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Building the Future: An integrated strategy

for nursing human resources in Canada

CANADIAN SURVEY OF NURSES FROM

THREE OCCUPATIONAL GROUPS

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This report is part of an overall project entitled Building the Future: An integrated strategy for nursing human resources in Canada.

Canadian Survey of Nurses from Three Occupational Groups

© 2005 The work in this publication was provided to The Nursing Sector Study Corporation courtesy of/or under licence from the respective authors.

Publisher The Nursing Sector Study Corporation

Authors Linda O’Brien-Pallas, RN, PhD

Gail Tomblin Murphy, RN, PhD Heather Laschinger, RN, PhD Sara White, MA

Sping Wang, PhD

Cheryl McCulloch, RN PhD

Editor Judith Whitehead

Translator Les Traductions Tessier S.C.C.

Designer Fuse Communications and Public Affairs Inc. Project Management The Nursing Sector Study Corporation

99 Fifth Avenue, Suite 10 Ottawa, Ontario K1S 5K4 Phone (613) 233-1950

E-mail info@buildingthefuture.ca Website www.buildingthefuture.ca

Canadian Survey of Nurses from Three Occupational Groups (English, PDF) ISBN 0-9738050-8-0

Également disponible en français sous le titre :

Enquête auprès des infirmières et infirmiers des trois groupes professionnels au Canada (document en français, PDF)

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.

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Preface ...v

Executive Summary ...vi

1. Introduction ...1

2. Literature Review ...2

2.1. Literature Search ...2

2.2. Literature Background ...2

2.2.1. Nursing Workforce Mobility ...2

2.2.2. Professional Practice Environments, Empowerment, and Nurses' Job Satisfaction ....3

2.2.3. Continuing Education in Nursing ...5

2.2.4. Nurse Health and Safety Issues ...7

2.2.5. Lifestyle and Nursing ...8

2.2.6. Nurse Staffing and Patient Outcomes ...9

3. Research Questions ...11

4. Research Design and Methodology ...12

4.1. Survey Design ...12

4.2. Pilot Testing ...12

4.3. Sampling Process ...13

4.4. Full Sampling Distribution ...13

5. Data Analysis, Findings, and Discussion ...15

5.1. Data Analysis ...15

5.2. Instruments ...15

5.3. Data Limitations ...16

6. Descriptive Data Analysis Findings ...17

6.1. Demographic Profile of Respondents ...17

6.1.1. Unweighted and Weighted Sample Response Rates ...17

6.1.2. Age and Gender of Respondents ...17

6.1.3. Household Income, Marital Status, and Children Under the Age of 16 ...17

6.1.4. Education ...17

6.1.5. Registration ...18

6.1.6. Educational Support ...18

6.1.7. Nursing Employment Status ...19

6.1.8. Union Membership and Satisfaction ...21

6.2. Career Paths and Patterns ...22

6.2.1. Nurses Employed in Non-Nursing Jobs...22

6.2.2. Coffee/Meal Breaks over the Last Two Weeks ...22

6.2.3. Overtime in the Past Year...22

6.2.4. Reasons Keeping Nurses in Nursing ...23

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6.2.6. Nurses Who Would Recommend Nursing as a Career to Others ...24

6.2.7. Nurses Planning to Leave Present Nursing Position in the Next Year ...24

6.2.8. Nurses Planning a Career Outside of Nursing in the Next Year ...25

6.2.9. Reasons for Leaving Previous Nursing Job ...25

6.2.10. Reasons Why Nurses Are Considering Leaving Nursing ...26

6.2.11. Reasons for Working in Nursing Outside of Canada in Last Position ...26

6.2.12. Nurses Engaged in Educational Advancement ...26

6.2.13. Changes Made over the Past Two Years ...26

6.2.14. Changes Nurses Plan on Making in the Next Two Years ...27

6.2.15. Plans to Reduce or Increase Weekly Hours in the Next Two Years ...27

6.2.16. Required and Anticipated Changes Due to Restructuring/Reorganization or Anticipating Job Elimination ...27

6.2.17. Nurses Looking for Nursing Work/Specific Employment Roles or Status ...28

6.2.18. Job Seeking Across Sectors ...28

6.2.19. Factors Important in Obtaining a Full-time Position ...28

6.3. Professional Practice Environments, Empowerment, and Nurses' Job Satisfaction ...29

6.3.1. Worked Hours...29

6.3.2. Autonomy and Control, Conditions of Work Effectiveness, and Job Satisfaction ....29

6.4. Quality of Care ...32

6.4.1. Workload ...32

6.4.2. Perceptions of Quality of Care...32

6.4.3. Injuries and Medication Errors ...33

6.4.4. Interventions Not Completed or Delayed ...33

6.5. Lifestyle ...34

6.6. Health and Safety of Nurses ...35

6.6.1. Missing Work Days ...35

6.6.2. Workers' Safety Compensation Claims ...37

6.6.3. Safety Equipment ...37

6.6.4. Workplace Violence ...38

6.6.5. Sharps Injuries and Protective Devices ...38

6.6.6. Physical and Mental Health Measure - SF12v2 ...39

6.6.7. Percentage of Nurses Found to Be Physically and Mentally Unhealthy...39

6.6.8. Physical and Mental Health and Overtime ...40

6.6.9. Physical and Mental Health and Job Stability ...41

6.6.10. Physical and Mental Health and Reasons Why Planning to Leave Nursing...41

7. Multivariate Data Analysis ...43

7.1. Statistical Terms...43

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8. Multivariate Data Findings ...45

8.1. Career Paths and Patterns ...45

8.1.1. Plan to Leave Current Position Within the Next Year (2003-04) ...45

8.1.2. Plan to Leave Nursing Within the Next Year (2003-04) ...45

8.2. Professional Practice Environment Characteristics and Workplace Empowerment ...46

8.2.1. Resources ...46

8.2.2. Total Empowerment ...47

8.2.3. Nurse-Physician Relations ...47

8.2.4. Satisfaction with Current Position ...47

8.3. Quality of Care ...48

8.3.1. Quality of Nursing Care ...48

8.3.2. Quality of Patient Care...48

8.3.3. Intervention Not Done and Delayed ...49

8.3.4. Total Medical Incidences ...49

8.4. Health and Safety...50

8.4.1. Absence from Work ...50

8.4.2. Physical and Mental Health ...50

8.4.3. Workers' Compensation Claims ...51

8.4.4. Violence ...51

9. Summary of Findings ...53

9.1. Demographic Profile of Respondents ...53

9.2. Career Paths and Patterns ...53

9.2.1. Nurses Planning to Leave Their Current Position ...55

9.2.2. Satisfaction with the Current Position ...56

9.3. Professional Practice Environment Characteristics and Workplace Empowerment ...57

9.4. Health and Safety of Nurses ...58

9.4.1. Absence from Work Due to Injury...59

9.4.2. Nursing Work Index and Empowerment ...59

9.5. Nurse-Physician Relations ...61

9.6. Quality of Care ...62

9.6.1. Quality of Nursing Care ...62

9.6.2. Quality of Patient Care...62

9.6.3. Intervention Not Done and Delayed ...62

9.6.4. Total Medical Incidences ...62

9.6.5. Autonomy and Control, Conditions of Work Effectiveness, and Job Satisfaction ....63

10. Recommendations ...64

REFERENCES ...67

Appendix A. Stratified Sampling Formula ...78

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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 Futurewill 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 non-government 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 (registered nurse, licensed practical nurse, and registered psychiatric 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:

Together, we are committed to building a better future for all nurses in Canada and a better health system for all Canadians.

