Seventy Per Cent (70%) Full-Time
RN Employment
Since 2000, RNAO has advocated for 70 per cent full-time
(FT) employment for RNs in the province of Ontario (RNAO, 2000).
Other organizations have also recommended moving to 70 per cent
FT as a minimum target. For example, the Canadian Nursing Advisory
Committee’s (CNAC) 2002 report entitled:
Our Health, Our Future: Creating Quality Workplaces for Canadian
Nurses recommends: “Governments, employers and unions
should collaborate to increase the proportion of nurses working
full-time to at least 70 per cent of the workforce in all healthcare
settings by April 2004, with an improvement of at least 10 per cent
to be completed by January 2003.”
RNAO’s rationale for 70 per cent FT employment is based on
the fact that this is VITAL to ensuring continuity of care and continuity
of caregiver for patients/clients in Ontario. And both continuity
of care and continuity of care provider are centrepieces for:
- Improved
Patient/Client Outcomes
- Efficient
RN Utilization and System Cost-Effectiveness
-
Improved RN-Physician Collaboration and Team Work
- Enhanced
Organizational Commitment
- Successful
Recruitment and Retention of RNs
- Sustainability
of the Nursing Profession
- Economic
Sense
RNAO believes continuity of care and continuity of care provider
cannot be achieved with the current low levels of full-time employment
amongst RNs; and the over-reliance on part-time, casual and agency
employment. The evidence and rationale are detailed below:
1. Improved patient/client
outcomes depend on 70 per cent FT:
“The ability of nurses to know their patient is significantly
compromised when nurses are assigned to different patients every
day which is mostly the case for agency, casual and part-time nurses,
and in particular for those who work for multiple employers. Caregiving
requires the nurse to have a detailed understanding of the patient’s
condition, response, needs, and wishes. It is through this human
relationship that nurses develop the comprehensive understanding
essential to respond to patients’ needs in a way that is relevant
to them. Undoubtedly, patient care is profoundly affected when the
nurse-patient relationship is short-lived due to intermittent, interrupted,
and inadequate interaction time” (Grinspun, 2003).
Several studies clearly demonstrate the links between continuity
of care and hospital patient outcomes (Aiken, 2002) and in home
care (O’Brien-Pallas, 2001).
Failure to rescue (Clarke and Aiken, 2003) links nurses’
experience directly to permanency in one unit (not a patchwork of
two, three or four employers). This paper also makes the link between
the quality of surveillance and the number of experienced nurses
compared to inexperienced nurses. Units with more experienced nurses
are more likely to detect problems/complications in a timely manner.
RNAO asks, how can nurses that run between several employers attain
expertise? Did you know that across Ontario, excluding Toronto,
30 per cent of casual nurses and 18 per cent of part-time nurses
work for multiple employers? The situation is worse still in Toronto
where 42 per cent of casual nurses and 25 per cent of part-time
nurses work for multiple employers.
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2. Efficient human resources utilization
and system cost-effectiveness requires 70 per cent FT:
A home care sector study (O’Brien-Pallas et al, 2001) found
that reducing the number of nurses going into a patient’s
home reduces the overall number of visits; more so if the principal
nurse makes the greatest proportion of visits. Thus, utilization
is improved when continuity of care provider is maintained. This
study also reveals that continuity of care provider (and for that
RNAO argues you need to have more FT nurses), significantly contributes
to cost-effectiveness. The study also demonstrates the greater effectiveness
of BScN prepared nurses compared to diploma RN or RPNs.
Overtime and related sick time are also linked to insufficient
numbers of full-time nurses and an over-reliance on part-time, casual
and agency staff. We all know that when a nursing unit receives
a last minute sick call for the upcoming shift, it is often the
full-time nurses who, by the mere fact of being there, are requested
to fill in the gap. “The excessive use of a part-time and
casual workforce has introduced job insecurity, intensification
of work, and added stress among full-time employees. The impact
is expressed in organizational performance through indicators such
as absenteeism and overtime” (Grinspun, 2003). O’Brien-Pallas’
interim results from focus groups conducted by the Nursing Effectiveness
Utilization and Outcomes Research Unit (NRU) reinforce this reality.
As a consequence, absenteeism is also higher among full-time nurses
than their casual and part-time counterparts (Shamian et al, 2002).
Indeed, we have created a truly sick cycle that must urgently be
reversed.
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3. Improved nurse-physician collaboration
and team work necessitates 70 per cent FT:
Much has been written about the poor working relationships between
nurses and physicians. Aiken’s work (2002), stresses the importance
of good working relationships between nurses and physicians to encourage
nurse satisfaction and optimal patient outcomes. The importance
of nurse–physician collaboration has also been supported in
Canadian-based replications of Aiken’s work (Laschinger et
al, 2001). RNAO believes that it is impossible to foster greater
collaboration without moving to 70 per cent FT employment for RNs.
