice...93 8.3.2. Dependence on and Availability of Preceptors...94 9. Under-represented Populations in Nursing...95 9.1. Previous Relevant Canadian Research...95 9.2. Current Focus Group Findings...96 9.2.1. Key Sources of Information and Influence...97 9.2.1.a. Nurses Participants Know...97 9.2.1.b. Social Context Racism, Cultural Issues, Stereotypes...97 9.2.1.c. Outreach...98 Building the Future: An integrated strategy for nursing human resources Page iii

9.2.1.d. Personal Experience, Media reports...99 9.2.2. Perceptions of Nursing as a Career...100 9.2.2.a. Diversity of Nursing Profession and Practice Settings...100 9.2.2.b. Work Conditions Effects on Personal Lifestyle...101 9.2.2.c. Professional Status, Treatment and Recognition...102 9.2.2.d. Salary, Job Security, and Upward Mobility...103 9.2.2.e. Independence, Freedom to Take Initiative...104 9.2.3. Educational Factors...104 9.2.3.a. Educational Requirements...104 9.2.3.b. Costs, Funding, Scholarships...104 9.2.3.c. Location of Schools...105 9.2.3.d. Cultural Sensitivity and Relevance Language, Type of Medicine...106 9.2.3.e. Role Models, Mentoring...107 10. Conclusions...108 10.1. LPN, RN and RPN Education in Canada...108 10.2. Educational and Clinical Capacity of Schools to Prepare RNs...108 10.3. Educational and Clinical Capacity of Schools to LPNs...109 10.4. Under-represented Groups in Nursing...110 11. Recommendations...112 REFERENCES...115 Appendix A. Acronyms...120 Appendix B. Nursing Associations...121 Appendix C. Glossary of Key Terms...122 Appendix D. Key to Geographical Names and Acronyms...124 Building the Future: An integrated strategy for nursing human resources Page iv

Preface This report is part of an overall project, Building the Future: An integrated strategy for nursing human resources in Canada. The goal of the project is to create an informed, long-term strategy to ensure that there is an adequate supply of skilled and knowledgeable nurses to meet the evolving health care needs of all Canadians. Through surveys, interviews, literature reviews, and other research, Building the Future will provide the first comprehensive report on the state of nursing human resources in Canada. The project comprises the following two phases. Phase I: Research about the nursing labour market in Canada is being conducted in stages. Reports will be released as the research work is completed to share interim findings and recommendations with the nursing sector. A final report will be produced at the conclusion of this phase that will include all of the recommendations accepted by the Nursing Sector Study Corporation. Phase II: A national strategy will be developed in consultation with government and nongovernment stakeholders that builds on the findings and recommendations presented at the completion of Phase I. To oversee such a complex project, the Nursing Sector Study Corporation (NSSC) was created in 2001. The Management Committee of NSSC comprises representatives of the signatories to the contribution agreement with the Government of Canada and other government groups. The multi-stakeholder Steering Committee for the project comprises approximately 30 representatives from the three regulated nursing occupations (licensed practical nurse, registered psychiatric nurse, and registered nurse), private and public employers, unions, educators, health researchers, and federal, provincial and territorial governments. The Steering Committee guides the study components and approves study deliverables including all reports and recommendations. Members of the Management Committee and the Steering Committee represent the following organizations and sectors. Aboriginal Nurses Association of Canada Association of Canadian Community Colleges Canadian Alliance of Community Health Centre Associations Canadian Association for Community Care Canadian Association of Schools of Nursing Canadian Federation of Nurses Unions Canadian Healthcare Association Canadian Home Care Association Canadian Institute for Health Information Canadian Nurses Association Canadian Practical Nurses Association Canadian Union of Public Employees Health Canada Human Resources and Skills Development Canada National Union of Public and General Employees Nurse educators from various institutions Ordre des infirmières et infirmiers auxiliaires du Québec Ordre des infirmières et infirmiers du Québec Professional Institute of the Public Service of Canada Registered Psychiatric Nurses of Canada Representatives of provincial and territorial governments Service Employees International Union Task Force Two: A human resource strategy for physicians in Canada Victorian Order of Nurses Canada Together, we are committed to building a better future for all nurses in Canada and a better health system for all Canadians Building the Future: An integrated strategy for nursing human resources Page v