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 Homecare 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

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This research report focuses on a Canadian nationwide occupational survey of three regulated groups of nurses: registered nurses (RNs), licensed/registered practical nurses (LPNs), and registered psychiatric nurses (RPNs). The purpose of the research survey was to determine and describe the perspectives of nurses regarding factors in their work environments that influence the nature and effectiveness of their nursing care. Other related issues such as education, career, health, safety, lifestyle, and job characteristics were also explored. The report complements the Review of Concurrent Research on Nursing Labour Market Topicsto be presented as part of the overall research project Building the Future. A review of current research regarding nursing practice issues, their impact on job satisfaction, empowerment, retention, and quality of care provided a framework for the survey.

Research Procedures. The Nursing Occupational Groups Survey was designed based on original research questions and the related literature. Validity was established using the Content Validity Scale and the measurement instruments were tested for their reliabilities. English and French versions of the surveys, consents, etc., were submitted to ethics review boards, approved and then mailed to respondents.

Sampling and Distribution. A pilot study was conducted with the three occupational groups of nurses in the spring of 2003 with a response rate of 36.9%. A stratified sampling formula for each occupational group was developed. Two different mailings of the survey kits occurred in the fall of 2003, resulting in a total of 37,868 valid surveys mailed to respondents. Of these, 13,620 nurses completed and returned surveys, thereby resulting in an overall valid mail-out response rate of 36%.

Data Analysis. The quantitative data were analyzed with descriptive and multivariate statistics while the qualitative data were coded, organized, and patterns identified. All data responses were examined by sector (Community Health Service (CHS), hospital, long-term care (LTC), and “Other”), region (province or territory), occupational and age cohort groups. A variety of measurement instruments were used to examine work conditions and work satisfaction, empowerment, physical and mental health status, and career patterns. All instruments had been previously tested and had acceptable psychometrics properties.

Data Limitations. Certain data limitations, however, were present in this study. First, to

represent the true distribution of the nursing workforce in Canada, the responses were weighted. Second, the results in certain cases were limited due to lower response rates. Third, while the overall response rate for this study was in keeping with acceptable response rates from other nursing surveys in Canada, there were variations by nursing group and region. Fourth, translation of questions in the survey from English to French resulted in subtle differences in meaning for a few questions. Responses for these items were removed from the data set.

Demographic Findings. The aging of the nurses across Canada was apparent in this study. Over 70% of nurses were 40 years of age or older. Males were under-represented but about one fifth of the RPNs were men. The majority of nurses were married and one third of the nurses had responsibility for children under 16. Educational advancement in terms of university degrees was evident across the three groups. In terms of educational support, a slightly higher percentage of RPNs indicated provisions for continuing education at work. A disproportionately high number of LPNs in the Northwest Territories

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were employed, in both nursing and non-nursing areas. The majority of nurses worked in direct patient care. LPNs retained their current positions longer than RNs and RPNs. While LPNs had the highest number of nurses working casual hours, RPNs were more likely to be employed full time. The top reason cited by respondents for “not working full time” was personal choice. RNs reported more often that family responsibilities combined with full-time positions were overwhelming. LPNs reported that they were not working full time because positions were not available.

Career Choices and Patterns. Across cohort and nursing groups, altruism and caring remained the most important reasons for becoming a nurse and staying in nursing. Economic factors such as salary and job security were also identified as important. Altruistic reasons for staying in nursing were ranked higher than benefits across the three groups. Nurses reported the top change over the last two years as “changes made to their worked hours.” Increased weekly hours were noted across the three groups of nurses. However, at the same time similar numbers of nurses across the three groups told us they were reducing their weekly worked hours. A number of nurses had taken temporary leaves of absence (LOA) within the past two years. Changes in worked hours planned for the next two years, however, varied by employment status across the groups. Nurses reported that they were planning to reduce their hours to less than 40 per week. On the other hand, a larger number of part-time LPNs said they were planning to increase their hours to between 21 and 30 hours per week. Nurses said that they were looking for full-time employment in the area of direct care.

The major overall reason across occupational groups for leaving nursing was identified as retirement, reflecting the current demographics and projected trends in the future. Through regression analysis, when controlling for age as a factor, we found that older nurses and nurses with dependent children under age 16 were found to be less likely to leave their current positions. Additionally, the longer nurses were in their current job, the less likely they were to consider leaving. Conversely, new nurses (defined as registration with a provincial licensing body within the last three years), nurses with degree preparation, and nurses expecting job instability in the foreseeable future were more likely to consider leaving their current positions.

The stronger leadership was perceived to be in their organizations, the less likely nurses reported that they were planning to leave their current positions. Nurses were also less likely to leave if they were more mentally healthy and more satisfied with their current positions.

All nursing groups were experiencing increased overtime hours in the past year but involuntary unpaid overtime was the type with the greatest increase and had the largest negative impact. Nurses worked more involuntary paid overtime in 2002-03 compared to 2001-02.

Professional Practice Environments, Empowerment and Nurses’ Job Satisfaction.There was little overall variation on the Nursing Work Index across the three nurse groups. According to results from Conditions of Work Effectiveness Questionnaire-II (CWEQ-II), nurses felt they were less empowered when they worked in direct care, when they anticipated instabilities in their job, when their supervisor was a nurse, and when they were diploma prepared. Nurses in direct care generally perceived leadership to be weaker. Leadership in the workplace was perceived as weaker by nurses who worked overtime, who

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anticipated job elimination or position changes due to restructuring, and who had been in their current positions longer. The stronger leadership was perceived to be in the workplace, the more resources nurses perceived were available to them.

More effective nurse-physician working relations were perceived when nurses stayed in their current positions longer, had more autonomy, had more resources, perceived stronger leadership, or were more empowered.

Moderate to moderately strong relationships were found between the measures of professional practice environments, workplace empowerment, and job satisfaction. Empowerment was most strongly related to job satisfaction, autonomy, control over practice, environment, and leadership.

Nurses who expected job instability and had experienced violence at work were more likely to be dissatisfied with their current positions. The provision of educational opportunities by employers was more likely to lead to job satisfaction for these nurses. The more autonomy, work empowerment, and resources nurses had, combined with strong leadership present at work, the more likely these nurses were satisfied with their current positions.

Quality of Care. A third of nurses believed that the quality of patient care had declined over the past year (2002-03). Overall, the greatest percentages of nurses across all groups reporting on interventions that had not been completed on their last shift were working in the LTC sector. Common interventions reported as not done included vital signs, medications, dressings, mobilizations, and turns. In addition, the common interventions reported as being delayed on their last shift due to time constraints across all sectors and nursing groups were responding to patient needs and establishing therapeutic relationships with patients. Interventions that were not done were associated with nurses who had fewer resources, less work empowerment, and nurses who were over-utilized in busy work environments.

Nurses reported that interventions were delayed when they had fewer resources available, had changed shifts frequently, and had worked in over-utilization situations. The risks associated with medication errors were significantly increased when shifts were longer than 12 hours, when nurses worked overtime, or when they worked more than 40 hours per week. A higher number of patient incidences occurred when nurses worked overtime. Interventions not done or delayed were associated with increased incidences, such as patient falls, medication errors, etc.

