https://www.infirmiere-canadienne.com/blogs/ic-contenu/2023/04/17/solutions-penurie-de-main-doevre-infirmiere
Ensuring work-life balance and adequate staffing among key recommendations
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How often have you come in for a shift to find out someone called in sick, and now everyone is picking up the slack? Excessive and unreasonable workloads make nurses ill. They increase absenteeism, decrease quality of care and are disrespectful to the profession
“Half of nurses currently working wish to change jobs. Ninety-four per cent are showing signs of burnout, and 83 per cent say they are so understaffed they worry for the quality of care they can provide” (Ahmed & Bourgeault, 2022).
Despite the many reports and recommendations to highlight and address the nursing workforce shortfall, it remains a perennial problem. The COVID-19 pandemic has only worsened a situation already described as approaching crisis (Almost & Mildon, 2022). In Canada, the health workforce makes up over 65 per cent of health-care costs, and nurses, the largest group of health workers, disproportionately bear the brunt of strategies to curb those costs (Bourgeault, 2021). A 2019 analysis predicted a shortage of 117,600 nurses in Canada by 2030 (Scheffler & Arnold, 2019). With currently only 10 nurses per 1,000 Canadians, action must be taken to stop further nurses from leaving health care (OECD, 2022).
Shortages have a far-reaching impact on the entire health-care system, affecting bed and unit closures, wait times and the quality of patient care (Bourgeault, 2021). So what can be done? After consulting a scoping review from the U.K. (Ball, Ejebu, & Saville, 2022), a report from the Canadian Federation of Nurses Unions (CFNU) (Ahmed & Bourgeault, 2022) and a policy brief sponsored by the Royal Society of Canada (Murphy et al., 2022), I compiled a short list of facility and organizational actions that can begin to address the nursing shortage in the immediate term.
Work-life balance
Work-life balance is often cited as a reason for our current physician shortage but is equally vital for nursing staff as well and frequently a reason for burnout (Ahmed & Bourgeault, 2022; Almost & Mildon, 2022; Ball, Ejebu, & Saville, 2022; Murphy et al., 2022). Supporting this balance can come in many forms. No longer mandating overtime or cancelling vacation time and providing on-premises, extended-hour child care to accommodate various shift lengths are a few examples that have improved job satisfaction among nursing staff (Ahmed & Bourgeault, 2022; Ball, Ejebu, & Saville, 2022; Murphy et al., 2022). Creating flexibility in scheduling is another way to support work-life balance. One novel initiative out of Alberta gives nurses the option to designate a period in which they work (e.g., winter or summer), and evaluations indicate that nurses are very satisfied with the hours they work as well as with their work-life balance (Weidner, Graham, Smith, Aitken, & Odell, 2012).
Adequate staffing and resources
The proverbial elephant in the room, working short-staffed is a fast track to burnout. How often have you come in for a shift to find out someone called in sick, and now everyone is picking up the slack? Excessive and unreasonable workloads make nurses ill. They increase absenteeism, decrease quality of care and are disrespectful to the profession (Almost & Mildon, 2022). Beyond war conditions, would a surgeon ever be asked to work without appropriate resources and support staff? Given the magnitude of this problem, here are several recommendations:
- Create policy dictating a minimum nurse-to-patient ratio or, in non-acute health-care settings, a minimum care standard. An example of a minimum care standard would be 4.1 direct care hours per resident per day within a long-term care setting and adjusting hours based on the complexity of the individual’s case. This improved not only resident quality of health, by providing more dedicated care time, but also nursing performance (Ahmed & Bourgeault, 2022). While CFNU advocates that these be legislated minimums, organizations need not wait for the federal government to act. Evidence has shown improved patient outcomes in both acute and non-acute care settings when such minimums are applied (Ahmed & Bourgeault, 2022).
- Integrate nurses in Canada with international education and training. Thousands of internationally educated nurses are living in Canada and struggling with the complex, costly and time-consuming registration process preventing them from working as nurses (Ahmed & Bourgeault, 2022). As previously explored in Canadian Nurse (Magno, 2022) and identified within the articles reviewed today, streamlined application processes, along with facilitating the employment and integration process for these nurses, can not only increase the workforce in a timely manner but also add rich cultural representation to organizations that are serving an increasingly diversified public (Ahmed & Bourgeault, 2022; Magno, 2022; Murphy et al., 2022).