Executive Summary This report describes the historical context of nursing education in Canada. This provides a background to the descriptions of current educational programs their current enrolments, future enrolment plans, resources available, constraints on resources, and access to clinical placements and teachers. It also includes qualitative findings from focus groups that shed light on why Aboriginals, Black Canadians, and men are so under-represented in nursing. Research Design & Methods Several research methods were used to generate the information required to answer the research questions. A descriptive survey design was used to collect information from schools of nursing in Canada that prepare RNs, LPNs, and RPNs about their current and future plans for capacity. Ethical approval for the study was received from the University of Toronto. Questionnaires in French or English were sent to all schools of nursing that participate in the education of nurses. Reminder postcards, e-mail messages, and direct appeals by professional organizations that relate to the schools of nursing were used to encourage schools to respond. Response rates of 40% for LPN schools and 57% for RN schools were achieved. Only one of three RPN schools responded. As a result, there is no report for RPN education. Data were entered on SPSS (Statistical Package for the Social Sciences) files and analyzed. In addition, searches were made of published literature, of unpublished documents, and of Web sites to assemble the information required to describe the historical context of the nursing education programs that are in place today. Interviews were conducted with key informants who had direct experience of critical events and activities that shaped contemporary nursing education. To answer questions about why certain groups were under-represented in nursing education programs specifically Aboriginal people, men and Black Canadians following ethical approval from the University of Toronto, focus groups were held with members of these three groups in Toronto, Prince Albert (Saskatchewan. Individuals who were college and university students but not studying nursing were recruited to participate; the tapes of the focus groups were transcribed and analyzed for themes that explain why members of these groups do not pursue nursing as a career. Findings: Schools That Prepare Registered Nurses (RNs) Responses were received from 57% of schools that participate in the education of registered nurses (RNs). The lowest provincial/territorial response rate was from schools in Quebec. The majority of schools indicated that they had increased their enrolment from 2002 to 2003, and 70% either met or exceeded their enrolment targets. However, 70% do not plan to expand their admissions in 2004, 17% do plan to expand and 13% plan to decrease the number of students they admit. A total of 20,634 full-time students were enrolled in the participating schools. Men comprise 9% of the enrolled students. Only 20% of schools have designated seats for Aboriginal students or specific strategies to try to recruit these students. Despite this, 39% of schools reported having a total of 433 self-identified Aboriginal students enrolled in 2003. Retention rates vary widely (from 33 to 100%) but the average retention rate across all schools was 67% of students admitted in 1998, and 61% of those admitted in 1999. Half the schools had retention rates of 74% or higher for both years of interest. Baccalaureate programs have had a higher retention rate than diploma programs. Five resource areas were examined: faculty, students, clinical placements, space, and administrative support. Currently 60% of schools report having insufficient faculty and clinical Building the Future: An integrated strategy for nursing human resources Page 1

placements, 70% have inadequate financial support for students, and 40 50% have inadequate space. Up to 20% of schools cannot increase their enrolments by even 10% because they have no ability to access the resources they require, particularly clinical teachers. However, up to 80% could increase by 10% if provided with additional financial resources; 50 65% could increase by 25%, about a third could expand by 50%, and 20% could double the number of students they admit, if they had the financial resources available to them. The resources in shortest supply, and which constrain the ability to expand, are clinical placements in the community and acute care hospitals, full-time faculty members, and clinical teachers. Schools sought to recruit 176 faculty members prepared at either the master s or doctoral level to fill tenure stream/permanent positions. They were able to fill 125 of these positions, frequently with individuals in the process of acquiring graduate degrees but not completed, or with the intention to begin studies. Schools were able to fill their 264 full-time contract positions with individuals who were master s prepared, or who were working towards one, and almost all of the 1,294 part-time contract positions with baccalaureate and master s prepared individuals. Sixty-one percent had some difficulty and 21% had a great deal of difficulty accomplishing this. All specialty areas were in short supply. Only 10% of schools do not compete with other health science programs for clinical placements, and the rest compete with between 1 and 8 other programs. Most of the schools find the majority of placements to be student-friendly. Schools used a distributed model of clinical placements (a combination of classes and clinical experiences) each week in years one and two, with a mix of distributed and block placements becoming more frequent in the upper years, particularly year four. Eight-five percent of schools are dependent on clinical preceptors for community and acute care in their senior years, and one third find there are insufficient numbers available to them. Schools generally offer non-monetary incentives to preceptors to recognize their contributions. Findings: Schools That Prepare Licensed Practical Nurses (LPNs) Forty percent of schools of nursing that prepare LPNs responded to the survey; the lowest response rates were from Quebec and the Atlantic Provinces. All 37 participating schools are publicly funded, with 59% having permanent funding, 13% contract and 7% funding from brokered programs. The majority of schools (57%) offered their programs on one site only, but the rest offered them on 2 12 sites. There was a wide range of hours of theory and clinical practice across the programs, but most schools provided between 700 and 1,000 hours of theory and laboratory practice and between 800 and 1,100 hours of clinical practice. About 70% of schools maintain waiting lists of students who apply but are not admitted to the class they apply to. These waiting lists range from a few weeks to several years. Enrolments ranged from 12 to 734 students, but the majority of schools had fewer than 100 students enrolled. Total enrolments for the most recent year were 3,947 full-time students and 1,003 part-time students. During the period 1999 2003, 50% of schools increased their admissions, 6% decreased them, and 12% remained the same. Over these same years, between 47% and 63% of schools met or exceeded their admission targets, and about one third of schools were below their targets each year, but only by a few students. The majority of schools do not plan to increase their admissions in 2004. Twelve percent of enrolled students were men. Twenty-two percent of schools reserved seats for Aboriginal students, and 14 schools reported a total enrolment of 149 self-identified Aboriginal students. The average retention rate for 1999 2002 was highly consistent at around 70%, with the median rates being 70 77%. Schools were asked about the adequacy of their resources in five areas: faculty, students, clinical placements, space, and administrative support. The areas of greatest shortage are clinical placements in acute care, clinical teachers, and laboratory and classroom space. Half the schools reported that their Building the Future: An integrated strategy for nursing human resources Page 2