Nurses’ perceived improved quality of patient care was associated with more resources, more effective nurse-physician relations, higher level of work empowerment, stronger leadership, and fewer intervention delays in the delivery of patient care.

Lifestyle. There were variations in lifestyle among the nurses. In general, RPNs reported healthier lifestyles than RNs, and RNs reported healthier lifestyles than LPNs. The factors associated with healthier lifestyles were regular exercise, satisfaction with their weight, and having a repertoire of strategies to deal with stress. RNs were the least likely to smoke among the three nursing groups. LPNs were the least

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likely to consume alcohol. Twice as many RNs and RPNs had seven or more drinks per week. This amount is above the recommended alcohol consumption level per week.

Health and Safety. Over 70% of nurses in Canada reported missing work days due to short-term illnesses with one to five days missed in the past year. Older nurses reported physical illness as the most common reason for missing work in the past year. Conversely, younger nurses missed days for mental health reasons. Nurses who were divorced, widowed, or separated were more likely to be absent from work than nurses who were married, whereas there was no difference between single and married nurses.

Nurses who preferred to increase their hours to full-time status were less likely to be absent from work while nurses who worked unpaid or paid overtime were more likely to be absent from work. Older nurses were less physically healthy than younger nurses, but they were more mentally healthy. Nurses with higher education (e.g., degrees) had better physical health, but education had no effect on nurses’ mental health. However, nurses who entered into nursing for altruist reasons had better mental health.

The number of Workers’ Compensation injury claims varied by occupational group, employment status, and sectors in terms of missed shifts related to injuries over the past year, 2002-03.

In terms of violence in the workplace, the most common type, regardless of the nursing group and sector, was verbal aggression. Reports of verbal aggression were experienced by nurses in each occupational group. Hospital RPNs, however, reported increased threats of assault as well as emotional abuse. Disturbing amounts of physical assault were experienced by all nurses in LTC, and by hospital RPNs. The source of violence in terms of aggressive behaviour was primarily the patient. Conversely, emotional abuse, more than any other type of violence, came from a source other than the patient, such as co-workers.

Work environments affected nurses’ physical and mental health. Nurses were less likely to be physically or mentally healthy when they worked involuntary overtime or preferred to reduce their work hours (from full time to part time or casual). Nurses were also less likely to be in good physical and mental health when there was violence at the workplace. Nurses who worked in direct care or those who anticipated job instability were less likely to be physically healthy. In addition, nurses who had frequent shift changes (more than twice within two weeks) reported poorer mental health.

After controlling for the effects of other factors, occupational group differences were noted: LPNs and RNs were less physically healthy than RPNs. Conversely, LPNs and RPNs were more likely to be mentally healthy than RNs.

An equal percentage of nurses who worked overtime in the past year were as healthy as those who did not work overtime. When nurses worked unpaid overtime, however, either voluntary or involuntary, the percentage of unhealthy nurses increased, particularly in terms of mental health status.

When job instability was present, the percentage of unhealthy nurses in terms of mental health was higher. In particular, RNs who were required to change units/locations in the last year reported the highest percent of mentally unhealthy nurses.

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When percentage distributions of nurses’ physical and mental health were calculated according to reasons they were planning to leave nursing, those nurses leaving the profession because of workload were less healthy than those leaving for other reasons.

Based on the evidence from this Canadian Nurses Survey, the following recommendations are presented:

Demographics

1) Increase the number of nurses across sectors with an emphasis on the creation of additional full-time positions by addressing cohort differences in preferred shifts and work status. 2) Provide options for older nurses to trade shifts with younger nurses to prevent exhaustion

due to shift work.

Career Patterns and Lifestyle

1) Examine the fit of the education and training of nurses with the realities of current practice environments to enhance recruitment and retention.

2) Develop creative work schedules and/or plan to balance nurses’ work life and family care commitments.

3) Foster leadership development across all areas of nursing and for all employment categories through leadership institutes and leadership practicums.

4) Understand the specific needs of nurses in different employment status categories regarding their continuing education needs.

Professional Practice, Empowerment, and Job Satisfaction

1) Provide adequate nursing resources so that nurses have manageable workloads to enhance patient safety, to prevent patient incidents, and to improve the health of nurses.

2) Place a moratorium on the use of overtime, as overtime (especially unpaid overtime) is increasing and has a negative impact on nurses’ health, patient care, and patient safety. 3) Focus on the development and measurement of nursing workload using common methods

across all sectors and work environments and develop and test productivity standards to enhance the quality of the work place and patient care.

4) Increase access to information, resources, and support in nursing work environments. 5) Support autonomous practice and control over working conditions to ensure that nurses are

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6) Foster collaborative working relationships among health care team members that communicate respect for the expertise and contribution of each to the overall patient care process.

7) Continue to focus on strategies to improve environments, particularly nurses’ sense of empowerment, and use nurses to their fullest capacity.

8) Maximize the scope of practice of nurses within all sectors and occupational groups. 9) Improve working conditions of nurses (including improving staffing and reducing workload

and role overload) through focusing on the development and measurement of work environment indicators and the testing of strategies to enhance the quality of the work place.

10) Involve nurses in decisions to manage staff workload and meet patient needs. 11) Provide appropriate ratios of nurses to patients to allow sufficient time to complete

workload and reduce non-nursing tasks.

Quality of Care

1) Support and increase research utilization for evidence-based approaches in administration, leadership, practice, and education.

2) Offer life and career counseling sabbaticals and access to recreation facilities and other mechanisms for stress reduction.

Health and Safety

1) Develop innovative health promotion strategies and conduct further research regarding the physical and mental status and lifestyles of nurses.

2) Create mandatory guidelines for all workplace environments regarding violence and aggression.

3) Enhance access to employee support programs and research best practice methods for disseminating support intervention groups for nurses.

4) Clarify and create ways to reduce violence and aggression in health care/workplace environments.

5) Minimize susceptibility of nurses to work-related injuries by redesigning ergonomically sensitive work spaces and by providing properly functioning lift equipment, as well as adequate staff support during patient mobilization, lifts, and transfers.

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General

1) Create and develop a central repository for nursing knowledge and databases in Canada that will facilitate easy retrieval and utilization of information in practice environments.

2) Continue to focus on strategies to improve environments and to use nurses to their fullest capacity in consideration of age cohorts, health care sectors, regions, and occupational groups. Areas that need to be the focus are:

a. Workload and Productivity b. Recruitment and Retention c. Innovative Scheduling

d. Salaries, Benefits, and Collective Agreements e. Maximizing Scope of Practice

f. Identifying Unique Attributes of Nursing Work and Contribution to Patient Care g. Fostering Leadership and Accountability Across All Nursing Positions and Groups 3) Explore ways that technology can enhance unique attributes of nursing work, as well as

reduce non-nursing activities.

4) Explore and address the unique challenges that nurses in LTC experience.

5) Work to better understand the supply and demand for nursing programs (formal and

continuing education) to address the changing roles of nurses and health care environments. 6) Address specific retention strategies to minimize early retirements, such as financial

incentives, pre-retirement education, and training; and improve pension benefits, part-time medical and retirement benefits, and flexible retirement initiatives.

7) Recognize that nursing is an endangered profession and without immediate action on the recommendations made above we will continue to see overall declines in the numbers of nurses and in the quality of care provided in Canada.

