CRITICAL CARE WORFORCE PROFILE Care Nursing/Critical... · Critical Care Services Ontario (CCSO) is proud to release the 6th edition of survey results in the 2017 Critical Care Workforce

CRITICAL CARE WORKFORCE

PROFILEProvincial Report

Critical Care Services Ontario | May 2017

Critical Care Workforce Profile — Provincial Report

2 Critical Care Services Ontario • May 2017

ACKNOWLEDGMENTSThe 2017 Critical Care Workforce Profile (CCWP) reflects data generated between April 1, 2015 to March 31, 2016. Critical Care Services Ontario would like to thank all Critical Care Stakeholders who have been instrumental in contributing data to complete the 2015/16 Critical Care Workforce Profile Survey. These contributions are vital to informing CCSO’s health human resource planning, efforts and work in identifying emerging challenges and considerations for the critical care workforce.


Critical Care Services Ontario • May 2017 3

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A Message from Dr. Bernard Lawless and Mrs. Linda Kostrzewa

Critical Care Services Ontario (CCSO) is proud to release the 6th edition of survey results in the 2017 Critical Care Workforce Profile (CCWP) Report. Health Human Resource (HHR) planning is a pillar to achieving and sustaining quality healthcare delivery. Since 2007, CCSO has been conducting surveys to track and gain insights into the healthcare workforce to support delivery of critical care. Survey development for the 6th edition, underwent consultation processes resulting in exciting expansions to both the depth and breadth of critical care workforce intelligence captured and presented over the years in this report.

Understanding the critical care workforce through comprehensive data increases forecasting accuracy, informs effective staffing practices, and can enhance retention and recruitment strategies to ensure resilient critical care Health Human Resources, which meets current and future system needs. The SARS pandemic in 2003 in particular, highlighted opportunities for improvement in Ontario’s critical care system including managing the sufficient supply of critical care HHR. In 2007, CCSO developed the original Critical Care Nursing Workforce Profile (CCWNP), created to focus research on critical care nurse staffing in Ontario. Since then, two cycles of survey refinements occurred. In 2014 changes were made incorporating CCSO’s 12 Peer Groups, allowing for comparison of like-units for more accurate trending and benchmaking. In the most recent survey conducted, the focus of the survey was expanded to capture Allied Health Professionals and employee engagement.

On behalf of CCSO, we extend sincere thanks and gratitude to all those who have continued to participate in our CCWP survey, year-on-year, without which such robust intelligence could not be produced in return. Finally, we wish to thank those who have thoughtfully contributed to the development over the years and particularly to the 6th edition of the CCWP. We hope our system collaborators will continue to find the insights here within of value to informing an adaptive and resilient critical care system.

Sincerely,

Bernard Lawless, MD, MHSc, CHE, FRCSC Provincial Lead Critical Care Services Ontario

Linda Kostrzewa, RN, BAS Hons., MHSC Senior Director Strategy and System Transformation Critical Care Services Ontario



EXECUTIVE SUMMARYThe 2017 Critical Care Workforce Profile, Provincial Report provides workforce analytics on critical care nurses and to a lesser degree on allied health professionals working in the Ontario Critical Care System. The report includes comprehensive critical care nurse demographic, workforce utilization, and recruitment and retention indicators with data from the 2015/16 year. Where available indicators have been trended over time from 2007/08, or compared to previous years of data from 2013/14. Where relevant, data is analyzed regionally by LHIN, and by Peer Group.

In this report, survey results are presented in two parts:

1. The Provincial Report, which provides both the LHIN and Peer Group level analysis.

2. There are ten Peer Group–level reports that have been included in appendices, presenting findings that are unique to Peer Groups and across the individual critical care units for that Peer Group.

The provincial executive summary below provides a highlight of the provincial and LHIN-level findings. Highlights of the Peer Group-level findings can be found in the individual executive summaries of each Peer Group Report.

Nurse Demographics

This section of the report covers experience in critical care, age, and gender. Information on nursing roles can be found in the body of the report.

EXPERIENCE IN CRITICAL CARE

In 2015/16, almost half (46%) of the critical care nursing workforce had worked in the field for 6 to 20 years. Since 2007, nurses early in their career with 3 to 5 years of experience as well as those late in their career with more than 20 years of experience have decreased by 2-3% while nurses with 11 to 20 years of experience has increased by 5%.

Across the province, the level of experience of critical care nurses vary:

• Central (LHIN 8) and South East (LHIN 10) reported the highest proportions of novice nurses (less than 3 years of experience), both at 32%.

• In Central West (LHIN 5) and South East (LHIN 10) there are the highest proportions of mid-career nurses with 3-10 years of experience (31% and 28% respectively).

• The Waterloo Wellington (LHIN 3) has a very high proportion of nurses with 11 to 20 years of experience (37%).

85%SURVEY

RESPONSERATE*

*Finance data collection tool



Since 2007, nurses early in their career with 3 to 5 years of experience as well as those late in their career with more than 20 years of experience have decreased by 2-3%

while nurses with 11 to 20 years of experience has increased by 5%.

NURSING EXPERIENCE TRENDS: 2007–2016

>20 Years

3–5 Years

11–20 Years3%

5%

3%

AGE

When the CCWP work was initiated in 2007, there were fears of an aging workforce and threats to sustainability from retirements. Since 2007, there has been a 4.5% increase in the proportion of nurses under age 30 and there has been an 8.8% decrease in the proportion of nurses aged 40 to 49. In 2015/16, the median age of critical care nurses in Ontario was between 30 and 39 years, representing 28% of all critical care nurses. In contrast, in 2007/08, the median age was 40 to 49, representing 34% of the workforce. This change over time may be showing a favorable demographic shift.

Some notable differences to these overall provincial trends include:

• Paediatric units (PG6) had the youngest nursing demographic with close to 70% of the nurses under the age of 40.

• Central East (LHIN 9) and South West (LHIN 2) have the largest proportion of nurses aged 50 to 59, representing 27% and 25% of their respective LHIN critical care nurse populations respectively.

GENDER

Since 2007, the proportion of male nurses in critical care, reported in the CCWP, increased from 7.5% to 10.2%. This is higher than the overall proportion of males in nursing in Ontario, which was 5.2% in 2011.

Notable exceptions to this in the province include the South West (LHIN 2) which reported the lowest percentage of male nurses at 7.1%, in 2015/16 while North West (LHIN 14) reported the highest proportion of critical care male nurses at 14.7%.

MEDIAN AGEOF CRITICAL CARE NURSES

28%

40-492007/08

of workforce

30-392015/16

of workforce

34%



Nurse Staffing Practices

This section covers employment status, overtime, sick time and managing short term nursing shortages, as well as nurse productivity. All other information on overtime hours and education time can be found in the related section in the body of the report.

EMPLOYMENT STATUS

In 2015/16, 66% of Ontario’s critical care nurses were employed full-time which is consistent with findings from previous years of the CCWP. The largest group of part-time staff can be found in nurses under 30 years old. Across the province, there are some exceptions to this however:

• North Simcoe Muskoka (LHIN 12) has the lowest proportion of full-time staff with only 53% of their critical care nursing workforce being from full-time staff.

• Some of the less urban LHINs have a greater reliance on earned hours from part-time staff, particularly Erie St. Clair (LHIN 1) and North Simcoe Muskoka (LHIN 12) where the proportion of earned hours from part-time staff is about 30%, far higher than the 17.5% provincial average.

OVERTIME, SICK TIME AND MANAGING SHORT TERM NURSING SHORTAGES

Provincially, the overtime rate for front-line staff in critical care units was 3.9%. In the South West (LHIN 2), the overtime rate is very low at 1.7%. At the other end of the spectrum, the Central West (LHIN 5) has the highest overtime rate for critical care units at 9.0%.

Since 2007, the CCWP sick rate for critical care nurses has been decreasing. The provincial sick rate in critical care units for bedside nurses in 2015/16 is 4.8% whereas in 2007/08 it was 7.0%.

OVERTIME RATE

2015/16

3.9%

2007/08

4.9%

SICK RATE

7.0%2007/08 4.8%2015/16



To manage short-term nursing shortages, whether from staff absences or surge in demand, critical care units deploy a number of strategies. Expanded patient assignments is the most frequently used approach to address these short-term nursing shortages in the province, with 22% noting this is frequently used and 43% noting it is sometimes used. Relying on internal critical care nursing pools or using agency staff were the next most frequently used approaches, used frequently or sometimes by 36% and 32% of units respectively.

NURSE PRODUCTIVITY

One way to view nursing productivity, or the resource intensity of care, is to consider the number of nursing hours worked per patient day. Provincially, in 2015/16 critical care nurses worked 17.1 hours per patient day, which was similar to the findings in 2013/14. There was variation across peer groups however, with level 3 units having more than 15 hours of nursing care per patient day while level 2 units had less than 12 hours of nursing care per patient day.

Nurse Training

This section covers educational attainment, and specialized critical care training. All other information on internationally educated nurses, life support training and professional development investments can be found in the related section in the body of the report.

EDUCATIONAL ATTAINMENT

Coinciding with the provincial policy shift in 2000, requiring a baccalaureate degree in nursing for entry to practice (Council of Ontario Universities Position Paper on Collaborative Nursing Programs in Ontario 2010 ), the proportion of nurses with diplomas has decreased since 2007/08 from 71% to 38% in 2015/16. Over the same period, critical care nurses with Bachelor of Nursing (BNs) or Baccalaureates has doubled from 27% in 2007/08 to 55% in 2015/16.

Regionally, Waterloo Wellington (LHIN 3) had the smallest percentage of nurses with an undergraduate nursing degree (28%) and Toronto Central (LHIN 7) had the greatest (67%). In addition, Central East (LHIN 9) although suburban in nature, reported only 38% of their nurses to having an undergraduate degree in nursing.

24

12

61817h

NURSING CAREHOURS PER DAY



SPECIALIZED CRITICAL CARE TRAINING

The Ontario Critical Care Nurse Training Standards recommend training completed through an in-house and/or college-based adult and/or paediatric critical care program that is at a minimum 300 didactic and clinical training hours for nurses new to critical care. Provincially almost 40% of critical care nurses have training to these training standards.

There were also some variation in training to critical care standards across the province.

• Waterloo Wellington (LHIN 3) and South East (LHIN 10) each reported less than 10% of their nurses had training to the Ontario Critical Care Nurse Training Standards (300 hours or more of training).

• North West (LHIN 14) reported the most nurses who have not completed specialized critical care training (39%).

CRITICAL CARE NURSE TRAINING STANDARDS**

56%38%

2015/162013/14

** Completed a minimum of 300 didactic clinical training hours for nurses new to critical care



Nurse Turnover

This section covers nurse separations by age group and nurse employee turnover. Information on nurse exit destinations and changes in employment status can be found in the related section in the body of the report.

EMPLOYEE TURNOVER

The overall turnover of direct care nurses was 8.7% in 2015/16, which is lower to the rate noted in a 2008 pan-Canadian study (9.5%) (Hayes, 2012). Nursing turnover is lower for full-time staff in critical care, which was reported in the 2015/16 CCWP at a provincial average of 5.7%.

The distribution of employee exits from the organization by age group noted that there are higher volumes of exits (excluding retirement) from younger age groups. Nurses under 40 years old represented 57% of exits, while exits from ages 40-59 represented 42%.

Regarding exits due to retirement, the greatest number of nurses retiring are in the 60- 64 age group (30%), although there are also a large number of retirements in the 50-59 age group (24%) and the age group 65+ (16%).

When considering tenure within an organization, nurses with less than 3 years of employment with an organization are the largest groups leaving for both the under 30 and 30 to 39 age groups. This group with less than 3 years with the organization represents almost 30% of exits for the 40 to 49 age group as well.

WHERE NURSES GO

Across Ontario for nurses changing employment status or nursing positions, most remain within an ICU environment (43%) while 21% move out of the ICU environment but stay within nursing. For those nurses who leave an ICU care environment but remain in nursing, most remain at the same hospital.

VACANCY RATE

Between the years 2007/07 to 2015/16, the vacancy rate has ranged from a low of 3.4% in 2013/14 to a high of 6.3% in 2010/11, and overall is showing a decreasing trend over time. Most recently, as of March 31 2016, the provincial vacancy rate for nursing in critical care units was 5.0%.



Retention and Employee Engagement

This section covers employee engagement. Information on recruitment such as recruitment strategies, new hires and vacancy rate can be found in the Recruitment section of the Report. Retention indicators such as retention strategies can be found in the Retention and Employee Engagement section in the body of the report.

EMPLOYEE ENGAGEMENT

Respondents to the 2015/16 CCWP were asked if their units participated in hospital-led employee engagement surveys, with over 90% of units reporting this was in place. Units were also asked to identify the top employee engagement improvement opportunities identified in these surveys. The most frequently identified improvement opportunity, noted by almost 50% of units, included dimensions of job characteristics (e.g. flexibility in schedule/work hours; balance of family/personal life with work; having adequate resources/equipment to do work; having time to carry out all work demands; getting recognition for good work).

Allied Health Professionals in Critical Care

This section of the report covers Allied Health Professionals and reports on the use of the different professions covering:

Pharmacy

92%

Physiotherapy

90%

Dietician/Nutritionists

88%

RespiratoryTherapists

87%

ALLIED HEALTH SUPPORT IN CRITICAL CAREPercentage of critical care units using allied health professionals.

• Chaplains/Spiritual Carers/Pastors

• Dietitian/Nutritionists

• Occupational Therapists

• Pharmacists

• Physiotherapists

• Respiratory Therapists

• Social Workers

Weekday and weekend support hours, and on-call provision for Pharmacists, Physiotherapists and Respiratory Therapists are provided in the body of the report.



TABLE OF CONTENTS

1. INTRODUCTION 19

1.1 ObjectivesandScopeoftheCriticalCareWorkforceProfile(CCWP) 20

1.2 Data Collection Methods 21

1.3 Structure of Report and Analysis 22

1.3.1 Peer Groups 22

1.3.2 LocalHealthIntegrationNetworks(LHINs) 23

1.4 Report Considerations 24

2. SURVEY RESPONSE RATE 25

2.1 Number of Nurses Represented in the CCWP 27

3. NURSE ROLES AND DEMOGRAPHICS 29

3.1 Nursing Roles 29

3.2 Level of Experience 31

3.3 Age 34

3.4 Gender 37

4. NURSE STAFFING PRACTICES 40

4.1 Employment Status 40

4.1.1 Employment Status by Headcount 40

4.1.2 Employment Status by Earned Hours 45

4.2 Distribution of Earned Hours 47

4.2.1 Overtime Hours as a Proportion of Productive Hours 48

4.2.2 Sick Time 50

4.2.3 Education Time 52

4.3 Managing Short-Term Nursing Shortages 53

4.3.1 Expanded Assignments 54

4.3.2 Critical Care Nursing Pool 55

4.3.3 AgencyStaffing 56

4.4 Nurse Productivity 57



5. NURSE TRAINING 59

5.1 Internationally Educated Nurses 59

5.2 EducationalAttainment 62

5.3 SpecializedCriticalCareTraining 65

5.4 LifeSupportTraining 69

5.4.1 AdvancedCardiacLifeSupport(ACLS)Training 69

5.4.2 PaediatricAdvancedLifeSupport(PALS)Training 70

5.5 Professional Development Investments 71

5.5.1 In-services 72

5.5.2 PaidCoursesandCertificates 73

5.5.3 Ministry of Health and Long-Term Care Support 74

6. NURSING TURNOVER 75

6.1 ScopeofNursingTurnoverAnalysis 75

6.2 SeparationsbyAgeGroup 76

6.3 EmployeeTurnover 77

6.4 WhereNursesGo 80

6.4.1 DestinationofExits 80

6.4.2 ChangesinEmploymentStatus 83

7. NURSING RECRUITMENT 84

7.1 Recruitment Strategies 84

7.2 NewHires 86

7.3 Vacancy Rate 87

8. RETENTION AND EMPLOYEE ENGAGEMENT 90

8.1 Retention Strategies 90

8.2 Participation in Hospital-Led Engagement Surveys 92

8.3 Employee Engagement Improvement Opportunities 95



9. ALLIED HEALTH PROFESSIONALS IN CRITICAL CARE 96

9.1 Use of Allied Health Professionals in Critical Care 98

9.2 Pharmacists 99

9.3 Physiotherapists 102

9.4 RespiratoryTherapists(RT) 104

9.4.1 FTE Allocation 107

10. CONCLUSION 108

11. GLOSSARY OF TERMS 110

12. PROVINCIAL REPORT APPENDICES 111

Appendix A. Ontario’s Local Health Integration Networks 111

Appendix B. Calculations Table 112

Appendix C. Additional Response Rate Details 114

Appendix D. Online Data Collection Tool 117

13. BIBLIOGRAPHY 127



LIST OF FIGURESFigure 1: CCWP Data Collection Tool Response Rate, Trend Over Time 25

Figure 2: Critical Care Nurses, by LHIN 28

Figure 3: Length of Nurse Experience in the Critical Care Unit, Trend Over Time 31

Figure 4: Length of Nurse Experience in the Critical Care Unit, by Peer Groups 32

Figure 5: Length of Nurse Experience in the Critical Care Unit, by LHIN 33

Figure6: AgeGroupDistributionofCriticalCareNurses,TrendOverTime 34

Figure 7: Age Group Distribution of Critical Care Nurses, by Peer Group 35

Figure8: AgeGroupDistributionofCriticalCareNurses,byLHIN 36

Figure 9: Gender Distribution of Critical Care Nurses, Trend Over Time 37

Figure 10: Age Group Distribution of Male Critical Care Nurses, Provincial 38

Figure 11: Gender Distribution of Critical Care Nurses, by Peer Groups 38

Figure 12: Gender Distribution of Critical Care Nurses, by LHIN 39

Figure13: EmploymentStatusDistributionofCriticalCareNurses,2013/14and2015/16 41

Figure 14: Employment Status Distribution of Critical Care Nurses by Age Group, Provincial 42

Figure 15: Employment Status Distribution of Critical Care Nurses, by Peer Group 43

Figure16: EmploymentStatusDistributionofCriticalCareNurses,byLHIN 44

Figure 17: Employment Status Distribution of Critical Care Nurse Earned Hours, by Peer Group 45

Figure18: EmploymentStatusDistributionofCriticalCareNurseEarnedHours,byLHIN 46

Figure 19: Distribution of Critical Care Nurse Earned Hours by Type, Provincial 47

Figure 20: Overtime Hours as a Proportion of Productive Hours for Critical Care Nurses, by Peer Group 48

Figure 21: Overtime Hours as a Proportion of Productive Hours for Critical Care Nurses, by LHIN 49

Figure 22: Sick Rate for Critical Care Nurses, Trend Over Time 50

Figure 23: Sick Rate for Critical Care Nurses, by Peer Group 51

Figure 24: Education Hours as a Proportion of Total Earned Hours for Critical Care Nurses, by Peer Group 52

Figure 25: Approaches to Manage Short-Term Nursing Shortages, Provincial 53

Figure26: Useof“ExpandedAssignments”toManageShort-TermNursingShortages,byPeerGroup 54

Figure27: Useof“CriticalCareNursingPool”toManageShort-TermNursingShortages,byPeerGroup 55

Figure28: Useof“AgencyStaff”toManageShort-TermNursingShortages,byPeerGroup 56

Figure29: CriticalCareNurseWorkedHours(includingOvertime)perPatientDay,byPeerGroup 57

Figure30: CriticalCareNurseWorkedHoursperPatientDayin2013/14and2015/16,byPeerGroup 58

Figure31: PercentofInternationallyTrainedCriticalCareNurses,TrendOverTime 60

Figure32: PercentofInternationallyTrainedCriticalCareNurses,byPeerGroups 60

Figure33: PercentofInternationallyTrainedCriticalCareNurses,byLHIN 61

Figure34: EducationalAttainmentDistributionofCriticalCareNurses,TrendOverTime 62



Figure35: EducationalAttainmentDistributionofCriticalCareNurses,byPeerGroups 63

Figure36: EducationalAttainmentDistributionofCriticalCareNurses,byLHINs 64

Figure 37: Proportion of Nurses that completed a Minimum of 300 Clinical or Didactic Critical Care Training Hours,2013/14and2015/16 66

Figure38: CriticalCareTrainingAttainmentDistributionofCriticalCareNurses,byPeerGroup 67

Figure39: CriticalCareTrainingAttainmentDistributionofCriticalCareNurses,byLHIN 68

Figure 40: Advance Cardiac Life Support Training Attainment Distribution of Critical Care Nurses, by PeerGroup 69

Figure41: PaediatricAdvancedLifeSupport(PALS)TrainingAttainmentDistributionofCriticalCareNursesinPaediatric Critical Care Units 70

Figure 42: Approaches to Professional Development Investment in Critical Care Units, Provincial 71

Figure43: Useof“In-services”forProfessionalDevelopment(PD)inCriticalCareUnits,byPeerGroup 72

Figure44: Useof“PaidCoursesandCertificates”forProfessionalDevelopment(PD)inCriticalCareUnits,by Peer Group 73

Figure45: Useof“MOHLTCSupport”forProfessionalDevelopment(PD)inCriticalCareUnits,byPeerGroup 74

