The New Year brings new ideas, challenges, and optimism. It also carries with it the problems of the old year, one of which is the ongoing shortage of nurses both nationally and internationally. Recruitment agencies from Canada are enticing US nurses north across the 49th parallel; agencies from the US are equally effective in coaxing Canadian nurses south. The cross-border shortage represents a true crisis in health care. There are approximately 300,000 registered nurses, licensed practical nurses, and registered psychiatric nurses working in Canada. There is 1 registered nurse for every 133 Canadian citizens, compared with 119 citizens in 1990. Federal and provincial funding has declined significantly in the past 10 years. In 1990, there were over 12,000 admissions to basic nursing programs; in 2000, there were just 8,790 admissions. The Canadian population increased by 11% in the past decade, but the admissions to nursing programs decreased by 26%, and the number of nursing graduates decreased by an alarming 46%.
In fact, nursing is a mess: too few on the job, too many suffering job dissatisfaction and burnout, and too many patients feeling short-changed in the care they receive. Treatments are delayed, family members are dissatisfied, and nurses are over-worked as they fill in the gaps, stretch overstretched resources, and work overtime hours. And, to save money, key 'plumb' or 'frills' hospital positions in nursing research or nursing advanced practice have all but been eliminated. Clinical nurse specialist roles have been collapsed so that, where previously one nurse was responsible for urology and another for surgery, the one remaining CNS is now spread out between plastics, general surgery, ophthalmology, and urology. This negates focused expertise, the time available to teach, and, most importantly, the time available to reflect on practice. Currently, part-time and casual positions may save money in benefits and salaries; however, they also ensure a lack of continuity of patient care and dissuade any feelings of loyalty to one unit. Overtime costs (both mandatory and voluntary) are huge and probably cost institutions more than maintaining a larger workforce. Of course, the overtime then takes its toll on physical injuries, medication errors, emotional collapse, and sick time.
These events combined have led nursing practice to a standstill with no energy remaining to challenge the evidence, explore questions, and pursue research. Moreover, at least one Canadian province has initiated a 2-year diploma program in an attempt to produce at least some of the graduates necessary. At a time when most centers have finally achieved BScN as an entry to practice, this retroactive, Band-Aid solution is disappointing, threatens to leave the profession at the status quo, and suggests to the government that BScN is not really necessary to practice nursing.
In response to the crisis, the Canadian Nursing Advisory Committee was created in March 2001 at the direction of the Federal and Provincial Ministers of Health. The Committee's initial mandate was to make recommendations that would improve quality of nursing work-life and provide a framework and context for work-life improvement strategies at the provincial and territorial level.1
The group was informed by 6 commissioned research projects addressing strategies for establishing healthy workplaces; economics associated with overtime, absenteeism, and part-time employment; job satisfaction; nurses' definitions of autonomy and respect in the workplace; and nursing dilemmas concerning power and respect. The results of the research, along with substantial reviews of the literature, focused on three root causes for the workplace crisis:
* An actual current shortage of nurses, due to a reduced number of seats in nursing education programs because of increased costs and stagnant Provincial and Federal university and college funding, and an aging nursing workforce
* Human resources management issues that make it impossible to maximize the productivity of the nurses who are available to work (high absenteeism, high overtime, high rate of part-time work, high number of non-nursing tasks, and limited scope of practice), and
* Insufficient funds to hire the number of nurses needed to deliver the care being demanded.
On the final point, even if the funds were available, there are no nurses to hire.
Nurses are valued and trusted by the public, and surveys always rank nurses highly as trusted professionals. Even the public may become less empathetic if inadequate working conditions remain the norm. Nurses have gone on strike for better working conditions but the public, informed by the media, sees the strike as a grab for higher wages. As the Honourable Anne McLellan, Federal Minister of Health, noted when the Advisory Report was released in August 2002: "It is not only what you pay nurses, it's about a whole host of work-related conditions that are probably for most nurses more important than what they are being paid."2
The Advisory Committee has called on the government to summon the necessary political will to restore stability to health care by funding university and college programs. Over 50 recommendations on salary, full time positions, student loans, and educational funding were posed.
They recommended that the government ensure salaries and benefits that are attractive and competitive; they noted that the number of first year nursing positions at university should be increased by 25% (nationally approximately 1100 places in Canada). The Committee suggested waiving tuition fees for nursing students for the next four years and pro-rating student loans for nurses who are willing to work in hard-to-staff settings, in isolated areas, and in northern Canada. They pointed out that the proportion of full-time positions should increase from 55% to 70% by April of 2004. The authors recommend strongly that employers carefully examine the 'manageable workload' that a nurse can safely undertake. Although such safe workload strategies are currently in place, they are clearly inadequate and are not perceived as protecting the nurse or the patient. Finally, the committee identified the amount of time that nurses spent doing non-nursing tasks such as portering, calling relief staff, cleaning up spills; the skills their education prepared them for were set aside for other equally important but non-nursing tasks.1
Having a comprehensive report that clearly identifies areas for change gives both Canadian and US nurses a powerful document to show to their government leaders. Similar action has been taken by the Oregon Nursing Leadership Council.3 While the Canadian and US healthcare systems may have differences, the issues and concerns are parallel. Individually, nurses can write to their leaders; collectively, organizations such as WOCN have power to shake the status quo. Perhaps 2003 will be the year that health care and nursing begin to receive the respect and attention they deserve.
Katherine N. Moore
References