8) Begin Nursing Sector Study Steering Committee work to develop a think tank charged with the mandate of communicating these survey results to key Canadian health care decision makers and stakeholders.

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This report focuses on a nationwide occupational survey of members of the three regulated nursing groups: registered nurses, licensed/registered practical nurses, and registered psychiatric nurses. The purpose of the survey was to determine the perspectives of nurses in the workplace regarding factors in their work environments that influenced the nature and effectiveness of the care they deliver. A secondary purpose was to identify related career issues, job characteristics, and health and safety issues. This report complements the Review of Concurrent Research on Nursing Labour Market Topicsto be presented as part of the overall research project Building the Future. The Occupational Nursing Groups Survey consisted of questions addressing several areas, including demographics, education and training background, continuing education, preceptorship burden, health and safety aspects of employment, utilization patterns, and reporting structures for nurses. An overview of the recent literature about nursing practice issues and their impact on job satisfaction and patient outcomes is presented. This is followed by an overview of the data collection methods, data analysis processes, and the presentation of the findings. The report concludes with recommendations for human resource policy geared toward the enhancement of nursing workplace environments.

The following acronyms are used in this report. • CHS community health service • LTC long-term care

• RNs registered nurses

• LPNs licensed/registered practical nurses • RPNs registered psychiatric nurses

(Although the acronym RPN refers to registered practical nurses in Ontario, it is not so used in this report. In this report, RPN refers to registered psychiatric nurse. Also, in Canada, RPNs are educated and regulated as a separate occupation in the four Western provinces.)

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2.1.

Literature Search

A literature search was conducted to examine the key issues affecting nurses and their practice environments. Information on published literature was searched through bibliographic databases such as MEDLINE, CINAHL, EMBASE, Healthstar/OVID, and PubMed. The Internet provided access to grey literature such as reports and news releases, as well as documents from university-based academic research units, governmental publications, and other current information. Once collected, the literature was organized and is presented according to the following key topic areas, including nursing workforce mobility, professional practice environments, empowerment and nurses’ job satisfaction, continuing education in nursing, lifestyle in nursing and nurse staffing, and patient outcomes.

2.2.

Literature Background

Health human resource research relating to quality of work life concerns is increasingly international in scope. Aiken, Clarke and Sloane (2002) examined the effects of nurse staffing and organizational support for nursing care on nurses’ dissatisfaction with their jobs, nurse burnout, and nurse reports of quality of patient care from more than 10,000 nurses in adult acute care hospitals in the United States (U.S.), Canada, England, Germany, and Scotland. Dissatisfaction, burnout, and concerns about quality of care were common in all five sites. In Canada, policy-makers are increasingly concerned about a nursing shortage, yet almost half of this country’s RNs are currently employed on a part-time or casual basis (Grinspun, 2002). Casualization of the nursing workforce has impacted continuity and quality of care, and in return acuity and complexity of the work environment have impacted on the workload of nurses (O’Brien-Pallas & Baumann, 1999). Further research would increase our understanding of nurses’ work status preferences. Recently, investigators suggested that part-time and casual nurses are not necessarily interested in full-time positions (McGillis Hall, Doran, Baker, Pink, Sidani, et al., 2002). Buerhaus, Staiger and Auerbach (2000) argued that the nature of the work environment in nursing contributes significantly to the nursing shortage. Thus, it is also important to identify factors in the work environment that are amenable to change and that can be put in place to improve the conditions of nurses’ work life in today’s highly charged health care environments.

2.2.1. Nursing Workforce Mobility

Mobility of the nursing workforce is an important consideration in health human resource planning since movement across geographical borders, as well as within and between nursing and other health occupations, impacts on the accessibility and quality of health services. While immigration from other countries can potentially augment the supply of nurses, the ability to recruit from outside the province or country is limited by national and global shortages (O’Brien-Pallas, Thomson, Alksnis, Luba,

Pagniello, et al., 2003). For the individual RN, the Canadian Nurses Association (CNA) respects the right of a nurse to determine the country in which she or he works, provided that competency requirements for registration/employment in that country are met and the nurse has proficiency in the national language(s) (CNA, 2000).

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Horizontal mobility implies career progression following completion of post-basic studies, for all three occupational groups. The Canadian Practical Nurses Association (CPNA) (2000) promotes continuing education and supports specialization for LPNs. Continuing education for LPNs does not necessarily imply pursuing a nursing degree and eventual licensure as an RN, which is often the focus in studies about LPNs’ career mobility (Coyle-Rogers, 2003; Ramsey, Merriman, Blowers, Grooms & Sullivan, 2004). Role advancement for LPNs as it relates to implementation of full scope of practice is currently taking place in Canada. Restricted practice and under-utilization of LPNs across Canada is a longstanding issue which has negatively impacted this profession as well as the availability of nursing services (CPNA, 2003).

In terms of inter-occupational mobility, there is very little research that identifies types of positions nurses assume when they actually leave the profession. In Australia, Duffield, Aitken, O’Brien-Pallas & Wise (2004) found many respondents moved to management positions outside the health industry, and many undertook additional study after leaving nursing. In addition, few identified difficulties in adapting to non-nursing employment, and most agreed that their nursing skills and experiences had assisted them in attaining these positions.

2.2.2. Professional Practice Environments, Empowerment, and Nurses’ Job Satisfaction

Many researchers have examined the nursing workplace characteristics that promote job satisfaction and retention. Many factors impact work environments including: workload, leadership style, opportunity for continuing education and promotion, nurse autonomy, scheduling, and co-worker relationships. Shaver and Lacey (2003) found that when RNs and LPNs felt that short staffing interfered with their ability to meet patient care needs, they were also less satisfied with both their jobs and their careers. Although increasing recruitment of nurses and improved compensation and benefits strategies may offset hospital nurse shortages in the short term, improving quality of work life may be a more practical and long-term approach to improving hospital nurse retention (Gifford, Zammuto & Goodman, 2002). Many nurses are dissatisfied with the chaotic pace and high patient acuity that is typical in current working environments; others thrive on the challenges of complex patients and the unpredictable nature of work, such as emergency room nurses who enjoy the intensity and fast-paced environment (Raingruber & Ritter, 2003). What is important in any practice setting is the adequacy of resources and support systems that enable nurses to derive meaning from provision of good quality care in a secure environment (Laschinger, Finegan, Shamian &Wilk, 2004). Uncomfortable work situations that force nurses to float to unfamiliar units have been associated with job dissatisfaction and nurse turnover (McHugh, 1997).

O’Brien-Pallas, et al. (2003) found that 30% of nurses in their study of cardiac and cardiovascular nursing units were at risk of emotional exhaustion. Full-time nurses were more prone than part-time or casual nurses, and nurses who experience job dissatisfaction were also at risk. These researchers also found that RNs prepared at the baccalaureate level were 56% more likely to be satisfied with their job. Nurses who rated the quality of care they were able to give on the last shift as good or excellent were 400% more satisfied. However, when productivity/utilization expectations moved beyond 80% on the unit nurses were less satisfied with their job and patient health status at discharge began to decline.

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The study also demonstrated that as productivity/utilization levels moved beyond 90%, the actual cost per acuity adjusted case increased.