Figure46: CriticalCareNurseExitsbyCategoryandAgeGroup,Provincial 76

Figure 47: Critical Care Nurse Turnover by Age Group, Provincial 77

Figure48: CriticalCareNurseTurnoverforFull-TimeStaffbyAgeGroup,Provincial 78

Figure 49: Critical Care Nurse Exits from the Organization by Age Group and Tenure with Employer, Provincial 79

Figure 50: Destination of Critical Care Nurses Leaving the Unit or Changing Employment Status, by Peer Group 80

Figure 51: Destination of Critical Care Nurses Changing Position and Remaining in ICU, by Peer Group 81

Figure 52: Destination of Critical Care Nurses Leaving ICU and Remaining in Nursing, by Peer Group 82

Figure 53: Changes in Employment Status for Critical Care Nurses, by Peer Group 83

Figure 54: Vacancy Rate for Critical Care Units, Trend Over Time 87

Figure 55: Vacancy Rate for Critical Care Units, by Peer Group 88

Figure56: VacancyRateforCriticalCareUnits,byLHIN 89

Figure 57: Critical Care Unit Participation in Hospital-Led Engagement Survey, by Peer Group 93

Figure 58: Critical Care Unit Participation in Hospital Led Engagement Survey, by LHINs 94

Figure 59: Employee Engagement Improvement Opportunities for Critical Care Units, Provincial 95

Figure60: RoutineUseofAlliedHealthProfessionalsinCriticalCareUnits,Provincial 98

Figure61: PharmacistSupportHoursperDayinCriticalCareUnits,byPeerGroup 100

Figure62: PharmacistProvisionofOn-CallSupportinCriticalCareUnits,byPeerGroup 101

Figure63: PhysiotherapistSupportHoursperDayinCriticalCareUnits,byPeerGroup 102

Figure64: PhysiotherapistProvisionofOn-CallSupportinCriticalCareUnits,byPeerGroup 103

Figure65: RespiratoryTherapistSupportHoursperDayinCriticalCareUnits,byPeerGroup 105

Figure66: RespiratoryTherapistProvisionofOn-CallSupportinCriticalCareUnits,byPeerGroup 106

Figure67: RespiratoryTherapistFTEAllocationinCriticalCareUnits,byPeerGroup 107



LIST OF TABLESTable 1: Data Elements Captured Over CCWP Survey Evolution 21

Table 2: Ontario’s Critical Care Unit Peer Groups 23

Table3: CCWPResponseRatebyLHIN 26

Table 4: Critical Care Nurses Reported in Data Collection Tools 27

Table 5: Headcount by Nursing Role Type 29

Table6: HeadcountDistributionbyNursingFunction 30

Table7: ClassificationofEmploymentStatus 40

Table 8: Data Collection Tools for Nursing Turnover Capture 75

Table9: UseandEffectivenessofRecruitmentStrategies,Provincial 84

Table10: UseandEffectivenessofRecruitmentStrategy“Mentorship”,byPeerGroup 85

Table11: NewCriticalCareNurseHiresbyCategory,2013/14and2015/16,byPeerGroup 86

Table12: UseandEffectivenessofRetentionStrategiesinCriticalCareUnits,Provincial 90

Table13: UseandEffectivenessofRecruitmentStrategy“Education/TrainingEvents”,byPeerGroup 91

Table 14: LHIN Rural Population 111

Table15: CalculationsUsedinDataCollectionforWorkforceProfile 112

Table16: CCWPResponseRatebyPeerGroup 114

Table 17: Critical Care Nurses Reported in Data Collection Tools, by LHIN 115

Table18: CriticalCareNursesReportedinDataCollectionTools,byPeerGroup 116



1. INTRODUCTIONHealthcare continues to face increasing demand pressures from both population growth and shifting demographics in Ontario. According to the 2016 population estimate by Statistics Canada, Ontario’s population has increased by over half a million residents (4%) since 2011 with the province’s metropolitan centers, such as Toronto, Hamilton, Kitchener-Waterloo and London having absorbed the bulk of these increases (“Estimates of population by census metropolitan area, sex and age group. ,” 2016). More importantly however, the proportion of Ontarians 65 years and older has increased by 16.8% per cent during the same time frame (“Population by sex and age group, by province and territory,” 2016), which is particularly relevant when planning for critical care needs as the majority of critically-ill patients are over the age of 65 years (Needham et al., 2005). This Critical Care Workforce Profile Report works to understand and profile the workforce in critical care, as an enabler to effective human resource planning and to capture any shifts in the composition of the workforce which may present sustainability risks for the system.

The 2017 Critical Care Workforce Profile Report is the 6th edition of a provincial survey looking into the demographics, staffing practices, and supports to critical care nursing in Ontario, across more than 160 critical care units. The original Critical Care Nursing Workforce Profile (CCNWP) developed in 2007 was created to focus research on critical care nurse staffing in Ontario. Enhancements to the data collection in the recent iteration of the survey (now called the Critical Care Workforce Profile (CCWP)) have expanded to include some data collection on the resourcing of allied health professionals in critical care, although much of the survey remains focused on nursing. The survey generally, and with its expansion to include allied health resourcing, is undertaken recognizing that Health Human Resource (HHR) planning is a system pillar to achieving and sustaining quality healthcare delivery.

In this report we examine HHR resourcing and trends for nurses and allied health professionals in the critical care workforce. While there has been jurisdictional data collected broadly on nursing and other professional groups, there has been relatively scarce data available to reflect upon the precise challenges and demand on a workforce in specialty services such as critical care, outside of this work undertaken by Critical Care Services Ontario (CCSO).



1.1 Objectives and Scope of the Critical Care Workforce Profile (CCWP)

The Critical Care Workforce Profile (CCWP) aims to provide critical care service providers, the Ministry of Health and Long-Term Care (MOHLTC) and other critical care stakeholders insights into the availability, utilization and adequacy of critical care HHR at provincial, Peer Group, and regional levels (Local Health Integration Networks (LHINs)) to ensure a resilient critical care workforce which meets current and future system needs.

Comprehensive workforce data increases forecasting accuracy, informs effective and efficient staffing practices, identifies and strengthens useful retention strategies and ensures workforce continuity. Up-to-date information about demographics, staffing practices, turnover, recruitment and retirement, workplace stressors, and professional development trends of the critical care workforce is essential for informing these efforts. Thus, the CCWP aims to:

• Track and trend demographics of the nursing workforce to identify emerging trends and pressures across the province;

• Understand the existing resourcing of the critical care nursing and allied health professional workforce in depth;

• Understand the training and development practices for the critical care nursing workforce;

• Assess recruitment and retention through staff departure rates and the number of new hires/trainees at the provincial, LHIN and Peer Group levels required to staff existing and proposed expanded capacity;

• Assess retention and recruitment challenges at the provincial, LHIN-level and track the impact of initiatives designed to improve retention and facilitate recruitment; and,

• Understand employee engagement pressures in critical care (new in 2017).



1.2 Data Collection Methods

The survey recipients identified to populate the 2017 CCWP Report have been expanded to include hospital human resources department and finance department submissions of standardized data sources as well as a survey to nurse managers as has occurred in previous surveys. A summary of the data elements and data sources captured over time is represented in Table 1 below.

Table 1: Data Elements Captured Over CCWP Survey Evolution

Subject Area Focus of Questions 2007/08 – 2010/11 2013/14 2015/16

Survey Target Unit Managers

Unit Managers

Unit Managers

Human Resources Finance

Nursing Roles and Demographics

Number of staff by discipline √ √ √ √

Length of time on the unit √ √ √Number of staff by age group and gender

√ √ √

Nurse Staffing Practices

Staff by employment status √ √ √ √Staffingstatistics(workedhours,overtimehours,sickhoursetc.)

√ √ √

Strategies for short-term nursing coverage

√ √

Worked hours per patient day √ √

Nurse Training

Highest level of education; proportion of internationally educated nurses

√ √ √

Typeoftraining(criticalcarecertificates,ACLS,paideducationhoursetc.)

√ √

Support strategies for nursing professional development

√ √

Nursing Turnover

Number of exits √ √ √ √ √

Reasonsforexits(whereknown) √ √ √

Nursing Recruitment

Recruitment strategies √ √

New Hires √ √ √

Vacancies √ √ √

Retention and Employee Engagement

Retention strategies √ √Use of employee engagement surveys by hospitals

√

Opportunities for engagement improvement at the unit level

√

Allied Health Professionals (AHP)

Allied health disciplines involved in regular care

√

Approximate FTE allocations of AHP by discipline

√

Coverage for weekdays, weekends, and call for AHP

√



1.3 Structure of Report and Analysis

The 2017 CCWP Report provides workforce profiling of critical care nurses including some trending analysis where possible for data captured from 2007/08 to 2015/16, and snapshot analysis for data representing the nursing and allied health workforce from April 1, 2015 to March 31, 2016. Each section will present the provincial trending analysis where possible, as well as Ontario, Peer Group or LHIN perspectives where relevant findings are noted.

1.3.1 PEER GROUPS

Peer-level groupings were first launched by CCSO in July 2013, outside of the CCWP work, to facilitate comparison of a unit’s performance with ‘like’ units. Assignment to a specific Peer Group (PG) took into account factors such as unit designation (Level 2 or Level 3), academic affiliation, and severity of illness of patients managed in the units. The Peer Groups can be used for comparing similar units or comparing one Peer Group with others. The Peer Groupings list was re-evaluated without change in December 2014.

For this 2017 CCWP Report, two smaller PGs have been merged with larger PGs to assist with comparison of results. In order to best represent these units’ data for Peer Group analysis, they were merged with the next closest Peer Group based on acuity of patients and hospital type.

• PG7 (two units) has been merged with PG1; and,

• PG12 (one unit) has been merged with PG10.

The list of Peer Groups and a summary of the criteria used to define each Peer Group is outlined in Table 2.



Table 2: Ontario’s Critical Care Unit Peer GroupsPeer Group # Criteria

Group 1 Level3TeachingHospitals(MedicalSurgicalICU)

Group 2Level3CommunityHospitals(MedicalSurgicalICUswithVentilatorPatientDayRateabovethemeanrateof46.95%)

Group 3Level3CommunityHospitals(MedicalSurgicalICUswithVentilatorPatientDayRateequaltoorlessthanthemeanrate46.95%)

Group 4 Level 3 and Level 2 Cardiac/Cardiovascular Unit

Group 5 Level 3 and Level 2 Coronary Care Units

Group6 Paediatric Units

Group 7 Level 3 Burn Units

Group 8 Level 2 Small - Low Acuity Units

Group 9 Level 2 Large - Low Acuity Units

Group 10 Level 2 Small - High Acuity Units

Group 11 Level 2 Large - High Acuity Units

Group 12 Miscellaneous

NOTES:

• For Groups 2 and 3, the data used to generate Mean Ventilator Patient Day Rate is based on fiscal 2011-12

• For Groups 4 and 5, identification of cardiac/cardiovascular unit is based solely on the unit name provided by each hospital

• For Groups 8-11, criteria Identified using mean values for total beds and MODS (6 and 1.1, respectively). Values equal to or below the means were defined as small (total beds ≤ 6) or low acuity (MODS ≤ 1.1). The data used to generate the mean MODS is based on fiscal 2011-12.

1.3.2 LOCAL HEALTH INTEGRATION NETWORKS (LHINS)

The LHIN-level analysis offers regional perspectives that can inform evaluation, planning and resource allocation. Rural and urban areas in particular can have unique workforce demographics and needs, which can be informed by examining LHIN-level analysis.

The compositions of LHINs, as well as the numbers and types of critical care units within each of them, limits direct comparison of the critical care nursing workforce across LHINs. As well, it should be noted that a considerable proportion of patients cross LHIN borders to receive care for sub-specialty programs.

The list of LHINs and the proportion of each LHIN that is considered rural can be found in Appendix A.



1.4 Report Considerations

When reviewing the report and analysis, the reader should be aware of the following considerations:

• Analysis may be at the staff-level or unit-level, depending on the focus of analysis.

• In figures and tables throughout the report, “N” denotes the provincial sum of respondents (nurses or units) who reported to the indicator, and “n” refers to the total number of respondents (nurses or units) in each Peer Group or LHIN as represented by the variable.

• Not all units that responded to the 2015/16 CCWP Survey completed all three data collection tools. For this reason, the number of units included in analysis may shift depending upon the data source.

• “N”, or the provincial sum of respondents, may be different for each question, as the same number of units may not have responded to each question. Percentages are therefore calculated from the number of responses to each question.

• In one instance combined results were submitted for human resource submissions (CCIS030 and CCIS217) and for the finance data submissions this occurred in two instances (CCIS030 and CCIS217 as well as CCIS126 and CCIS127). Each pair of these units are treated as one unit in the analysis; assigned to the higher-level acuity Peer Group.

• The calculations for different analyses presented in figures and tables throughout the report can be found in Appendix B.



2. SURVEY RESPONSE RATECritical Care Services Ontario (CCSO) has been tracking and profiling the critical care nursing workforce since 2007. In the summer of 2016, CCSO disseminated the Critical Care Workforce Profile Survey to Chief Nursing Officers, Vice Presidents responsible for ICU, ICU Directors, and ICU Nurse Managers with detailed instructions as well as invitation to CCSO-led webinars to assist with data collection requirements and survey completion.

The approach to data collection was revised in the 2015/16 survey. The revisions aimed to make the analysis more robust, adding collection of data from hospital Human Resources (HR) departments and Finance departments to allow for more comprehensive analysis. The completion of all three data components was internally managed and submitted to CCSO by Hospitals.

The CCWP has had consistently successful response rates since 2007, collecting data from the majority of Ontario’s critical care units. Since 2007, survey response rates have ranged from 73% to 87% as identified in Figure 1. In the 2015/16 data collection process, response rates varied between 75% and 85% from the three data collection tools, with the newly implemented finance department data collection tool having the highest response rate from hospitals at 85% compliance (170 out of a total 199 Ontario critical care units).

Figure 1: CCWP Data Collection Tool Response Rate, Trend Over Time

0%

20%

40%

60%

80%

100%

2015/16(199)

2014/152013/14(206)

2012/132011/122010/11(200)

2009/10(200)

2008/09(200)

2007/08(216)

Response Rate Finance Data Collection ToolHR Data Collection ToolOnline Survey

PERC

ENTA

GE

YEAR (N)

85%

73%

87% 87%

81%

83%

75%

85%



Table 3 offers a snapshot of the response rate to our three data collection tools by LHIN. Two of the LHINs, South West (LHIN 2) and North Simcoe Muskoka (LHIN 12) had low response rates for at least two of the survey collection tools, suggesting an opportunity for greater engagement with these LHINs to support survey participation in future surveys. Survey response by Peer Group did not demonstrate similar wide variation in response rates. Response rates ranged from 70% to 100% among all Peer Groups across survey data collection tools.

Table 3: CCWP Response Rate by LHIN

LHINTotal # of Critical Care Units

Number of Critical Care Units Responded Response Rate

Online Survey

Human Resources* Finance* Online

SurveyHuman

Resources Finance

Ontario 199 165 150 170 83% 75% 85%

1.ErieSt.Clair(ESC) 7 7 6 6 100% 86% 86%

2.SouthWest(SW) 29 19 16 23 66% 55% 79%

3. Waterloo Wellington (WW)

11 8 9 9 73% 82% 82%

4. Hamilton Niagara HaldimandBrant(HNHB)

28 25 24 25 89% 86% 89%

5.CentralWest(CW) 6 6 5 6 100% 83% 100%

6.MississaugaHalton(MH)

9 9 7 9 100% 78% 100%

7.TorontoCentral(TC) 33 29 29 28 88% 88% 85%

8.Central(C) 10 9 9 9 90% 90% 90%

9.CentralEast(CE) 13 9 10 13 69% 77% 100%

10.SouthEast(SE) 10 7 9 9 70% 90% 80%

11.Champlain(CH) 20 19 11 19 95% 55% 95%

12. North Simcoe Muskoka(NSM)

7 3 3 3 43% 43% 43%

13.NorthEast(NE) 13 12 10 9 92% 77% 69%

14.NorthWest(NW) 3 3 2 2 100% 67% 67%

* Where units submitted combined data, both units are included in this count. When results are discussed in later sections, these combined units are treated as one.

Details on response rate for each data collection tool by Peer Group can be found in Appendix C.



2.1 Number of Nurses Represented in the CCWP

Of the three data collection tools used, the online survey submissions provided information on the highest number of critical care nurses from a headcount perspective. Information requested on nursing headcount was omitted for a number of units in the finance data collection tool which led to this result. The number of nurses represented in each of the data collection tool submissions is identified in Table 4 below.

Table 4: Critical Care Nurses Reported in Data Collection Tools

Total # of Critical Care Units

Online Data Submission

Human Resources Submission

Finance Submission*

Total Units Responded: Ontario

199

165 150 170

Total Number of Units Providing Headcount Data

165 150 160

Total Number of Critical Care Nurses (Headcount)Represented:Ontario

9,414 8,224 8,576


The online survey responses, submitted by 83% of Ontario’s critical care units, collected information on 9,414 registered critical care nurses of the total 97,418 overall registered nurses in Ontario. While this accounts for 10.3% of all registered nurses employed in 2015 (College of Nurses of Ontario, Membership Statistics Highlights. , 2015), there is believed to be some degree of inflation in this figure as some nurses may be employed by more than one organization.



Figure 2 shows the total number of critical care nurses represented by the online survey data collection tool from each of Ontario’s LHINs. Toronto Central (LHIN 7) has approximately 25% of the critical care nurses represented by the survey across all the Ontario LHINs. This highlights the centralization of many specialized services, which rely upon critical care in the Toronto area.

Figure 2: Critical Care Nurses, by LHIN

0

500

1000

1500

2000

2500

NWNENSMCHSECECTCMHCWHNHBWWSWESC

384

865

308

1329

540 596

2246

617

451 427

994

121

426

110

1413121110987654321

TOTA

L N

UM

BER

LHIN

Source: 2015/16 CCWP Online Data Collection Tool, Question 1B



3. NURSE ROLES AND DEMOGRAPHICSThis section presents an overview of the nursing roles in critical care units and the demographic characteristics of Ontario’s current critical care nursing workforce. A view of current demographics offers insight into the current and potential demands for training and recruitment in critical care (Kabene, Orchard, Howard, Soriano, & Leduc, 2006). A clear understanding of these factors provides guidance for effective planning, utilization, and management of the critical care nursing workforce. In addition, this data provides important contextual insights to inform recruitment and retention of the critical care nursing workforce.

3.1 Nursing Roles

Over 90% of nurses working in critical care are working in “registered nurse” roles. This is consistent across both the information submitted by nurse managers in the online survey data collection tool as well as with the headcount information submitted by Finance departments. There are discrepancies between nurse manager and finance department reporting of nursing support roles however (see Table 5). This difference, including reporting numbers of nurse managers, nurse educators, clinical nurse specialists and others seems to suggest that these roles are not uniformly captured within the critical care functional centres (which was the source of the finance data), or that the information was not fully disclosed in the information provided in the survey.

Table 5: Headcount by Nursing Role Type

Nursing RoleOnline Data Submission

(N= 165 units)Finance Data Submission*

(N= 160 units)

Number Percent Number Percent

Registered Nurse 8,485 90.1% 8,116 94.6%

Other Nurse / Undefined Nurse 270 2.9% 279 3.3%

Permanent Charge / Nurse without Assignment 207 2.2%

Nurse Manager 152 1.6% 62 0.7%

Nurse Educator 124 1.3% 27 0.3%

Clinical Nurse Specialist 75 0.8% 18 0.2%

Registered Practical Nurse 67 0.7% 45 0.5%

Nurse Practitioner 34 0.4% 29 0.3%

TOTAL 9,414 8,576




In both the finance data submission as well as the human resource data submission units were asked to identify whether roles were associated with direct care (e.g. Unit Producing Personnel (UPP) in finance terminology) or with support roles (e.g. Management and Operational Support (MOS) in finance terminology). As indicated in Table 6, more than 97% of staff was identified as performing direct care / UPP functions. Again, the lower number of MOS staff identified through the finance data submission seems to indicate that these roles are not uniformly captured within the critical care functional centres, or that the information was not fully disclosed in the information provided in the survey.

Table 6: Headcount Distribution by Nursing Function

Nursing RoleFinance Data Submission*

(N= 160 units)Human Resource Data

Submission (N= 150 units)

Number Percent Number Percent

Direct Care Nurses / Unit Producing Personnel(UPP)

8,435 98.4% 7,992 97.2%

Support Nurses / Management and OperationalSupport(MOS)

112 1.3% 232 2.8%

NursePractitioners(NP) 29 0.3%

TOTAL 8,576 8,224


Due to inconsistencies in the completeness of data on support roles in the human resource and finance data collection tools compared with the online data collection tool, as well as the core interest in profiling front-line care workers, the remainder of analysis from the human resources and finance data sources in this report will restrict focus to the information provided for direct care and/or UPP staff.



3.2 Level of Experience

The 2015/16 CCWP online survey data collection tool introduced a set of nuanced questions pertaining to length of experience in nursing. Survey respondents were asked to report on the following:

• Length of experience as an RN;

• Length of experience in Critical Care;

• Length of experience in the Unit.

