Exploring Clinical Information and Communication of Healthcare Professionals in Home care: Resources, Challenges and Solutions

Posted on May 15, 2012 by mkoh

Research Team:

Dr. Diane Doran
Ivana Matic
Dr. Sima Ajami

This summary is the first of two summary sheets, presenting highlights and key messages from the study entitled “Exploring Clinical Information and Communication of Healthcare Professionals in Homecare: Resources, Challenges and Solutions.” The second summary sheet will be posted here shortly.

The full report will be available soon on our website: www.nhsru.com. For more information please contact Jenny Carryer at doran.research@utoronto.ca.

View PDF Summary

Building and Sustaining a Quality Nursing Workforce in Home and Community Care: March 2012 Interim Report

Posted on May 10, 2012 by mkoh

Research Team:

Diane Doran, RN, PhD, FCAHS
Laureen Hayes, Research Officer
Sang Nahm, Data Analyst
Ping Zou, Research Officer
Paul Rizk, Research Officer
Chris Bai, Research Officer
Dan Laporte, Research Manager

Executive Summary:

Effective strategies are needed to address the projected nursing shortage, particularly in home care where demand for health care is expected to increase and where disparities in nursing supply have been the greatest. Nurses are the primary providers of home care services and work in diverse settings but, unfortunately, are often under-utilized and in some areas in short supply. This applied research is aimed at generating evidence about effective strategies for recruiting and retaining home care nurses in Ontario. Project 1 provides a demographic analysis of the nursing workforce in community settings, and describes RN/RPN allocation criteria and current challenges to nurse utilization. Project 2 examines recruitment and retention strategies and challenges specific to early, mid and late career home care nurses.

In order to promote a stable nursing workforce in home care, the needs of nurses at different stages of their career must be considered. Home care organizations changed their hiring prerequisites so that new nurses could enter home care upon graduation. Therefore, greater emphasis must be placed on student placements and mentorship/ preceptorship support when planning strategies for recruitment and retention in home care nursing. Given the increasing number of nurses over the age of 50, it is vital to understand the factors that influence retention in the home care sector in the later career stage. However, less attention has been paid to retaining nurses in this sector than to recruiting them, and still less on retaining older nurses (Storey et al., 2009). Clearly, there is a need to distinguish between different career stages of the individual nurse when developing and implementing recruitment and retention strategies.

This study was designed to generate evidence about effective strategies for recruiting and retaining home care nurses and sustaining home care nursing capacity, in order to meet the health needs of Ontario’s diverse population. A second goal of this applied research project is to inform policy decisions, through valid research, about effective strategies for optimizing the utilization of RNs and RPNs in community practice settings. The primary objectives of this study are to:

Compile a detailed demographic profile of nurses working in the home care sector and identify areas of concern/strength related to current trends in the home care nursing workforce.
Determine how decisions, on the utilization and allocation of RNs and RPNs, are currently being made in Ontario home care provider agencies; investigate the feasibility of, and provide input into, the development of an RN/RPN Utilization Toolkit for the home care sector.
Evaluate the unique challenges of attracting and retaining early, mid and late career nurses to the home care sector and describe factors or policy initiatives that may be instrumental in attracting new graduates to community nursing as an employment choice.

To date, researchers have completed a detailed demography of visiting home care nurses working in Ontario, and administered surveys to a stratified sample of early, mid and late career nurses in this sector. Concurrent with the survey administration, interviews with home care decision makers and front-line nurses were conducted to address issues associated with the RN/RPN utilization, and recruitment and retention in Ontario’s home care settings.

Findings

The demographic profile of the 2009 CNO database shows that the total number of visiting nurses in 2010 compared to 2009 has increased slightly. However, of concern is that there was a steady decline in the proportion of visiting nurses year-over-year in the years 2007 to 2010 because of the discrepancy in the trends in the number of visiting nurses and the overall nurses in Ontario. Nurses 45-54 yrs of age make up the largest proportion of the workforce, in both visiting nurses and the overall nursing workforce. Analyses revealed a slightly higher proportion of nurses aged 55 and older and 35-44 years old, among visiting nurses when compared to the rest of Ontario’s nursing workforce. Conversely, there was a slightly lower proportion of visiting nurses younger than 35 years of age compared to the rest of Ontario’s nursing workforce. A relatively low proportion of visiting nurses reported an education of a BScN degree or higher, and there was a trend of increasing part-time and casual employment compared to the overall nursing workforce in Ontario. .

Based on interviews of decision-makers within home care organizations (ex. senior leaders), there is a range of decision criteria for allocating RN/RPN visits, although the criteria are primarily based on matching a nurse’s level of skill to patient characteristics and complexity. There appears to be some discretion and variance as to which factors weigh most into allocation decisions. Decision-makers agree that the current funding model of managed competition is an obstacle to optimizing RN/RPN utilization, citing their inability to adjust their staff mix in response to the increasing demands of their client population, due to the fact that they were subject to the terms and conditions of multi-year contracts and funding agreements with CCACs.

This study explored the intention of nurses to leave their current position. The late career nurses are the most likely to remain in their job until retirement even though they work more part-time or casual and rank their work environment the lowest. For nurses in general, lack of job security and poor compensation for travel and visit time are serious concerns. Nurses voiced concerns related to lack of orientation and full time hours for new grads and early career nurses. The late career RPNs described the pressures of having to learn new skills and work long hours being on call. The middle and late career nurses voiced concerns about the lack of pension and benefits, and the pressure to learn new skills. Nurses value teamwork, respect, participation in decision-making, autonomy and independence, and require learning support, manageable workloads and effective care coordination and communication. The current study findings suggest that many of these aspects are lacking in the home care environment.

Recommendations

With a rising complexity of home care clients’ care needs, a skilled nursing workforce is needed to ensure the population’s health care needs are met. The following recommendations were derived from the findings and the related literature.