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4. FT nurses and enhanced organizational
commitment:
There is much “talk” among CEOs and others about the
lack of organizational commitment that “nurses today”
demonstrate. It is difficult to understand how organizational commitment
can improve with nurses coming and going all the time. Nurses feel
that organizations are not committed to securing FT work for them;
thus, they owe nothing to organizations. RNAO’s Executive
Director, Doris Grinspun, explained this “broken psychological
contract” to the CEOs of the Toronto Academic Health Science
Council in 2000 when they invited her to help them address this
issue. CEOs at that meeting said: “We call them and they don’t
want to come.” The issue was also addressed in Hospital
Quarterly (Grinspun, 2000). The notion of commitment, both
by the nurse and towards the nurse, is one that in many reports/analyses
has been linked to nurse satisfaction and patient satisfaction.
RNAO conducted a survey of nurses’ assessments of changes
after the Nursing Task Force released its initial report: Tracking
the nursing task force: RNs rate their nursing work life (2002).
The report provides clear evidence of the importance of organizational
commitment. It is a theme that appears in other key reports such
as Baumann et al (2001), which finds that commitment is much harder
to build given the numbers of casual/part-time compared to full-time
nurses. This issue was also discussed in Laschinger et al (2001).
Aiken et al’s work (2002) identifies nurses’ work environment
as a key organizational trait explaining higher patient satisfaction
in magnet hospitals. Not only were magnet hospital patients were
more satisfied, but they were also more likely to have a single
nurse taking prime accountability for care. RNAO believes that this
cannot be achieved under current staffing patterns.
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5. Successful recruitment and retention
outcomes mandate 70 per cent FT:
So many more registered nurses want full-time employment. Earning
Their Return: When and Why Ontario RNs left Canada and What Will
Bring Them Back (RNAO, 2001) [PDF - 712 KB] found that the lack
of full-time positions was a key reason why Ontario RNs left the
country in the first place. Further, the availability of full-time
positions was a key factor that would encourage the return of those
same RNs to Ontario. RNAO’s
Survey of Casual and Part-time Registered Nurses in Ontario
(2003) revealed similar findings. We found that despite current
work environment challenges, if respondents had their preferred
status, there would be an immediate net shift of 11 per cent from
part-time and casual to full-time. This would translate into almost
4,000 more full-time RNs and, if certain conditions changed (and
it must be emphasized that these are not unreasonable conditions)
42.7 per cent, (the equivalent of well over 15,000 more full-time
positions, or more than 6,000 FTEs) would move to full-time, putting
Ontario at 74 per cent full-time employment for RNs.
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6. Sustainability of the nursing profession
depends on 70 per cent FT:
The fundamental question is: What kind of profession – and
professionals – do we need to have? The nursing profession
is central to health and health care, then how can we allow it to
be structured in a way that makes relationships with patients/clients,
other professionals and the organizations where nurses work sporadic?
Nursing is so much more than “doing tasks to patients,”
then why would we allow so many RNs to continue to practise in a
way that makes familiarity and engagement with patients, families
and other agency resources more difficult and less meaningful? How
can we support a system that obliges nurses to run between two,
three and four employers to make ends meet, therefore rendering
commitment almost impossible to achieve?
What other profession would tolerate this percentage of their members
practising in this fashion?
How can one actively engage in the structures of organizational
decision-making when there is so much coming and going?
How can we appropriately mentor our new graduates?
We challenge those who say “nurses want casual work because
they want control over their lives.” Our response is (and
our survey data show) that much of this so-called interest in part-time
and casual employment is a result of a lack of full-time opportunities
and unacceptable working conditions. We must immediately open the
doors to full-time employment for RNs or they will continue to leave
the country. We must fix work environments to improve the employment
experiences of all nurses.
When it comes right down to it, we simply cannot afford to encourage
members of our profession to believe that nursing is something in
which you “casually engage.”
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7. 70 per cent FT makes economic sense:
It makes little sense that nursing education programs, which are
highly subsidized by government, would produce a workforce with
approximately 50 per cent of its professionals working less than
full-time hours, or leaving for the U.S.
O’Brien-Pallas has demonstrated significant cost efficiencies
can be realized through reductions in workload. Reduction in sick
time through improved workloads would save over $39M, the equivalent
of 765 full-time equivalent positions (O’Brien-Pallas, et
al., 2001).
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A final comment:
How many nurses have you heard say, “I can’t find part-time
or casual work?” RNAO has not heard of a single one!
How many nurses have shared with you their frustration of not being
able to find full-time work? RNAO has received hundreds of calls
like that, and every year we help new graduates look for full-time
work; often all they can find is casual or part-time work.
On the other hand, the U.S. consistently makes 71.6 per cent full-time
employment available to its RNs.
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