Due to some inconsistencies in information reported across the three questions (e.g. length of experience as an RN less than length of experience on the unit), for the purpose of the 2015/16 CCWP, only nursing length of experience in unit is reported and remains consistent with information collected in previous surveys.

Length of experience on the unit has been linked with influencing various patient outcomes (Dunton, 2007). As shown in Figure 3, almost half (45.6%) of the critical care nursing workforce have worked in the unit for 6 to 20 years. Since 2007, the percentage of critical care nurses working on the unit with over 20 years of experience has decreased slightly by 1.6%. As reported in this year’s CCWP, almost a quarter (23.9%) of critical care nurses working on the unit has less than 3 years of experience.

Figure 3: Length of Nurse Experience in the Critical Care Unit, Trend Over Time

Experience >20 yrs11–20 yrs 6–10 yrs3–5 yrs<3 yrs

PERC

ENTA

GE

YEAR (N)

10%

15%

20%

25%

30%

2015/16(9414)

2014/152013/14(8268)

2012/132011/122010/11(8510)

2009/10(8389)

2008/09(6237)

2007/08(7309)

14% 15% 15% 15% 15%

13%

18%17%

18% 19%

22%23%

22% 21%

24%

23% 23% 23%

21%21% 21%

23%

19%18%

26% 26%

23%

21%

22%

24%

Source for 2015/16 Data: CCWP Online Data Collection Tool, Question 2A



Novice RNs are defined as those with less or equal to 3 years of experience, mid-career as those with 3 to 10 years and experienced RNs as those with over 11 years of service in a critical care unit (Ontario, 2016-17). The Peer Group snapshot in Figure 4 displays subtle differences between the level of experience among nurses across Peer Groups. The combined PG1+7 (Level 3 units in teaching hospitals) has the highest number of experienced nurses, where 20.9% of nurses had over 20 years of experience on the unit. Paediatric critical care units (PG6) tend to have a greater number of younger nurses (as shown in Section 3.3), which informs the greater presence of novice nurses, with 28.5% of respondents having < 3 years of experience on the unit. In contrast, the lowest number of novice nurses was reported in PG4 at 12.0%

Figure 4: Length of Nurse Experience in the Critical Care Unit, by Peer Groups

PERC

ENTA

GE

PEER GROUP (N)

0%

20%

40%

60%

80%

100%

PG11(831)

PG10+12(448)

PG9(424)

PG8(554)

PG6(428)

PG5(603)

PG4(574)

PG3(842)

PG2(1794)

PG1+7(1912)

ON(9414)

Length of Experience >20 yrs11–20 yrs6–10 yrs3–5 yrs<3 yrs

23.6

25.6

23.9 22.926.1

26

18.920.2

26.921.2

19.3

22.921.6

25.1

19

28.6

19.721.3 24 17.7 21.9 26.7

17.515

14.216.3

15.9

18.7

17.121.3

21.928.1

21.3

20.7 16.9 21 25.8 12 20.9 28.5 25.3 22.4 17.2 22.7

15.5 20.9 15.8 16 17.4 14.6 14.3 9.2 11.1 11.6 10

Source: 2015/16 CCWP Online Data Collection Tool, Question 2A



A LHIN breakdown of length of experience in unit in Figure 5 shows some regional variation across the province.

• Central West (LHIN 5) has a low proportion of novice RNs, (<3 years’ experience on the unit) while the Central (LHIN 8) and South East (LHIN 10) have high proportions of novice nurses.

• For mid-career nurses (3-10 years’ experience on the unit), South West (LHIN 2) and Waterloo Wellington (LHIN 3) have a lower proportion of these nurses, while Central West (LHIN 5) and South East (LHIN 10) have quite high proportions of mid-career nurses.

• For experienced nurses, those with more than 10 years of experience, Waterloo Wellington (LHIN 3) has a very high proportion of these nurses, while Central (LHIN 8) and South East (LHIN 10) have relatively low proportions of these highly experienced staff.

Figure 5: Length of Nurse Experience in the Critical Care Unit, by LHIN

PERC

ENTA

GE

LHIN (N)

0%

20%

40%

60%

80%

100%

NW(110)

NE(422)

NSM(119)

CH(988)

SE(251)

CE(453)

C(617)

TC(2221)

MH(573)

CW(541)

HNHB(1245)

WW(272)

SW(920)

ESC(372)

ON(9104)

Length of Experience >20 yrs11–20 yrs6–10 yrs3–5 yrs<3 yrs

22.517.2

18.5

37.1

24.124.2 24.3

23

20.6

22.7

17.1

20.718.5

24.6 27.3

23.122 17.2

16.5

20.430.9

24.623.5

28.9

20.8

28.3

27

20.217.1

26.4

17.7 22

14

8.1 19.6

22

18.918.5

14.6

13.3

20.3

15.9 24.4 19.919.1

23.9 23.9 31.3 25.7 22.2 13.3 24.4 21.3 32.3 24.5 32.3 22.6 25.2 24.9 19.1

12.8 14.8 19 12.5 13.7 9.6 7.9 13.6 3.7 18.8 2.0 13.9 11.8 13.5 8.2




3.3 Age

As shown in Figure 6, individuals between the ages of 30 to 39 represent the largest age cohort in the province for critical care nurses in 2015/16, with close to 30% of critical care nurses in this age range. The prominence of this age cohort has changed over the last few years; in 2007, the ages of 40 to 49 represented the largest age cohort with close to 35% of Ontario’s critical care nurses in this age range.

The data collected between 2007 and 2015, shows the following changes in the age distribution of the critical care nursing workforce:

• There has been an 4.5% increase in the proportion of nurses aged 30 and younger;

• The proportion of nurses aged 30 to 39 has remained relatively stable around 28%.

• There has been an 8.8% decrease in the proportion of nurses aged 40 to 49.

• There has been a slight increase in the proportion of nurses aged 50 to 59 and 60 and above of 2% and 2.1% respectively.

• The number of nurses aged > 65 has remained relatively stable.

Figure 6: Age Group Distribution of Critical Care Nurses, Trend Over Time

Age 65+60-6450-5940-4930-39<30

0%

10%

20%

30%

40%

2015/16(7991)

2014/152013/14(8439)

2012/132011/122010/11(8554)

2009/10(8586)

2008/09(6577)

2007/08(7983)

PERC

ENTA

GE

YEAR (N)

34% 34%32% 31%

28%

25%

29% 28%

28% 28%27%

28%

14% 15%16% 16%

20%19%

20% 20% 20% 20% 20%22%

2.4% 2.7% 3.4% 3.6% 4.1% 4.5%

0.5% 0.4% 0.5% 0.6% 1.1% 1.8%

Source for 2015/16 Data: CCWP Human Resource Data Collection Tool, Direct Care Nursing



Figure 7 shows the percentage breakdown of critical care nurses by age in each Peer Group. This graph shows that the median age of critical care nurses in Ontario tends to fall between 30 and 39 years. However, paediatric units (PG6) have the youngest nursing demographic, where close to 70% of the nurses are under the age of 40. These findings suggest that younger nurses tend to favour working in paediatric critical care units, supporting findings by Happell (1999) and Rognstad, Aasland, and Granum (2004), and continue this path for the first half of their career. (Happell, 1999);(Rognstad, 2004).

Figure 7: Age Group Distribution of Critical Care Nurses, by Peer Group

0% 20% 40% 60% 80% 100%

PG11 (304)

PG10 + 12 (473)

PG9 (244)

PG8 (333)

PG6 (605)

PG5 (689)

PG4 (678)

PG3 (765)

PG2 (2208)

PG1 + 7 (1690)

ON (7991) 4.5%

4.4%

4.2%

4.1%

4.1%

7.1%

2.1%

4.9%

5.3%

5.8%

5.1%

22%

23%

23%

21%

23%

21%

13%

22%

24%

25%

20%

25%

25%

29%

28%

31%

25%

17%

19%

22%

20%

21%

28%

30%

28%

27%

29%

27%

32%

26%

20%

26%

28%

19%

16%

15%

19%

12%

18%

36%

26%

28%

19%

26%

1.8%

2.5%

1.5%

1.7%

1.6%

2.5%

0.0%

3.0%

0.7%

3.8%

0.5%

PERCENTAGE

Age 65+60-6450-5940-4930-39<30

PEER

GRO

UP

(N)

Source: 2015/16 CCWP Human Resource Data Collection Tool, Direct Care Nursing



Figure 8 is broken down by Ontario LHINs and highlights the age distribution of critical care nurses in Ontario. Central West (LHIN 5) and North Simcoe Muskoka (LHIN 12) seem to have the smallest number of nurses aged 29 years or less, while the age distribution among all other age groups and across all LHINs seems to be relatively similar.

Figure 8: Age Group Distribution of Critical Care Nurses, by LHIN

0% 20% 40% 60% 80% 100%

14-NW (95)

13-NE (368)

12-NSM (92)

11-CH (332)

10-SE (402)

9-CE (601)

8-C (681)

7-TC (2179)

6-MH (498)

5-CW (283)

4-HNHB (1138)

3-WW (312)

2-SW (723)

1-ESC (286)

ON (7991) 4.5%

3.8%

5.3%

3.6%

4.3%

7.8%

4.4%

4.4%

3.5%

6.2%

5.0%

3.6%

3.3%

3.5%

4.2%

1.8%

1.4%

3.7%

0.0%

1.7%

2.8%

1.6%

2.4%

0.9%

1.5%

1.2%

1.2%

0.0%

1.1%

0.0%

22%

19%

26%

19%

24%

23%

21%

20%

21%

27%

21%

21%

23%

17%

18%

25%

29%

24%

23%

23%

35%

29%

24%

30%

27%

20%

20%

36%

25%

25%

28%

34%

23%

31%

23%

21%

31%

31%

31%

25%

28%

29%

27%

28%

32%

19%

14%

19%

24%

25%

10%

14%

18%

13%

13%

24%

26%

11%

25%

21%

PERCENTAGE

Age 65+60-6450-5940-4930-39<30

LHIN

(N)




3.4 Gender

Men represented 6.6% of RNs employed in nursing in 2011 in Canada.(“Workforce profile of registered nurses in canada,” 2011) with this proportion being slightly higher than the 2011 provincial level, of 5.2% in Ontario’s general nursing workforce. (“Workforce profile of registered nurses in canada,” 2011). An even smaller proportion of male nurses are found in rural compared to urban Ontario communities (Paterson J, 2014). The small number of male RNs in the nursing workforce highlights the opportunity for more targeted recruitment strategies to attract men to the profession (“Registered Nurses’ Association of Ontario,” 2010) (Twomey, 2008). One of the most significant barriers identified as an obstacle for men entering the nursing workforce is the perception of nursing as a female-dominated role, due to the nature of the work focusing on caring, compassion, and nurturance (Twomey, 2008).

In Figure 9 from the CCWP results show that males make up 10.2% of the critical care nursing workforce in Ontario. Although, the 10.2% of males represented in the critical care nursing workforce is higher than for males in the general nursing workforce, it is important to note, that the percentage of male critical care nurses has slightly decreased in the last few years. In 2013/14, males made up 12.0% of the nurses practicing in critical care (Critical Care Nursing Workforce Profile Provincial Report, 2015). This suggests that males may be an important target for initiatives aimed at increasing the critical care nursing workforce.

Figure 9: Gender Distribution of Critical Care Nurses, Trend Over Time

Gender Male Female

PERC

ENTA

GE

YEAR (N)

0%

20%

40%

60%

80%

100%

2015/16(7991)

2014/152013/14(8457)

2012/132011/122010/11(8540)

2009/10(8619)

2008/09(6648)

2007/08(8142)

92% 92% 92% 92%88% 90%

7.5% 7.8% 7.8% 8.1%12% 10%

Source for 2015/16 Data: CCWP Human Resource Data Collection Tool, Direct Care Nursing



As shown in Figure 10, critical care nurses aged 40 to 49 make up 11.7% of the male population working in critical care. This number decreases to nearly half that (6.1%) for male critical care nurses over the age of 65.

Figure 10: Age Group Distribution of Male Critical Care Nurses, Provincial

10% 11.5% 11.7%7.6% 7.2% 6.1%

0%

10%

20%

65+(147)

60-64(261)

50-59(1745)

40-49(2020)

30-39(2236)

<30(1480)

PERC

ENTA

GE

AGE GROUP (N)Source: 2015/16 CCWP Human Resource Data Collection Tool, Direct Care Nursing

Figure 11 presents the percentage of male nurses by Peer Groups. The combined PG1+7 reported the largest proportion of male RNs with 20.1%. This percentage is nearly double the provincial average of 10.2%. PG8 reported the lowest portion of critical care male RNs (5.1%). Teaching Hospitals are equipped with a range of technologies (Wayne, 2008) a factor that has been found to attract men into nursing (Twomey, 2008).

Figure 11: Gender Distribution of Critical Care Nurses, by Peer Groups

0% 20% 40% 60% 80% 100%

PG11 (304)

PG10+12(473)

PG9 (244)

PG8 (333)

PG6 (605)

PG5 (689)

PG4 (678)

PG3 (765)

PG2 (2288)

PG1+7(1610)

ON (7991)

PERCENTAGE

Gender MaleFemale

PEER

GRO

UP

(N)

10%

20%

11%

7.2%

11%

12%

6.6%

5.1%

8.2%

5.9%

9.5%

90%

80%

89%

93%

89%

88%

93%

95%

92%

94%

91%




Figure 12 presents the percentage of critical care male nurses by Ontario LHINs. South West (LHIN 2) reported the lowest percentage of male nurses at 7.1%. Waterloo Wellington (LHIN 3), Hamilton Niagara Haldimand Brant (LHIN 4) and North Simcoe Muskoka (LHIN 12) fell within similar percentages. However, North West (LHIN 14) reported the highest proportion of critical care male nurses at 14.7%.

Figure 12: Gender Distribution of Critical Care Nurses, by LHIN

0% 20% 40% 60% 80% 100%

14-NW (95)

13-NE (368)

12-NSM (92)

11-CH (332)

10-SE (402)

9-CE (601)

8-C (681)

7-TC (2179)

6-MH (498)

5-CW (283)

4-HNHB (1138)

3-WW (312)

2-SW (723)

1-ESC (286)

ON (7991)

Gender MaleFemale

PERCENTAGE

LHIN

(N)

10%

11%

7.1%

7.2%

7.9%

9.2%

12%

12%

12%

8.9%

9.0%

12%

7.6%

11%

15%

90%

90%

93%

93%

92%

91%

88%

88%

88%

91%

91%

88%

92%

89%

85%




4. NURSE STAFFING PRACTICESThe information collected through the three data sources (nurse managers, human resources department, and finance department) allows for profiling of different components of nurse staffing in critical care. In this section we will provide an overview of the composition of the nursing workforce in relation to:

• Employment status of the nurse workforce;

• Distribution of earned hours;

• Strategies for covering short-term staffing shortages; and,

• Nursing productivity.

4.1 Employment Status

In previous years of the CCWP, nurse managers were asked to report the distribution of full-time and part-time staff. In the 2015/16 survey however, we have relied upon finance data submitted for the critical care units. The Ontario Healthcare Reporting Standards (OHRS) define six different categories of employment status, however for our reporting these have been grouped into three categories, as identified in Table 7 below.

Table 7: Classification of Employment Status

OHRS Employment Status Group CCWP Employment Status Group

Full-Time Full-Time

Part-Time Regular Part-Time

Part-Time Temporary Full-Time Part-Time

Part-Time Job Share Part-Time

Casual Regular Casual

Casual Temporary Full-Time Casual

4.1.1 EMPLOYMENT STATUS BY HEADCOUNT

In 2001, Ontario’s Nursing Secretariat proposed a 70/30 ratio of full-time to part-time RN staff as a potential target to meet operational efficiencies (Baumann, 2010). This structure would allow unit managers to maintain consistent schedules, while using part-time and casual staff for routine coverage and during times of high demand (Baumann, 2010). In a 2014 report prepared for the Registered Nurses’ Association of Ontario (RNAO), policy makers were encouraged to continue to pursue the target of attaining 70% full-time employment target for all classes of nurse (RN, NP and RPN) in all sectors and geographic areas. Specifically, it was recommended that the 70% full-time target be applied to direct care nurses to enhance continuity of care. The 70% full-time target is also believed to be particularly important for new nursing graduates, to ensure they are



integrated into the health system and to retain Ontario’s nursing graduates (RNAO’s 70 per cent Full-Time Employment for Nurses Survey: Hospital and Long-Term Care Sectors, 2014).

According to the 2015/16 CCWP, 65.9% of Ontario’s UPP critical care nurses are employed full-time, while 66.7% of Ontario’s general nursing workforce in 2015 consisted of full-time employees (The Nursing Workforce Canadian Federation of Nurses Unions Backgrounder, 2012). In 2011, 63.4% of Canadian critical care nurses were employed full-time and only 58.6% of Canada’s registered nurses (across all sectors) worked full-time (RN Workforce Profile by Area of Response, 2013) .

It is important to note the different focus of these statistics, as the overall provincial and national figures include nurses in roles other than providing direct patient care, such as nurse educators, clinical nurse specialists, nurse managers, etc. This consideration must also be applied when considering the trending of the CCWP data over time, as in previous years it was not explicitly stated to define UPP vs. MOS staff. A summary of trends in employment status over time from the CCWP from 2013/14 and 2015/16 is provided in Figure 13 below, and shows very consistent distributions over the two time periods.

Figure 13: Employment Status Distribution of Critical Care Nurses, 2013/14 and 2015/16

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CasualPart-TimeFull-Time

66%

23.5%

11%

67%

23.7%

9.2%

PERC

ENTA

GE

EMPLOYMENT STATUS

Critical Care Workforce Year 2015/162013/14

Source for 2015/16 Data: Human Resource Data Collection Tool, Direct Care Nursing



The method of data collection of nurse demographics in the Human Resources data submission, the 2015/16 CCWP allows for review of employment status by age groups. As seen in Figure 14, Full time status among critical care nurses aged 30-59 is approaching the target of 70%. The full-time status percentage starts to drop for those critical care nurses who are over the age of 60, ranging from 59.7% to 47.2%. The largest group of part-time staff can be found in the under 30 age range.

Figure 14: Employment Status Distribution of Critical Care Nurses by Age Group, Provincial

0% 20% 40% 60% 80% 100%

< 30 (1480)

30-39 (2236)

40-49 (2020)

50-59 (1745)

60-64 (261)

> 65 (147) 47%

60%

70%

68%

69%

62%

35%

21%

11%

11%

9.7%

7.6%

18%

19%

19%

21%

22%

30%

Employment Status CasualPart-TimeFull-Time

PERCENTAGE

AG

E G

ROU

P




When examining the employment status of the workforce across Peer Groups, as shown in Figure 15, some differences in staffing practices emerge. In some Peer Groups with smaller level 2 units (PG8 and PG10+12) the proportion of full-time staff is around 55%. Also for PG3, the proportion of full-time staff is also below 60%. These units as well as PG6 (paediatric units) have part-time staffing proportions around 30%, higher than the provincial average of 23.5%.

Figure 15: Employment Status Distribution of Critical Care Nurses, by Peer Group

0% 20% 40% 60% 80% 100%

PG11 (13)

PG10+12 (17)

PG9 (8)

PG8 (23)

PG6 (7)

PG5 (19)

PG4 (11)

PG3 (18)

PG2 (26)

PG1+7 (16)

ON (158)

PERCENTAGE

11%

8.7%

12%

12%

10%

11%

8.6%

13%

8.1%

14%

6.6%

PEER

GRO

UP

(N)

CasualPart-TimeFull-TimeEmployment Status

24%

21%

23%

30%

19%

24%

29%

33%

23%

30%

20%

66%

70%

65%

58%

70%

65%

63%

55%

69%

56%

74%

Source: 2015/16 CCWP OHRS UPP Data from Finance Department Submission



Differences in the composition of the critical care nursing workforce and employment status are notable across the province as shown in Figure 16. North Simcoe Musoka (LHIN 12) has the lowest proportion of full-time staff with only 52.7% of their critical care nursing workforce being full-time staff. Erie St. Clair (LHIN 2) also has a lower proportion of full-time staff, and the highest proportion of part-time staff in the province with 38.3% of their critical care nursing workforce being part-time staff. Regarding the use of casual staff, there appear to be larger casual staffing pools in the western GTA LHINs with both Central West (LHIN 5) and Mississauga Halton (LHIN 6) having identified more than 20% of their workforce headcount being from casual staff.

Figure 16: Employment Status Distribution of Critical Care Nurses, by LHIN

0% 20% 40% 60% 80% 100%

14-NW (2)

13-NE (9)

12-NSM (3)

11-CH (19)

10-SE (8)

9-CE (12)

8-C (9)

7-TC (27)

6-MH (8)

5-CW (4)

4-HNHB (23)

3-WW (9)

2-SW (19)

1-ESC (6)

ON (158)


PERCENTAGE

11%

4%

7%

9%

7%

20%

21%

14%

14%

9%

12%

4%

13%

7%

1%

LHIN

(N)

24%

38%

27%

31%

26%

18%

19%

19%

19%

25%

24%

21%

34%

32%

32%

66%

58%

67%

60%

67%

63%

60%

68%

67%

66%

64%

75%

53%

61%

67%




4.1.2 EMPLOYMENT STATUS BY EARNED HOURS

As part of the 2015/16 CCWP, the survey also collected information on earned hours, and the proportion of earned hours from full-time, part-time, and casual staff. This provides greater clarity and comparability regarding the proportion of hours worked by staff with different employment status.