The proportion of home care nurses compared to the Ontario overall nursing workforce has been decreasing since 2007. Strategies are needed to recruit more nurses into home care, especially the new grads and early career nurses (see bullet points below).
The majority of home care nurses indicated that their highest level of nursing education was an RN diploma or RPN certificate; therefore, provide funding or support incentives for community RN/RPN skills training/advanced practice certification.
Evaluate the current funding model for home care provider agencies. The managed competition model may not provide agencies with the ability to ensure appropriate RN/RPN utilization, due to an inability to allocate additional funding or resources to address the growing needs of their client population.
If managed competition is continued in Ontario, implement a program of transitional support for skill upgrading of displaced employees, and Request For Proposals (RFP) processes that could provide incentives (including pension benefits and mileage compensation), as well as resources for orientation, and ongoing clinical support and education (Shamian et al., 2006).
Promote strategies to reward excellence and ensure that performance of care providers is acknowledged and encouraged. This includes recognition of and providing support to clients’ family members who fulfill care-giving responsibilities in their homes.

Strategies to optimize clinical, technical, communication and documentation skills needed to provide care in a client’s home.

- To attract nursing students, educators should provide a range of community experiences and home care placements, introducing students to a variety of roles and diverse populations in community settings (Prestia et al., 2008; Brooks & Rojahn, 2011; Leh, 2011; Betony, 2012).

- An extended period of orientation is needed for the new grads, for example, a phased approach to ensure nurses are able to provide safe care along with care planning and coordination, followed by formal instruction to refine knowledge about quality improvement and financial issues, resource allocation and management of human resources (Smith-Stoner & Markley, 2007; DeCicco, 2008)

- With continuing technological advances in health care, it is vital that older nurses are encouraged and supported to seek further education and skill development if they are to maintain competency (Storey et al., 2009; Lefebre et al., 2011; McGillis Hall et al., 2011).

- Mentors need just as much support and coaching as the mentee, and must be empowered to share what is working effectively and what is not (Meadows, 2009).

Retention and recruitment strategies should consider the unique professional and personal needs and challenges that are associated with different career stages. All nurses need job security and adequate compensation. While needs of new grads relate more to orientation and mentorship, the mid to late career nurses are especially concerned about pension and sick time benefits, and workload that is less physically demanding and uses preventative measures to reduce injury.
A supportive work environment is critical to build workforce capacity and stability in home care. Nurse leaders should explore ways to promote teamwork, respect, participation in decision-making, autonomy and independence, ongoing learning support, manageable workloads and effective care coordination and communication of information.
Strengthen research in home care to inform policy that promotes the best mix of resources and care delivery models to achieve the most optimal client outcomes in an efficient and cost-effective manner.

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Evaluating the Impact of Ontario’s Late Career Nurse Initiative: March 2012 Interim Report

Posted on May 10, 2012 by mkoh

Research Team:

Diane Doran, RN PhD, FCAHS
Autumn Chilcote, Research Officer
Paul Rizk, Research Officer
Yu Qing (Chris) Bai, Data Analyst
Dan Laporte, Research Manager

Executive Summary:

In an effort to stem the loss of Ontario’s late career nurses, in 2005 the Ontario Ministry of Health and Long-Term Care (MOHLTC) introduced the Late Career Nursing Initiative (LCNI). This initiative involved providing funding to hospitals and long-term care homes for salary/benefits replacement costs for late career nurses (Registered Nurses (RN), Registered Practical Nurses (RPN) and Nurse Practitioners (RN(EC))) that submitted proposals detailing a workable plan to implement a .20 FTE reduction of physically or psychologically demanding duties of nurses aged 55 or over. This .20FTE was to then be repurposed to engage the nurses in enriching employment activities.

The current study was developed to systematically evaluate the impact of the MOHLTC’s LCNI on the retention of late career nurses in Ontario, as well as explore the degree to which it is impacting nurses’ job satisfaction and feelings of organizational commitment. In addition to these primary objectives, the study explores the secondary benefits of the initiative, such as capacity building and its impact on patient care.

The specific objectives of the study currently underway at the NHSRU are to:

Determine the extent to which the LCNI has had an impact on retention rates of late career nurses;
Evaluate the MOHLTC’s Retention Performance Target formula for assessing the success of organizations’ efforts to retain nurses;
Determine the extent to which the LCNI has had an impact of the job satisfaction, autonomy, control over the work environment, and burnout of late career nurses;
Describe the secondary impacts of the LCNI on organizations (i.e., secondary benefits and consequences); and
Determine which specific characteristics of late career proposals are associated with improved retention rates.

To date, the NHSRU has distributed 5,000 survey packets to Late Career Nurses (LCN) to 65 organizations and conducted 19 interviews with Nurse Leaders and 10 interviews with Late Career Nurses (participants and non-participants). Survey respondents have numbered over 800, with over 200 Late Career Nurses also volunteering to participate in follow-up interviews. Both Nurse Leader and Late Career Nurse interview participants have been asked to characterize the components of a successful LCNI program or a retention initiative focused on the needs of Late Career Nurses. The current report reflects the preliminary analyses of both survey and interview feedback.

Key Messages

Successes. Preliminary analysis indicates that respondents feel effective in their jobs and low levels of cynicism about their careers. Late Career Nurse respondents who have participated in the LCNI rate leadership and support of managers higher than non-participants. Late Career Nurse participants also reported that they participated more often in hospital affairs than those who did not participate in the LCNI. Job satisfaction, nurse participation in hospital affairs and nursing foundations for quality care may all influence Late Career Nurse commitment to the organization. Interview data adds that Nurse Leaders from participating organizations support the LCNI, perceiving improved job satisfaction and commitment from participants. Both Late Career Nurses and Nurses Managers agree that programs offering opportunities for programs focusing on patients, mentorship and relationship development, or those that were specifically designed for the Late Career Nurse participants result in higher levels of satisfaction with the experience. Nurse Managers identified secondary benefits of participation in the LCNI, including improved clinical outcomes with patients and a range of organizational benefits from improvements in organizational culture (e.g. reputation as a good employer, values-driven organization) to completion of important special projects.

