Tag Archives: Baumann

Series Report #28 Ergonomic Program Implementation Continuum (EPIC): Integration of Health and Safety – A Process Evaluation

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Authors: Baumann, A., Holness, L., Norman, P., Idriss-Wheeler, D., & Kaba, A.

Executive Summary

The Public Service Health and Safety Association (PSHSA), formerly the Ontario Safety Association for Community & Healthcare (OSACH), recently developed a unique approach to the prevention of musculoskeletal disorders (MSD) and slips, trips and falls (STF) for staff, clients and the public.  The Ergonomic Program Implementation Continuum (EPIC) is the first of its kind in Ontario and provides vital information and guidance to employers and employees. The Ontario Neurotrauma Foundation (ONF) and PSHSA conducted a pilot project to evaluate EPIC as a “best practice in the health and community care sector”. Limitations aside, all sites indicated that EPIC benefited their organization. The program was structured but flexible enough to address the unique needs of each organization. In particular, the program supported the inclusion of frontline staff in reducing hazards and improving their work environment.

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Forecasting Future Workforce Demand: A Process Evaluation

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Authors: Baumann, A & Kolotylo, C.

Executive Summary:

Funded by the Nursing Secretariat, Ontario Ministry of Health and Long-Term Care, the Forecasting Workforce Demand Project is a demonstration of health human resources (HHR) planning. This study focuses on the implementation and evaluation of the Forecasting Future Workforce Demand Tool (the Tool) developed by The Advisory Board Company (2007a, b). It was hypothesized that implementation of the Tool would enable hospitals to enter historical workforce data to create oneto fi ve-year forecasts for proactive HHR planning and strategy development.

The participant organizations consisted of five hospitals: three teaching, one community, and one rehabilitation and complex continuing care. The organizations and the Ontario Hospital Association sought to address a gap in the provincial healthcare system and contribute to strategic HHR planning. Initially a one-year project, permission was obtained to use the Tool for a second year. The organizations that participated in year two were the same as in year one.

The sample for the organizations varied to meet the needs of each site. Two teaching hospitals and the rehabilitation hospital chose nursing and allied health disciplines as their forecasting groups, the other two organizations chose only nursing. While focused efforts were made to improve consistency in implementation, consideration was given to the unique setting of each organization in order to generate relevant fi ndings.

This project is the fi rst of its kind in Ontario to use a forecasting tool as a standardized approach to human resource (HR) planning across healthcare organizations.
Key findings include the approach to HR planning varied across organizations, it takes time to collect and enter the data elements, and standardized defi nitions are critical to accuracy and applicability. Another key fi nding was that organizations vary in how they store data and how they code employees.

The Tool was a systematic method for data collection. It captured historical data and was useful for pre-planning and identifying trends. However, historical information became less valuable when there were major changes in the organization. The Tool breaks forecasting down into fi ve easy steps and provides user-friendly tools to assist the organization. In addition, client support is offered by The Advisory Board Company.1

All participants agreed it was a useful process and that the exercise provided insight both into comparability of data and organizational differences in HR data collection and storage. The company has moved from an Excel-based application to a web-based format that may be more convenient, but all data in this format will be stored in the United States. Organizations would need to explore any implications this might have for privacy and data protection.

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Nurses in Public Health in Ontario

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Authors: Underwood, J., Baumann, A., Deber, R., & Dragan, A.

The total number of nurses employed in public health in Ontario has been remarkably stable over the past decade. This fact sheet analyzes the yearly registration data provided by the College of Nurses of Ontario (CNO) for 1993 to 2009 to clarify the supply trends as well as the age, and registration profile of nurses who work in public health. It updates the 2007 fact sheet on Nurses in Public Health in Ontario.

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A Questionnaire for Assessing Community Health Nurses’ Learning Needs

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Author(s): Akhtar-Danesh, N., Valaitis, R., Baumann, A., Underwood, J., Schoenfeld, R., Martin-Misener, R., & Kolotylo, C.

Publication: Western Journal of Nursing Research, August 11, 2010.

Abstract

Key Messages: Learning needs assessment is an important stage of every educational process that aims to inform changes in practice and policy for continuing professional development. Professional competencies have been widely used as a basis for the development of learning needs assessment. The Canadian Community Health Nursing Standards of Practices (CCHN Standards) were released in 2003. However, it is not known whether community health nurses (CHNs) have the educational background to enable them to meet these standards. This article reports on the development of a learning needs assessment questionnaire for CHNs. Exploratory and confirmatory factor analyses were conducted to examine the consistency of factors underpinning the CCHN Standards. Also, validity and reliability of the questionnaire were evaluated using appropriate techniques. This process resulted in a valid and reliable CHN learning needs assessment questionnaire to measure learning needs of large groups of practitioners, where other forms of measurement cannot be feasibly conducted.