While about 66% of the critical care workforce in Ontario is full-time staff, almost 80% of earned hours are paid to full-time staff. Earned hours include all hours paid for regular worked shifts, overtime hours, paid sick hours, paid vacation hours, paid education and orientation hours, and any other paid hours.

As seen in Figure 17, most Peer Groups have about 80% of earned hours from full-time staff. There are two exceptions to this, with PG3 and combined PG10+12 having 72% to 73% of earned hours from full-time staff. These two Peer Groups appear to rely more heavily on part-time staff for the provision on care to critical care patients.

Figure 17: Employment Status Distribution of Critical Care Nurse Earned Hours, by Peer Group

0% 20% 40% 60% 80% 100%

PG11 (14)

PG10+12 (17)

PG9 (10)

PG8 (30)

PG6 (7)

PG5 (19)

PG4 (11)

PG3 (17)

PG2 (26)

PG1+7 (17)

ON (168) 80%

83%

80%

73%

83%

80%

78%

79%

79%

72%

81%

2.7%

2.4%

3.2%

2.9%

2.5%

2.5%

1.2%

3.0%

2.5%

4.0%

2.0%

18%

15%

17%

24%

15%

18%

21%

19%

19%

24%

18%


PERCENTAGE

PEER

GRO

UP

(N)




When looking at staffing practices across LHINs, as shown in Figure 18, differences in proportion of earned hours for full-time staff are also evident. Some of the less urban LHINs have a greater reliance on earned hours from part-time staff, particularly Erie St. Clair (LHIN 1) and North Simcoe Muskoka (LHIN 12) where the proportion of earned hours from part-time staff is about 30%, far higher than the 17.5% provincial average. As well, there are a few LHINs where casual staff play a greater role in staffing critical care units, particularly Mississauga Halton (LHIN 6), North Simcoe Muskoka (LHIN 12), and North West (LHIN 14).

Figure 18: Employment Status Distribution of Critical Care Nurse Earned Hours, by LHIN

0% 20% 40% 60% 80% 100%

14-NW (2)

13-NE (9)

12-NSM (3)

11-CH (19)

10-SE (8)

9-CE (13)

8-C (9)

7-TC (28)

6-MH (9)

5-CW (5)

4-HNHB (25)

3-WW (9)

2-SW (23)

1-ESC (6)

ON (168)


PERCENTAGE

LHIN

(N)

3%

1%

2%

2%

2%

0%

6%

3%

4%

3%

2%

1%

5%

2%

6%

18%

31%

19%

24%

19%

18%

13%

13%

15%

21%

19%

15%

28%

25%

20%

80%

68%

79%

74%

79%

82%

81%

84%

81%

76%

79%

84%

67%

74%

74%




4.2 Distribution of Earned Hours

As noted above, earned hours include all hours paid for regular worked shifts, overtime hours, paid sick hours, paid vacation hours, paid education and orientation hours, and any other paid hours. As shown in Figure 19, about 81% of all earned hours in critical care in Ontario are for the direct provision of patient care in regular worked and overtime hours.

Figure 19: Distribution of Critical Care Nurse Earned Hours by Type, Provincial

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

EducationOrientationOtherSickVacationOver TimeRegular

PERC

ENTA

GE

WORK HOUR TYPES

78%

3.1%7.1% 4.7% 4.4%

1.8% 0.8%

Source: 2015/16 CCWP OHRS UPP Data from Finance Department Submission (N=166)

In this section, a review of overtime rate, sick rate, and education hours will be provided for Peer Groups, as well as across LHINs in some instances.



4.2.1 OVERTIME HOURS AS A PROPORTION OF PRODUCTIVE HOURS

Research has shown a relationship between excessive hours of work, fatigue and, client and nurse safety (Canadian Nurses Association [CNA] & Registered Nurses Association of Ontario [RNAO] 2010). Summarizing the potential impact, Maddalena and Crupi (2008) state “working in areas that are short staffed, working excessive paid and un-paid overtime, being called into work on days off, and the inability to take vacation time contribute to fatigue and burn out. The ability to provide nursing care in such an environment can lead to moral distress and directly influence the quality of the professional practice environment” (Excessive Hours of Work: Professional and Union Considerations, 2011).

To understand the reliance of overtime work to cover patient care activities, analysis was undertaken to review the proportion of productive hours (regular worked hours and overtime hours) that were filled by overtime staff. Provincially, the overtime rate for UPP staff in critical care units was 3.9%, as shown in Figure 20. This rate varied from a low of 2.0% in PG6 to a high of 5.3% in PG2.

Figure 20: Overtime Hours as a Proportion of Productive Hours for Critical Care Nurses, by Peer Group

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

PG11(14)

PG10+12(17)

PG9 (10)

PG8(28)

PG 6(6)

PG5(19)

PG4(11)

PG3(16)

PG2(26)

PG1+7(16)

ON(163)

PERC

ENTA

GE

PEER GROUP (N)

3.9%

3.2%

5.3%4.9%

4.1%3.5%

2.0%

2.9%

3.8%3.4%

3.0%




Across the province, the overtime rate is relatively stable and close to the provincial average with a few notable exceptions, as shown in Figure 21. In the South West (LHIN 2) the overtime rate is very low at 1.7%. At the other end of the spectrum, the Central West (LHIN 5) has the highest overtime rate for critical care units at 9.0%. The overtime rate in the North West (LHIN 14) is also quite high at 6.3%. This suggests challenges in adequately staffing units with planned resources in both the Central West and North West LHINs.

Figure 21: Overtime Hours as a Proportion of Productive Hours for Critical Care Nurses, by LHIN

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

NW(2)

NE(8)

NSM(3)

CH(19)

SE(8)

CE(13)

C(9)

TC(27)

MH(9)

CW(5)

HNHB(25)

WW(8)

SW(21)

ESC(6)

ON(163)

PERC

ENTA

GE

LHIN (N)

3.9%

5.3%

1.7%

5.5%

3.1%

9.0%

4.8%4.4% 4.4%

4.1%4.4%

2.3%

4.0%

3.1%

6.3%




4.2.2 SICK TIME

In 2011, the Canadian Labour Force Survey (Uppal, 2012) reported that full-time Canadian nurses had an absentee rate of 10.6%. The rates for sick time in critical care seem to be considerably below this rate, as shown in Figure 22. Over the years since 2007, the CCWP sick rate for critical care nurses has been decreasing. It should be noted that prior to the 2015/16, sick rate was calculated for full-time staff only. The lower rate in 2015/16 is likely influenced by including all paid sick time for all employees, as outside of full-time staff, sick benefits are more limited.

Figure 22: Sick Rate for Critical Care Nurses, Trend Over Time

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

2015/162014/152013/142012/132011/122010/112009/102008/092007/08

Sick Rate

PERC

ENTA

GE

YEAR

7.2%

5.8%6%

6.5%

5.9%

4.8%

Source for 2015/16 Data: CCWP OHRS UPP Data from Finance Department Submission



As shown in Figure 23, the provincial sick rate in critical care units for UPP staff is 4.8%. Most Peer Groups have rates similar to this, with three notable exceptions. PG8 and PG11 appear to have lower sick rates at 2.9% and 3.8% respectively. At the other end of the spectrum, PG10 has a higher sick rate at 6%. Results for sick rate by LHIN show little variation between LHINs and has not been shown for that reason.

Figure 23: Sick Rate for Critical Care Nurses, by Peer Group

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

PG11(13)

PG10+12(16)

PG9(10)

PG8(30)

PG6(6)

PG5(19)

PG4(10)

PG3(17)

PG2(26)

PG1+7(16)

ON(163)

4.8%5.1% 5.0%

4.5%

5.2%

4.5%4.2%

2.9%

6.0%

4.1%3.8%

PERC

ENTA

GE

PEER GROUP (N)




4.2.3 EDUCATION TIME

Although 168 critical care units submitted data for earned hours as part of the OHRS finance data submission, only 129 units submitted information on education hours. This may be due to either an omission in reporting as part of the CCWP, or because no education hours were recorded within the units. Although it appears there are data quality concerns with the compliance for reporting education hours, the information is included in Figure 24 below by Peer Group as an opportunity for reflection, and to encourage greater compliance in reporting in future surveys.

Figure 24: Education Hours as a Proportion of Total Earned Hours for Critical Care Nurses, by Peer Group

0%

1%

2%

3%

4%

5%

PG11(9)

PG10+12(13)

PG9(9)

PG8(18)

PG6(4)

PG5(15)

PG4(8)

PG3(15)

PG2(24)

PG1+7(13)

ON(128)

PERC

ENTA

GE

PEER GROUP (N)

0.8%

1.2%

0.8%0.5% 0.6% 0.7%

0.2%0.5%

1.3%

0.5%

1.0%




4.3 Managing Short-Term Nursing Shortages

The complexity of critical care patients requires nurses with advanced training and makes shortages in this specialization particularly challenging, as it may require replacement of nurses with appropriate skillsets. Nursing shortages can also be viewed either as a short-term issue or an on-going long-term issue with differing challenges. Overall, a global study on nursing shortages suggests solutions should focus on the motivation of nurses, and incentives to recruit and retain them, to encourage them back into nursing, as well as the broader supply and demand planning necessary for any profession (Buchan, 2008). This section will take a look at the short-term solutions employed by critical care units to manage nursing shortage challenges.

Figure 25 shows that “expanded assignments” are the most frequently and commonly used approach to short-term nursing shortage in the province, with 22.3% and 42.8% using this approach amongst critical care units respectively. “Agency” staff and “critical care nursing pool” (CC RN pool) were the next most frequently used approaches.

Figure 25: Approaches to Manage Short-Term Nursing Shortages, Provincial

0% 20% 40% 60% 80% 100%

Agency (147)

Bed Closure (147)

Over Time (142)

ScheduledChange (147)

ExpandedAssignment (152)

CC RN Pool (146) 64%

35%

76%

88%

83%

68%

TYPE

OF

APP

ROA

CH (N

)

PERCENTAGE

11%

22%

2.7%

5.6%

0.7%

14%

Approach Usage SometimesFrequent Never/Rarely

25%

43%

21%

6%

16%

18%

Source: 2015/16 CCWP Online Data Collection Tool, Question 15

The following figures show the Peer Group breakdown of the top three most frequently used approaches to short-term nursing shortages by Peer Group.



4.3.1 EXPANDED ASSIGNMENTS

An expanded assignment occurs when a nurse is asked to assume care for more patients than initially planned. For example instead of caring for two patients as would be ideal, a nurse would be tasked with caring for three patients. As shown in Figure 26, Peer Group 4 used “expanded assignments” the most, in 44% of their units and combined PG10+12 “sometimes used” this approach in 60% of their units.

Figure 26: Use of “Expanded Assignments” to Manage Short-Term Nursing Shortages, by Peer Group

0% 20% 40% 60% 80% 100%

PG11 (15)

PG10+12 (15)

PG9 (8)

PG8 (25)

PG6 (7)

PG5 (18)

PG4 (9)

PG3 (19)

PG2 (21)

PG1+7 (15)

ON (152) 22%

27%

10%

26%

44%

22%

57%

32%

27%

20%

Short-term “Expanded Assignment” Usage Frequent Sometimes Rarely/Never

PEER

GRO

UP

(N)

35%

33%

43%

26%

22%

39%

43%

28%

63%

13%

53%

PERCENTAGE

40%

48%

47%

33%

39%

40%

38%

60%

27%

43%

Source: 2015/16 CCWP Online Data Collection Tool, Question 15b



4.3.2 CRITICAL CARE NURSING POOL

Critical care nursing pools are a group of hospital-employed nurses not assigned to a specific nursing unit, but instead available to cover staffing shortages in critical care areas. As shown in Figure 27, Peer Group 3 “frequently or sometimes” used a critical care nursing pool in 60% of their units. Peer Group 4, Peer Group 9 and Peer Group 11 only used critical care nursing pools “sometimes” or “rarely/never’.

Figure 27: Use of “Critical Care Nursing Pool” to Manage Short-Term Nursing Shortages, by Peer Group

0% 20% 40% 60% 80% 100%

PG11 (14)

PG10+12 (16)

PG9 (8)

PG8 (21)

PG6 (7)

PG5 (18)

PG4 (8)

PG3 (17)

PG2 (21)

PG1+7 (16)

ON (146) 11%

6%

5%

29%

11%

14%

19%

13%

PERCENTAGE

PEER

GRO

UP

(N)

64%

69%

81%

41%

75%

78%

57%

57%

63%

50%

64%

“Short-term” CC Nursing Pool Usage Frequent Sometimes Rarely/Never

25%

25%

14%

29%

25%

11%

29%

24%

38%

38%

36%

Source: 2015/16 CCWP Online Data Collection Tool, Question 15a



4.3.3 AGENCY STAFFING

In times of nursing shortage, a third party staffing agency may be used to provide additional nursing staff. In recent years, hospitals have been working to move away from relying on agency staff; however, their use remains in place for some Peer Groups. Peer Group 2 frequently use “agency staff” in 41% of their units and “sometimes use” this approach in 18% of their units. Peer Group 5 also seem to “frequently or sometimes” use agency staff, in half of their units.

Figure 28: Use of “Agency Staff” to Manage Short-Term Nursing Shortages, by Peer Group

0% 20% 40% 60% 80% 100%

PG11 (14)

PG10+12 (16)

PG9 (9)

PG8 (22)

PG6 (6)

PG5 (16)

PG4 (9)

PG3 (17)

PG2 (22)

PG1+7 (16)

ON (147) 14%

13%

41%

12%

11%

25%

5%

13%

Short-term “Agency Staff” Usage Frequent Sometimes Rarely/Never

PERCENTAGE

PEER

GRO

UP

(N)

68%

75%

41%

88%

56%

50%

100%

77%

56%

69%

86%

18%

13%

18%

33%

25%

18%

44%

19%

14%

Source: 2015/16 CCWP Online Data Collection Tool Question 15f



4.4 Nurse Productivity

When patient-to-nurse staffing levels are high, (e.g. a single nurse is responsible for a greater number of patients) studies have found that a range of negative health outcomes are associated, including increased mortality rates; adverse events after surgery; increased incidence of violence against staff; increased accident rates and patient injuries; and increased cross infection rates (Buchan, 2008). At the same time, it is important to utilize specialized critical care nursing resources in an efficient way. A common productivity and efficiency measure used to understand nursing workload is worked hours per patient day. Nursing Hours per Patient Day is simply a ratio of how many hours of nursing care are given to each patient (Nash-Arnold, 2015).

Worked hours per patient day can vary considerably across Peer Groups, as patient needs and care demands differ. As shown in Figure 29, Peer Groups 1+7, PG4, and PG6 have more than 20 worked hours per patient day, reflecting the complex care needs of their patient populations. At the lower end of patient acuity, all of the level 2 Peer Groups (PGs 8, 9, 10+12, and 11) have around 10 worked hours per patient day.

Figure 29: Critical Care Nurse Worked Hours (including Overtime) per Patient Day, by Peer Group

0

5

10

15

20

25

PG11(14)

PG10+12(16)

PG9(10)

G8(18)

PG6(6)

PG5(19)

PG4(11)

PG3(16)

PG2(26)

PG1+7(16)

ON(164)

HO

URS

PEER GROUP

17

22

18

16

23

16

25

10.79.1

11.410.5


In the Peer Group appendices (beginning on ), distribution of worked hours per patient day is provided by unit within each Peer Group.



Results from the 2015/16 CCWP were contrasted against the findings from the 2013/14 CCNWP for worked hours per patient day, with slight differences over the two time periods. In 2013/14 the reported worked hours per patient day was 17.2 provincially as compared to the 17.1 hours noted above for 2015/16.

Figure 30 compares the worked hours per patient day from 2013/14 to 2015/16 from the CCWP surveys by Peer Group. Generally, differences between the two time periods are subtle; however, there appears to have been a dramatic shift in results for PG9, which are related to some extreme results in the 2013/14 data collection from a couple of units.

Figure 30: Critical Care Nurse Worked Hours per Patient Day in 2013/14 and 2015/16, by Peer Group

0

5

10

15

20

25

30

PG11PG10+12PG9PG8PG6PG5PG4PG3PG2PG1+7ON


HO

URS

PEER GROUP

17.1

21.8

18.4

15.5

22.7

15.7

24.7

10.7

9.1

11.4 10.5

17.2

22.2

18.3

14

21.1

16.3

22.4

12.6

18.7

9.8

11.8

Source for 2015/16 CCWP OHRS UPP Data from Finance Department Submission

Source: 2013/14 CCNWP Survey, Question 14



5. NURSE TRAININGGeneral nursing workforce research across Canada has reported an association between RN training and staff development efforts, with lower turnover in healthcare organizations (Rondeau, 2009). In particular, according to this study, healthcare organizations are encouraged to pay attention to workforce training investments as an effective long-term solution to RN shortages (Rondeau, 2009).

This chapter will show the provincial overview, (and Peer Group and LHIN breakdown where relevant) of the following nurse training dimensions:

1. Internationally educated nurses in critical care

2. Educational attainment of critical care nurses

3. Critical Care Nurse Training Standards

4. Life Support Training

a. Advanced Cardiac Life Support (ACLS)

b. Paediatric Advanced Life Support (PALS)

5. Professional development investments

5.1 Internationally Educated Nurses

There is a global shortage of, and therefore a global competition for, health professionals in all disciplines.(The Nursing Workforce Canadian Federation of Nurses Unions Backgrounder, 2012). Being able to attract internationally trained nurses suggests an appealing healthcare employment market in Canada. 8.6% of RNs employed in Canada graduated from an international nursing program (The Nursing Workforce Canadian Federation of Nurses Unions Backgrounder, 2012). This percentage is slightly lower for critical care nurses.

Many internationally-educated nurses face difficulty becoming accredited in Ontario due to financial hardships, recognition of foreign credentials, and obtaining placements to upgrade their educational qualifications (Blythe, 2009) (Higginbottom, 2011).



Since 2007, the CCWP has consistently collected data on the percentage of critical care nurses who obtain their training outside of Canada. Figure 31 provides a snapshot of the provincial trend for this indicator. The percentage of internationally trained nurses has remained relatively consistent since 2011/12 in the range of 7.5%.

Figure 31: Percent of Internationally Trained Critical Care Nurses, Trend Over Time

PERC

ENTA

GE

YEAR (N=Total number of CC Nurses)

7.0%

9.6%

6.0%7.0% 7.6% 7.4%

0%

5%

10%

15%

2015/16(9414)

2014/152013/14(8727)

2012/132011/122010/11(8561)

2009/10(8593)

2008/09(6947)

2007/08(7983)

Source for 2015/16 CCWP Online Data Collection Tool, Question 4

Figure 32 highlights differences in internationally trained critical care nurses among Peer Groups. All Peer Groups in the province have nurses working in their critical care units who are internationally trained. Peer Group 2 and Peer Group 5 reported the highest proportion of foreign trained nurses at approximately 14%. While Peer Group 3 and Peer Group 4 are significantly lower at 1.7% to 3%

Figure 32: Percent of Internationally Trained Critical Care Nurses, by Peer Groups

0%

5%

10%

15%

PG11(910)

PG10+12(485)

PG9(433)

PG8(631)

PG6(549)

PG5(703)

PG4(698)

PG3(924)

PG2(1962)

PG1+7(2119)

ON(9414)

PERC

ENTA

GE

PEER GROUP (N)

7.4%

4.3%

13.4%

1.7%3.0%

14.2%

4.0%

8.7%

5.5% 5.2%

8.4%




Looking across the province in Figure 33, Mississauga Halton (LHIN 6), Central West (LHIN 5) and Central (LHIN 8) have the greatest proportion of internationally educated nurses, where approximately 14 to 22% of critical care nurses are foreign trained. Paterson (2014) found that there were fewer internationally trained nurses in rural compared to urban areas. This is apparent in LHINs with higher proportions of rural areas in the province where rates are between 0% and 2.5%.

Figure 33: Percent of Internationally Trained Critical Care Nurses, by LHIN

0%

5%

10%

15%

20%

25%

NW(110)

NE(426)

NSM(121)

CH(994)

SE(427)

CE(451)

C(617)

TC(2246)

MH(596)

CW(540)

HNHB(1329)

WW(308)

SW(865)

ESC(384)

ON(9414)

PERC

ENTA

GE

LHIN (N)

7.4%

0.0%1.6%

0.0%

3.5%

14.1%

22%

11%

14.4%

9.5%

0.7%

3.5%2.5%

0.0%0.7%




5.2 Educational Attainment

In 2000, based on the recommendations from the Nursing Task Force, the Provincial Government of Ontario legislated that all new nurses entering the nursing profession must hold a baccalaureate degree in nursing, effective in 2005 (Workforce Profile of Registered Nurses in Canada, 2010).