Nakata and Saylor (1994) found a positive correlation between perceived management style and staff nurse job satisfaction: the closer the management style to the participative group management style, the higher the level of staff nurse job satisfaction. Managers with leadership styles that sought and valued contributions from staff, promoted a climate in which information was shared effectively, promoted decision making at the staff nurse level, and influenced coordination toward a stable work environment were considered the most favourable by nurses (Boyle, Bott, Hansen, Woods & Taunton, 1999; Laschinger, Wong, McMahon & Kaufmann, 1999; Trofino, 2003). A recent study showed that nurses experienced higher levels of respect when their managers provided them with explanations regarding upcoming organizational decisions and showed concern about the implications of these decisions on staff nurses’ working conditions (Laschinger, 2004). Consequently, nurses had greater job satisfaction, lower burnout, better mental and physical health, and lower turnover intentions.

As well as support from managers, co-worker relationships and teamwork are important aspects of nurses’ support systems. Focus group findings suggest that quality of administrative management systems and relationships with physicians, nurse managers, peers, and administrators are important to continued employment (Parsons & Stonestreet, 2004). High teamwork scores were found to be associated with higher job satisfaction, lower burnout scores, higher level of nurse-assessed quality of care, higher levels of autonomy, and greater involvement in decision making (Rafferty, Ball Aitken, 2001). Similarly, survey findings of hospital staff nurses suggested that perceived autonomy, control, and physician relationships influenced the trust, job satisfaction, and perceived quality of patient care (Laschinger & Sabistion, 2000). These factors, in combination with aspects of workplace empowerment, were also found to predict job satisfaction in samples of nurses from urban teaching and rural community hospitals in Ontario, and among advanced practice nurses in both acute care and primary health care settings across Ontario (Laschinger, Almost & Tuer-Hodes, 2003). In a study of Ontario staff nurses, stress associated from poor working relations with co-workers was also a major predictor of nurses’ feelings of being respected in their work setting and, ultimately, of their job satisfaction and commitment to their organizations.

Researchers have tried to determine the type of work schedules that enhance nurse job satisfaction as well as meet the needs of the workplace. The types of work schedules found in the literature included: stable work schedules (Shader, Broome, Broome, West & Nash, 2001); self-schedules (Hung, 2002; Teahan, 1998; Vetter, Felice & Ingersoll, 2001), flexible scheduling (MacPhee, 2000; Manias, Aitken, Peerson, Parker & Wong, 2003; Moyle, Skinner, Rowe & Gork, 2003), and job sharing (Kane, 1999). Vetter, et al. (2001) found that success of self-scheduling can be enhanced by recognizing and rewarding staff members who adjust their work schedules to meet the needs of the unit. Teahan (1998) found self-scheduling to be a solution when staff dissatisfaction, absenteeism, vacancies, and staffing costs increased, although complaints of peer pressure, favouritism and unavailability of staff on certain shifts emerged. Some agency nurses identify flexibility as the primary reason for their work arrangement, although important issues for agency nurses include appropriate notification of shift availability, appropriate

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assignment of work, recognition as a valuable member of the health care team, and comprehensive orientation and education (Manias, et al., 2003).

2.2.3. Continuing Education in Nursing

The CNA and the Canadian Association of Schools of Nursing (CASN) promote flexible nursing programs to enhance accessibility and to address the needs of registered nurses for life-long learning (CNA & CASN, 2004). Nursing education is a major determinant in the development and enhancement of competencies for safe and quality nursing practice. While preparation at the baccalaureate level provides the foundation RNs require to enter the profession, they need to maintain and continuously enhance their competencies. In light of the current nursing shortage, RNs who have been away from clinical practice are a valuable resource, warranting increased examination of nurse refresher courses as a strategy to help nurses regain competence and re-enter the workplace (Hawley & Foley, 2004).

New nurse graduates also have a need for knowledge and skill development as well as being socialized into the profession. Their orientation, therefore, into the workplace is often a challenge (Lavoie-Tremblay, Viens, Forcier, Labrosse, Laliberté, et al., 2002). Employers of RNs have the responsibility to put mechanisms in place that foster a professional practice environment; help registered nurses identify their learning needs; facilitate access to educational activities; and provide support for registered nurses in advancing their education (CNA, 1998). Canada’s educational institutions utilize technology and other means to increase accessibility, yet researchers have shown that RNs perceive barriers relating to distance, family and work obligations, tuition and travel expenses, lack of employer financial support, lack of available relevant educational activities, and lack of replacement for study leave (CNA & CASN, 2004). This situation is unfortunate, given the link between continuing education and job satisfaction of nurses (Robertson, Higgins, Rozmus & Robinson, 1999).

Like RNs, entry-level programs for LPNs provide the foundation for entry into the profession and life-long learning is an inherent part of practice. The parameters of the practice scope are defined by entry-level preparation and postgraduate and/or advanced education. Within this scope of practice, LPNs are accountable to remain current and increase their expertise and competence level in a variety of ways, such as practice experience, continuing education, in-service education, and postgraduate studies. Practice responsibility, accountability, and levels of independence are also expanded in this way (CPNA, 2003). It is also recognized that LPN employers have a key role to play in identifying and supporting the learning of LPNs. LPNs also face many barriers related to accessing continuing education, including financial support, access, availability, and time off.

Continuing education and continuing competence are also provincial jurisdiction issues for RPNs. Each of the regulatory bodies administers a mandatory continuing competence or continuing education program.

Considerable attention in research has been paid to the educational needs of nurses as they relate to specific practice areas and associated knowledge and skill requirements. In critical care, educational

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techniques include in-service education, bedside instruction, and competency-based education modules (Arbour, 2003), with life-long learning a key to competency (Huggins, 2004). The health care needs of elderly individuals have prompted policy support of advancing nursing education and expertise in gerontology (LeCount, 2004). In relation to mental health services, one report emphasized the importance of continuing professional development for qualified mental health diplomats (those with a diploma in Mental Health Nursing from the United Kingdom [UK]), since there were long-standing issues related to the provision of appropriate courses and opportunities for attendance (Robinson & Tingle, 2003). Ryan-Nicholls (2003) conducted focus groups with psychiatric nurses who voiced concerns about continuing competence in an evolving mental health care system, an issue that Chang, Daly, Bell, Brown, Allan, et al. (2002) indicated is even more problematic to address in rural and remote areas.

Public health nurses experience difficulty in maintaining competency, at times feeling somewhat unprepared for their roles; therefore, nurses need initial preparation and continuing education (Schoenfeld & MacDonald, 2002). As the community health centre model of care delivery is gaining acceptance throughout Canada, regional health authorities are being challenged to ensure the attainment and maintenance of practice competencies. One study of strategies used in selected parts of Canada to prepare and support rural diploma-prepared nurses for role transition from acute care into community care indicated a need for additional educational preparation and supportive strategies (Pearson & Care, 2002). New knowledge and upgraded skills are perceived needs by nurses experiencing job change, requiring orientation programs that are tailored to meet specific learning needs (Butt, Baumann, O’Brien-Pallas, Deber, Blythe, et al., 2002).

Innovative, virtual education opportunities promote an environment in which each nurse is able to acquire knowledge, learn new skills, and share and communicate this knowledge with other colleagues (Rick, Kearns & Thompson, 2003). Billings and Rowles (2001) discussed the implementation and evaluation of continuing nursing education on the World Wide Web (WWW) to promote professional development that was accessible, convenient, and available at any time and any place. Charles and Mamary (2002) conducted a survey with the entire population of licensed advanced practitioners of nursing in Nevada to assess practices, preferences, and barriers to use of various delivery modes for continuing education. The top three preferences, in rank order, were in-person conference, print-based self-study, and interactive video conference.