current resources are adequate for the number of students they enroll; 50% have inadequate clinical placements and clinical teachers available, although they are adequately resourced in other areas. Half the schools could increase their enrolments by 10% with their current resources; with additional financial resources, 50% of schools could increase by 25%, 40% could increase by 50%, and 33% could double their enrolments. The participating schools were able to fill their faculty vacancies in 2003. These consisted of 39 permanent positions, 102 full-time contract positions, and 185 part-time contract positions. Sixty-five percent of schools were able to fill these positions with little difficulty. The preferred credential for most of these positions was a baccalaureate degree in nursing. Only 8% of schools did not compete with other health science programs for clinical space: 76% competed with programs that prepare RNs and 38% competed with other LPN programs. Half the schools reported that the majority of places that provided clinical experience for their students were studentfriendly. Half the schools use block placement for students in the first year of the program, and 29% used a mix of block and distributed placements. Block involves having the students spend blocks of time in practice and then blocks of time in classes. Distributed means having students combine classes and clinical practice periods each week. The reasons these models are used is because the schools believe such models are academically superior (50%) and that they maximize the use of clinical resources (65%). Only half the schools use preceptors, and half of these schools are not able to find the number of preceptors they require. They reward preceptors with plaques and receptions. Findings: Under-represented Groups in Nursing Six focus groups were held with university and college students who were Aboriginal, Black Canadians, or men pursuing non-nursing careers. They reported that, for them, nursing consisted of dealing with blood, needles, dying people, and mess. Nurses were invisible on the health care team, endured poor working conditions, were abused by patients, took orders from doctors, were subservient, and lacked job security. The Aboriginal students gained most of their impressions from nurses who worked on reserves where they grew up, and they did not believe that nurses were respectful of their people. Black students had family members who were nurses, or family members of friends who were nurses, and they saw these women as overworked and trapped in exhausting jobs. These students had little to no sense that there were three different professions within nursing or what the career opportunities were within nursing. Both Black Canadian and Aboriginal students reported that their families would not find nursing as an acceptable career for them because there are not enough opportunities to justify the investments they would have to make in their children s future. Aboriginal students recommended that nursing provide opportunities for members of their communities to blend traditional healing and medicines with western medicine in nursing programs. They believed that members of their communities needed opportunities to change nursing, and, in the course of doing that, could give something back to their community. This desire to give something back was also strongly felt by Black students who saw nursing as a career that would allow them to do that. Both Black and Aboriginal students identified racism as a problem in nursing, which was manifest by a lack of members of their communities in senior management positions. Role models are important for all three groups as a way of attracting members of their communities to nursing. These role models should visit students in elementary schools and high schools and in the first year of college and university programs in Building the Future: An integrated strategy for nursing human resources Page 3