When examining the education level of critical care nurses, the data in Figure 34 shows that the proportion of RNs with diplomas has decreased since 2007 from 71.3% to 38.3% in 2015. While critical care nurses with Bachelor of Nursing (BNs) or Baccalaureates has nearly doubled over the years from 27.4% in 2007 to 55% in 2015. These trends are also consistent with findings from a national study by Edwards et al (2012) that showed that 37.5% of critical care nurses in Canada reported degree preparation.

Figure 34: Educational Attainment Distribution of Critical Care Nurses, Trend Over Time

0%

20%

40%

60%

80%

100%

2015/16(8293)

2014/152013/14(7639)

2012/132011/122010/11(8289)

2009/10(8299)

2008/09(5960)

2007/08(6641)

Education Nursing Diploma Undergraduate Degree Masters/Doctorate Degree

PERC

ENTA

GE

YEAR (N)

1.3% 2% 2% 2.1% 2.2%4.6%

27%32% 33%

36%

51%55%

71%66% 65%

62%

47%

38%




Figure 35 shows that the proportion of critical care nurses with an undergraduate nursing degree is consistent with the provincial average of 57.1% across most Peer Groups. Paediatric Units (PG6) reported the highest percentage of nurses with a baccalaureate degree (80.4%). This percentage reflects the young cohort employed in Paediatric Units (PG6). This trend has been consistent over the last several years. This may also suggest that diploma-trained critical care RNs are being replaced by those with undergraduate degrees, particularly in units with a high portion of young RNs.

Figure 35: Educational Attainment Distribution of Critical Care Nurses, by Peer Groups

0% 20% 40% 60% 80% 100%

PG11 (969)

PG10+12 (413)

PG9 (410)

PG8 (525)

PG6 (591)

PG5 (532)

PG4 (475)

PG3 (925)

PG2 (1744)

PG1+7 (1718)

ON (8293)

Education Level Masters/DoctorateUndergraduateDiploma

PERCENTAGE

PEER

GRO

UP

(N)

4.6%

6.6%

5.0%

2.2%

6.5%

3.9%

6.6%

2.3%

2.2%

4.6%

3.3%

38%

38%

43%

46%

33%

40%

13%

41%

35%

46%

35%

57%

55%

52%

52%

60%

56%

80%

57%

62%

50%

62%




A LHIN perspective (Figure 36) shows that Waterloo Wellington (LHIN 3) has the smallest percentage of nurses (27.9%) with an undergraduate nursing degree and Toronto Central (LHIN 7) has the greatest (67.3%). Although Central East (LHIN 9) has a high proportion of urban areas, (refer to Appendix A) it reports a high rate of diploma prepared nurses (59.7%). Toronto Central (LHIN 7) also reported the highest percentage of nurses with postgraduate education, at 8.4%. This number has nearly doubled since 2013 where only 4.1% of nurses possessed postgraduate education. This is not surprising as RNs working in urban areas have achieved higher levels of education than their rural counterparts (Paterson J, 2014).

Figure 36: Educational Attainment Distribution of Critical Care Nurses, by LHINs

0% 20% 40% 60% 80% 100%

14-NW

13-NE

12-NSM

11-CH

10-SE

9-CE

8-C

7-TC

6-MH

5-CW

4-HNHB

3-WW

2-SW

1-ESC

ON

Education Level Masters/DoctorateUndergraduateDiploma

PERCENTAGE

4.6%

3.1%

1.0%

1.1%

2.2%

4.1%

7.8%

8.4%

4.4%

2.2%

2.5%

4.8%

3.3%

2.3%

2.1%

LHIN

(N)

38%

64%

42%

71%

43%

47%

28%

24%

36%

60%

37%

37%

25%

40%

33%

57%

33%

57%

28%

55%

49%

64%

67%

60%

38%

61%

58%

72%

58%

65%




5.3 Specialized Critical Care Training

Nurses provide specialized, complex, and intensive care that is enabled by ongoing training and experience. This is particularly relevant in critical care where the recruitment and retention of a skilled and specialized nursing labour force has emerged as an important Health Human Resource (HHR) priority(Siela, 2008; Stechmiller, 2002) .

The Ministry of Health and Long-Term Care’s 2005 Critical Care Strategy identified Health Human Resource planning as an essential factor in the delivery of critical care services, particularly focusing on the training, recruitment and retention of critical care nurses. To support this strategy, in 2006/07, the Ministry announced the annual Nurse Training Fund, a $4.5M initiative designed to assist hospitals with the costs of training critical care nurses. The Critical Care Nurse Training Fund requires training to be completed through an in-house and/or college-based adult and/or paediatric critical care program that is at a minimum 300 didactic and clinical training hours for nurses new to critical care (Nurse Training Fund: Funding Analysis Report, 2013).

For the purpose of aligning with industry standard regarding a minimum requirement of critical care training hours, the CCWP collected data on the total number of RNs on the unit who had completed 300 (or more) didactic and clinical critical care training hours.



The Figure 37 below compares the proportion of nurses who completed the 300 or more didactic and clinical critical care training hours from years 2013/14 to 2015/16. All peer groups have shown an increase since 2013/14, especially PG 6, 9 and 11 (increase of 66.4%, 45.5% and 41.4%). PG 10 + 12 saw a decrease of 5.5% since 2013/14.

Figure 37: Proportion of Nurses that completed a Minimum of 300 Clinical or Didactic Critical Care Training Hours, 2013/14 and 2015/16

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PG11(880)

PG10+12(417)

PG9(361)

PG8(426)

PG6(526)

PG5(668)

PG4(546)

PG3(914)

PG2(1810)

PG1+7(2327)

ON(8875)


PERC

ENTA

GE

PEER GROUP (N)

5662

68

60

85

57

28 27.622

61

25

7581 83

67

85.9

77

93

40

68

55

66

Source: 2015/16 CCWP Online Data Collection Tool, Question 5 Source: 2013/14 CCNWP Survey, Question 17b



In the 2015/16 CCWP survey, units were asked to identify what critical care training their nursing staff had. Figure 38 demonstrates that there is variability in the type of training that critical care nurses across Ontario have received. Provincially almost 40% of critical care nurses have been trained according to the Ontario Critical Care Nurse Training Standards, 17% have a diploma in critical care,19% have other types of critical care training, while 11% have less than 300 hours of critical care training. Finally, an average of 13% of nurses did not report having completed any critical care training.

Across Peer Groups, combined Peer Group 1 and 7 (Level 3 Teaching Hospitals and Level 3 Burns Units), Peer Group 2 (Level 3 Community Hospitals) and Peer Group 4 ( Level 3 and Level 2 Cardiac/Cardiovascular Units) all reported that more than 50% of their nurses had Critical Care Training according to the Nurse Training Standards (Standards for Critical Care Nursing in Ontario, 2012).

Figure 38: Critical Care Training Attainment Distribution of Critical Care Nurses, by Peer Group

0% 20% 40% 60% 80% 100%

PG11 (880)

PG10+12 (417)

PG9 (361)

PG8 (426)

PG6 (526)

PG5 (668)

PG4 (546)

PG3 (914)

PG2 (1810)

PG1+7 (2327)

ON (8875)

≥ 300 hrs (Other)

< 300 hrs (Other)

Not CompletedTraining Attainment

≥ 300 hrs (CC Diploma)

≥ 300 hrs (ON CC Nurse Training)

PERCENTAGE

PEER

GRO

UP

(N)

13%

11%

11%

23%

2.4%

12%

4.9%

32%

10%

19%

19%

39%

49%

57%

14%

60%

27%

23%

19%

19%

11%

34%

11%

8.9%

6.6%

10%

12%

11%

1.7%

28%

22%

26%

15%

19%

17%

10%

20%

12%

14%

71%

19%

18%

22%

22%

17%

15%

15%

33%

35%

2.4%

31%

22%

11%

14%




Looking at training practices across LHINs in Figure 39, Waterloo Wellington (LHIN 3) and South East (LHIN 10) reported that less than 10% of their nurses had training to the Ontario Critical Care Nurse Training Standards. Waterloo Wellington (LHIN 3) identifies most of their nurses (72%) training in “other” formats. North West (LHIN 14) reported the most nurses who did not complete critical care training at 39% which may be impacted by access to training programs.

Figure 39: Critical Care Training Attainment Distribution of Critical Care Nurses, by LHIN

0% 20% 40% 60% 80% 100%

14-NW (102)

13-NE (431)

12-NSM (119)

11-CH (1152)

10-SE (251)

9-CE (423)

8-C (508)

7-TC (2223)

6-MH (576)

5-CW (539)

4-HNHB (1236)

3-WW (155)

2-SW (782)

1-ESC (378)

ON (8875)

PERCENTAGE

13%

1.1%

16%

7.1%

11%

16%

21%

5.5%

13%

9.2%

26%

24%

39%

10%

39%

LHIN

(N)

39%

55%

53%

3.9%

34%

68%

37%

33%

63%

44%

7.6%

35%

51%

17%

36%

11%

12%

12%

5.2%

22%

0.9%

6.4%

5.4%

3.9%

15%

28%

6.9%

9.2%

41%

3.9%

19%

12%

16%

72%

16%

4.1%

9.9%

35%

7.7%

3.8%

7.6%

20%

13%

15%

17%

21%

5%

12%

17%

11%

26%

21%

12%

28%

32%

14%

0.8%

18%

5.9%

≥ 300 hrs (Other)

< 300 hrs (Other)

Not CompletedTraining Attainment

≥ 300 hrs (CC Diploma)

≥ 300 hrs (ON CC Nurse Training)




5.4 Life Support Training

The CCWP survey asked about staff training for life support in both adult and paediatric critical care units. The presence of these training certifications for critical care nurses are described in the sections below.

1 Only adult critical care units were considered for this analysis since this certification is not relevant to the paediatric specialty.

5.4.1 ADVANCED CARDIAC LIFE SUPPORT (ACLS) TRAINING

ACLS training is intended for healthcare professionals responding to cardiopulmonary emergencies and working in critical care environments; such as physicians, nurses, respiratory technologists and paramedics (“Advanced Cardiac Life Support (ACLS),” 2017).

As shown in Figure 40 from the 2015/16 CCWP survey, more than half of the nurses in all adult critical care units1 across Ontario have had ACLS Training in the last two years. Peer group 3, level 3 community hospital medical/surgical ICUs with ventilator patient day rate less than 47%, had the highest rate of compliance for ACLS training within the last two years. Conversely, the combined Peer Group 1 and 7 (Level 3 Teaching Hospitals and Level 3 Burns Units) had the lowest proportion of nurses who had completed ACLS training in the previous 2 years, and the greatest proportion who were unknown.

Figure 40: Advance Cardiac Life Support Training Attainment Distribution of Critical Care Nurses, by Peer Group

0% 20% 40% 60% 80% 100%

PG11 (812)

PG10+12 (440)

PG9 (380)

PG8 (428)

PG5 (688)

PG4 (377)

PG3 (945)

PG2 (1832)

PG1+7 (1762)

ON (7664) 15.8%

35%

5.8%

5.2%

11%

5.8%

10%

18%

21%

19%

53%

32%

70%

81%

44%

54%

49%

44%

51%

42%

15%

18%

3.9%

2.0%

19%

15%

31%

29%

19%

16.3%

15%

21%

12%

26%

26%

10%

8.7%

8.6%

25%13%

ACLS Training Not Completed Unknown> 2 Years Ago< 2 Years Ago

PERCENTAGE

PEER

GRO

UP

(N)




5.4.2 PAEDIATRIC ADVANCED LIFE SUPPORT (PALS) TRAINING

The Pediatric Advanced Life Support (PALS) Provider Course is designed for healthcare providers who either direct or participate in the management of respiratory and/or cardiovascular emergencies and cardiopulmonary arrest in pediatric patients (“Pediatric Advanced Life Support (PALS),” 2017).

There are 8 paediatric critical care units in Ontario. Of these 8 units, information on PALS training was reported for 542 nurses. As shown in Figure 41, almost half (45.2%) of all nurses in these units had completed PALS training within the last two years. 17% had completed the training more than 2 years ago, and about a third were unknown.

Figure 41: Paediatric Advanced Life Support (PALS) Training Attainment Distribution of Critical Care Nurses in Paediatric Critical Care Units

0%

10%

20%

30%

40%

50%

UnknownNot Completed> 2 Years Ago< 2 Years Ago

PERC

ENTA

GE

COMPLETED PALS TRAINING

PG6 (n=542)

45%

17%

3.9%

34%




5.5 Professional Development Investments

Studies have found that RNs who believe their organizations are interested in making real investments in their development will be more likely to stay with their employer, even when market conditions facilitate movement between jobs, and other employers highly value their skills and competencies (Rondeau, 2009).

The CCWP collected data on professional development support provided to nurses by critical care units. Survey respondents were asked to identify how frequently different approaches to professional development are used on their units. This section displays the different options of professional development within critical care units in Ontario, and the frequency with which they are used.

As shown in Figure 42 the most common form of professional development support offered by units across the province was “In-service Delivery”, frequently used by 68% of units. Meanwhile, payment of membership fees” or providing “Research Grants” was the least-used method only being used by 4% and 3% of all units across the province. “In-services” during work hours, “MOHLTC support”, and “Paid courses and Certifications” are further analyzed below by Peer Group.

Figure 42: Approaches to Professional Development Investment in Critical Care Units, Provincial

0% 20% 40% 60% 80% 100%

ResearchGrants (147)

VendorSupport (150)

MOHLTCSupport (149)

In-Serviceduring work (158)

Community/Foundation Support (147)

Bursaries/Scholarships (159)

Paid Course &Certification (159)

Membership Fee(148)

Paid Conference(159)

20%

61%

60%

7.2%

4.1%

68%

28%

2.7%

35%

21%

21%

56%

71%

6.3%

36%

65%

97%

TYPE

OF

APP

ROA

CH (N

)

Approach Usage SometimesFrequent Rarely/Never

PERCENTAGE

45%

18%

18%

37%

25%

25%

36%

32.0%

3.4%




5.5.1 IN-SERVICES

As shown in Figure 43, in-service professional development during work hours is frequently used in particular with Peer Group 4 and with combined Peer Group 1+7 amongst 89% and 94% of the units in these Peer Groups.

Figure 43: Use of “In-services” for Professional Development (PD) in Critical Care Units, by Peer Group

0% 20% 40% 60% 80% 100%

PG11 (14)

PG10+12 (17)

PG9 (10)

PG8 (30)

PG6 (7)

PG5 (19)

PG4 (11)

PG3 (17)

PG2 (26)

PG1+7 (17)

ON (168) 68%

94%

64%

58%

89%

61%

57%

73%

75%

56%

67%

6.3%

6.3%

15.8%

11.1%

3.9%

12.5%

5.6%

13.3%

“In-service” Usage for PD Rarely/NeverSometimesFrequent

PEER

GRO

UP

(N)

PERCENTAGE

25.3%

36.4%

26.3%

38.9%

42.9%

23.1%

12.5%

38.9%

20.0%

Source: 2015/16 CCWP Online Data Collection Tool, Question 16f



5.5.2 PAID COURSES AND CERTIFICATES

Figure 44 shows that support for “Paid Courses and Certificates” seem to be used frequently across all Peer Groups, but the most by Peer Group 5, with 78% of units in this Peer Group accessing this kind of support for professional development.

Figure 44: Use of “Paid Courses and Certificates” for Professional Development (PD) in Critical Care Units, by Peer Group

0% 20% 40% 60% 80% 100%

PG11 (14)

PG10+12 (17)

PG9 (10)

PG8 (30)

PG6 (7)

PG5 (19)

PG4 (11)

PG3 (17)

PG2 (26)

PG1+7 (17)

ON (168) 60%

44%

68%

75%

67%

78%

86%

48%

43%

61%

40%

21%

19%

23%

10%

33%

11%

14%

26%

43%

17%

33%

“Paid Course/Certification” Usage for PD Rarely/NeverSometimesFrequent

PEER

GRO

UP

(N)

PERCENTAGE

18%

38%

9.1%

15%

11%

26%

14%

22%

27%

Source: 2015/16 CCWP Online Data Collection Tool, Question 16c



5.5.3 MINISTRY OF HEALTH AND LONG-TERM CARE SUPPORT

Figure 45 shows that PG2 uses support from the Ministry of Health and Long-Term Care (MOHLTC) to support professional development activities (such as the nurse training fund) frequently or sometimes amongst a collective 95% of all units in that Peer Group. In contrast, level 2 critical care units (peer groups 8 to 11) use this resource less frequently.

Figure 45: Use of “MOHLTC Support” for Professional Development (PD) in Critical Care Units, by Peer Group

0% 20% 40% 60% 80% 100%

PG11 (14)

PG10+12 (17)

PG9 (10)

PG8 (30)

PG6 (7)

PG5 (19)

PG4 (11)

PG3 (17)

PG2 (26)

PG1+7 (17)

ON (168) 28%

47%

38%

30%

33%

19%

29%

8.7%

35%

29%

40%

“MOHLTC Support” Usage for PD Rarely/NeverSometimesFrequent

36%

13%

5%

30%

33%

31%

29%

78%

35%

43%

33%

PEER

GRO

UP

(N)

PERCENTAGE

36%

40%

57%

40%

33%

50%

43%

13%

29%

29%

27%

Source: 2015/16 CCWP Online Data Collection Tool, Question 16g



6. NURSING TURNOVERTurnover is an important HHR measure associated with high costs and increased risks to patient safety. A Pan-Canadian study in 2006 on the general nursing workforce found that the mean nurse turnover rate was 9.5% and the average cost of turnover per nurse was $21,514 (Hayes, 2012). The largest contributions to direct costs were incurred through temporary replacements, and the largest indirect costs were due to decreased initial productivity of the new hire. Reasons for high nursing turnover have been associated with lower job satisfaction, as well as being a result of role ambiguity and role conflict. More importantly, high nursing turnover coupled with greater role ambiguity is also associated with increased likelihood of medical errors (O’Brien-Pallas, 2010). It has been found that RNs who believe their organizations are interested in making real investments in their development will be more likely to stay with their employer, even when market conditions facilitate movement between jobs, and other employers highly value their skills and competencies (Rondeau, 2009).

6.1 Scope of Nursing Turnover Analysis

In the CCWP survey, units were asked about employee exits and turnover with data from three different sources, as identified in the table below.

Table 8: Data Collection Tools for Nursing Turnover Capture

Data Collection Tool Scope of Information Collected Number of Exits Captured

Finance department submission

The number of nurses that left the organization capturing employmentstatus(UPPandNPonly).

204 exits from 92 units

Human Resources submission

Thenumberofnurseswholefttheorganization(Includesseparateinformationfordirectcarenursesandsupportcarenurses)

• Captured information on age group, gender, and employment status of nurses leaving

• Captures information separately for retirements vs. other exits (voluntaryandinvoluntarycombined)

• Captures information on tenure within the organization

744 exits from 130 units

Online data submission

Total number of nurses who left or changed employment status (includescombinedinformationforallnursesincludingclinicalnurse specialists, nurse educators, nurse managers, nurse practitioners,RNandRPN).

• Where known, collected information on reasons for exits, destination of staff exiting, and changes in employment status.

1,094 exits or changes in employment status from 159 units

Due to the low volume of exits reported through the finance data submission, these results will not be presented in this report. Information available through the human resources data submission as well as the Online data submission is discussed in the sections that follow.



6.2 Separations by Age Group

From the data collected in the 2015/16 CCWP a number of different views on employee separations were possible. Starting with the distribution of employee exits by age group in Figure 46 it is noted that there are higher volumes of exits from younger age groups. As well the Figure shows the age distribution of nurses retiring. It is interesting to note that all age groups have identified nurses retiring, which may highlight a data quality issue. The greatest number of nurses retiring is in the 60-64 age group, although there are also a large number of retirements in the 50-59 age group.

Figure 46: Critical Care Nurse Exits by Category and Age Group, Provincial

0

20

40

60

80

100

120

140

160

180

200

Other ExitsRetired

NU

MBE

R

TYPE OF EXIT

< 30Age 30–39 40–49 50–59 60–64 65+

24

4637

151814 1426

89

120

182

159

Source: 2015/16 CCWP Human Resources Data Collection Tool, Direct Care Nurses (N=130 units with 744 exits)



6.3 Employee Turnover

Again, this year’s CCWP allowed for a greater review of employee turnover, looking at distribution of nurse turnover by age group along different dimensions including gender and employment status.

Figure 47 shows the overall turnover of direct care nurses at 8.7% (turnover calculated by total exits from 2015/16 over unit workforce as of March 31, 2016). This rate is lower thanthat noted above of at 9.5% from the 2008 pan-Canadian study (O’Brien-Pallas, 2010). Figure 47 also shows that the nursing turnover is higher at the older age groups, with more stability of nurses remaining with organizations for age groups from 40 to 59 years old. Trends in turnover by gender were also analyzed, with rates similar for both male and female nurses across age groups (not shown).

Figure 47: Critical Care Nurse Turnover by Age Group, Provincial

0%

10%

20%

30%

40%

65+60-6450-5940-4930-39<30ON

PERC

ENTA

GE

AGE GROUP

8.7%11%

8.2%6.1% 6.8%

19.5%

26%




When looking at trends by employment status, nursing turnover is lower for full-time staff. The overall nursing turnover for full-time staff, as shown in Figure 48, is 5.7%. Similar patterns in the distributions across age groups still exist as with the overall nursing turnover.