The Definition of Underserviced: Policies, Issues, and Relevance

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Authors: Blythe, J., & Baumann, A.

Executive Summary:The paper begins by clarifying two terms: shortage and underserviced. Provincial and federal programs for underserviced areas in Ontario are then described and considered in terms of their relevance to nursing. Policies to address issues of shortage and underserviced areas are discussed, followed by recommendations for the future.

The terms shortage and underserviced are two perspectives on the same phenomenon. Shortage denotes inadequate numbers and is used when the supply of human resources is insufficient to meet demand (Unruh & Fottler, 2005). It refers to deficits at macro (national) and micro (organizational) levels and is used by the media to discuss shortfalls in nursing supply, particularly in hospitals. Underserviced (or underserved) denotes locations with perceived disparities in access to health care services (Barer, Wood, & Schneider, 1999). It is used to describe deficits in physician services based on physician-to-patient ratios. Communities are not considered underserviced for nurses because, unlike family physicians, most nurses do not provide services as independent practitioners. There are practical and methodological problems associated with measuring shortages and designating underserviced areas.

Most programs for underserviced areas in Ontario are for physicians, but the Ministry of Health and Long-Term Care (MOHLTC) also provides incentives for medical specialists and rehabilitation professionals. Other Initiatives by the Ontario government are aimed at improving access to primary care in underserviced areas through involvement of a range of professions and better integration of physician services into the community. Family Health Teams and increased investment in nurse practitioner (NP) educational programs are examples of such strategies.

Since regulated in 1998, NPs have had an established role in underserviced areas. It is vital to know whether they are being effectively recruited, retained, and utilized. Many NPs currently work in non-NP roles. However, anecdotal evidence suggests there are as many as a 100 vacancies for NPs in programs funded by the MOHLTC. Details of these vacancies are difficult to establish because aggregated vacancy data from these programs is unavailable. It is important to establish the exact number of vacancies and the reasons for their persistence.

Shortages within professions tend to be generalized rather than discussed in context. This means that the supply problems of smaller sectors (e.g., home care, public health) are not differentiated from those of larger sectors (e.g., acute care), and shortages in rural areas are not differentiated from those in urban centres. Differential shortages by specialty are acknowledged The Definition of Underserviced: Policies, Issues, and Relevance 3 but not well studied. The advantage of the term underserviced is that it directs attention to local variation. Focus on family physicians makes it difficult to assess health care delivery in underserviced areas. Information about local shortages among all health care workers is required.

Problems associated with underserviced areas include intractable physician shortages and overemphasis on a single type of health care service provider. Primary care characterized by independent physician practice leaves many without access to services. Implementing Family Health Teams may improve this situation, but other interventions may be needed.

Recommendations

Recommendations for health human resource planning for underserviced areas are:
• Broaden the scope of underserviced to include a range of health care services (e.g., longterm care, home care, public health) rather than restricting it to the services of selected health care professions (e.g., physicians).

• Expand the concept of shortage to identify regional, local, and specialist nursing shortages.

• Take a systemic rather than discipline-based approach to local health care.
For example:

o Create or expand collaborative organizations and networks (e.g., Family Health Teams, community health centres) for health care delivery in underserviced areas.

o Maximize the contribution of all professions with relevant competencies who are available to deliver health care services in local communities.

o Collect and organize statistical data on health professions and health services to facilitate planning health care delivery in the new Local Health Integration Networks (LHINs).

o Consolidate data about NP vacancies in a central MOHLTC repository for analysis and action.

• Construct profiles of health care services and delivery within each LHIN, including information on communities and catchment areas, health care organizations, partnerships, and alliances.

• Explore health human resource capacity in the newly established LHINs using the concepts of underserviced and shortage. For example, assess which communities within each LHIN are underserviced based on how easily residents can access health care services and whether health human resource shortages contribute to access problems.

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Educated and Underemployed: The Paradox for Nursing Graduates

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Authors: Baumann, A., Blythe, J., Cleverley, K., Grinspun, D., & Tompkins, C.