It is important to understand what motivates participation in continuous professional development. According to Smith (2002), RNs attended continuing education when the following conditions existed: programs addressed self-initiated and self-discovered knowledge and skill; there was commitment to the topic; cost was reasonable; personal and professional development was valued and supported; nurses were supported to implement new knowledge; instructors were effective; benefits were perceived as greater than costs; personal learning goals were more important than those identified for them; there was input into topics; educators address them as knowledgeable and skillful professionals; and programs were accessible. Smith (2004) found that mandatory continuing education does not necessarily result in more professional growth and that RNs and LPNs attend classes whether they are mandated or not.

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2.2.4. Nurse Health and Safety Issues

Undesirable workplace environments have contributed to musculoskeletal injuries (Bruce, Sale, Shamian, O’Brien-Pallas & Thomson, 2002; Shamian, Kerr, Spence Laschinger & Thomson, 2002) and increased risk of needle stick injuries for RNs and LPNs (Clarke, Rockett, Sloane & Aiken, 2002). O’Brien-Pallas, Shamian, Thomson, Alksnis, Koehoorn, et al. (2004) examined effects of job strain on nurses’ health status by examining trends in injury compensation claims and factors contributing to claims. Data from a nurse survey, the Ontario Ministry of Health and Long-Term Care hospital submissions, and Workplace Safety Insurance Board (WSIB) lost-time claim rates were examined. The researchers found higher rates of absenteeism, emotional exhaustion, musculoskeletal pain, and higher injury claim rates among nurses versus non-nurses. The probability of RN lost-time claim rates and sick time increased with overtime. Other researchers report similar results. Back pain disabilities in RNs were found to be associated with more years worked in nursing, frequent lifting, and low social support (Byrns, Reeder, Jin & Pachis, 2004). Bruce, et al. (2002) found that workload was the top factor in contributing to high injury rates, with other comments relating to lack of equipment, crowded space, and lack of ergonomics in their work setting. Lipscomb, Trinkoff, Geiger-Brown & Brady (2002) examined relationships

between work-schedule characteristics and reports of musculoskeletal disorders in RNs, finding a significant association between working “long hours” and “off hours” and musculoskeletal disorders in the neck, shoulder, and back. Preventive measures require scheduling approaches that reduce the time of exposure to demanding work conditions and promote healthful work-rest patterns. O’Brien-Pallas, et al. (2003) found that physical health as measured by the SF12 was negatively influenced by feelings of an effort and reward imbalance and emotional exhaustion. At the unit level, both RNs’ and LPNs’ physical health were negatively influenced by increasing worked hours and the average age distribution on the unit. Mental health scores were positively influenced by satisfaction with the current job and negatively influenced by presence of emotional exhaustion. This study found that both RNs and LPNs were working beyond capacity for more than 62% of the shifts studied.

Work status has been shown to impact nurse outcomes. Burke (2004) examined the relationship of work status congruence (full-timers preferring full-time work, part-timers preferring part-time work) on selected work outcomes and indicators of psychological and physical well-being of RNs. Nursing staff with a congruent work status were generally more work satisfied and reported greater psychological well-being (less burnout, fewer psychosomatic symptoms) than nursing staff with an incongruent work status. Full-time status has been linked to increased risk of poor nurse outcomes, perhaps contributing to the apparent lack of interest in full time that is suggested by some of the current researchers. Based on a sample of RNs in acute care hospitals in Ontario, Shamian, et al. (2002) found that, after controlling for basic differences in nurse workforces, higher (better) work environment scores were found to be generally associated with higher health indicator scores, while a larger proportion of full-time than part-time nurses were found to be associated with lower (poorer) health scores. Similarly, Zboril-Benson (2002) found that higher rates of absenteeism in front-line acute care and LTC RNs in Saskatchewan were associated with lower job satisfaction, longer shifts, working in acute care, and working full time. The threat of being placed on recall, or being bumped or laid off was related to depression, anxiety, job insecurity, and poor physical health in RNs (Greenglass & Burke, 2001; Maurier & Northcott, 2000).

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All nurses experience significant threat and verbal abuse in their work, often with inadequate support from other health care professionals or from administration (Henderson, 2003). The CPNA (1999) stated that health care staff should adopt zero tolerance for harassment/violence in their places of work - that many practical nurses are regularly subject to the threat or use of violence. In a study examining relationships between aggressive behaviour and staff burnout in homes for the elderly, aggression and the number of weekly working hours was associated with emotional exhaustion of staff (Evers, Tomic & Brouwers, 2002). Psychiatric nurses are also said to experience work stress due to perceived risk of assault. Ito, Eisen, Sederer, Yamada & Tachimori (2001) examined intentions of psychiatric nurses in Japan to leave their job in relation to their perceived risk of assault, their job satisfaction, and their supervisory support. Based on 1,494 nurses (response rate, 76.5%), 44% reported intention to leave their job and 89% of those perceived a risk of assault. High levels of emotional exhaustion were evident in Canadian RPNs. Robinson, Clements & Land (2003) found lower burnout and higher job satisfaction in forensic nurses than in their counterparts from mainstream mental health services.

2.2.5. Lifestyle and Nursing

There is limited research about nurses’ lifestyles, whether for RNs, LPNs, or RPNs, and much of it has been conducted in Europe. Often, the studies are focused on relaxation measures and recreational activities with nursing students. These researchers are promoting nurses’ health and wellness from the onset of their careers (Czabak-Garbacz, Skibniewska, Mazurkiewicz & Wisowska, 2002; Haddad, Kane, Rajacich, Cameron & Al-Ma’aitah, 2004; Romero Collado, Cayuela Andreu, Molina Hernandez & Solsona Tuneu, 2004; Ziccardi, Sedlak & Doheny, 2004). Haddad, et al. (2004) examined health-promoting practices of Canadian and Jordanian first-year baccalaureate nursing students with results showing low scores in health responsibility, physical activity, and interpersonal relations. Similarly, Czabak-Garbacz, et al. (2002) found that third-year nursing students preferred passive types of leisure time activity, such as listening to the radio, watching television, and reading. Chalmers, Sequire & Brown (2002) reported findings about baccalaureate student nurses’ attitudes, beliefs, and personal behaviour in relation to tobacco issues based on a cross-sectional survey of the total population of baccalaureate nursing students in one Canadian province. Two hundred and seventy-two students (61.9%) responded. Of the 22.1% who indicated that they smoked daily or in social situations, 91.4% said they wanted to quit yet few were actively engaged in the quitting process (16.9%). Non-smokers indicated more health-promoting behaviours, especially on the variables of physical activity, nutrition, and stress management. Few studies examine lifestyles of practising nurses. Study findings by Jaarsma, Stewart, De Geest, Fridlund, Heikkila, et al. (2004) indicated that cardiac nurses adopt a healthier lifestyle than the general population, perhaps heeding their own advice on lifestyle modification to reduce cardiovascular risk and role modelling health promotion behaviours.