Figure 48: Critical Care Nurse Turnover for Full-Time Staff by Age Group, Provincial

0%

10%

20%

30%

40%

65+60-6450-5940-4930-39<30ON

PERC

ENTA

GE

AGE GROUP

5.7%7.5%

4.8% 4% 5%

15%

23%




In Figure 49, analysis was undertaken to understand the tenure of nursing staff leaving their employers. Those who stayed less than 3 years with an employer are the largest group exiting from those less than 30 years old. What is more striking however, is that those nurses with less than 3 years with an organization are also the largest groups leaving for the 30 to 39 age group, and are still at almost 30% of exits for the 40 to 49 age group as well. This suggests a need to focus on employee retention for those new to the organization, across all age groups.

Figure 49: Critical Care Nurse Exits from the Organization by Age Group and Tenure with Employer, Provincial

0% 20% 40% 60% 80% 100%

> 65 (38)

60-64 (72)

50-59 (126)

40-49 (135)

30-39 (200)

< 30 (173)

AG

E G

ROU

P

PERCENTAGE

0.0%

6.6%

40%

40%

53%

0.6%

Years With Employer 6–10 11–20 >203–5 <3

11%

33%

23%

21%

7.9%

5.1%

31%

16%

12%

14%

18%

36%

23%

16%

7.9%

14%

13%

58%

35%

30%

17%

11%

7.9%




6.4 Where Nurses Go

Information on reasons for nursing exits from the unit, or changes in employment status were captured in the 2015/16 CCWP online survey data collection tool. When interpreting these results, there are a few considerations to be aware of:

• Information presented above in the report on nursing turnover was for nurses that left the organization. In contrast, information collected on reasons for exits was collected from units, and may include nurses who left the unit, or changed employment status, but did not leave the organization. For this reason, the number of exits represented in the two sections differs.

• Information on nursing turnover was restricted to analysis on direct care nurses. Information related to reasons for exits include all nursing staff, including those performing support functions.

6.4.1 DESTINATION OF EXITS

Figure 50 shows information on the destination for nurses who change roles or leave the unit. Most common, nurses remain within an ICU environment (this will be explored further below). There are two notable exceptions where a larger proportion of nurses are leaving to assume roles outside of the ICU, as noted for PG3 where 44% of nurses remain in nursing outside the ICU, and for PG8 where 35% of nurses leave the ICU care environment.

Figure 50: Destination of Critical Care Nurses Leaving the Unit or Changing Employment Status, by Peer Group

0% 20% 40% 60% 80% 100%

PG11 (53)

PG10+12 (48)

PG9 (45)

PG8 (71)

PG6 (67)

PG5 (121)

PG4 (36)

PG3 (136)

PG2 (254)

PG1+7 (263)

ON (1094)

PEER

GRO

UP

(N)

PERCENTAGE

36%

60%

39%

15%

17%

36%

15%

38%

20%

27%

21%

43%

30%

41%

41%

67%

44%

63%

27%

78%

54%

55%

21%

11%

21%

44%

17%

19%

22%

35%

2.2%

19%

25%

Destination N/A, Unknown, OtherRemain in Nursing Outside of ICURemain in ICU




For those nurses who remain in ICU, Figure 51 shows the distribution of settings where nurses go on to practice. In most Peer Groups, the majority of nurses are staying within the same ICU and simply changing roles or employment status.

Figure 51: Destination of Critical Care Nurses Changing Position and Remaining in ICU, by Peer Group

0% 20% 40% 60% 80% 100%

PG11 (53)

PG10+12 (48)

PG9 (45)

PG8 (71)

PG6 (67)

PG5 (121)

PG4 (36)

PG3 (136)

PG2 (254)

PG1+7 (263)

ON (1094)

PEER

GRO

UP

(N)

PERCENTAGE

28%

22%

24%

32%

47%

26%

49%

10%

58%

19%

36%

6.8%

5.1%

14%

14%

4.5%

14%

16%

23%

15%

7.9%

7.2%

11.0%

9.6%

5.6%

5.0%

9.0%

2.8%

4.4%

12.5%

3.8%

Destination Non-Hospital SettingDifferent HospitalSame Hospital




For those nurses who leave an ICU care environment but remain in nursing, most remain at the same hospital, as shown in Figure 52. Peer group 3 has a larger proportion who leave to go to another hospital, and Peer Groups 3, 8, and 10 appear to have larger proportions leaving in-hospital nursing.

Figure 52: Destination of Critical Care Nurses Leaving ICU and Remaining in Nursing, by Peer Group

0% 20% 40% 60% 80% 100%

PG11 (53)

PG10+12 (48)

PG9 (45)

PG8 (71)

PG6 (67)

PG5 (121)

PG4 (36)

PG3 (136)

PG2 (254)

PG1+7 (263)

ON (1094)

PEER

GRO

UP

(N)

PERCENTAGE

14%

6.5%

13%

28%

11%

14.1%

12%

24%

10%

23%

4.5%

2.3%

5.1%

11%

2.8%

5.0%

7.5%

4.0%

2.8%

1.9%

2.0%

5.2%

2.8%

3.0%

7.0%

2.2%

8.3%

1.9%

Destination Non-Hospital SettingDifferent HospitalSame Hospital




6.4.2 CHANGES IN EMPLOYMENT STATUS

For those nurses who changed employment status, unit managers were asked to identify the change that took place. Figure 53 shows that most instances of staff movement were reported as unknown or other (such as moves from or to temporary assignments). Where the moves were to or from permanent roles, provincially about 16% of nurses moved from part-time to full-time roles, 13% moved from full-time to part-time roles, and 13% moved from permanent roles to casual roles. Variability by Peer Groups is show in Figure 53 below.

Figure 53: Changes in Employment Status for Critical Care Nurses, by Peer Group

0% 20% 40% 60% 80% 100%

PG11 (60)

PG10+12 (33)

PG9 (46)

PG8 (59)

PG6 (63)

PG5 (104)

PG4 (34)

PG3 (137)

PG2 (193)

PG1+7 (252)

ON (981)

PEER

GRO

UP

(N)

PERCENTAGE

Status Change Casual from F/T or P/T Other/UnknownP/T from F/TF/T from P/T

13%

16%

11%

6.6%

8.8%

2.9%

21%

10%

11%

15%

37%

13%

7.9%

12%

25%

18%

12%

14%

10%

6.5%

24%

15%

58%

68%

65%

56%

35%

65%

51%

75%

33%

49%

12%

16%

7.9%

12%

12%

38%

20%

14%

5.1%

50%

12%

37%




7. NURSING RECRUITMENTThe following sections in this chapter will provide an overview of the recruitment feedback captured by critical care units in the 2015/16 CCWP. Where relevant, a Peer Group or LHIN breakdown is also provided for select strategies:

• Recruitment strategies;

• New Hires;

• Vacancy Rate.

7.1 Recruitment Strategies

Survey respondents were asked to identify the frequency with which they used a number of different recruitment strategies, as well as their perceived usefulness of each strategy. Table 9 shows that across all Ontario critical care units, recruitment strategies used are variable. The most commonly used recruitment strategies (either “frequently” or “sometimes used”) are “mentorship” used 52% of the time across units, followed by “flexible scheduling” (46%) and “employee reference” (35%).

To contrast the reliance on different recruitment strategies, survey respondents were asked to evaluate the perceived effectiveness of recruitment strategies. Perceived effectiveness shows a similar trend to the level of use of each strategy with “Mentorship” being reported as the most effective strategy used across the province with a total of 62% of units reported mentorship as either “very effective”, or “somewhat effective”. However, while “Employee Reference” was used by 34.9% of all units, it was reported as being very effective amongst 27.7% of units.

Table 9: Use and Effectiveness of Recruitment Strategies, Provincial

Use of Recruitment Strategy (% of usage)

Effectiveness of Recruitment Strategy (% of time hires are identified)

Frequently (>50%)

Sometimes (10-50%)

Rarely/never (<10%)

Very (>50%)

Somewhat (10-50%)

Not Effective (<10%)

JobFairs(N=153,138) 5.9% 21.6% 72.6% 7.3% 23.9% 68.8%

Internship(N=151,133) 11.3% 19.2% 69.5% 26.3% 14.3% 59.4%

Scholarship(N=147,127) 2.0% 6.1% 91.8% 7.1% 13.4% 79.5%

EmployeeReferralProgram(N=152,137) 5.3% 29.6% 65.1% 27.7% 24.1% 48.2%

FinancialIncentive(N=148,126) 0.7% 2.7% 96.6% 5.6% 14.3% 80.2%

Mentorship(N=150,142) 24.7% 27.3% 48.0% 43.0% 19.0% 38.0%

FlexibleScheduling(N=155,135) 15.5% 30.3% 54.2% 29.6% 23.7% 46.7%

Legend: Top Option Second Option Third Option




To understand further which units are using mentorship as their method of recruitment, Table 10 below shows the use and effectiveness of “mentorship” by Peer Group breakdown. Mentorship is used the most in Peer Group 9 by 87% of their units (“frequently” and “sometimes”) and equally found to be very effective by a collective 75% of their units. Interestingly, while only 27% of Peer Group 3 used mentorship, 64% of their units found it to be effective, which may indicate a recruitment practice opportunity.

Table 10: Use and Effectiveness of Recruitment Strategy “Mentorship”, by Peer Group

Use of Mentorship (% of usage)

Effectiveness of Mentorship (% of time hires are identified)

Frequently(>50%)

Sometimes (10-50%)

Rarely/never (<10%)

Very (>50%)

Somewhat(10-50%)


ON(N=150,142) 24.7% 27.3% 48.0% 7.3% 23.9% 68.8%

PG1+7(n=14,13) 14.3% 35.7% 50.0% 15.4% 23.1% 61.5%

PG2(n=21,21) 14.3% 33.3% 52.4% 28.6% 38.1% 33.3%

PG3(n=19,14) 10.5% 15.8% 73.7% 35.7% 28.6% 35.7%

PG4(n=8,7) 37.5% 12.5% 50.0% 42.9% 14.3% 42.9%

PG5(n=18,18) 16.7% 44.4% 38.9% 44.4% 16.7% 38.9%

PG6(n=7,7) 28.6% 71.4% 14.3% 85.7%

PG8(n=25,24) 40.0% 20.0% 40.0% 62.5% 16.7% 20.8%

PG9(n=8,8) 50.0% 37.5% 12.5% 75.0% 25.0%

PG10+12(n=16,16) 37.5% 25.0% 37.5% 56.3% 6.3% 37.5%

PG11(n=14,14) 28.6% 21.4% 50.0% 42.9% 7.1% 50.0%


Source: 2015/16 CCWP Online Data Collection Tool, Question 17f



7.2 New Hires

New graduate RNs are a particularly valuable health human resource, especially when the overall workforce enters retirement. A recent study on newly graduated nurses who are in their first two years of practice in Ontario found that empowerment, work engagement, and burnout were significant predictors of job and career satisfaction, as well as turnover intentions (Laschinger, 2012).

The Table 11 bellow shows that in 2015/16, a total of 132 nurses were hired in critical care units across Ontario. Of these new hires, 29% of were new graduates (that is, nurses who graduated from an accredited nursing program within the last 12 months). By comparison, the 2013/14 CCNWP reported that new graduates accounted for 16% of all new hires. However, this figure may need to be interpreted with caution since there were less respondents for this question for 2015/16.

Table 11: New Critical Care Nurse Hires by Category, 2013/14 and 2015/16, by Peer Group

Category of Hire 2013/14 (N=932) 2015/16 (N=132)

Category of Hire 2013/14(N=932) 2015/16(N=132)

New Graduates 149(16.0%) 38(28.7%)

Established Nurses 783(84.0%) 71(53.8%)

Undefined 23(17.4%)

Source: 2013/14 CCWP Online Data Collection Tool and 2015/16 Finance Data Collection Tool



7.3 Vacancy Rate

It has been suggested in the literature that the degree to which an organization is seen as an attractive place to work, is an important factor on vacancy rate. Generally, the more people are attracted to work for an organization unit type or region, the lower the vacancy rate (Rondeau, 2009).

As shown in Figure 54 below, the vacancy rate for nurses in critical care units has been variable year over year and may be decreasing somewhat over time. All rates included in the Figure are for full-time, part-time and casual vacant positions combined. Between the years 2007/08 to 2015/16, the vacancy rate has ranged from a low of 3.4% in 2013/14 to a high of 6.3% in 2010/11. Most recently, as of March 31 2016, the provincial vacancy rate for nurses in critical care units 5%.

Figure 54: Vacancy Rate for Critical Care Units, Trend Over Time

PERC

ENTA

GE

YEAR

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

2015/162014/152013/142012/132011/122010/112009/102008/092007/08

6.4%

4.1%

6.3%

4.1%

3.4%

5.0%

Source for 2015/16 CCWP Online Data Collection Tool, Question 14

*The vacancy rate for the 2013/14 CCWP was calculated using a weighted reported vacancy rate submitted per unit.



As seen in Figure 55, the critical care unit nurse vacancy rate across Peer Groups is variable. PG2 and combined PG10+12 reported the highest rates at 9.1% and 9.0% respectively. The lowest vacancy rate was reported in PG6 at 0.9%.

Figure 55: Vacancy Rate for Critical Care Units, by Peer Group

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

PG11(943)

PG10+12(533)

PG9(451)

PG8(651)

PG6(554)

PG5(728)

PG4(728)

PG3(898)

PG2(2147)

PG1+7(2177)

ON(9887)

PERC

ENTA

GE

PEER GROUP (N)

5.0%

2.9%

9.1%

5.2%

4.1%

3.4%

0.9%

3.4%

4%

9%

3.5%




By LHIN, Figure 56 shows that LHINs 5, 6, 8 and 12 in particular had vacancy rates above 8% in 2015/16, almost double that of the Ontario average rate of 4.8%.

Figure 56: Vacancy Rate for Critical Care Units, by LHIN

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

11.0%

NW(110)

NE(426)

NSM(121)

CH(994)

SE(251)

CE(451)

C(507)

TC(2246)

MH(596)

CW(540)

HNHB(1329)

WW(308)

SW(800)

ESC(384)

ON(9063)

PERC

ENTA

GE

LHIN (N)

5.0%

4.0% 4.4%

3.4%

4.1%

8.2%

10%

3.0%

9.9%

4.9% 4.9%

4.2%

3.0% 3.0%

9.8%




8. RETENTION AND EMPLOYEE ENGAGEMENT

8.1 Retention Strategies

Survey respondents were asked to identify the frequency with which they used a number of different retention strategies. As seen in, critical care units cite, “regular staff meetings with leadership” and “education or training events” as the most commonly used retention strategies, frequently used by 92.5% and 89.2% of all critical care units. The third most common retention strategy was “team building”, frequently used by 78.6% (121) of all critical care units.

According to the reported effectiveness of strategies, “education or training events” (88.5%) was reported as the top “very effective” method, followed by “staff appreciation events” (84.6%) and “team building events” (81.4%). This may indicate that “staff appreciation events” may be an underutilized strategy.

Table 12: Use and Effectiveness of Retention Strategies in Critical Care Units, Provincial

Use of Retention Strategy (# of times per year)

Effectiveness of Retention Strategy (% of staff who valued strategy)

Frequent (10+)

Sometimes (3-9)

Rarely/ never (0-2)

Very (>75%)

Somewhat (25-75%)


EmployeeRecognition(n=157,156) 66.9% 24.2% 8.9% 72.4% 17.3% 10.3%

LongServiceRecognition(n=157,157) 30.6% 48.4% 21.0% 55.4% 22.9% 21.7%

TeamBuilding(n=154,156) 78.6% 16.2% 5.2% 81.4% 14.7% 3.9%

StaffAppreciation(n=160,156) 69.4% 29.4% 1.3% 84.6% 12.8% 2.6%

FlexibleStaffScheduling(n=157,156) 51.6% 24.2% 24.2% 70.7% 7.0% 22.3%

Regular Staff Meetings with Leadership (n=160,159)

92.5% 6.9% 0.6% 79.9% 18.9% 1.3%

UnitCouncil(n=156,155) 65.4% 13.5% 21.2% 58.1% 20.7% 21.3%

Education/TrainingEvents(N=158,157) 89.2% 10.1% 0.6% 88.5% 9.6% 1.9%

Scholarship(N=152,153) 5.3% 26.3% 68.4% 27.5% 15.7% 56.9%

Preceptor(<3months)(N=150,151) 56.0% 18.0% 26.0% 63.6% 13.9% 22.5%

Preceptor(>3months)(N=153,155) 41.8% 19.0% 39.2% 54.8% 13.6% 31.6%

Mentorship(N=157,152) 39.5% 28.7% 31.9% 57.9% 14.5% 27.6%

Employee Wellness Initiatives - Hospital (N=160,157)

61.3% 23.1% 15.6% 40.1% 47.8% 12.1%

Employee Wellness Initiatives - Critical Care(N=155,154)

12.3% 27.7% 60.0% 31.8% 14.9% 53.3%

ExitInterviews(N=157,157) 22.9% 35.0% 42.0% 31.8% 28.7% 39.5%




To discover further which units are using “Education/ Training Events” as their method of retention, the following Table 13 below shows the use and effectiveness of this strategy by Peer Group.

The combined Peer Group 1+7, 4 and 9 all reported “frequent use” of Education/Training Events, as well that this method is “very effective” by greater than 90% in all of the units in their Peer Groups. Meanwhile, PG6 and combined PG10+12, are reporting less than 75% use of this approach in their units which may indicate improvement opportunities for units without this offer.

Table 13: Use and Effectiveness of Recruitment Strategy “Education/Training Events”, by Peer Group

Use of “Education/Training Events” (# of times used per year)

Effectiveness of “Education/Training Events” (% of staff who valued events)

Frequently (10+)

Sometimes (3-9)

Rarely/ never (0-2)

Very(>75%)Somewhat (25-75%)


ON(N=158,157) 89.2% 10.1% 0.6% 88.5% 9.6% 1.9%

PG1+7(n=16,16) 100% 93.8% 6.3%

PG2(n=22,21) 86.4% 13.6% 85.7% 14.3%

PG3(n=19,19) 89.5% 10.5% 89.5% 5.3% 5.3%

PG4(n=9,9) 100% 100%

PG5(n=18,18) 88.9% 11.1% 83.3% 16.7%

PG6(n=7,7) 71.4% 28.6% 100%

PG8(n=26,26) 92.3% 7.7% 88.5% 7.7% 3.9%

PG9(n=9,9) 100% 100%

PG10+12(n=18,18) 72.2% 27.8% 77.8% 22.2%

PG11(n=14,14) 92.9% 7.1% 85.7% 7.1% 7.1%


Source: 2015/16 CCWP Online Data Collection Tool, Question 18h



8.2 Participation in Hospital-Led Engagement Surveys

As a new addition to the 2015/16 CCWP survey, critical care units were asked about the use of employee engagement surveys in their hospitals. This area of inquiry was added to the CCWP survey to better understand issues of staffing turnover, employee burnout, and engagement opportunities.

Engagement at work has emerged as a potentially important employee performance and organizational management topic, however, the definition and measurement of engagement at work, and more specifically, nurse engagement, is poorly understood (Simpson, 2008). Studies have found that RNs who believe their organizations are interested in making real investments in their development will be more likely to stay with their employer, even when market conditions facilitate movement between jobs, and other employers highly value their skills and competencies (Rondeau, 2009).

Employee engagement has been shown to have a statistical relationship with productivity, profitability, employee retention, safety, and customer satisfaction (Buckingham, 1999); (Coffman, 2002). Furthermore, Fernandez (2007) suggests that employee satisfaction is not the same as employee engagement, and recommends that measures of employee satisfaction cannot be used to help retain the best and the brightest but instead employee engagement in a more reliable concept (C.P., 2007).



As shown in Figure 57, PG9 and PG11 report having 100% of their critical care units engage in hospital-led engagement surveys. Other Peer Groups such as PG1+7 and PG5 also reported high levels of hospital-led engagement survey participation. PG3 reported the highest percentage (25%) of critical care units that do not participate in hospital-led engagement surveys.

Figure 57: Critical Care Unit Participation in Hospital-Led Engagement Survey, by Peer Group

0% 20% 40% 60% 80% 100%

PG11 (15)

PG10+12 (18)

PG9 (9)

PG8 (27)

PG6 (7)

PG5 (18)

PG4 (9)

PG3 (20)

PG2 (22)

PG1+7 (16)

ON (155)

PEER

GRO

UP

(N)

PERCENTAGE

CCU Survey Participation % No/Other<50%>50%

66%

50%

73%

70%

67%

67%

71%

26%

67%

39%

67%

7.7%

6.3%

14%

25%

11%

5.6%

14%

15%

0%

22%

0%

27%

44%

14%

5.0%

22%

28%

14%

59%

33%

39%

33%




As shown in Figure 58, Mississauga Halton (LHIN 6) and North Simcoe Muskoka (LHIN 12) reported that 100% of their critical care units engage in hospital-led engagement surveys. Several LHINs such as Toronto Central (LHIN 7), Central (LHIN 8), Central East (LHIN 9) and Champlain (LHIN 11) reflect higher than provincial averages. Erie St. Clair L (LHIN 1) reported that more than half 57.1% of their critical care units have no participation in hospital-led engagement surveys.