order to recruit them into nursing. For young men, the words nursing and nurse are problematic because they convey such overwhelmingly female images. Recommendations 1. One of the major constraints on the expansion of programs to prepare RNs is the availability of faculty members with master s and doctoral preparation. Therefore, it is recommended that enrolments in graduate programs be expanded immediately. Special initiatives to make it financially possible for students to study full-time are needed. As a model for achieving this goal, nursing traineeships awarded to students by the U.S. federal government should be explored; this was started in the 1960s to address a shortage of master s prepared nurses. The expansion of doctoral programs requires the availability of more doctoral and post-doctoral fellowships funded at levels that make full-time study realistic for nurses. 2. Clinical education of students is a critical component of nursing education and yet it is difficult to identify best practices in clinical nursing education. Expansion of both LPN and RN programs is constrained by perceived limits in the capacity of acute care and community practice environments to absorb more students. Therefore, it is recommended that an immediate study be undertaken of how to maximize current clinical resources. Secondly, it is unlikely that all of the clinical practice needs for the current level of enrolment, let alone an expanded one, can be met within the available practice environments. Therefore, it is recommended that funds be made available to all schools of nursing to introduce or expand the simulation opportunities available to their students; this would help to conserve the clinical practice opportunities for those activities and processes that cannot be learned through simulation alone. As well, consideration should be given to establishing some central simulation laboratories that could be used by several schools of nursing, and potentially by other health science disciplines, for their training needs. 3. Half the schools of nursing that prepare LPNs, and 60% of those that prepare RNs, describe themselves as highly stressed and having difficulty managing the numbers of students they have with the resources available to them. Nursing education has never been adequately costed. It is recommended that a study to cost nursing education be undertaken immediately in preparation for an expansion of enrolments so these expansions are adequately funded and current levels of funding adjusted. 4. More than 80% of schools of nursing can manage some degree of expansion in enrolment, and a few of them can expand considerably if they have adequate financial resources to support the increased numbers involved. It is recommended that a national strategy be developed for expanding enrolments in schools of nursing. In collaboration with the provinces, the strategy should address the additional numbers of graduates needed per province to meet the nursing workforce needs, the enrolment increases required to meet these graduation targets, the identification of schools with the potential to expand, and the financial costs of doing so (including the costs of developing simulation laboratories). 5. Retention rates are too low in many LPN and RN schools of nursing. This comes with a high cost to students, and it is an enormous waste of students potential and of faculty resources. Importantly, some schools of nursing have excellent retention rates. It is recommended that target retention Building the Future: An integrated strategy for nursing human resources Page 4

rates of 90% be established for schools of nursing, while acknowledging there are year-to-year fluctuations. A great deal is known about how to increase retention: admit students with appropriate academic backgrounds; portray nursing realistically in recruitment activities; once students are admitted, assist them to develop strategies to cope with the current upheavals in nursing and more generally in the health care system; aggressively support students, particularly those entering with grades lower than the class average; and make it clear to students how and where they can seek assistance. This information should be incorporated into retention strategies established within every school. 6. There are too few Aboriginal people and men in nursing schools. Additionally, although not supported by statistics, there is a perception that nursing is recruiting too few Black Canadians into its ranks. Several studies have been undertaken that provide direction for increased recruitment and retention of members of these under-represented groups. It is recommended that specific recruitment initiatives be developed by schools of nursing to attract Aboriginal students based on recommendations identified in Against the Odds (National Task Force on Recruitment and Retention Strategies [NTFRRS], 2002) and by replicating the activities undertaken by several schools in Western Canada that have been successful in both recruiting and retaining Aboriginal students. Similarly, recommendations in the report Men in Nursing (Hanvey, 2004) should be followed to attract and retain men. i) The participants in the focus group study conducted as part of this project added new perspectives and ideas about how to recruit students from the three populations of interest. There is a need to make the view of nursing and nurses held by university and college students, their families, and perhaps the public at large more positive. This means a public relations campaign that is beyond the scope of any one school of nursing. Health Canada, professional nursing associations and provincial/territorial health ministries should combine efforts to position nursing in a positive light. This includes correcting the view that nursing is only about blood, needles, death, and mess, that nurse are invisible members of the health care team, that nursing is not a prestigious career, and that nurses working conditions are uniformly negative. The opportunities to give back to Aboriginal and Black communities through nursing are important messages for potential students from those communities. Emphasizing the career opportunities in nursing is needed, including the opportunities in management and teaching and the salaries available for these positions. The issue of racism in nursing cannot be ignored because of its impact on recruitment. The quote from a young person in a focus group involving Black students, It gets more diverse as you go lower is an indictment of nursing s openness to people of all races, particularly among the registered nurse and registered psychiatric nurse professions. ii) It is important that practising nurses be made aware of the impact of their behaviour and attitudes on Aboriginal and Black communities (and, frankly, on all communities). Every nurse is potentially a role model and the impression that each nurse makes on the people she/he cares for can be profound. This is particularly true in Aboriginal communities where the need to portray nursing as a desirable career to young Aboriginal people is crucial. Individual nurses may be the most important and influential tool in this recruitment strategy. iii) The recommendation from men that the nursing consider changing the name of practitioners cannot be dismissed. Nurse and nursing are intrinsically female names and it is difficult for Building the Future: An integrated strategy for nursing human resources Page 5