Various stress management techniques in nursing have been identified in the literature. Edwards and Burnard (2003) reviewed research undertaken in the UK published between 1966 and 2000 to determine the effectiveness of stress management interventions for those working in mental health nursing. Relaxation techniques, training in behavioural techniques, stress management workshops, and training in therapeutic skills were effective stress management techniques. Although a great deal is known about sources of stress, how to measure it, and its impact, there is a lack of research assessing

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interventions that attempt to minimize or eliminate these stressors. Pierlot and Warelow (1999) advanced the view that humour has been well researched as an agent of therapeutic value and as a communication tool which helps to relieve stress, but is not used to its fullest potential and is therefore underestimated in both general and psychiatric nursing areas. They claim that humour can promote health and well-being for both the patient and the nurse, and can be of immense therapeutic value. Several authors explored energetic techniques, such as Reike, to treat and prevent burnout for nurses (Fortune & Price, 2003; Gallop, 2003). Relaxation, pain relief, physical healing, reduced emotional distress, and a deepened awareness of spiritual connection are among the benefits. In a qualitative study, Cavendish, Luise, Russo, Mitzeliotis, Bauer, et al. (2004) described nurses’ spiritual perspectives as they related to education and practice and identified the following themes: strength, guidance, connectedness, a belief system–as promoting health–and supporting practice.

However, the effectiveness of these stress management strategies will be short-lived unless efforts are made to reduce the sources of stress in work environments. Many of the sources are amenable to change through management activities and policies. Therefore, “upstream” strategies, such as assuring that information, support, and resources are in place to ensure that nurses can perform their jobs in meaningful ways, and creating an environment of respect and trust among co-workers and management, are even more important ways of reducing stress in nursing environments (Laschinger, 2004; Laschinger, Finegan, Shamian & Wilk, 2004).

2.2.6. Nurse Staffing and Patient Outcomes

Recent studies have linked nurse staffing with quality of care indicators (Mark, Salyer & Harless, 2002; Sochalski, 2004; Vahey, Aiken, Sloane, Clarke & Vargas, 2004). Schnelle, Simmons, Harrington, Cadogan, Garcia, et al. (2004) compared nursing home staffing statistics on quality of care and concluded that higher staffing levels and lower care load resulted in better care. Based on a large sample of RNs, Sochalski (2004) found that quality of care ratings were significantly associated with the number of patients who nurses care for, rates of unfinished care for those patients, and the frequency of patient safety problems. Use of measurable patient outcome indicators are providing further evidence of the link between nurse staffing and patient outcomes (Cho, Ketefian, Barkauskas & Smith, 2003; Person, Allison, Kiefe, Weaver, Williams, et al., 2004). Yang’s (2003) study of nurse staffing variables (daily average hours of care, ratio of RNs to average patient census, workload, and skill mix) and patient outcomes (unit rates of patient falls, pressure ulcers, respiratory and urinary tract infections, and patient/family complaints) showed that workload of nurses is the most powerful predictor of nosocomial infections and hours of care best predicted the five adverse patient outcome indices. Researchers suggest that the impact of staffing on outcomes is variable across specialty units. However, when present, the relationships are inversely related with lower staffing levels, resulting in higher rates of all outcomes (Whitman, Kim, Davidson, Wolf & Wang, 2002). Occurrence of adverse events and higher patient complexity is shown to be associated with prolonged length of stay and increased nursing resources and medical costs (Cho, et al., 2003; McGillis Hall, Doran & Pink, 2004).

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Staffing skill mix, not just staffing numbers, contribute to patient care outcomes. Tourangeau, Giovannetti, Tu & Wood (2002) supported a relationship between lower 30-day mortality and a richer RN skill mix and more years of experience on the clinical unit. McGillis Hall, Doran, Baker, Pink, Sidani, et al. (2003) evaluated the impact of different nurse staffing models on the patient outcomes of functional status, pain control, and patient satisfaction with nursing care in all 19 teaching hospitals in Ontario, Canada. The proportion of regulated nursing staff on the unit was associated with better functional status at hospital discharge. In addition, a mix of staff that included RNs and unregulated workers was associated with better pain outcomes at discharge than a mix that involved RNs/LPNs and unregulated workers. Finally, patients were more satisfied with their obstetric nursing care on units where there was a higher proportion of regulated staff. Similarly, Needleman, Buerhaus, Mattke, Stewart & Zelevinsky (2002) found more desirable health outcomes in medical and surgical patients when a higher proportion of care was provided by RNs.

A consequence of nurse staffing shortages is undesirable overtime which in itself is detrimental to quality of care and patient outcomes. Overtime is grounded in the obligation to prevent harm to patients by guaranteeing adequate nurse-patient ratios. However, this practice does not guarantee that adequate nurse-patient ratios are synonymous with quality care or preventing harm to patients (Bosek, 2001). A study that was recently released and received media attention (CNN, July 7, 2004; CTV.ca News, July 8, 2004) emphasized the public message that overtime increases nursing errors. Rogers, Hwang, Scott, Aiken & Dinges (2004) found the likelihood of a hospital nurse making a mistake, such as a medication error, was three times higher once a shift stretched past 12.5 hours. The risks of making an error were significantly increased when work shifts were longer than 12 hours, when nurses worked overtime, or when they worked more than 40 hours per week. Researchers in Canada point to similar findings, that staffing and nurses working overtime does impact on error rates (CTV.ca News, July 8, 2004, citing CNA).

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The following research questions guided this study of nurses from all three registered nursing occupational groups in Canada:

• What are the demographic characteristics of nurses in Canada?

• What is the nature of nursing work environments today from the perspective of nurses in Canada? • What are the career patterns, paths, issues, job characteristics, and health and safety issues for

nurses?

• What are the characteristics of the work environments in which nurses work?

• What are the associations between key work environment factors and select quality of care outcomes?

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4.1.

Survey Design

The Nursing Occupational Groups Survey was designed based on original research questions and the related literature. External and internal reviewers across health care sectors and nursing groups refined the survey questions to ensure their reliability and validity. Both English and French versions of the questionnaires, consent letters, and introduction letters were developed and submitted to ethics review boards for approval. Following ethical approval from the University of Toronto and Dalhousie University’s Research Ethics Boards, an ad hoc review committee was struck to review/evaluate the survey’s validity via the use of a Content Validity Scale (Waltz & Bausell, 1981). Once revisions were completed, the Nursing Occupational Groups Survey, consent letter, and introduction letter were translated into French and translated back into English for context errors.

4.2.

Pilot Testing

Before implementing the full-scale sampling, the research team conducted a pilot study with nurses from Ontario, Alberta, and British Columbia between March 25 and April 24, 2003. The purpose of the pilot study was twofold: 1) to make sure questions in the survey were clear and relevant, and 2) to test the survey distribution process among a small sample of registrars.

Following the stratified sampling formula developed by the research team, the Canadian Institute for Health Information (CIHI) randomly selected a sample of 300 nurses from its nursing database of RNs, LPNs, and RPNs across Canada. It was determined that approximately 90 completed surveys were needed to evaluate the questionnaire for reliability and validity; consequently, 180 nurses were randomly drawn. The distribution was as follow: 60 RNs (30 each from Ontario and British Columbia), 60 LPNs (30 each from Ontario and Alberta), and 60 RPNs (all 60 from British Columbia). Participants of the pilot study sample were excluded from the pool of nurses eligible for the full-scale study.

Each of the registration bodies for nurses across Canada was sent pilot-testing instructions. Registration bodies were sent the pilot sample and were responsible for matching the research code with the registration number per nurse sampled to create address labels for the pilot mail-out. The corresponding registration numbers, anonymous study identification number, and “LINK” field of this random sample per province were stored on an Excel file and later transferred onto a CD-ROM for distribution to the respective regulatory body.