Figure 58: Critical Care Unit Participation in Hospital Led Engagement Survey, by LHINs

0% 20% 40% 60% 80% 100%

14-NW (3)

13-NE (11)

12-NSM (3)

11-CH (18)

10-SE (5)

9-CE (9)

8-C (6)

7-TC (29)

6-MH (9)

5-CW (6)

4-HNHB (25)

3-WW (8)

2-SW (16)

1-ESC (7)

ON (155) 7.7%

57%

6.3%

12.5%

0%

0%

0%

3.4%

0%

0%

20%

0%

0%

27%

33%

66%

14%

56%

63%

60%

33%

98%

79%

83%

78%

40%

78%

100%

55%

33%

PERCENTAGE

Survey Participation Yes (CC >50% of Unit) Yes (CC <50% of Unit) No/Other

LHIN

(N)

26.5%

28.6%

37.5%

25.0%

40.0%

68%

17%

16.7%

22.2%

40.0%

22.2%

18.2%

33.3%




8.3 Employee Engagement Improvement Opportunities

As nurse engagement correlates directly with safety, quality and patient experience outcomes, understanding the current state of nurse engagement and its drivers must be a strategic imperative (Dempsey, 2016). In addition to data collected on hospital-led employee engagement, the CCWP online data collection tool asked participants to identify the top two improvement opportunities for employee engagement. The improvement opportunities of choice were:

• Job Characteristics (e.g. flexibility in schedule/work hours; balance of family/personal life with work; have adequate resources/equipment to do work; have time to carry out all your work; get recognition for good work)

• Training and Development (e.g. opportunity to make improvements in how your work is done; opportunity to receive education/training; opportunity to advance in career),

• Work Team (e.g. enough staff to handle workload; we work in crisis mode),

• Senior Management (e.g. senior management acts on staff feedback).

The frequency with which these items were noted is found in Figure 59 below.

Figure 59: Employee Engagement Improvement Opportunities for Critical Care Units, Provincial

0%

10%

20%

30%

40%

50%

60%

Other / Not Identified

OrganizationSeniorManagement

WorkTeam

Training andDevelopment

JobCharacteristics

PERC

ENTA

GE

IMPROVEMENT OPPORTUNITIES(N=153) MULTIPLE SELECTIONS POSSIBLE

48%

33% 33% 33%

12% 11%




9. ALLIED HEALTH PROFESSIONALS IN CRITICAL CAREAllied Health Professionals (AHPs) are important members of the critical care team and system. Although AHPs have traditionally not been the focus of national or provincial leadership or policy-making conversations for health and care systems, this is starting to change (8.2 Allied health workforce, 2013; Bardsley, 2014; Boyce, 2001; Colleges, 2012; I. C. S. Committee, 2007; I. C. S. I. Committee, 2010). In particular, AHPs have been recognized as experts in transforming models of care using their strengths in system and team integration as they work across many parts of the healthcare system as shared staff (8.2 Allied health workforce, 2013; Boyce, 2001; Fund, 2013; Oliver, 2014). As well, they are known for their contribution to maintaining health and supporting rehabilitation, especially for the frail elderly and growing complex care patient populations (8.2 Allied health workforce, 2013; Oliver, 2014).

Although there has been limited research on the role and impact of AHPs in critical care specifically, one research paper reviewing ten years of organization and management of allied health services in Australian acute care, acknowledged the AHP role in improving productivity by leading service redesign, and preventing both admission and readmissions. In particular, AHPs were recognized for exploring and sharing the best practice of “allied health packages of care”, an integrated and decentralized care model in acute care institutions (Boyce, 2001).

In Ontario, the Interprofessional Care Steering Committee commissioned by the government of Ontario, produced two seminal reports; Interprofessional Care: A Blueprint for Action in Ontario (I. C. S. I. Committee, 2010), and Implementing Interprofessional Care in Ontario (I. C. S. Committee, 2007). The focus of these reports was to formalize the practice principles for patient-centered care – being integrated and interprofessional. This work has resulted in the development of an Interprofessional Education Curriculum and Interprofessional Core Competency (I. C. S. I. Committee, 2010).

Despite noting the key role that AHPs play in health and care systems, there remains a lack of health human resource intelligence across Canada and in Ontario for labour market information, data collection and planning, as highlighted in Health Canada’s 2012 report on sustaining the Allied Health professions. Although the Canadian Institute for Health Information (CIHI) collects supply-based information on 24 health occupations through the Health Personnel Database, the information is reliant on data from professional associations, regulatory bodies, governments and educational institutions which does not capture labour market information from professionals nor managers themselves, therefore limiting the scope of insights it can provide on workforce issues (Colleges, 2012).



New to this year’s CCWP Report is the collection of high level human resource intelligence on a range of AHPs as selected through stakeholder consultations. The survey collected information on the following disciplines:

• Chaplains/Spiritual Carers/Pastors

• Dietitian/Nutritionists

• Occupational Therapists

• Pharmacists

• Physiotherapists

• Respiratory Therapists

• Social Workers

For the first look into the AHP workforce in Ontario’s critical care units, the following was collected in this year’s survey:

• The prevalence of the seven AHPs listed above in critical care units;

• Full-time equivalent (FTE) allocations for each discipline, with a minimum capture of 0.2 FTE; and,

• Both the weekday and weekend coverage, further broken down by the number of support hours per week, and the provision of on-call services, by discipline.



9.1 Use of Allied Health Professionals in Critical Care

Response rate was strong for CCWP questions related to AHP. Of the 165 units that responded to the online survey data collection tool, 154 units completed information on AHP staffing.

Units were asked to identify the allied health disciplines that were routinely (e.g. daily or weekly) involved in care delivery and support. As shown in Figure 60. Pharmacy is the most commonly used allied health support in critical care units, used by 92% of units. Physiotherapists are used within 90% of critical care units who responded to the survey question, Dieticians/Nutritionists are used within 88% of units, and Respiratory Therapists within 87%.

Figure 60: Routine Use of Allied Health Professionals in Critical Care Units, Provincial

ALL

IED

HEA

LTH

PRO

FESS

ION

(N)

PERCENTAGE

0% 20% 40% 60% 80% 100%

OccupationalTherapist (104)

Chaplain /Spiritual Carer /

Pastor (106)

Social Worker (139)

RespiratoryTherapist (146)

Dietitian /Nutritionist (147)

Physiotherapist (151)

Pharmacists (154) 92%

90%

88%

87%

83%

63%

62%

Source: 2015/16 CCWP Online Data Collection Tool (N=154), Question 22A

Due to the frequent use of pharmacists and physiotherapists in critical care units overall, as well as the strong reliance on respiratory therapists in level 3 critical care units, the following sections in this chapter will explore a further breakdown of these three disciplines by FTE allocation, as well as both weekday and weekend coverage by hours of support, and provision of on-call services in the unit.



9.2 Pharmacists

Pharmacy services in critical care are recognized as an essential component of multidisciplinary care for critically ill patients. Benefits to having pharmacists within the critical care unit include assisting physicians and clinicians with pharmacotherapy decision-making, reducing medication errors, and improving medication safety systems to optimize patient outcomes. There have been documented improvements in the management of infections, anticoagulation therapy, sedation, and analgesia for patients receiving mechanical ventilation and in emergency response (Preslaski CR, 2013).

Critical Care Services Ontario (CCSO) has supported the use of pharmacists in critical care teams since 2005, as stated in the Final Report of the Ontario Critical Care Steering Committee, which recommends “a model that encourages the formation of a specialized critical care team consisting of full time intensivists, ICU nurses, respiratory therapists and pharmacists.”(Final Report of the Ontario Critical Care Steering Committee, 2005).

According to the Ontario College of Pharmacists, in 2015 there were a total of 13,540 active pharmacists of which 2,363 (17%) worked in the hospital or other healthcare facilities, accounting for the second largest area of practice for pharmacists (76% of pharmacists work in the community)(Ontario College of Pharmacists Annual Report, 2015).

While there has been profiling on the general pharmacy workforce across Canada through CIHI’s Health Workforce capture, and across Ontario from the Ontario College of Pharmacists, there does not seem to be research conducted on pharmacists specialized in critical care.



Across the province, units reported an average of 8 hours per day during the week, and 2.4 hours per day on weekend of pharmacist staffing, as shown in Figure 61. Peer Group 6 (Paediatric Units) reported the greatest weekday hours per day, with an average of 12.6 hours. Weekend support ranged from an average of 0.5 hours on average per day in PG9 to an average of 4.6 hours per day by PG11.

Figure 61: Pharmacist Support Hours per Day in Critical Care Units, by Peer Group

0

2

4

6

8

10

12

14

PG11(14)

PG10+12(17)

PG9(8)

PG8(14)

PG6(7)

PG5(16)

PG4(8)

PG3(20)

PG2(21)

PG1+7(14)

ON(138)

2.41.6

0.9

3.6

1.72.1

3.9

2.5

0.5

3.8

4.9

8.0 7.9 7.6

5.0

7.07.5

12.6

5.7

3.6

8.5 8.3

Daytime Hours WeekendWeekday

HO

URS

PER

DAY

PEER GROUP (N)




As seen in Figure 62, for on-call coverage across Ontario 78% of units had pharmacists on-call during the week, and 16% had on-call pharmacy services on the weekends. Weekend on-call pharmacy services were variable ranging from 6% of units in PG3 to 100% of units in combined PG1+7 that had weekend pharmacy services on-call. All units in the combined PG1+7 also had on-call access to pharmacists on the weekdays.

Figure 62: Pharmacist Provision of On-Call Support in Critical Care Units, by Peer Group

0%

20%

40%

60%

80%

100%

PG11(11)

PG10+12(13)

PG9(6)

PG8(14)

PG6(6)

PG5(13)

PG4(6)

PG3(17)

PG2(18)

PG1+7(10)

ON(114)

16

100

85

5.6

29

20

40

21

33

67

27

78

100

78

94

6769

67

79

50

62

91

PRO

VIS

ION

OF

ON

-CA

LL IN

CC

PEER GROUP (N)

On Call WeekendWeekday




9.3 Physiotherapists

According to a recent systematic review conducted in 2016, there is evidence indicating that physiotherapy intervention focusing on early progressive mobilization that is feasible and safe, results in significant functional benefits, which may translate into a reduced ICU and hospital LOS (Laurent. H, 2016) .

While there has been profiling on the general physiotherapist (PT) workforce across Canada through CIHI’s Health Workforce capture, and across Ontario from the Ontario College of Physiotherapists, there does not seem to be human resource data collected on physiotherapists specialized in critical care.

Figure 63 below shows that across the province the average hours per day of physiotherapist support is 5.6 during the week, and 1.6 during the weekend. Coverage during the week is variable ranging from 3.7 hours per day in PG3, to 8 hours per day in PG6. Weekend coverage of physiotherapy support ranged from 0.5 hours per day in PG11 to 3.2 hours per day in PG4.

Figure 63: Physiotherapist Support Hours per Day in Critical Care Units, by Peer Group

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

PG11(14)

PG10+12(16)

PG9(8)

PG8(18)

PG6(6)

PG5(16)

PG4(7)

PG3(20)

PG2(21)

PG1+7(14)

ON(140)


HO

URS

PER

DAY

PEER GROUP (N)

1.6

2.4

1.5 1.7

3.2

1.1

2.2

0.7

2 1.9

0.5

5.9

7.7

6.6

3.7

6.3

4.6

8

3.7

4.95.2

5.5




As seen in Figure 64, across Ontario 24.5% of all critical care units (N=106) have on-call provision for physiotherapy services. Peer Group 6 had 100% coverage for on-call physiotherapy services during the weekends. The lower on-call provision on weekdays and higher weekend provision can be attributed to the consistently secured FTE allocation of PT services during the weekday, as seen in the previous Figure 63.

Figure 64: Physiotherapist Provision of On-Call Support in Critical Care Units, by Peer Group

0%

20%

40%

60%

80%

100%

PG11(8)

PG10+12(10)

PG9(6)

PG8(15)

PG6(5)

PG5(13)

PG4(6)

PG3(16)

PG2(16)

PG1+7(11)

ON(106)

68

42

22

63

7177

50

67

83

20

78

2518

31

25

17 15

100

33

1720

50

PRO

VIS

ION

OF

ON

-CA

LL IN

CC

PEER GROUP (N)





9.4 Respiratory Therapists (RT)

The profession of Respiratory Therapy (RT) is a relatively new specialization in critical care, having celebrated only 50 years of existence in 2014, since the inception of the Canadian Society of Inhalation Therapy (Nickerson, 2014). Despite this, respiratory therapists have historically played a vital role in critical care and continue to do so. As summarized in an American study looking at the manpower needs and activities in respiratory therapy, The Society of Critical Care Medicine (SCCM) has numerous articles, recommendations and guidelines for safe and effective critical care practice including the use of RTs. Some of the examples of the benefits cited include (Mathews, 2006):

• “The presence of full-time respiratory therapists dedicated to the ICU can reduce length of stay, shorten ventilator days and reduce overall ICU costs.”

• SCCM recommends that “respiratory services must be available 24 hours a day, 7 days a week” in facilities that have level 1 ICU and by extension, in level 2 facilities. Level 3 centers state that “A critical care trained nurse and respiratory therapist should be available on site, 24hrs per day.”

Critical Care Services Ontario (CCSO) has supported the use of RTs in critical care teams since 2005.

According to the College of Respiratory Therapists of Ontario, in 2014 in Ontario, there were 3,269 RTs of which 3,053 were active. Of those, about half or 1,622 (53%) worked in acute care at least some of the time, and 1,199 (39%) worked in this setting as their primary employment site, accounting for the top area of practice for this profession. At the time of membership renewal, 11% held extra certificates in Paediatric Advanced Life Support, 31% in Advanced Cardiac Life Support, 32% in Basic Cardiac Life Support and 34% had completed the Neonatal Resuscitation Program. Finally, reported employment status showed that 69% were employed full-time, 22% were part-time and 9% were casual (CRTO, 2014).

While there has been profiling on the general respiratory therapy workforce, there does not seem to be research conducted on respiratory therapy resource implications specifically within critical care in Canada or in Ontario.



Across the province respiratory therapists are highly used in all Peer Groups on weekdays, including in some Peer Groups on weekends. As shown in Figure 65, on average in Ontario, critical care units had 16 hours per day of RT coverage during the weekday and 7.2 hours per day on weekends. Weekday coverage ranged from 22.8 hours per day in combined Peer Group 1+7 to a low of 7.3 hours per day in Peer Group 8. On the weekends, combined Peer Group 1+7, Peer Group 2, and combined Peer Group 10+12 had equally high coverage of RTs on weekends at 23.2, 21.3, and 15.7 hours per day respectively.

Figure 65: Respiratory Therapist Support Hours per Day in Critical Care Units, by Peer Group

0

5

10

15

20

25

PG11(12)

PG10+12(15)

PG9(6)

PG8(13)

PG6(7)

PG5(14)

PG4(8)

PG3(19)

PG2(21)

PG1+7(14)

ON(129)


HO

URS

PER

DAY

PEER GROUP (N)

7.2

23

21

1.73.2

1.12.2

0.72

16

0.5

16

2321

15

19

14

16

7.3

12

15

19




Despite the generally lower provision of FTE dedicated RTs on the weekend, as seen in the previous figure (Figure 65), only 50% or fewer of all units, with the exception of Peer Group 4, had RT services on-call in their critical care units as shown in Figure 66.

Figure 66: Respiratory Therapist Provision of On-Call Support in Critical Care Units, by Peer Group

0%

20%

40%

60%

80%

100%

PG11(9)

PG10+12(12)

PG9(6)

PG8(14)

PG6(6)

PG5(14)

PG4(7)

PG3(17)

PG2(16)

PG1+7(10)

ON(111)

49

22

3640

60

39

50 50 5054

4248

20

44

59

40

50

33

50 50 50

67

PRO

VIS

ION

OF

ON

-CA

LL IN

CC

PEER GROUP (N)





9.4.1 FTE ALLOCATION

Respiratory Therapist FTE allocation is presented separately, as units may have more than one respiratory therapist covering the unit, particularly in units with a high use of mechanical ventilation. FTE allocation varies considerably across Peer Groups as seen in Figure 67. On average across the province, FTE allocation for Respiratory Therapist services in critical care units was 2.3. Peer Groups 1+7, 4, and 6 reported the highest FTE allocations, ranging from 4.5 FTEs to 6.7 FTEs. The remaining Peer Groups reported values less than 2.0 FTEs.

Figure 67: Respiratory Therapist FTE Allocation in Critical Care Units, by Peer Group

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

PG11(12)

PG10+12(13)

PG9(6)

PG8(14)

PG6(7)

PG5(14)

PG4(8)

PG3(18)

PG2(21)

PG1+7(14)

ON(127)

FTE

ALL

OCA

TIO

N >

0.2

PEER GROUP (N)

2.3

5.1

2.3

1.1

4.5

0.7

6.7

0.2 0.3

1.10.9

Source: 2015/16 CCWP Online Data Collection Tool, Question 22C



10. CONCLUSION

About the Data

The 2015/16 CCWP utilized data for hospital information systems to allow for more complete and comprehensive analysis of staffing practices. This transition to data collection from the OHRS began in 2013/14, and was further enhanced in 2015/16 with data requests directly to hospital finance departments. As well, the request of demographic information directly from hospital Human Resource departments allowed for more granularity of analysis in separations and overall workforce by age and employment status.

Although data was requested from existing systems, the completeness of data reported varied across different dimensions of analysis. For future iterations of the survey, there will be a goal to improve the completeness of data submitted so that a more fulsome understanding of such issues as roles in critical care (including nursing support roles), benefit hours for staff (including education time), staffing turnover, and hiring practices may be reviewed. Particular areas of reporting gaps in the 2015/16 OHRS finance data collection included:

• Head count data for both MOS and UPP staff;

• Alignment of some roles to appropriate MOS and UPP staff designations;

• Complete reporting of earned benefit hours;

• Complete reporting of separations;

• Complete reporting of new hires.

In the lead up to 2017/18 data collection, which will occur in the Spring of 2018, CCSO welcomes feedback from stakeholders on the data collection template and inclusion criteria for measures analyzed.



Concluding Remarks

Critical care units perform a central role in our healthcare system, delivering care to the most acutely ill patients, and responding to increased demands in times of epidemic and system surge. As well, the nursing resources in critical care units across the province account for more than 10% of all nurses in the Ontario and are thus an important group in understanding overall nursing trends.

This report has undertaken a comprehensive review of staffing practices in critical care across Ontario. The report has also highlighted areas of variation in the composition of the workforce, staffing practices and training of staff across the province, or across peer groups. The intention of highlighting this variation in practice is to allow regions, through the Regional Critical Care Networks, and individual units to understand where variation exists, and to address areas that may be of concern. At a provincial level, these insights can be used to more effectively target supports and investments in education, career development opportunities, and other areas. Such efforts, at the unit, regional, and provincial levels, will foster a more robust workforce and help ensure patients have access to timely and quality care.



11. GLOSSARY OF TERMS

Direct Care Nurses Intended to capture nursing roles providing direct bedside care to patients. Includes roles such as Registered Nurses or Registered Practical Nurse.

Full-Time Equivalent (FTE) Hours paid to one employee working on a full-time basis. Includes both worked and benefit hours. Does not include overtime hours. In most organizations,1FTE=1,950hoursannually.

Functional Center A department or unit within a hospital to which costs and activity are tracked.

Headcount Count of individuals employed, regardless of FTE allocation. Intended to capture the number of staff, across each nursing and allied health role, associated with the unit/functional centre that support critical care activities.

Management and Operational Support (MOS)

Terms from the Ontario Healthcare Reporting Standards. Staff that are indirectly supporting the core functions of a unit. In the case of critical care units, these staff would include clerical roles, management roles, and indirect care nurses.

Ontario Healthcare Reporting System (OHRS)

OHRS provides the framework for the accounting and reporting of financial and activity data across healthcare organizations in a consistent and standardized way.

Support Nurses Intended to capture roles not directly providing bedside care. Includes roles such as Clinical Nurse Specialist, Nurse Educator, Nurse Manager, Nurse Practitioner.

Unit Producing Personnel (UPP)

Term from the Ontario Healthcare Reporting Standards. Staff that are directly contributing to the core function of a unit. In the case of critical care units, these staff would include staff delivering direct bedside care.



12. PROVINCIAL REPORT APPENDICES

2 The 2011 Census by Statistics Canada defines all areas outside of population centres as classified as rural areas (less than 1,000). The Table presents the LHIN level breakdown of the population which is considered rural by this definition. Statistics Canada. Table 109-0400 - Census indicator profile, Canada, provinces, territories, health regions (2014 boundaries), CANSIM (database). (accessed: February 6 2017 )

Appendix A. Ontario’s Local Health Integration Networks

Table 14: LHIN Rural Population

Local Health Integration Networks (LHIN) Proportion of Population Considered as Rural2

1. ErieSt.Clair(ESC) 19.3

2. SouthWest(SW) 27.8

3. WaterlooWellington(WW) 11

4. HamiltonNiagaraHaldimandBrant(HNHB) 11.9

5. CentralWest(CW) 6.5

6. MississaugaHalton(MH) 1.7

7. TorontoCentral(TC) 0

8. Central(C) 4.5

9. CentralEast(CE) 13

10. SouthEast(SE) 44.8

11. Champlain(CH) 20

12. NorthSimcoeMuskoka(NSM) 32

13. NorthEast(NE) 30.2

14. NorthWest(NW) 34.2



Appendix B. Calculations Table

Table 15: Calculations Used in Data Collection for Workforce Profile

Measure Related Figures Definitions Calculation

Response Rate

Figure 1

Table 3

Table16

A unit was included in the overall response rate if any usable data was provided for the data collection tool.