- Increase float team/pool capacity. Evidence exists to support the use of a float pool as a cost-effective solution to mitigate overtime and contract labour. This solution can improve teamwork and nursing satisfaction provided that adequate resources are available to ensure that float staff can work competently in different units and interact confidently with regular staff (Ahmed & Bourgeault, 2022). Although a robust float team can improve system resiliency, employers should also cultivate permanent employees as experts in their area of care who can provide mentoring and support for float staff and new hires (Murphy et al., 2022).
- Implement a support team to reduce non-nursing duties. Too often nursing staff are pulled away from their scope of practice because of non-nursing tasks. Budgetary cuts to departments, such as security, housekeeping and administration, can undermine staff safety, access to vital resources and ability to work. When supplies such as linen, wheelchairs and IV pumps begin to go scarce, nurses cannot be expected to search the hospital for these materials (Ahmed & Bourgeault, 2022; Almost & Mildon, 2022). Security, clerks, personal support workers and cleaning staff can be brought in to ensure the efficient functioning of a hospital ward so that nurses can focus on patient care.
- Use evidence-based tools and processes to address heavy workloads. A number of evidence-based tools developed in Canada now exist to help identify nursing workload issues within a unit or an organization, and several examples are provided in the CFNU report. Support staff such as clerks could be trained to apply these tools in collaboration with nursing staff and the employer to identify changing staff needs as they develop. Additionally, care models, such as the synergy professional practice model, align patient needs with staff competencies, demonstrating effectiveness in improving workload management in various care settings (Ahmed & Bourgeault, 2022).
Sense of control and being heard
Nurses need representation around the budgetary, administrative and policy table (Almost & Mildon, 2022; Murphy et al., 2022). They need to be included in facility planning, program planning and unit organization. Time away from the bedside must be provided for front-line nurses to interact and voice their needs and concerns to organizational management and system stakeholders (Murphy et al., 2022). This was a major recommendation from the Royal Society of Canada’s policy brief. The authors found that nurses are remarkably underrepresented in planning and policy decisions even though their expertise is critically important for planning and decision-making, spanning both clinical and policy spaces. Given the intimate knowledge nurses have about addressing the key challenges they face at the point of care, it is obvious that they should be consulted about the best way individual units can improve processes and conditions.
Pay and reward
While increased wages alone won’t fix the nursing crisis, competitive wages and benefits are a significant factor in fostering nurses’ motivation and job satisfaction (Ahmed & Bourgeault, 2022). Wages should reflect the skills, effort, responsibility and working conditions of the role. In addition, the work must offer rewards outside of monetary compensation, such as being interesting and attractive enough to offer its own intrinsic rewards to those who carry it out (Almost & Mildon, 2022). Lastly, rewards such as recognition and respect cannot be paid out as token gestures during periods of crisis but should be constant in order to foster the job satisfaction nurses so honestly deserve.
Opportunities to develop
Employers can provide mentorship programs and other supports bridging nurses’ return to work and new nurse onboarding. Retention of more experienced nurses is needed to provide junior and novice nurses with effective mentors, which may, in turn, support retention (Murphy et al., 2022). The value of these programs is not only to learn the salient points of a particular skill or unit but also to learn how the facility works overall and function within it (Ahmed & Bourgeault, 2022). Beyond mentorship programs, providing education days, either reimbursed or built in to an employee’s schedule, creates opportunities for staff to develop and expand their skills. One recommendation was to scale up the Ontario nursing education initiative to cover further jurisdictions (Ahmed & Bourgeault, 2022). Designed to provide access to continuing education and professional development opportunities, it reimburses nurses’ registration fees for courses, conferences, seminars or workshops to improve their knowledge and skills. This program has been so successful that it expanded its application to all other health-care sectors, including primary care, home health care and long-term care facilities (Ahmed & Bourgeault, 2022).