With the assistance of the provincial nursing regulatory bodies of nurses, the surveys were mailed in March 2003, with a return by date of April 24, 2003. The survey package kit consisted of instructions for participating; information on participation in the pilot study; the 28-page questionnaire (30 minutes estimated completion time); and a prepaid return envelope for comments and feedback.

A total of 99 questionnaires was returned from the total of 268 mailed surveys, resulting in an overall response rate of 36.9%. By nursing group, the response rate was 43.9% for RN, 30.4% for LPN, and 35.6% for RPN. The difference of 32 was attributed to unmatchable “LINK” fields to generate a valid mailing address.

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4.3.

Sampling Process

In 2002, the numbers of registered and practising (active) nurses in Canada were 232,412 RNs, 62,106 LPNs, and 5,416 RPNs. Based on these figures, the research team proposed to send nearly 40,500 surveys with the intent of receiving completed surveys from 50% of this target sample.

To ensure representation from each sector and the confidentiality of nurses, the research team collaborated with CIHI, 26 nursing regulatory bodies across Canada, and an external research firm (Focal Research Consultants Inc) which specializes in survey preparation/execution and data coding. The University of Toronto Project Research Team developed the stratified sampling formula (Appendix A) and coordinated the overall process. CIHI drew the sample based on this formula, and generated the information needed by the regulatory bodies to identify the nurses selected. The regulatory bodies generated the mailing address labels, matched the research code number with the representative nurse registration number, and affixed these labels to the survey packages. The registration bodies completed the mail-out for all nurses sampled in their province. If registration numbers could not be matched to the respective research code number or were flagged to not receive any type of mailing due to other circumstances (i.e. pending/overdue renewal fees, disciplinary action, or refusal to receive registrar mailings), these nurses did not receive a survey package.

Each of the nurse groups was stratified by province/territory, age cohorts, and employment settings. For both the RNs and LPNs, the provinces/territories were aggregated into six groups: 1) British Columbia and the three territories; 2) Alberta; 3) Saskatchewan and Manitoba; 4) Ontario; 5) Quebec; and 6) Atlantic Provinces. Within these six regional groups, there were 1,000 nurses per cell (meaning that surveys had to be distributed to 2,000 potential respondents within each region). Next, the sampling fraction (k) was estimated (k = strata population/sample size). The RN and LPN data were sorted according to employment setting and age groups to allow for the systematic sampling of potential respondents, stratified appropriately along these dimensions. This yielded sample sizes of approximately 12,000 RNs and 12,000 LPNs (Appendix A).

Although the RPN designation occurs solely in the Western provinces and accounts for only 2% of the national nursing workforce, the sampling frame was adjusted to reflect the relatively more substantial proportion of the nursing labour force that RPNs represent in those provinces. In the Western provinces, the regional stratum was collapsed into two groups: 1) British Columbia and Alberta, and 2) Saskatchewan and Manitoba. Within these two regional groups, it was desirable to obtain at least 500 nurses per cell (meaning surveys needed to be distributed to 1,000 potential respondents within each region). This same strategy was applied when stratifying the RPN group along age and employment settings, thus yielding a sample size of approximately 2,000 RPNs.

4.4.

Full Sampling Distribution

Focal Research Consultants Ltd was contracted to assist in the questionnaire formatting/printing, survey distribution, data collection, data entry, and coding of the Nursing Occupational Groups full-scale survey. Focal provided the means for the regulatory body to affix accurate envelope labels to intended

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package recipients using the registration number. Although Focal had temporary access to survey results to complete its contractual obligation of data collection and data entry, a signed confidentiality agreement with the researchers was in place outlining Focal’s data use limitations as well as the destruction and return of files to the research team upon completion of the project. A toll-free hotline was set up in English and French to respond to inquiries and to receive comments from participants. A total of 185 calls were received during the course of the survey.

The survey distribution plan consisted of two waves of mass mailing. Response rates were monitored by the research team to determine whether another course of mass mailing was necessary. The research team provided the mailing labels addressed to specific nurses, while the CIHI supplied the corresponding registration and identification numbers to Focal to prepare the survey package kits.

The first mailing of 29,842 survey kits occurred on September 2, 2003, with a return date by October 24, 2003. One week after the initial mailing, a reminder postcard was mailed. The poor response rate of 32% prompted a second mailing of 10,636 survey packages during the week of November 10 to 14, 2003, with a return date by December 10, 2003. The Prince Edward Island registrar had difficulty producing labels from its registration database; thus, the second mail-out for this province did not take place until January 28, 2004. Quebec RNs opted not to participate in part of the study and were excluded from both waves of mailing. Again, one week after the mail-out a reminder postcard was sent. This second mailing received an overall response rate of 15.9%; 58.5% from RNs, 34.8% from LPNs, and 6.7% from RPNs. Due to incorrect addresses or outdated registration status, the two waves of mailings resulted in a total of 37,868 valid surveys mailed out to respondents. Of the 37,868 total valid surveys, 13,620 nurses completed and returned the survey, thereby resulting in an overall valid mail-out response rate of 36%.

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5.1.

Data Analysis

Quantitative survey data were analyzed using SPSS 12.0 for Windows. Qualitative data were categorized, coded, and analyzed using Microsoft Excel. Descriptive statistics were used to summarize data. Responses were analyzed by sector (CHS, hospital, LTC, and other) and province.

5.2.

Instruments

Nursing work conditions and work satisfaction were examined through the 5 subscales of the Revised Nursing Work Index (NWI) (Aiken & Patrician, 2000), 6 subscales of the Conditions of Work Effectiveness Questionnaire-II (CWEQ-II) (Laschinger, Finegan, Shamian & Wilk, 2003), and the index of satisfaction with current job.

The Nursing Work Index, first developed by Kramer and Hafner (1989), has been used extensively in the nursing research for measuring work attributes demonstrated as important to nurses. The initial work attributes included in the NWI were autonomy, control over practice, and nurse-physician relations. However, factor analysis completed by O’Brien-Pallas, et al. (2003) produced a 5-factor solution and identified leadership and resource adequacy as two additional subscales; they have been added to the original index. NWI subscale scores are based on the sum scores of items on a 4-point Likert scale, ranging from 1=strongly disagree to 4=strongly agree. The maximum score for autonomy was 24, control was 28, nurse-physician relations was 12, leadership was 48, and resource adequacy was 16. In short, the higher the score on the subscale, the more positive nurses feel about work. The alpha reliabilities for each of the subscales were acceptable at 0.79, 0.79, 0.83, 0.84, and 0.85 respectively.

The CWEQ-II consists of 19 items that measure the 6 components of structural empowerment described by Kanter (1997; 1993): opportunity, information, support, resources, formal power, and informal power. Items on each of the 6 CWEQ-II subscales are summed and averaged to provide a score for each subscale ranging from 1 to 5. These scores of the 6 subscales are then summed to create the total empowerment score (score range: 6-30). Higher sc

References

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Notwithstanding, even if the relevant difference that separates civil law systems from common law countries, can be found in the creative function which vested to a judge, having as

The total HCV load and load per 1000 cells in CD45 leukocytes in the total patient group and the untreated and treated groups are summarized in Table 4.9. Spearman’s test