Concerns over time frame. Concern has been expressed about the insufficient time provided to organizations to put their programs in place and utilize the LCNI funding, especially the announcement of funding in late December with a requirement to fulfill program goals by March. Both Late Career Nurses and Nurse Managers reported that the short timeframe allotted for projects was problematic due to scheduling difficulties and insufficient time to roll-out proposed projects in order to use the funds offered. Nurse Managers suggested that the funding period of January through March was further complicated by winter holidays combined with the increased needs of patients during cold and flu season. Late Career Nurses felt unprepared for projects announced with short-notice, or did not want to leave their unit or area understaffed. Late Career Nurses also added that at times their projects were not completed due to last minute schedule changes or staffing shortages.

Response to Retention Performance Target. Nurse Managers conveyed that they had little understanding of the purpose or meaning behind the Retention Performance Target (RPT). Recurrent themes appearing in the interview data included difficulty in completing the form, lack of comprehension of the calculations, and little connection between the Target and the initiative (e.g., retention is not the only relevant outcome to organizations, as other indicators of success, such as capacity building and improved patient outcomes are not captured by the RPT). Based on these results, the NHSRU will be conducting future focus groups with health human resources professionals to explore an enhanced retention metric related to the LCNI.

Recommendations

The following are the recommendations based on the study findings.

Provide training materials, a workshop, or a sample proposal for applicants, or offer opportunities to connect applicants to other agency Managers that have been successful in their funding requests.
Offer a vehicle for sharing successful programs across agencies.
Provide follow-up feedback about what worked for other agencies for retention so that it can be made locally relevant and turn into best practice.
Provide flexibility for full-time and part-time participants related to .20 FTE.
Explore the possibility of Late Career Nurse retention planning at the agency level, with the LCNI offering opportunities for career development, recognition, interest and skill specialization for Late Career Nurses.
Consider measures of secondary benefits or alternate domains (e.g., job satisfaction, participation in hospital affairs, pre- and post- participation) as a measure of the success of the LCNI in agencies.

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Final Report: Leading Practices and Programs for Developing Leadership Among Health Professionals at the Point of Care

Posted on March 20, 2012 by mkoh

Research Team:

Diane Doran, RN, PhD, FCAHS
Marianne Koh, MS
Andrea Dick, MS
Laureen Hayes, RN, EdD
Cassie VanWiechen, BSc
Odilia Yim, MA

Executive Summary:

The Nursing Health Services Research Unit at the University of Toronto reviewed both nurse‐specific evidence and evidence from other professions as well as models of leadership development initiatives at the point of care. This research is intended to support policy development and planning to improve Ontario’s health system.

The objectives of this study were to:

Conduct a comprehensive literature review of currently or recently implemented health professional leadership development initiatives around the world
Identify relevant leading practices and programs, or innovations of new nursing and allied health roles or models, with demonstrated evidence of quality work environment or quality patient care outcomes at the point of care
Engage with key informants knowledgeable about front‐line health professional leadership development initiatives for further research evidence
Analyze literature and consultations with key informants, to derive major themes throughout leadership initiatives with evidence of successful outcomes. Barriers and facilitators to building leadership capacity were also examined.
Formulate conclusions and recommendations that will provide evidence to support policy development and leadership opportunities for frontline nurses
Develop a chart of the leading frameworks, programs and practices for developing health professionals as leaders, with further details and key contacts for follow‐up

Current evidence and knowledge gaps

Nursing leadership development at all levels is increasingly important as health care systems and organizations become more complex, and resources are increasingly strained (Heller et al. 2004). Frontline nurses are a valuable resource of expertise for improving care, and a vast source of untapped leadership potential. Literature demonstrates that nurses want opportunities for professional development and engagement in leadership activities. At the same time, nurses have concerns related to entering managerial titles due to role concerns, such as the need for more education and reduced patient contact (UWO, 2010).

Leadership can be developed by acquiring specific training and education, and practicing leadership competencies. However, there is lack of evidence and systematic analysis about the types of training and development that is effective and the essential competencies that need to be enhanced (MacPhee et al, 2011; Cummings et al, 2008). Although some opportunities to develop leadership skills at the point of care exist, not all are equally available in all sectors, or even within sectors.

Leadership development opportunities for frontline nurses could lead to significant organizational benefits including healthy work environments and quality patient care.

Approach

A scoping review methodology was used to examine international empirical and grey literature on leadership initiatives for nurses and other health professionals, and the subsequent impacts on quality work environments and patient care. Information exchange with key informants knowledgeable about front‐line health professional leadership development practices and programs provided a valuable source of additional resources included in this report.

The review focused on leadership initiatives with demonstrated evidence of developing health professionals at the point of care as leaders. Approximately 169 documents were reviewed, of which 88 were used to inform this report. Major themes across leadership initiatives were identified independently by three reviewers. The themes were refined and verified with a fourth senior reviewer.

Findings

Leadership Frameworks and Models:
LEADS in a caring environment, Kouzes and Posner’s leadership model, Transformational Leadership, and Humanbecoming concept are commonly cited in literature included in this report. Several successful healthcare leadership programs and practices included in this report are based either formally on these selected frameworks and models, or on similar concepts. There are varying levels of evidence in support of the leadership frameworks and it was beyond the scope of this project to systematically review the evidence or endorse any particular approach.

Mentorship:
Current literature indicates that mentorship is important for professional and leadership development in the health care sector. Mentoring was an integral component of nine leadership development programs and practices. Participants commonly attributed growth in expertise and leadership skill development to the mentorship they received, particularly in terms of building confidence and empowering others around them. Mentoring is also useful in sharing knowledge specific to particular work environments that may not be covered in a general leadership development curriculum.

Leadership Competencies:
The theme of leadership as a learned behaviour with specific competencies, rather than a formal role or personality trait, is another recurring theme in existing literature and in conversations with key informants. Leadership competencies training are central to nine initiatives, and link with the idea of empowerment through confidence and skills building, project and change management, and effective communications and inter‐professional collaboration skills.