most men to embrace them and identify with them. Perhaps it is time to take this recommendation seriously. iv) Finally, carefully designed recruitment initiatives are needed to present career opportunities (not job opportunities) in nursing to students from these three under-represented groups at the elementary level, in Grade 9, and to students in first year of university and college; these are critical years in which career decisions are made. Sending nurses from these three groups to recruit in schools is crucial to the success of these recruitment efforts. 7. There is a need for greater communication, and potentially collaboration, across the educational sectors of the three nursing professions. At this time, there are no ongoing mechanisms in place to allow this communication to occur. Therefore, it is recommended that a mechanism, such as a council, be established, with representatives from all three nursing professions, with the objectives of enhancing communication among the three professions, planning for intra-disciplinary collaboration, and presenting a coherent, collaborative and mutually respectful face of nursing education in Canada. Building the Future: An integrated strategy for nursing human resources Page 6

1. Introduction This report focuses on the education of members of the three regulated nursing professions: registered nurses, licensed/registered practical nurses, and registered psychiatric nurses. It does not include information on the capacity of educational programs to prepare registered psychiatric nurses because only one school responded to the survey. This report is intended to complement the Canadian Nursing Labour Market Synthesis to be presented as part of the overall research for Building the Future. It begins with a description of the methodology used to gather data for the report. To offer a context for the current findings, the next chapter presents an historical overview of nursing education for each of the three nursing professions. This is followed by a brief overview of nursing education in Canada and key source countries. The report then moves into a presentation of the findings from the surveys mailed to all nursing schools involved in the preparation of RNs and LPNs (separate chapters), with each chapter followed by a discussion of these findings. The literature review is integrated into these discussions. Chapter 9 presents the findings of focus groups that were held with Aboriginal Canadians, men, and Black Canadians to better understand why members of these three groups are under-represented in nursing. Finally, the conclusions to be drawn overall from this research are presented. The final chapter then presents the recommendations for action. For a list of other acronyms used in the report, please see Appendix A. The following acronyms for nurses are used in this report. RNs registered nurses LPNs licensed/registered practical nurses RPNs registered psychiatric nurses (Note that although the acronym RPN refers to registered practical nurses in Ontario, Canada, it is not so used in this report. Also, in Canada, RPNs are educated and regulated as a separate profession only in Manitoba, Saskatchewan, Alberta, and British Columbia) Building the Future: An integrated strategy for nursing human resources Page 7

2. Methods Overall Research Questions. Research questions were formulated to address the objectives of this study. 1. What is the history of the education of LPNs, RNs and RPNs in Canada, including the following? provincial/territorial variations across the three nursing groups significant decisions in the evolution of education of each group factors influencing the educational patterns and decisions current patterns and locations of nursing education programs and Canada-wide trends in nursing education 2. What are the international trends in nursing education, including educational preparation to enter the RN, LPN and RPN professions in relevant countries and the location of schools? 3. What is the current capacity of the education sector, the limits of that capacity, factors limiting the capacity, and admission and retention rates? 4. What is the clinical training capacity, models of clinical nursing education, use of preceptors, and limitations in the capacity of preceptors? 5. Why are Aboriginal people, men and Black Canadians not choosing nursing as a career? 2.1. Consultations with Stakeholders History of Nursing RNs. Dr. Jan Storch provided the background information on the development of collaborative programs in British Columbia. Dr. Storch was Director of the School of Nursing at the University of Victoria from 1996 to 2001 and continues as a professor. Professor Penny Ericson provided background information on the process used in New Brunswick. Professor Ericson was Dean of Nursing at the University of New Brunswick from 1988 to 1998. She is now professor emeritus and dean emeritus and continues to teach and supervise graduate students. Professor Rivie Seaberg provided the background information on the process in Ontario. Professor Seaberg chaired the Umbrella Working Group for the College of Nurses. She is now Director of the Centre for Nursing at George Brown College in Toronto. Dr. Susan French provided information on the current situation in Quebec. Dr. French is Director of the School of Nursing at McGill University. LPNs. Professor Rivie Seaberg provided background information on the Ontario process. Professor Seaberg is the Director of the Centre for Nursing at George Brown College in Toronto and chaired the Umbrella Working Group for the College of Nurses of Ontario that oversaw the consultation process for LPN education. Verna Holgate, Executive Director of the College of Licensed Practical Nurses of Manitoba, provided background information on LPNs in Manitoba. This information was taken from the following documents from the Manitoba Association of Licensed Practical Nurses: An Historical Perspective 1946 1986 and Educational Enhancement Criteria & Supply/Demand Requirements (August 1995). Patricia Fredrickson, Executive Director/Registrar of the College of Registered Licensed Practical Nurses of Alberta provided information on the development of LPN education in Alberta. Building the Future: An integrated strategy for nursing human resources Page 8