Executive Summary:

There are three sources of nursing supply: new graduates, internationally educated nurses, and nurses returning to the workforce. This report focuses on the supply and employment of new nursing graduates in Ontario and their absorption into the workforce during the two-year period covering 2003/4 to 2004/5. Historically, economic cycles have created fluctuations in supply and demand. Between 1993 and 1999, Ontario lost 7275 nurses from the system. This was largely in the hospital sector which lost 9.8% of its nursing workforce. The loss was fi nally recouped by 2003, mainly through growth in the community sector (Alameddine et al., 2006, in press).

There are currently 89,054 registered nurses (RNs) and 24,482 registered practical nurses (RPNs) working in Ontario (College of Nurses of Ontario, 2005). The largest potential employer of new nurses is the hospital sector with 24/7 service and over 31,000 patient beds. Other sectors such as community and public health are much smaller. The uptake of new graduates in Ontario is good. However, some concerns arise from market conditions and the availability of receptor sites (i.e., sites where jobs are available at a given point in time). Job opportunities are unpredictable in areas with few health care institutions. Organizations should have suffi cient annual turnover and a relatively large system to absorb new employees (Baumann, Keatings, Holmes, Oreschina, & Fortier, 2006). Employment opportunities are aff ected by economic booms and turnover resulting from retirement, job change, and workers leaving the profession or moving between sectors. Th e education system functions with relative independence from the employment market. There are no projections of required supply. From 1999 to 2004, the number of graduates in Ontario doubled, but the supply was dramatically reduced by more than half in 2005.

A survey of RN and RPN graduates in Ontario was conducted in 2004 and 2005.
The majority who responded to the surveys indicated they wanted full-time work. However, most of the contract off ers they received were part-time, casual, or temporary. Although there was a 9% increase in employed nurses with full-time status between 2004 and 2005, this may have been due to the small number of students graduating that year rather than the greater availability of fulltime work. The majority of new graduates sought employment in the central region and preferred employment in large teaching hospitals. Fewer favoured the community and public health sectors. Actual employment corresponded with these preferences.

Resurveys at six months and two years after graduation indicated that few graduates had left Ontario for employment, despite their stated intent or willingness to do so. Just over half of those who replied to the two-year follow-up of 2004 graduates had full-time contracts. Over half indicated that their employment had changed since graduation (usually from casual to full-time), suggesting that new graduates experience considerable job mobility in their first years of employment. The government of Ontario has implemented a targeted employer incentive to increase the number of full-time nurses. In addition, on May 8, 2006, a new provincial task force was created to examine the issue of full-time positions for new graduands. Other provinces have strategies to improve uptake and increase retention such as bursaries, loan forgiveness, and mentorship.

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Registered Nurse and Registered Practical Nurse Decision Making

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Authors: Boblin, S., Baxter, P., Alvarado, K., Baumann, & Akhtar-Danesh, N.

Executive Summary:

Nursing is the largest human resource expenditure for many departments, and the necessity for articulating nursing work and differentiating between levels of knowledge and skills required has become paramount. In Ontario, nursing is one profession with two categories of registration in the general class – the Registered Nurse (RN) and the Registered Practical Nurse (RPN). Both the RN and RPN are governed by the same regulatory body – the College of Nurses of Ontario (CNO), practice within the same Scope of Practice, and frequently work in similar settings. In some aspects, the roles and responsibilities of these nurses are shared; in other circumstances, they are considered distinct. One differentiation between RNs and RPNs is in the nature of the client population for whom care is provided: the RN cares for acute clients with unpredictable outcomes; the RPN cares for stable clients with predictable outcomes. The CNO has established standards of practice for nurses and competencies for entry-level practitioners, which may be interpreted differently by agencies and by individual nurses. The profession, regulatory bodies, and employers are struggling to differentiate between these nurse categories in their attempts to respond to changing client demographics, fiscal restraints, and shortages in nursing resources. Nursing decision making has been identified as one of the ways to differentiate between categories of nurses; this assumption, however, has not been thoroughly tested empirically. Work by Boblin, Baumann and colleagues (Baumann, Boblin & Deber, 2002; Baumann, Deber, O’Brien-Pallas, Donner, Mitchell, Boblin-Cummings & Mulkins, 1992; Baumann, Deber, Silverman & Mallette, 1998; Boblin-Cummings, Baumann, Deber, 1999; Boblin-Cummings, 1996) suggests ways that this might happen. Boblin’s work on implementation decisions and Baumann’s work on the development of an instrument to measure nursing decision making were combined within this study. This study identified and described nursing decision making. Nursing decision making, for the purposes of this study, included a) the Decision Making Process (how nurses make decisions); b) Nursing Interventions and Clinical Activities (what they make decisions about); c) Considerations Prior to Implementation (decisions about how to implement selected interventions); and d) Factors Influencing Decision Making. A combination of quantitative (survey), and qualitative (focus groups and document analysis) approaches were used. The survey identified and described decisions made by RNs and RPNs, determined the frequency that RNs and RPNs made these decisions, and described the difficulty perceived when so doing. It also investigated the influence of variables such as education, experience, and setting on these decisions. Similarities in and differences between RN and RPN decision making were revealed. The results of the survey were further explored through focus groups with nurses. Documents were reviewed to determine whether they captured the components of nursing decision making.