Healthy work environments:
Promotion of healthy work environments is a key objective of several of the leadership initiatives that were reviewed. Evaluations of the initiatives demonstrated encouraging results related to positive impacts on work environment, increased job satisfaction and improved nurse retention (Abraham, 2011; Morgan & Konrad, 2008; Krugman & Smith, 2003).

Overall, evaluation results of current leadership initiatives are highly encouraging in terms of potential immediate impacts on clinical practice and work environments. However, there was a lack of evidence indicating sustained impacts in studies evaluated over a longer timeframe. Thus the challenge of sustaining an initiative and its impacts should be considered when developing policies on leadership development at the point of care.

Quality Patient Care:
Most leadership initiatives reviewed in this report address the importance of leadership development for patient care. However, patient outcomes are difficult to measure and attribute directly as a result of clinician participation in leadership initiatives.

Only two studies used actual patient ratings or accounts to examine impacts on patient care. The Ottawa Hospital’s MoNCP© (Kerr, 2011) and the RCN Clinical Leadership Program (Cunningham & Kitson, 2000) used pre and post‐test evaluations, and only the latter documented improvements. Three initiatives in this review of evaluations demonstrated some evidence of quality improvement without patient data, such as patient safety process improvements, through feedback from participants, their colleagues or supervisors.

Recommendations

Organizational support given by managers, peers, and mentors, allow individuals to demonstrate their leadership capabilities and behaviours, without feeling inhibited by workplace policies, or feelings of self‐doubt, or fear. Organizational support is widely cited in literature and consultations with key informants as crucial to the successful uptake of a leadership initiative and work‐based project.
Insufficient resources and time are major barriers for practicing leadership behaviours among health care professionals. Organizations should support protected time for leaders to discuss leadership goals and activities to ensure sustained leadership development and subsequent impacts in their practice context (MacPhee & Suryaprakash, 2011), such as using the 80/20 model.
Theoretical frameworks or models to frame the challenge and guide the program should be incorporated at the development stage as they serve to illustrate key areas of growth and development, and guide and justify the selection of content and learning experiences.
Evaluation of nursing leadership development programs is necessary to demonstrate program effectiveness and justify allocation of program resources. A provincial wide leadership development strategy for frontline nurses should consider incorporating comprehensive evaluation during the initial stages of program development and continue to occur at all stages of the program, assessing: the need for the program; program design and theory; cost and efficiency; how the program is being implemented; and outcome or impact.

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(Note: Appendix not included. Please contact the NHSRU University of Toronto site for more information.)

Structural Equation Modeling: An Introduction Workshop

Posted on February 6, 2012 by mkoh

The NHSRU, University of Toronto site, is hosting a half day Structural Equation Modeling (SEM) workshop that will include an introduction covering a description of the technique, SEM terminology, assumptions, limitations and appropriate uses. Further, we will work through examples using AMOS software. These examples will cover Confirmatory Factor Analysis (CFA) and Structural Regression Models. Further, it is intended that by working through these examples, participants will learn to deal with a variety of issues that need consideration when conducting SEM analyses, such as non-convergence and missing data.

Structural Equation Modeling (SEM) is a quantitative data analysis technique that combines factor analysis and path analysis. Key advantages of SEM include the ability to test full models based on complex theory, few limitations regarding what types of models can be tested (e.g., mediation, moderation), and measurement error is accounted for when examining relations between latent variables.

Visit the workshop webpage for more course and registration information

Date: Feb. 24, 2012

Time: 1 pm – 5 pm

Fee: $50 ($25 for students)

Location: Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Health Sciences Building, 155 College St. , Toronto, Room 270

December 2011 NHSRU Nursing Research Bulletin

Posted on December 12, 2011 by mkoh

E-News

NHSRU’s newsletter is published twice a year and is available on the NHSRU website or by subscription. To unsubscribe to the newsletter, select the link “unsubscribe now” at the bottom of the email alert sent to your mailbox.

We’d Like To Hear From You

For bulletin suggestions or inquiries about our research, please leave us a comment or email us at noonant@mcmaster.ca and marianne.koh@utoronto.ca.

Under The Microscope

McMaster University Site

Nursing Graduate Guarantee Initiative

In 2007, the Ontario Ministry of Health and Long-Term Care (MOHLTC) created the Nursing Graduate Guarantee (NGG) Initiative as a financial incentive for employers to stimulate full time (FT) employment for Ontario new nursing graduates. The funding supports up to six months of employment and includes an extended orientation and mentorship program. Dr. Andrea Baumann and her research team have been evaluating the NGG Initiative since 2007. A mixed methods design was used including surveys of employers, new nursing graduates and union representatives, focus groups with employers and interviews with new nursing graduates. Over 18% of all healthcare employers (n=1198) in Ontario have participated in the NGG Initiative since its inception. A total of 11,700 new nursing graduates obtained temporary FT orientation positions through the NGG Initiative. Survey results indicated that employers used the NGG Initiative as a recruitment strategy to hire new nursing graduates and support workforce planning within their organizations. Interview findings revealed that the extended orientation and mentorship supported new nursing graduate transition from school to work. The NGG Initiative offers one model of best practice in workforce integration of new nursing graduates. A study will be conducted on retention of new nursing graduates following the NGG Initiative.

Research Trends in Nurse Workforce Integration

A study was recently completed of a class of 281 nursing students who graduated from a university in the Canadian border community in south western Ontario in 2011.The purpose was to describe the pre-employment profile, employment goals, and intent to migrate of these new graduates. The response rate to the survey was 40.9 per cent (n = 115). Preliminary results are described. The mean age of the participants was 25.7 years (Mdn 23; Min = 21; max = 53) and females composed 80.4 per cent (n= 86) of the sample. As would be expected in an undergraduate nursing program, the majority were single (72 per cent; n= 77) and had no children (84.1 per cent; n= 90). The majority of graduates preferred to work in Canada (86 per cent; n= 98) although two thirds (66.1 per cent; n= 76) identified that they were considering migrating for work outside of Canada. Lower value-expectancy scores for the migrant group, suggests that there is an increased probability that they would leave Canada to have their economic, professional, healthy work environment and autonomy job values met.