RPNs. The following people provided background information for the historical overview: Annette Osted, Executive Director of the College of Registered Psychiatric Nurses of Manitoba and member of the Board of Directors of Registered Psychiatric Nurses Association of Canada; Dr. Marlene Smadu, Associate Dean of Education (Regina Campus) of the University of Saskatchewan. From 1992 to1994, Dr. Smadu was Assistant Program Head Curriculum of the SIAST (Saskatchewan Institute of Applied Science and Technology) Wascana Institute nursing program; Professor Diana Davidson Dick, Dean of Nursing at the Saskatchewan Institute of Applied Arts and Technology. 2.2. Surveys of Schools of Nursing Capacity of Schools Survey methodology using a mailed questionnaire was employed in this study. Ethical approval was received from the Office of Research Services of the University of Toronto, including approval of an information letter informing the schools of nursing of the context of the study and the protection they had in participating. The participants were not required to sign a consent form, but rather their decision to complete and return a questionnaire conveyed their consent to participate. Anonymity of the participants was one of the conditions of participation. The purpose of this study was to gain information about the capacity of schools of nursing in Canada that prepare RNs, LPNs, and RPNs, in terms of their current enrolment of students, their plans for future enrolments. and their judgment about the extent of their capacity. As well, information was sought about the resources available to them and the resources they would need to maintain and expand their enrolments. For this type of information, a descriptive survey is an appropriate approach because through it, information about prevalence, distribution and interrelationships of variables can be ascertained (Polit, Beck & Hungler, 2001). Three different but complementary versions of the questionnaire were developed for each nursing profession based on the objectives of the study. There were many common questions across the three versions of the questionnaire as well as questions specific for each profession, particularly regarding the structure and capacity of the programs. Structuring the questionnaire for RN schools was a particular challenge for two reasons. The education of RNs is in transition in Ontario and the majority of Englishlanguage RN programs are members of university/college collaborative programs; thus, the questionnaire had to accommodate these factors. Pilot Versions. Drafts of these questionnaires were distributed to members of the Steering Committee of the project for their input regarding the clarity, relevance, and comprehensiveness of the questions, given the objectives. They were invited to make revisions and suggest areas that required further questions. In addition, selected school administrators from all three professions were asked to review the questionnaire, complete the questions, and provide feedback as to the clarity of the questions and their format, and to suggest areas and specific questions to fill gaps. The following people provided feedback. two administrators of university programs that prepare RNs, from different provinces two administrators of community college programs that prepare RNs, from different provinces two administrators of college programs that prepare LPNs, from different provinces Building the Future: An integrated strategy for nursing human resources Page 9