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Better Data, Better Decisions A Profile of the Nursing Workforce

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Authors: Baumann, A., Keatings, M., Holmes, G., Oreschina, E., & Fortier, V.

Executive Summary:Human resource data routinely collected by hospitals can be utilized in workforce planning, and for comparisons to provincial/territorial and national work forces. Of the various workforces in hospitals, nursing has the largest number of employees. The development and maintenance of hospital databases help planners monitor their workforces by better understanding their characteristics and dynamics.

 

The study of the Hamilton Health Sciences (HHS) human resource database revealed an interesting profile of the nursing workforce. On average, nurses at HHS were younger compared to those in the Ontario and Canadian workforces. Over the period of fiscal year 2002–03, the average age of the nurses decreased from 44 to 43 years of age. Recruitment of the younger age category (22–29) increased, but the majority of the new recruits worked part-time. The age profile differed across programs and services. Most nurses lived close to the hospital.

The overall number of nurses increased in all employment categories by over 9% in the fiscal year. The amount of overtime also increased, reflecting increased work intensity and absenteeism. An interesting finding was that there were low annual external turnovers coupled with a high retention rate. The vacancy rates decreased over the year, which supports the latter finding. Internal turnover rates were high due to job advancement or job changes available within the hospitals. Retention within the hospitals is good, with the average nurse being employed for approximately 14 years. The amount of overtime and absenteeism is high. Studies have attributed these findings as being a measure of the increased work intensity and historical staff reductions. In response, the overall nursing work force growth was twenty five percent over a period of a year with a nine percent increase in full time staff. Another interesting finding is the number of staff on unpaid leave. This is the type of data that is worth exploring further in order to develop an understanding of the characteristics of this group.

This data creates a profile of the nursing workforce, which is useful for projecting trends and estimating future requirements. At the corporate level, longitudinal examination over a series of years would demonstrate the relationship between the characteristics of the nursing workforce and the overall requirements for patient care. At the unit level, the data is helpful to examine human resource needs and fluctuations in the workforce characteristics. A human resource profile has many data elements and results from the input of a variety of sources and requires high standards of data entry and management. It is an important element of workforce planning, especially when it is supported by an information system with accurate statistical and research information.

Decision makers today have more data about the workforce than was available in the past. The main recommendation would be to produce a template that would provide a basis for comparison of the workforce for planning purposes. The required variables would have to be identified and analyzed both at the department and organization level on an annual basis. This data should be enhanced by comparing it to provincial and national data to provide insight into workforce trends. The collection and analysis of baseline data on workforce is an essential component of planning change. Ultimately this approach will facilitate planning, increase forecasting accuracy and strengthen recruitment and retention strategies.

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The New Healthcare Worker: Implications of Changing Employment Patterns in Rural and Community Hospitals

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Authors: Andrea Baumann, Mabel Hunsberger, Jennifer Blythe, Mary Crea

Executive Summary:Rural health care is changing. Following restructuring in the 1990s some small hospitals remained independent, while others reorganized as amalgamations and alliances. In 2004, Ontario was divided into 14 Local Health Integration Networks (LHINs) to create accessible, quality health care at a local level. Th is study was designed to gain an understanding of the impact on nursing work and the workforce. It focused on 19 rural hospitals in Local Health Integration Network (LHIN) 2 in South West Ontario, and examined how employment patterns have evolved. Th e study provides critical information to assist policy makers in understanding the rural context of nursing practice and the eff ect of government policies on workforce sustainability.