Internationally Educated Nurses: an Employer’s Guide

Dr. Andrea Baumann presenting at the IEN think tank.

The new web-based resource, Internationally Educated Nurses: an Employer’s Guide was launched earlier this month. With an aging workforce and the threat of nursing shortages, effective management of the recruitment, retention and integration of Internationally Educated Nurses (IENs) has become every employer’s priority. Find sections on:

The obstacles and advantages IENs represent in the workplace
Case studies of organizational successes and leading practices
A comprehensive literature review of policies, structure and strategies to create a harmonious workforce while optimizing the skills and experience of all
Links to useful resources, including video clips of interviews with a number of healthcare organizations

This web-guide was produced in partnership by The Ontario Hospital Association (OHA) and the Nursing Health Services Research Unit (NHSRU), McMaster site and funded by the Ontario Ministry of Citizenship and Immigration. The research leads for the initiative are Dr. Andrea Baumann, Scientific Director, NHSRU and Dr. Jennifer Blythe, Senior Researcher, NHSRU.

The Changing Nature of Health Professionals’ Work: The Impact of Infectious Disease

Little is known about the impact of infectious disease on the changing nature of work for frontline nurses, healthcare executives, laboratory staff and infection control practitioners (ICPs) in community hospitals. With an increase in the incidence of infectious disease in Ontario in the last decade, there has been implementation of new infection control policies and practices. This study explores the impact of hospital-acquired infections (HAIs) on the changing nature of work of frontline nurses, healthcare executives, laboratory staff and infection control practitioners. The findings demonstrate work has changed for all health professionals because of (1) the continued increase in infectious diseases, (2) the proliferation of infection control policies and practices, (3) the increase in data management and data-based decisions, and (4) increased communication and connectivity required across disciplines. Watch for an e-mail alert for the Research in Action summary coming soon.

University of Toronto site:

Maintaining Ontario’s Nursing Workforce: Evaluating the Impact of Ontario’s Late Career Nurse Initiative (LCNI)

Since 2010, the NHSRU has led an evaluation of the Ontario Ministry of Health and Long-Term Care (MOHLTC) Late Career Nurse Initiative (LCNI). Collaborating with over 60 healthcare organizations across Ontario, the NHSRU is collecting data from career nurses, nurse managers, and LCNI coordinators via interviews and surveys.

Over 3,000 surveys assessing nurse practice environment, organizational commitment, burnout and job satisfaction have been distributed to late career nurses across Ontario. Early survey results point to trends in increasing participation in the LCNI, with 86% of past participants indicating they would recommend participation to other nurses. Interviews with nurse managers revealed concerns related to the MOHLTC’s proposal development and funding timelines, and similarly provided valuable insight on potential organizational benefits and areas for improvement in retention strategies. Descriptive analysis will be conducted on emerging areas of interest, such as nurse involvement in hospital affairs and a supervisory staff that is supportive of nurses. The NHSRU will continue to evaluate survey and interview results to determine the characteristics of successful LCNI projects and retention efforts.

Evaluate Nurse Staffing Changes, Quality Work Environments and Health Outcomes for Better Information and Care (HOBIC)

This study has been developed to collect the expert opinions of nurse executives and leaders across Canada on workplace interventions that effectively promote healthy work environments and positive nurse outcomes. The evaluation builds on the systematic literature review conducted by Doran, Almost and Mildon (2010) and applies a Delphi methodology to facilitate the development of consensus among the expert panel on the specific strategies believed to be most effective and most feasible in healthcare settings. Round 1 data collection of the online survey is complete and the responses are currently being used to develop a second round of surveys. The final results will provide consensus-driven recommendations on the best interventions for improving working conditions and maintaining healthy workplace environments for nurses.

Transition Patterns of Nurses Across Health Sectors (Specialist Nursing)

Specialist nursing roles may provide a career pathway suitable for retaining nurses who wish to pursue career advancement opportunities while maintaining a clinical practice focus. Utilizing the College of Nurses of Ontario (CNO) Registration Database, the study is exploring the types and characteristics of specialist nurses throughout Ontario, and the transition patterns of specialist nurses across health care sectors, including exit rates by sector and demography. The project will determine whether exit rates vary for nurses who identify within a specialist role compared to nurses who identify as general registered nurses.

Primary data is currently being collected from specialist and non-specialist nurses registered with both the Canadian Nurses Association and the CNO to explore issues influencing professional development, job satisfaction, and intention to remain in nursing across the two groups. This research is expected to have policy implications with regard to specialist nursing roles as a career pathway and strategies for retaining nurses in clinical practice roles within Ontario’s healthcare system.

The Scope of Practice for Nurses Working in Correctional Facilities in Ontario: A Pilot Study of an Educational Intervention to Optimize Practice

A two-year project is underway to examine the scope of practice and practice needs of nurses working in Ontario correctional facilities, and to tailor an educational intervention for practice development to the realities of this work environment. The previous MOHLTC-funded study “Exploring Worklife Issues in Provincial Correctional Settings” generated significant interest and led to some revised processes for nurses working in correctional settings. In the current study, nurses and managers from three correctional facilities are being interviewed and surveyed about nurses’ scope of practice, practice needs and factors that influence their ability to practice to their full scope. Based on the priorities identified by the nurses, an educational program will be developed and pilot tested at three correctional facilities. Sites with access to a telemedicine network were selected as the initial focus of this project so that e-learning strategies could be used if appropriate. This study will generate information and innovative solutions to addressing practice and learning needs specific to correctional nurses.