Relationships and support
Based on a network meta-analysis from the Royal Society of Canada, a supportive work environment is the optimal recommendation to reduce voluntary turnover (Murphy et al., 2022). The CFNU recommends that employers adopt policies to foster caring interpersonal relationships between nurses, nurse managers, other health-care professionals, patients and their families. This has been shown to develop engagement, empowerment and nurse satisfaction, increasing feelings of inclusion and retention (Ahmed & Bourgeault, 2022). Promoting a respectful and safe environment is also a shared responsibility that supports physical and psychological health and safety, which is strongly tied to job satisfaction (Ahmed & Bourgeault, 2022; Almost & Mildon, 2022; Ball et al., 2022; Murphy et al., 2022). Recommendations around psychological well-being include embedding mental health supports, such as dedicated mental health days, peer-support programs, access to internet-based cognitive-behavioural therapy (iCBT) and wellness programs (Ahmed & Bourgeault, 2022). These interventions are described as flexible, accessible and cost-effective ways of building relationships and resiliency to enhance job performance.
Although not exhaustive by far, these are some short-term initiatives that may help individual organizations or facilities retain the nursing staff they have left. These, along with medium- and long-term interventions, can slowly build back a resilient nursing cohort.
My first move would be to have a staff meeting and hear what nurses have to say. Triage the concerns and deal with them as quickly as possible. Solicit nursing input for solutions. Advocate on their behalf when policy or process becomes an unnecessary obstacle. Above all, respect and appreciate the work they do.
References
Ahmed, H. E. B., & Bourgeault, I. L. (2022). Sustaining nursing in Canada. Ottawa: Canadian Federation of Nurses Unions. Retrieved from https://nursesunions.ca/wp-content/uploads/2022/11/CHWN-CFNU-Report_-Sustaining-Nursing-in-Canada2022_web.pdf
Almost, J., & Mildon, B. (2022). R-E-S-P-E-C-T: A key to nurse retention. Nursing Leadership, 35(2), 12–28. doi:10.12927/cjnl.2022.26876
Ball, J., Ejebu, O.-Z., & Saville, C. (2022, October 10). What keeps nurses in nursing? A scoping review into nurse retention [Electronic version]. Nursing Times, 118(11). Retrieved from https://www.nursingtimes.net/roles/nurse-managers/what-keeps-nurses-in-nursing-a-scoping-review-into-nurse-retention-10-10-2022/
Bourgeault, I. L. (2021). Vulnerabilities in the nursing workforce in Canada: The anatomy and physiology of nursing workforce challenges and potential solutions for better planning, policy and management. Nursing Leadership, 34(4), 11–18. doi:10.12927/cjnl.2021.26694
Magno, C. M. L. (2022, October 17). Q&A (part 1): How IENs could be part of the solution to Canada’s nursing shortage. Retrieved from https://www.canadian-nurse.com/blogs/cn-content/2022/10/17/q-a-part-1-iens-solution-to-nursing-shortage
Murphy, G. T., Sampalli, T., Bearskin, L. B., Cashen, N., Cummings, G., Rose, A. E., ... Villeneuve, M. (2022). Investing in Canada’s nursing workforce post-pandemic: A call to action. FACETS, 7, 1051–1120. doi:10.1139/facets-2022-0002
OECD. (2022). Nurses (indicator). Retrieved from https://data.oecd.org/healthres/nurses.htm
Scheffler, R. M., & Arnold, D. R. (2019). Projecting shortages and surpluses of doctors and nurses in the OECD: What looms ahead. Health Economics, Policy and Law, 14(2), 274–290. doi:10.1017/s174413311700055x
Weidner, A., Graham, C., Smith, J., Aitken, J., & Odell, J. (2012). Alberta: Evaluation of nursing retention and recruitment programs. Nursing Leadership, 25(sp), 130–147. doi:10.12927/cjnl.2012.22799
Emily Durant, MN, RN, is the provincial transfusion coordinator for Nova Scotia Health. When she is not developing educational resources for nursing students and professionals, you can find her writing health content for her freelance business www.frontline2freelance.com or hiking trails around Halifax.
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