 

Lack of a standard defi nition of rural is a challenge, and data on rural human resources is limited. Th e only report that provides statistics on registered nurses (RNs) employed in rural Canada is for the years 1996-2000. Th is study, published in 2002 by the Canadian Institute for Health Information (CIHI), is now out of date. From 1994 to 2000, the number of RNs working in rural Ontario decreased by 2.32% and increased in urban areas by 0.22%. Th e rural nurse to population ratio declined from 73 to 70 nurses per 10,000 population, similar to the urban ratio of 69.9 (CIHI, 2002). Only 47% of rural nurses had full-time employment, compared to 54.8% of urban nurses (CIHI, 2002).

The study showed that nurses in rural practice are required to be generalists with a broad range of skills that equip them to stabilize critical patients. Th e transport of critically ill patients to tertiary care centres requires a high proportion of rural nurses to be profi cient in emergency care. Nurses refer to themselves as “being it” because they have few resources on site.

Staffing and scheduling in rural hospitals presents unique challenges because of the changing census and small staff pool. A high proportion of part-time nurses are necessary for scheduling fl exibility. Th e full-time to part-time ratio in this study was 46:54. Availability of nurses to meet contingent staffi ng needs is a problem because some part-time nurses have two or three employers. Nurses are called in when the patient census is high and sent home when it is low. This “just in time” approach to hospital staffi ng causes considerable stress to both nurses and managers.

Numerous strategies are being employed by managers to improve staffi ng and scheduling practices. Cross-training is commonly used, and nurses must have a broad range of skills to care for multiple types of patients. Some managers try to predict patterns of overtime and schedule extra shifts. Th e number of overtime hours worked in one year by RNs and registered practical nurses (RPNs) was 18,452.7 hours, which translates into approximately $750,000.00. Managers also introduced cross-site employment as a way to off er full-time employment and the opportunity for nurses to focus on one specialty area.

From 2002 to 2004, there were 243 nurses hired, but only 27% were new graduates. Of the nurses that left their organization during the same time period, 66 (30%) nurses retired and 153 (70%) resigned. Given the complexities of rural practice, nurses and managers in this study reported that more orientation for new hires was essential. Mentorship is diffi cult due to limited staff availability. Innovative strategies such as rehiring experienced post-career nurses to mentor and coach newly hired nurses are recommended.

Maintaining the competence of all rural nurses is essential owing to the isolation of their practice. Upgrading programs for nurses vary across hospitals. A uniform strategy across amalgamations, alliances and independent hospitals would help to coordinate access to educational resources. Educational requirements could be assessed at the LHIN level, and the use of available resources throughout the network optimized. Th e context of rural work environments should be a consideration in establishing safe working conditions. Concerns about violence and security are foremost in the minds of nurses, patients and the public. Various approaches are currently in use to facilitate nurse protection and police access. However, these systems are not standardized, and some hospitals have more security measures than others. Minimum standards are required for all hospitals. A continued challenge is the fi t between rural needs and government initiatives/policies. Th e study hospitals reported it is diffi cult to access programs such as the new graduate and mentorship initiatives. Obstacles include small staff numbers and limited resources available to apply for and implement the programs. A rural advisory panel is needed to assist the government to address specifi c, customized policies that refl ect rural context.

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Retention Strategies for Nursing: A Profile of Four Countries

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Executive Summary:

A seven-point framework was used to analyze retention strategies in four countries: Uganda, the United Kingdom, Canada, and Thailand. This framework draws upon available country data and includes GDP and investment in health, mix of private/public investment, international migration, health policy frameworks, countrywide strategies, provincial/regional strategies, and professional associations/regulatory bodies. Comparison of the countries demonstrated that progress has been made in nurse retention. The analysis showed that each country has made a considerable investment in health. All had a system of basic preventive and primary health care services, a significant acute care hospital sector, and low external migration of the general population. In addition, each had a comprehensive health policy framework in place and professional/regulatory bodies that reinforced the national strategies.

All the strategies addressed similar issues such as increasing nursing workforce numbers, role expansion of nursing aides, and a commitment to continuing education. Uganda and Thailand had strategies that included a salary plan for health personnel and professional development. In Canada and the UK, the national strategy filtered down to the regional level where other complementary policy frameworks exist. Both countries had specific human resources plans that focused on healthy workplace initiatives and strategies for improvement of nurse morale.

The report emphasizes the relationship between health investment, policy frameworks, the existence of professional associations, and the retention of nurses. Although some might argue that this is a loose association, the countries have been successful in retaining nurses. The sevenpoint framework is helpful as a means for countries to look at ways to stem the rate of external migration and the continual loss of a valuable health resource.

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Research Team

Andrea Baumann
Jean Yan
Jaclyn Degelder
Kamil Malikov