New Publications

Latest Fact Sheets/Research in Action

McMaster University site:

Research in Action: Current Projects

Workforce Integration of New Nurses: Exploring Employment Goals, Expectations, and Intent to Migrate of Nursing Graduates in a Canadian Border City

Evidence Note on Workforce Integration

University of Toronto Site:

Journal Articles

McMaster University site

Baumann, A., Hunsberger, M., & Crea-Arsenio, M. (In Press). Workforce Integration of New Graduate Nurses: Evaluation of a Health Human Resource Employment Policy. Healthcare Policy.

Freeman, M., Baumann, A., Blythe, J., Fisher, A., & Akhtar-Danesh, N. (In Press). Migration: A concept analysis from a nursing perspective. Journal of Advanced Nursing.

University of Toronto site:

Newman, K. & Doran, D. (in press). Critical care nurses’ information-seeking behaviour during an unfamiliar patient care task. Dynamics: The Official Journal of Critical Care Nurses.

Clarke, S.P. (2011, in press). The future of nursing workforce research [Guest Editorial]. Journal of Research in Nursing.

Doran, D.M., Mildon, B. & Clarke, S. (2011). Toward a national report card in nursing: a knowledge synthesis. Canadian Journal of Nursing Leadership, 24(2), 38-57.

Meyer, R. M., & Clarke, S. P. (2011). Shifts with nurse understaffing and high patient churn linked to heightened inpatient mortality risk in a single site study. Commentary on: Needleman, J., Buerhaus, P., Pankratz, V.S., Leibson, C.L., Stevens, S.R., & Harris, M. (2011). Nurse staffing and inpatient hospital mortality. New England Journal of Medicine, 64(11), 1037-1045. Evidence Based Nursing. Advance online publication. doi: 10.1136/ebn.2011.100052.

What’s New?

Social Media Alert

The NHSRU has a twitter account as @NHSRU, sign-up as a follower and we will update you when our latest research is posted on www.nhsru.com

MOHLTC Showcase December 1, 2011

The NHSRU participated in the 2011 Health Research Showcase on December 1, 2011. The showcase is a learning and knowledge exchange opportunity for Ontario’s research community to explore leading-edge health research innovations and advance quality across the health care system. The audience for the event included senior ministry staff, senior staff from other areas of the Ontario Public Service, representatives from Local Health Integration Networks, research institutions and members of the broader Ontario health sector.

McMaster University site:

Investment in Health Research: A Strategy for Building Nursing Research Capacity in Ontario

The NHSRU McMaster site held an educational showcase and dialogue on Investment in Health Research: A Strategy for Building Nursing Research Capacity in Ontario on November 3, 2011. The McMaster site of the Nursing Health Services Research Unit (NHSRU) did an evaluation on its unique undergraduate student intern model for research capacity building. Debra Bournes, Provincial Chief Nursing Officer was the keynote speaker. Several of the past student interns participated on a panel to share how their experience as a student intern with the NHSRU influenced their career path.

Expo exhibit

The NHSRU McMaster site hosted an exhibit on the Internationally Educated Nurses Employer’s Guide, at Leading Healthcare Quality Summit & Innovations Expo on November 9th. This year’s event focus was showcasing leadership in quality improvement in Ontario.

University of Toronto site:

Mobile Health Symposium: Imagine the Possibility of M-Health Technologies

Dr. Irmajean Bajnok giving a demonstration of the RNAO Best Practice Guidelines at the Mobile Health Technology Cafe.

Dr. Frank Knoefel and Dr. Rafik Goubran from Carleton University demonstrate their model of real-time transfer analysis from a sensor mat data on a BlackBerry device.

Dr. Diane Doran and the NHSRU hosted a one-day symposium on mobile health technologies on October 17, 2011. This event featured an interactive Technology Café for industry partners, health care providers and researchers to exchange information about mobile health innovations. Topics on mobile health addressed through a panel discussion and presentations included

Development of intelligent home systems for elder care and health wellness
Innovative technologies that enhance health and dignity of people with disabilities and their caregivers
Adaptive tools for nurses and clinical applications

For full event recap and PowerPoint Presentations, visit the Mobile Health Symposium webpage.

The Canadian National Nursing Quality Report Initiative

The Canadian National Nursing Quality Report initiative is envisioned as a selected minimum set of input, process, and output indicators that can be collected nationally across the continuum of care. The indicators will be available through dashboard applications in healthcare institutions, and be benchmarked and used to influence policy directions for nursing to improve client outcomes in all care settings. In the fall of 2010, the Academy of Canadian Executive Nurses (ACEN) Leadership/Policy Committee made the decision to focus on nurse sensitive indicators to make explicit the contribution of nursing to quality health outcomes, as well as to envision a report card that could be used to formulate policy and examine the delivery of nursing services and the outcomes achieved by those services.

To date, funding proposals have been submitted for: 1) a project to apply a consensus building methodology on a set of nursing quality indicators for the National Nursing Quality Report in Canada, and to develop a dashboard template based on the indicators that achieved consensus; and 2) implement a national dashboard of nurse sensitive indicators and evaluate the use of these indicators to impact selected quality outcomes, with the ultimate goal of launching a National Nursing Quality Report in Canada that is cross sectoral.

Health Care Trends and Priorities Discussion Group

The NHSRU, under the lead of Deputy Director Dr. Sean Clarke, has initiated a health care trends and priorities discussion group to actively scan the environment to understand the future of Nursing Health Services Research. The group, consisting of fellow researchers and graduate students, meet periodically to share details on major publications or events attended that address the state of health care delivery and the health care workforce. This informal, high level discussion is expected to help inform the planning of new research projects and the dissemination of existing ones.

The NHSRU held a discussion group this November in conjunction with a site visit from the Provincial Chief Nursing Officer, Dr. Debra Bournes, and partner investigators from Queen’s University, the University of Western Ontario and the University of Toronto.

On The Road (presentations, webcasts, podcasts)

McMaster University site:

November 1, 2011. Andrea Baumann. Environment of Work and Care, Canada’s Virtual Forum on Patient Safety and Quality Improvement. Edmonton, Alberta.