members of the Steering Committee, including an administrator of a college program that prepares LPNs and a teacher in a program for RPNs Revised versions. The questionnaires were revised on the basis of this feedback; refinement of specific questions continued in collaboration with members of the Steering Committee until acceptable versions were developed. The original intent for RN schools involved in collaborative programs was to send a two-part questionnaire to the credential-granting partner (in all cases, the university partner) and to ask that partner to distribute the first part (which sought information about enrolments, admission rates, retention rates, etc.,) to each college partner and to complete the second part themselves (which sought information about resources on behalf of all partners in the consortium). As a result of feedback from the pilot study, we sent each partner sections one and two and had them respond separately. Participants. All schools of nursing in Canada were asked to participate. Lists of all schools in Canada that participate in the preparation of RNs, LPNs, and RPNs were compiled from information provided by members of the Steering Committee, the Canadian Nurses Association, and the Ordre d Infirmiers/Infirmières Auxiliaire du Québec. Each school received a package containing a cover letter from the co-chairs of the Steering Committee of the project, the information letter approved by the Research Ethics Board, a copy of the version of the questionnaire appropriate for the school, and a stamped and addressed envelope in which to return the completed questionnaire. The questionnaire and covering letters were translated into French, and French-language LPN and RN schools received these versions. Packages were sent to English-language RN schools in early February 2004 and to Frenchlanguage RN schools in late February, to English-language LPN and RPN schools in early March, and to French-language LPN schools in late March. One month after the questionnaires were sent to English-language schools, a reminder postcard to return the questionnaires was sent to all schools that had not responded. Approximately one month after the French-language schools received their questionnaires, a postcard in French and English was sent to all French-language schools that had not responded and also to the non-responders in the Englishlanguage schools. Therefore, the English-language schools received two reminder postcards and the French-language schools received one. Since the response rates from the French-language schools were low, e-mails were sent to the directors of all the French-language schools (LPN and RN) repeating the French-language message from the postcard and attaching copies of the questionnaires and the information letter. The Canadian Association of Schools of Nursing (CASN) sent an e-mail message to all of its members encouraging them to respond to the questionnaire; all members of the Steering Committee received an e-mail message asking them to contact schools of nursing in sectors that they represented to encourage them to participate. Finally, individualized e-mail messages (in English) asking that the schools participate were sent to many English- and French-language RN school directors with attached questionnaires and information letters, and to faculty members in the RPN programs that had not responded. Three data files were constructed, one for each nursing profession (RN, LPN, and RPN). Responses from the completed questionnaires were entered into these data files and analyzed using the SPSS statistical package. Written responses to questions and comments that accompanied answers were recorded in a Word file and analyzed using a qualitative descriptive approach. Building the Future: An integrated strategy for nursing human resources Page 10

Data Quality and Limitations. The following response rates were achieved across the three different types of programs. Table 1. Response Rates for RNs, LPNs, and RPNs Type of program No. sent No. returned Response rate RN programs 128 73 57% LPN programs 93 37 40% RPN programs 3 1 33% The response rates were low in all sections. The response rate from RN schools was particularly low in Quebec, at only 37.5%. Outside of Quebec, the overall response rate was 65%. Therefore, caution must be exercised in generalizing about all RN programs but particularly about programs in Quebec. The response rate for LPN programs was also low and again particularly so for Quebec and the Atlantic Provinces, where it was only 26% and 31% respectively. Again, caution must be exercised in generalizing about all LPN programs. Note: Only one response was received from RPN programs so no report is included in order to protect the anonymity of the one respondent. 2.3. Literature Review Educational Capacity and Trends Note: There is no literature section in the report per se; rather, the literature is integrated into the discussions in Chapters 6 and 8. Search Strategies and Identification of Relevant Literature. Both broad and narrow key words and phrases were used to search all sources. A broad term such as nurse(s) was used in an effort to capture information relating to all three regulated nursing professions. More focused words and phrases such as registered nurse(s), licensed practical nurse(s), and registered psychiatric nurse(s) were used in an effort to access data for each of the regulated nursing professions. Published Literature and Bibliographic Databases. Information on published literature was searched through bibliographic databases such as MEDLINE, CINAHL, Healthstar and Ovid. Popular publications and academic literature were also scanned. Grey Literature. The Internet provided access to grey literature such as reports, news releases, statistical data, and databases, as well as to documents from university-based academic research units, governmental publications, and nursing regulatory bodies. Documents and data were also obtained through direct correspondence with government officials, research units, nursing associations, and regulatory bodies. Data from Regulatory Bodies. Direct contact was made with regulatory bodies for the regulated nursing professions in some provinces and territories. RNs and LPNs are regulated in all provinces and territories, whereas RPNs are regulated only in the four provinces of Western Canada. A review of the literature was conducted to examine perspectives of a chief executive officer (CEO) about a number of key issues influencing nursing practice. Areas relating to the CEO role, cost containment, evidenced- Building the Future: An integrated strategy for nursing human resources Page 11