=[Num.ofunitsResponded]/[TotalNumberofUnitsinGroup]

UPP Nursing Earned Hours by Type

Figure 19

• UPP regular worked hours (OHRSaccount635***2)

• UPP overtime hours (OHRSaccount635***1)

• UPP sick hours (OHRSaccount635***3)

• UPP vacation hours (OHRSaccount635***4)

• UPP education hours (OHRSaccount635***5)

• UPP orientation hours (OHRSaccount635***6)

• UPP other hours (OHRSaccount635***7and635***8)

• UPPearnedhours(OHRSaccount635****)

• Nursing(occupationalclasses11-18)

• Includes all employment status groups (e.g.1-6)

=[UPPnursinghrs.type]/[UPPnursingearnedhrs.]

UPP Nursing Overtime Hours as a Proportion of Productive Hours

Figure 20

Figure 21

• UPP overtime hours (OHRSaccount635***1)




• Units included in the numerator match units included in the denominator

=[UPPnursingovertimehrs.]/[(UPPnursingregularworkedhrs.)+(UPPnursingovertimehrs.)]

UPP Nursing Sick Rate

Figure 22

Figure 23

• UPPsickhours(OHRSaccount635***3)





=[UPPnursingsickhrs.]/[UPPnursingearnedhrs.]



Measure Related Figures Definitions Calculation

UPP Nursing Education Time

Figure 24

• UPP education hours (OHRSaccount635***5)




• Units included in the numerator do not match units included in the denominator. All units reporting earned hours are included in denominator.

=[UPPnursingeducationhrs.]/[UPPnursingearnedhrs.]

UPP Nursing Worked Hours per Patient Day

Figure 29

Figure 30

• UPPovertimehours(OHRSaccount635***1)




• Patientdays(OHRSaccount403****)


=[(UPPnursingregularworkedhrs.)+(UPPnursingovertimehrs.)]/[Patientdays]

Direct Care Nurse Turnover

Figure 47

Figure 48

• Number of direct care nursing exits (includingretirements)asidentifiedinHuman Resources data submission for the fiscalyear(e.g.April1toMarch31)

• Number of direct care nurses as identified by Human Resources data submission as of March 31


=[Num.ofdirectcarenursingexits]/[Num.ofdirectcarenurses]

Vacancy Rate

Figure 54

Figure 55

Figure56

• Number of reported vacant nursing positionsasofMarch31,2016asidentifiedin the online data submission

• Number of nursing staff as identified in question1Boftheonlinedatasubmission

• Includes all nursing staff for full-time, part-time and casual positions

=[Num.ofvacantnursingpositions]/[(Num.ofnursingstaff)+(Num.ofvacantnursingpositions)]



Appendix C. Additional Response Rate Details

Table 16: CCWP Response Rate by Peer Group

Peer Groups

Tota

l # o

f Crit

ical

Ca

re U

nits

Number of Critical Care Units Responded Response Rate

Onl

ine

Subm

issi

on

Hum

an

Reso

urce

s Su

bmis

sion

Fina

nce

Subm

issi

on

Onl

ine

Subm

issi

on

Hum

an

Reso

urce

s Su

bmis

sion

Fina

nce

Subm

issi

on

Ontario 199 165 149* 168* 83% 75% 84%

PG1. Level 3 Teaching Hospitals + PG7. Level 3 Burn Units

17 17 14 17 100% 82% 100%

PG2.Level3CommunityHospital(VentRate>mean)

28 23 26 26 82% 93% 93%

PG3.Level3CommunityHospital(VentRate<=themean)

22 20 18 17 91% 82% 77%

PG4. Level 3 and Level 2 Cardiac / CV Units 11 9 10 11 82% 91% 100%

PG5. Level 3 and Level 2 Coronary Care Units 22 18 17 19 82% 77% 86%

PG6.PaediatricUnits 8 7 7 7 88% 88% 88%

PG8. Level 2 Small-low Acuity Units 40 29 23 30 73% 58% 75%

PG9. Level 2 Large-Low Acuity Units 11 9 7 10 82% 64% 91%

PG10. Level 2 Small-High Acuity Units + PG 12. Miscellaneous

24 18 18 17 75% 75% 71%

PG11. Level 2 Large High Acuity Units 16 15 9 14 94% 56% 88%

*Where units submitted combined data, only one unit is included in this count.



Table 17: Critical Care Nurses Reported in Data Collection Tools, by LHIN

LHIN

Tota

l # o

f Crit

ical

Ca

re U

nits

Number of Critical Care Units Responded

Number of Critical Care Nurses Represented

Onl

ine

Subm

issi

on

Hum

an

Reso

urce

s Su

bmis

sion

Fina

nce

Subm

issi

on

Onl

ine

Subm

issi

on

Hum

an

Reso

urce

s Su

bmis

sion

Fina

nce

Subm

issi

on

Ontario 199 165 149* 168* 9,414 8,224 8,576

LHIN1.ErieSt.Clair(ESC) 7 7 6 6 384 286 364

LHIN2.SouthWest(SW) 29 19 16 23 865 723 897

LHIN3.WaterlooWellington(WW) 11 8 9 9 308 312.8 343

LHIN 4. Hamilton Niagara Haldimand Brant(HNHB)

28 25 24 25 1,329 1,138 1,031

LHIN5.CentralWest(CW) 6 6 4 5 540 283 276

LHIN6.MississaugaHalton(MH) 9 9 7 9 596 498 580

LHIN7.TorontoCentral(TC) 33 29 29 28 2,246 2,179 2016

LHIN8.Central(C) 10 9 9 9 617 681 676

LHIN9.CentralEast(CE) 13 9 10 13 451 602 605

LHIN10.SouthEast(SE) 10 7 9 8 427 402 450

LHIN11.Champlain(CH) 20 19 11 19 994 332 820

LHIN12.NorthSimcoeMuskoka(NSM) 7 3 3 3 121 92 93

LHIN13.NorthEast(NE) 13 12 10 9 426 368 327

LHIN14.NorthWest(NW) 3 3 2 2 110 95 97

*Where units submitted combined data, only one unit is included in this count.



Table 18: Critical Care Nurses Reported in Data Collection Tools, by Peer Group

Peer Group

Tota

l # o

f Crit

ical

Ca

re U

nits

Number of Critical Care Units Responded

Number of Critical Care Nurses Represented

Onl

ine

Subm

issi

on

Hum

an

Reso

urce

s Su

bmis

sion

Fina

nce

Subm

issi

on

Onl

ine

Subm

issi

on

Hum

an

Reso

urce

s Su

bmis

sion

Fina

nce

Subm

issi

on

Ontario 199 165 149 168 9414 8,224 8,576

PG1. Level 3 Teaching Hospitals + PG7. Level 3 Burn Units

17 16 13 17 2119 1,610 2,232

PG2.Level3CommunityHospital(VentRate>mean)

28 24 27 26 1962 2,289 2,286

PG3.Level3CommunityHospital(VentRate<=themean)

22 20 18 17 924 765 781

PG4. Level 3 and Level 2 Cardiac / CV Units 11 9 10 11 698 678 796

PG5. Level 3 and Level 2 Coronary Care Units 22 18 17 19 703 689 852

PG6.PaediatricUnits 8 7 7 7 549 605 538

PG8. Level 2 Small-low Acuity Units 40 29 23 30 631 333 209

PG9. Level 2 Large-Low Acuity Units 11 9 7 10 433 244 177

PG10. Level 2 Small-High Acuity Units + PG 12. Miscellaneous

24 18 18 17 485 473 296

PG11. Level 2 Large High Acuity Units 16 15 9 14 910 304 409



Appendix D. Online Data Collection Tool

QUESTIONS RELATED TO THE NURSING WORKFORCE AND TRAINING:

Please answer the questions 1 to 9 relating to the nursing staff employed in your Critical Care unit on March 31, 2016:

1. A. What is the total number of nurses ( i.e.. individuals, not FTEs) on your Critical Care unit in each of the following groupings:

a. Clinical Nurse Specialist (CNS)

b. Nurse Educator

c. Nurse Manager

d. Nurse Practitioner (NP)

e. Permanent charge nurse without a patient assignment

f. Registered Nurse (RN), not included in other groupings listed

g. Registered Practical Nurse (RPN)

h. Other (please specify)______________

1. B. What is the total number of nurses in your Critical Care unit from Question 1A: ____ (Free numeric text)

2. A. Of the X number of nurses on your Critical Care unit, please identify your understanding of how many have been working in THIS particular unit for the following periods of time:

a. Less than 3 years

b. 3 - 5 years

c. 6 - 10 years

d. 11 - 20 years

e. More than 20 years

2. B. Of the X number of nurses on your Critical Care unit, please identify your understanding of how many have been working in Critical Care for the following periods of time:


b. 3 - 5 years

c. 6 - 10 years

d. 11 - 20 years




2. C. Of the X number of nurses on your Critical Care unit, please identify your understanding of how many have been working as a registered nurse for the following periods of time:


b. 3 - 5 years

c. 6 - 10 years

d. 11 - 20 years


3. Of the X number of nurses on your Critical Care unit, please indicate your understanding of the number of nurses whose highest level of education falls into the following categories:

a. Nursing diploma

b. Non-nursing undergraduate degree

c. Nursing undergraduate degree

d. Nursing master’s degree

e. Non-nursing master’s degree

f. Nursing doctorate

g. Non-nursing doctorate

4. Of the X number of nurses on your Critical Care unit, please identify your understanding of the number of nurses who attained their basic nursing training outside of Canada (If there are none please indicate 0):_____ (free numeric text)

5. Of the X number of nurses on your Critical Care unit, please identify your understanding of the number of nurses who have completed a Critical Care Course, according to the following categories:

a. 300+ hours of didactic and clinical training (Ontario Critical Care Nurse Training Standards)

b. 300+ hours of didactic and clinical training (Critical Care Diploma)

c. 300+ hours of didactic and clinical training (Other)

d. < 300 hours of didactic and clinical training

e. Not completed a critical care course

6. Of the X number of nurses on your Critical Care unit, please identify your understanding of the number who have completed Advanced Cardiac Life Support (ACLS) Training, according to the following categories:

a. Have completed ACLS training within the last two (2) years

b. Have completed ACLS training more than two (2) years ago

c. Have not completed ACLS Training

d. Don’t know if ACLS Training has been completed



7. Of the X number of nurses on your Critical Care unit, please identify your understanding of the number who have completed Pediatric Advanced Life Support (PALS) Training, according to the following categories:

a. Have completed PALS training within the last two (2) years

b. Have completed PALS training more than two (2) years ago

c. Have not completed PALS Training

d. Don’t know if PALS Training has been completed

8. Of the X number of nurses on your Critical Care unit, please identify your understanding of the number who have completed Trauma Nursing Core Course (TNCC) Training, according to the following categories:

a. Have completed TNCC training within the last year

b. Have completed TNCC training more than a year ago

c. Have not completed TNCC Training

d. Don’t know if TNCC Training has been completed

9. Of the X number of nurses on your Critical Care unit, please identify your understanding of the number who have completed Critical Care Response Team (CCRT) Training, according to the following categories:

a. Have completed CCRT training within the last year

b. Have completed CCRT training more than a year ago

c. Have not completed CCRT Training

d. Don’t know if CCRT Training has been completed

QUESTIONS RELATED TO NURSING TURNOVER:

Please answer questions 10 to 13 based on staff who left your unit or changed employment status (e.g. went from full-time to casual, etc.) in your Critical Care unit between April 1, 2015 and March 31, 2016.

10. Please identify the total number of nurses who have left or changed employment status (e.g. went from full-time to casual, etc.) in your Critical Care unit between April 1, 2015 and March 31, 2016. Please include nurses in the following categories: Clinical Nurse Specialist (CNS); Nurse Educator; Nurse Manager; Nurse Practitioner (NP); Registered Nurse (RN); Registered Practical Nurse (RPN). ________ (free numeric text)

11. Of the X number of nurses that left or changed employment status (e.g. went from full-time to casual, etc.) in your Critical Care unit between April 1, 2015 and March 31, 2016, please identify your understanding of how many exited their roles for the following reasons:

a. Move to a new nursing role or position

b. Retirement

c. Illness or disability

d. Left to pursue non-nursing education



e. Exit from nursing profession

f. Promotion to another role

g. Personal relocation

h. Not Applicable / Unknown

i. Other

12. Of the X number of nurses that left or changed employment status (e.g. went from full-time to casual, etc.) in your Critical Care unit between April 1, 2015 and March 31, 2016, please identify your understanding of how many moved to the following destinations:

a. Remains in ICU – same unit

b. Remains in ICU - different unit within same hospital

c. Remains in ICU - different hospital

d. Remains in nursing outside of ICU - within same hospital

e. Remains in nursing outside of ICU - different hospital

f. Remain in nursing - outside of hospital setting

g. Promotion to another role

h. Not Applicable / Unknown

i. Other

13. Of the X number of nurses that left or changed employment status (e.g. went from full-time to casual, etc.) in your Critical Care unit between April 1, 2015 and March 31, 2016, please identify your understanding of how many changed their employment status in the following categories:

a. Move from full time to part time

b. Move from full time to casual

c. Move from part time to full time

d. Move from part time to casual

e. Move from casual to a permanent or temporary position

f. End of a temporary assignment

g. Not Applicable / Unknown

h. Other



QUESTIONS RELATED TO RECRUITMENT AND RETENTION

Please answer questions 14 to 18 based on your experience with recruitment and retention in your Critical Care unit between April 1, 2015 and March 31, 2016.

14. On March 31, 2016 please indicate the total number of vacant budgeted RN positions (according to your hospital’s position management system) for your Critical Care unit in the following categories:

a. Full-time

b. Part-time

c. Casual

15. How does your Critical Care unit deal with short-term (shift-to-shift) RN shortages?

Please identify how often each approach is used, according to the scale provided.

Frequently used (i.e..>50%ofthetime)

Sometimes used (i.e.10-50%ofthetime)

Rarely / never used (i.e..<10%ofthetime)

a. Hospital-wide critical care RN staffing pool

b. Expanded staff assignments

c. Scheduled changes (e.g. cancelling ORs)

d. Mandatory overtime (including weekend staffing)

e. Bed closures

f. Agency staff

g. Other (please specify)____________

16. Please indicate how your Critical Care unit RNs receive support for professional development.





a. Paid conference registration (full or partial)

b. Payment of professional organization membership fees (full or partial)

c. Paid courses and certifications e.g. ACLS (full or partial)

d. Bursaries/scholarships

e. Community/foundation support

f. In-services during work hours

g. MOHLTC support (e.g. Nurse Training Fund)

h. Vendor support (e.g. pharmaceutical, supplies, equipment) support

i. Research grants

j. Other (please specify____________



17 A. What recruitment strategies do you use for nurses within your Critical Care unit?





a. Attending job fairs (either the hospital, or the unit)

b. Internship programs

c. Scholarship programs

d. Employee referral programs

e. Financial incentives

f. Mentorship programs

g. Flexible scheduling opportunities

h. Other (please specify)_____________

17. B. What has proven to be the most effective recruitment strategies you use to hire nurses within your Critical Care unit?

Please identify how effective each strategy is, according to the scale provided.

Completely effective (i.e.identifieshireseachtime)

Very effective (i.e.identifieshires>50%ofthetime)

Somewhat effective (i.e.identifieshires10%-

50%ofthetime)

Not effective (i.e.identifieshires<10%ofthetime)

a. Attending job fairs (either the hospital, or the unit)

b. Internship programs

c. Scholarship programs

d. Employee referral programs

e. Financial incentives

f. Mentorship programs

g. Flexible scheduling opportunities

h. Other (please specify)________________



18 A. What retention strategies do you use to keep nursing staff engaged within your Critical Care unit?

Please identify how often each strategy is used, according to the scale provided.

Frequently used (i.e.10+timesperyear)

Periodically used (i.e.3-9timesperyear)

Infrequently used (i.e.1-2timesperyear)

Never used

a. Employee recognition events - unit level

b. Long service recognition - unit level

c. Team building events e.g. pot lucks, seasonal events – unit level

d. Staff appreciation events – unit or hospital led

e. Flexible staff scheduling

f. Regular staff meetings with staff leadership

g. Unit council

h. Education/training events for staff

i. Scholarship programs

j. Preceptor program (≤3 months)

k. Preceptor program (> 3 months)

l. Mentorship program

m. Employee wellness initiatives – hospital level

n. Employee wellness initiatives – critical care specific

o. Exit interviews that are acted upon

p. Other (please specify)______________



18. B. What strategies do you believe are most effective for staff retention on your Critical Care unit?

Please identify how effective each strategy is, according to the scale provided.

Very effective (i.e.perceiveisvaluedby>75%ofstaff)

Somewhat effective (i.e.perceiveisvaluedby25%to75%ofstaff)

Limited effect (i.e.perceiveisvaluedby<25%ofstaff)

Not applicable as this strategy is not

used

a. Employee recognition events (unit level)

b. Long service recognition (unit level)

c. Staff appreciation events

d. Team building events (e.g. pot lucks, seasonal events)

e. Flexible staff scheduling

f. Regular staff meetings with staff leadership

g. Unit council

h. Education/training events for staff

i. Scholarship programs

j. Preceptor program (≤3 months)

k. Preceptor program (> 3 months)

l. Mentorship program

m. Employee wellness initiatives – hospital level

n. Employee wellness initiatives – critical care specific

o. Exit interviews that are acted upon

p. Other (please specify)_____________



QUESTIONS RELATED TO EMPLOYEE ENGAGEMENT

Please answer questions 19 to 21 relating to employee engagement for all staff in your Critical Care unit.

19. A. Does your unit participate in hospital-led employee engagement surveys?

a. Yes – critical care beds represent 50% or more of my unit

b. Yes – critical care beds represent less than 50% of my unit

c. No (please proceed to Q. 22)

d. Other (please specify)

19. B. In which fiscal year was the last staff engagement survey conducted?

a. 2015/16

b. 2014/15

c. Other (please specify)

20. For the last survey conducted, what was the response rate for your unit? ( i.e. what percentage of staff in your unit responded to the employee engagement survey?)

a. Please specify a percent here _________

b. If don’t know, enter zero here_________

21. Please identify the top two (2) improvement opportunities identified for employee engagement within your unit that was outlined in this survey.

a. Job characteristics (e.g. Flexibility in schedule/work hours; Balance of family/personal life with work; Have adequate resources/equipment to do work; Have time to carry out all your work; Get recognition for good work)

b. Training and development (e.g. Opportunity to make improvements in how your work is done; Opportunity to receive education/training; Opportunity to advance in career)

c. Work team (e.g. We have enough staff to handle workload; We work in crisis mode)

d. Senior management (e.g. Senior management acts on staff feedback)

e. Organization (e.g. I feel that I can trust this organization)

f. Other (please specify)

g. Improvement opportunities were not identified per unit



QUESTIONS RELATED TO ALLIED HEALTH PROFESSIONALS

Please answer questions 22 and 23 relating to Allied Health support on your Critical Care unit, referring to the period between April 1, 2015 and March 31, 2016

22 A. Recognizing the many team members that support critical care patients, please identify which allied health team members are routinely (e.g. daily or weekly) involved in care within your Critical Care unit. Please check all that apply. Please do not include assistants or technicians.

a. Chaplain/Spiritual Care/Pastoral Care

b. Dietitian/Clinical Nutritionist

c. Occupational Therapist

d. Pharmacist

e. Physiotherapist

f. Respiratory Therapist

g. Social Worker

h. Other (please specify)

22 B. For the identified disciplines in Q 22A, please identify which are included within your Critical Care unit budget vs. which are allocated from an allied health department budget.

a. Included in nursing unit budget

b. Allocated from allied health department budget

c. Not present in my unit

22 C. For the identified disciplines, please provide your Critical Care unit’s approximate FTE allocation for each. (Between 0.2 FTE to 1+ FTEs or casual as needed). _____(Free numeric text)

23 A. For the identified disciplines, please identify the weekday hours of coverage.

a. Average days per week (Between 0 to 5)

b. Average hours per day on the days with coverage above (Between 0 to 24)

c. Provision of “on-call” (No or Yes)

23 B. For the identified disciplines, please identify the weekend hours of coverage.

a. Average days per week (Between 0 to 2)

b. Average hours per day on the days with coverage above (Between 0 to 24)

c. Provision of “on-call” (No or Yes)



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Documents

CRITICAL CARE WORFORCE PROFILE Care Nursing/Critical... · Critical Care Services Ontario (CCSO) is proud to release the 6th edition of survey results in the 2017 Critical Care Workforce