November 17, 2011. The Changing Nature of Nursing Work: Implications for Quality Care, Andrea Baumann is the Marion Woodward Lecturer, UBC, and School of Nursing

Dec. 15, 2011. Research to Policy Dialogues, Andrea Baumann will present Getting new nurses into the workforce in Ontario: Strategies for effective integration and Diane Doran will present Health care delivered to your door: Investing in home care nursing to create a sustainable healthcare system.

University of Toronto site:

May 29- June 1, 2011. A Formative Evaluation of a Clinical Information System for Community Nursing. E-Health Conference. Toronto, Ontario.

June, 2011. Safety at Home: A Pan Canadian Home Care Safety Study. Canadian Patient Safety Institute. Presentation to Knowledge to Action Steering Committee. Ottawa, Ontario.

October, 2011. Social capital and relational coordination in outpatient clinics. International Nursing Administration Research Conference. Denver, CO

Interim Report: Home Care Nursing Health Human Resources – Building and Sustaining a Quality Nursing Workforce

Posted on December 12, 2011 by mkoh

Research Team

Diane Doran, RN, PhD, FCAHS
Dan Laporte, Research Manager, NHSRU
Sang Nahm, Data Analyst, NHSRU
Laureen Hayes, Research Officer,
NHSRU Roshan Khan, Research Officer, NHSRU

Executive Summary

Ontario faces enormous health care challenges driven by realities that include: a shortage of nurses, an aging workforce, issues in inter-professional care, advancing technologies, increasing patient complexity, and a need for chronic-disease management. Underlying all of this is a recognized concern about the available supply of the nursing workforce and projected shortages of Registered Nurses in Canada of almost 60,000 full-time equivalents (FTEs) by 2022 (Tomblin Murphy, 2009). Effective strategies are needed to address the impending nursing shortage, particularly in sectors such as home care and Long-Term Care (LTC), where demand for health care is expected to increase and where disparities in nursing services supply and demand have been the most glaring. Furthermore, new possibilities in service delivery are being created, through the Ontario provincial government’s Aging at Home (AAH) strategy (MOHLTC, 2009), which emphasize community-based partnerships and an integrated continuum of services. Researchers, home care nurses, nurse leaders and policy makers need to work together to generate the evidence required to support the goals of effective chronic disease management and improved outcomes for Ontario’s diverse population.

This study was designed to generate evidence about effective strategies for recruiting and retaining home care nurses and sustaining home care nursing capacity, in order to meet the health needs of Ontario’s diverse population. It is the researchers’ intention that the findings of this study will assist with creating solutions for attracting nurses to under-resourced areas by improving the prospects for rewarding, long term employment for home care nurses through the creation of policy change. A second goal of this applied research project is to inform policy decisions, through valid research, about effective strategies for optimizing the utilization of RNs and RPNs in community practice settings.

The primary objectives of the study currently underway at the Nursing Health Services Research Unit (NHSRU) are to:

Determine how decisions, on the utilization and allocation of Registered Nurses (RNs) and Registered Practical Nurses (RPNs), are currently being made in Ontario home care provider agencies; investigate the feasibility of, and provide input into, the development of an RN/RPN Utilization Toolkit for the home care sector.
Compile a detailed demographic profile of nurses working in the home care sector and identify areas of concern/strength related to current trends in the home care nursing workforce.
Evaluate the unique challenges of attracting and retaining early, mid and late career nurses to the home care sector and describe factors or policy initiatives that may be instrumental in attracting new graduates to community nursing as an employment choice.

To date, researchers have completed a detailed demography of visiting home care nurses working in Ontario, and are in the process of administering surveys to a stratified sample of 900 early, mid and late career nurses in this sector. Concurrent with the survey administration, interviews with a sample of home care (HC) decision makers are being conducted by NHSRU staff. Interview questions have been developed to address issues associated with the allocation and utilization of RN/RPNs in Ontario’s home care settings.

View Full PDF Report

Mobile Health Symposium: Imagine the Possibilities of M-Health Technologies

Posted on November 9, 2011 by mkoh

Mobile Health Symposium

Mobile health technologies can transcend the boundaries of health care delivery limitations, and fill gaps in health care services as demands increase. An aging population and overstrained health care resources are realities Canadians face in coming years. Innovative thinking and collaboration across sectors to support ideas from conception into practical application is taking place across Ontario, to address health care needs.

On October 17, 2011, the Nursing Health Services Research Unit at the University of Toronto and Lawrence S. Bloomberg Faculty of Nursing Professor Dr. Diane Doran hosted a one-day symposium to explore the current state of mobile health technologies developments for promoting safer patient care, and potential use for the future. This Mobile Health Symposium “Imagine the Possibilities of M-Health Technologies” featured collaborative research across sectors between nursing, medicine, engineering, human geography and computer science, as well as partnerships with the IT industry.

Some examples of innovations developed by researchers and partners presented during the symposium included use of an iPhone application ‘bant’ to manage diabetes, use of a pressure sensitive bed mat to monitor the mobility of home care clients in bed and while getting in and out of bed , a hand hygiene sensory system linked to electronic badges, and an intelligent cognitive device ‘COACH’ to support health and wellness of older adults living at home.

Scientific Technology Café

Dr. Diane Doran with industry partner HInext

The symposium also featured an interactive Technology Café to allow participants to experience live demonstrations of the mobile health innovations in rotating small groups. Industry partners such as IT firms HInext and CellTrak, and researchers were able to showcase their products developed through collaboration. Drs. Rafik Goubran and Frank Knoefel from the Department of Engineering and Design at Carleton University demonstrated a sensory bed mat that can be placed under a regular bed mattress to monitor sleep. Other café stations demonstrated software developed to facilitate communication, care planning, and access to best practice guidelines at point-of-care.