based decision-making, means of coping with tight labour markets, employee utilization patterns, and patient safety programs and concerns were examined. 2.4. Focus Groups Under-represented Groups A qualitative methodology was used in this investigation. Focus groups were created comprising university and college students in groups under-represented in university and college nursing programs. They were asked about the reasons nursing is not appealing as a career choice within their group and what can be done by nursing to address this problem. Ethics approval was received from the Health Sciences 1 Research Ethics Board at the University of Toronto. 2.4.1. Target Group The target populations for the focus groups were students who are members of the particular communities of Canadians that are under-represented in most nursing education programs and in the workforce. These groups are Aboriginals/Native (includes First Nations and Métis), Black Canadians of African or Caribbean descent, and men. The criteria for participation were that students be pursuing postsecondary education and neither be currently enrolled in a nursing program nor have chosen nursing as a career. These samples purposely differed from those in previous studies; earlier work had involved male and Aboriginal students in either high school or nursing programs. No previous research on these groups of interest and about the appeal of nursing as a career had targeted students who had demonstrated the capacity to gain entrance to post-secondary education and to explore a range of career options but had not pursued nursing as one of those options. Their voices and their opinions were viewed as another important source of information about the appeal of nursing as a career. 2.4.2. Data Collection The focus group guide used in the Canadian Nurses Association (CNA) study (Hanvey, 2004) was expanded and revised. A number of questions were added to those used in the CNA study of men in nursing. For example, students were asked if they knew about the three different nursing professions and if this made any difference to the appeal of nursing. Students were also asked whether the costs of study, the location of nursing schools, the types of clinical study required, and mentors/role models make a difference to the attractiveness of nursing as a career choice. Participants had the opportunity to ask questions about the study. There were no notable differences in process among the focus groups. In every group, participants appeared very eager to contribute. Differences of opinion were voiced, lively discussion among the participants was generated, a group problem-solving approach emerged at times, and requests for information and questions were voiced by participants, signalling their interest in the directions of this research inquiry. 2.4.3. Recruitment Educational institutions were selected as recruitment sites based on the types of nursing education programs they offered and the availability of students whose views were of interest in this research. The three groups of interest were recruited as follows. First Nations students were recruited through the University of Toronto, using e-mail announcements and flyers posted at First Nations House, which houses the Office of Aboriginal Student Building the Future: An integrated strategy for nursing human resources Page 12

Services and Programs, and at the Native Students Association of the University of Toronto. The focus group was held at First Nations House. Flyers were posted in buildings at First Nations University, SIAST, and the University of Saskatchewan. These schools offer a collaborative program to prepare registered nurses and a program to prepare licensed practical nurses. The focus group was held at First Nations University. Black Canadian students of African or Caribbean descent were recruited at two sites in Toronto. At George Brown College (LPN and RN programs), flyers were posted on student bulletin boards (George Brown also offers a broad range of technical and human service programs). This focus group was held in the Centre for Nursing at George Brown College. At the University of Toronto (RN program), flyers were posted in buildings that house programs with a high enrolment of Black Canadian students. An e-mail announcement was also sent to electronic lists for faculty and teaching assistants in these programs. This focus group was held at the Faculty of Nursing of the University of Toronto. Male students were recruited at two institutions. At George Brown College, where the focus group was held, flyers were placed on student bulletin boards and in the career centre. At the University of Toronto, were the second focus group was held in the Faculty of Nursing, flyers were the only method used and were placed in high-traffic buildings that house the major libraries, the bookstore, and the career centre. They were also placed in a college of the university that houses a number of diversity studies programs, in an effort to encourage participation by ethnoculturally diverse male students. The University of Toronto offers programs to prepare registered nurses as well as graduate level nurses. No RPN Site. The original proposal included the plan for a third focus group with Aboriginal students at a college site that offered an RPN program. Many attempts were made to reach people at this college to secure permission to recruit students and conduct a focus group on campus, and to recruit an individual who could lead a focus group. After several weeks, with no success in making contact with individuals who could facilitate the process and with time running out, the idea was abandoned. 2.4.4. Participants Mixed purposeful sampling methods were used, including criteria-based sampling, cascading snowball sampling, and maximum variation sampling methods. Maximum variation sampling was used to achieve ethnocultural variation within focus groups for male students. A total of 52 students participated in the following six focus groups: 18 First Nations students, 18 Black Canadians, and 25 males. Two focus groups (16 students) were held with Aboriginal/Native students (includes First Nations and Métis), (2 of whom were men). Two focus groups (16 students) were held with Black Canadian students of African or Caribbean descent (3 of whom were men). Two focus groups (20 students) were held with male students of ethnoculturally diverse backgrounds (2 of whom were First Nations, and 2 Black Canadian). The groups ranged in size from 7 to 10 students. Within each focus group, participating students represented a wide variety of areas of study. The recruitment was successful therefore in sampling a broad range of students on all three campuses. At the same time, many of the students who contacted the researcher reported that they had learned about the study from another student. The focus groups for male Building the Future: An integrated strategy for nursing human resources Page 13