Plenary Sessions

Dr. Joseph Cafazzo

Dr. Joseph Cafazzo Assistant Professor in the Department of Health Policy, Management and Evaluation, and the Institute of Biomaterials and Biomedical Engineering, Faculty of Medicine (U of T), gave a keynote address on the role of m-health in self-care. He led a research team to develop the iPhone application ‘bant.’ ‘bant’ was designed to help adolescents with diabetes to self-manage their blood glucose levels. While other diabetes applications function mostly as log books and are only available in English, this application is unique in that it is available in multiple languages and it collects data wirelessly from glucometers and uses prompts to help teens identify changes in treatments or self-management behaviour.

Instead of passive logging of blood sugar, ‘bant’ encourages active self-monitoring through teaching prompts and reward incentives such as earning iTunes dollars. For instance, the application can detect a trend of a series of low lunch readings affecting blood sugar levels, prompting the user to select options such as “adjust basal ??” or “change ratio” to stop the low trend from continuing. The application also helps teens to form a community by linking to social networking media such as Twitter. The application was pilot tested at the Hospital for Sick Children with 20 adolescents. Results indicated that users were satisfied with system, and nearly all indicated that they will continue to use the application. ‘bant’ currently has approximately 5000 active daily users, with growing numbers around the world.

Dr. Alex Mihailidis

Dr. Alex Mihailidis, Research Chair in Rehabilitation Technology at the University of Toronto and Associate Professor at the Department of Occupational Science and Occupational Therapy and in the Institute of Biomaterials and Biomedical Engineering (U of T) led a research team in developing the Cognitive Orthosis for Assisting Activities in the Home (COACH). COACH has been developed to track older adults living at home, many of whom have dementia, to improve their safety. COACH is built into homes and provides clients with cues as necessary such as to turn off the tap, and a hands-free personal emergency response system such as calling an ambulance or caregiver when a client has fallen. Research trials have shown that the system is effective in providing assistance to users. Future steps include further work to refine and personalize the system, and move towards commercialization.

Dr. Peter Rosso, Chief Medical Information Officer at University Health Network (UHN) and Associate Professor of Medicine at University of Toronto discussed the requirements of m-health technologies in the acute care setting, the adoption of current technologies, and next steps in acute care m-health solutions. Improved clinical communication to improve patient safety was the overarching benefit of using m-health technologies in acute care. Dr. Rosso reviewed communication flow at UHN and the current challenges of using mobile devices to determine critical factors to successfully implement mobile health solutions in the acute care setting. Key success factors include ease of access and use, acceptable response time, inclusion of required functionality, meeting security requirements and available support on a long-term basis.

Dr. Geoff Fernie, Vice President of Research at the Toronto Rehabilitation Institute with cross appointments at several departments in the University of Toronto including the Department of Surgery and Department of Mechanical and Industrial Engineering, presented his research on solving the age-old problems of inadequate hand hygiene. His team devised a sensory tool to monitor and support hand washing in clinical settings by sending light and vibration prompts to electronic badges worn by clinicians and patients.

Dr. Diane Doran, Scientific Director of the Nursing Health Services Research Unit, University of Toronto site, presented her research study investigating the integration of bio-mobility information obtained through remote monitoring with decision support technologies to support safer client care. Her study determined the types of useful client data for case managers and an appropriate prototype display of information. Client data were collected from a non-intrusive monitoring system included a pressure-sensitive mat that was placed under a regular bed mattress to monitor a person’s mobility and time spent in bed and a GPS-equipped BlackBerry to monitor a person’s mobility outside of the home. Phrase two of the study included development of the prototype web-based platform with industry partner HInext and the evaluation of the usability of the system in a live community setting through a pilot field study. Results indicated that the client in the field study was able to learn more about his/her health status and was able to be actively involved in planning care. The client also perceived that the system had the potential to enhance home care safety, especially for older adults. Home care clinicians perceived the system to be helpful in developing individualized care plans and in making informed decisions about client care. Overall, the system was perceived as an excellent communication tool to facilitate inter-professional collaboration.

The Past, Present and Future of Mobile Health Technologies

(Left to Right) Dr. Irmajean Bajnok, Dr. Frank Knoefel, Dr. Rafik Goubran, Mrs. Cheryl Reid-Haughian and Panel Moderator Dr. Lynn Nagle

The day ended with a discussion of the past, present and future of mobile health technologies with panelists Dr. Frank Knoefel and Dr. Rafik Goubran from Carleton University, Dr. Irmajean Bajnok from RNAO, and Cheryl Reid-Haughian from ParaMed Home HealthCare.

Panel moderator and Lawrence S. Bloomberg Faculty of Nursing Associate Professor Dr. Lynn Nagle referred to current news headlines, including the vision and legacy of Apple founder Steve Jobs, to incite comment from the panelists about the importance of innovation and the tremendous progress that has been made over the years.

Overall, while there was consensus that mobile health technologies cannot fully take over the role of health care clinicians and the social impact of technologies needs be studied to determine negative outcomes, the day’s discussions indicate that there is pervasive consumer demand for such technologies

The possibilities of adapting technologies to meet health care needs are infinite. This symposium clearly demonstrated the human ability to innovate, collaborate and develop technology that was considered impossible in the recent past. In the future, further collaboration between researchers across health care, engineers, computer science sectors and health care decision-makers and end users, will continue to improve and humanize mobile technologies into further real-life application. As m-health technologies evolve, so will approaches to health care from the current reactive approach to a more proactive approach that anticipates needs and interventions to improve health outcomes.

Speaker PowerPoint Presentations

Patient, heal thyself The Role of mHealth in Self-Care (Dr. Joseph Cafazzo)

Intelligent Systems and Homes to Support Health and Wellness of Older Adults
(Dr. Alex Mihailidis)

m-Health@Point of Acute Care: Leaving the Trenches? (Dr. Peter G. Rossos)

Integration of Bio-physiological information with a point-of-care decision support system for safer patient care (Dr. Diane Doran)

The Past, Present and Future of Mobile Health Technologies (Dr. Irmajean Bajnok)