Evidence-based hospital nurse staffing: the challenges
Health care providers are an important — and costly — resource for hospitals. Canadian hospitals spend about 60% of their overall budgets on health care providers’ salaries.
Nurses, who provide most of the patient care at Canada’s hospitals, are often seen by hospital decision makers as a source of savings during tight financial times. One way that hospitals can save money is by changing the mix of nursing staff. In particular, many hospitals in Canada are replacing Registered Nurses (RNs) with Licensed Practical Nurses (LPNs), or Registered Practical Nurses (RPNs) as they are known in Ontario.
Stephen Duckett, former CEO of Alberta Health Services suggests that this shift is motivated by a number of factors. “In some places it is not possible to recruit RNs so an employed LPN is seen as being better for everyone than getting existing RNs to work overtime,” he says.” Duckett also acknowledges the importance of costs, saying “LPNs are generally paid less and they can perform many RN functions at equivalent quality.”
Some applaud this direction, arguing that part of running an efficient hospital is to have all professionals working at their full capacity. However, others point to evidence linking RNs with better patient outcomes and worry that patient care will be negatively affected.
What are the challenges in making evidence-based decisions about nursing staff mix?
Different nursing roles and training
Many hospitals units today are staffed by a mix of nurses, each of whom should ideally be working to their full scope of practice in delivering patient care. For example, an RN might be serving as the primary nurse for 5 or 6 acutely ill patients, while an LPN might be caring for a similar number of patients who are awaiting transfer to a rehabilitation facility.
In Canada, RNs are university educated. Their bachelor’s degree includes education and training in clinical practice, critical thinking and research. An important aspect of RN skills is the ability to care for complex, unstable patients with unpredictable health needs, such as those who have been admitted to hospital from the emergency department.
LPNs or RPNs are typically graduates of two-year college programs in nursing, with training focused on developing skills to care for patients with less complex, predictable health needs, such as those who are recovering from elective surgery.
LPN/RPNs are not a new role to nursing, and came into existence in Canada as ‘nursing aides’ or ‘practical nurses’ due to a nursing shortage during the Second World War. In the 75 years since then, this group has evolved into an independent and regulated health profession.
Comparing RNs & LPN/RPNs
Health Canada notes that the “main difference between LPN/RPNs and RNs is the breadth and depth of their education” which influences the kinds of patients they can care for. However, the differences between these professionals go beyond education and practice.
Regulation that sets out the clinical acts that RNs and LPN/RPNs can perform is set by provincial governments. In each province, there is a body that oversees the licensing and regulation of RNs and RPNs. In some provinces, such as Ontario, the same regulatory college is responsible for the licensure of both RNs and RPNs. However, in other provinces, like Alberta, there are separate regulatory bodies for RNs and LPNs.
LPN/RPNs and RNs also have different union and labour structures across Canada.
In Ontario, for example, almost all RNs are represented by a single union, the Ontario Nursing Association (ONA), which bargains for salary and other benefits on behalf of RNs with hospitals and other employers. Unlike RNs, RPNs tend to be represented by many different unions and tend to lack the same collective bargaining strength.
Across Canada, LPN/RPNs are paid less than RNs. The Canadian Federation of Nursing Unions provides comparative contract information for nurses across Canada. For example, the hourly wage for an LPN in Alberta ranged from about $21 to $28. A full time RN’s hourly rate ranges from about $32 to $43.
In the past five years, the number of LPN/RPNs in Canada grew by about 20%, exceeding the growth rate of RNs which was about 6%.
These growing numbers of LPN/RPNs are entering the work force, and in some hospitals substituting for RNs. For example, in Ontario, the Sault Area Hospital in Sault Ste. Marie replaced a number of positions previously held by RNs in its hemodialysis unit with RPNs. That unit, however, still maintains a majority of RNs on staff, with RPNs assigned to busy daytime shifts.
Nurse staff mix & patient outcomes: what does the evidence say?
Critics of moves to replace RN positions with LPN/RPNs point to the research literature, which has linked the presence of more RNs on a unit to better patient outcomes.
What has not been as well studied, however, is what happens when RNs are replaced with LPNs/RPNs. As such, decision makers and administrators balancing tight budgets have only limited evidence to turn to when trying to determine what is the right mix of RNs and LPN/RPNs.
Sean Clarke, a nurse practitioner and Director of the Nursing Collaborative at McGill University suggests that nurse staffing decisions are both an art and science. “It’s that business of trying to figure out where the wiggle room is in all of this … RNs are a big expense, everyone’s looking to find that minimum.”
While decision makers try to work on minimum RN staffing levels, researchers like Anne Tourangeau, an RN and Associate Dean at the University of Toronto Bloomberg School of Nursing, note increased ‘failure to rescue’ rates on units with less RNs.
Failure to rescue refers to the situation that arises when health care providers do not recognize that a patient’s status has deteriorated. For example, a patient with heart failure might require transfer to an intensive care unit if early signs of deterioration go unrecognized. Tourangeau emphasizes that RNs have an important role “as a surveillance system” to constantly monitor the rapidly changing medical status of complex patients. As such, failure to rescue is seen as an important indicator of the quality of nursing care.
However, Tourangeau argues that decision makers have not heeded the evidence when making nurse staffing mix decisions. “Death certificates don’t have a section for inadequate nurse staffing,” she says.
Tools that may establish a safe nurse staff mix
Vanessa Burkoski, an RN and Chief Nursing Officer at London Health Sciences Centre, describes how that organization has used standardized tools to determine in what circumstances retiring RNs can be replaced by RPNs. One such tool, known as the Patient Care Needs Assessment, looks at patient criteria in a hospital unit to determine what level of nurse is required to ensure their safety.
The Patient Care Needs Assessment is based on a questionnaire that is administered twice to patients during their stay. The questionnaire uses concepts from the research literature as well as the College of Nurses’ of Ontario’s standard for RN and RPN staffing to measures a patient’s stability, complexity, predictability and risk for negative outcomes. This is then translated into a score which can be used to assess the level of nursing care needed by the patient, or group of patients on a unit.
Burkoski describes how this was a unit by unit decision-making process, where nursing staff are matched to patient needs. She acknowledged the political sensitivities of justifying management decisions where one level of nurse is replaced by another, with less training and experience.
“We used an evidence-based approach, and so we have the data and analysis and have been open with the union about that, so they can see first hand that this isn’t about meeting bottom line budgets, its about ensuring the right level of care is there to meet patient needs,” she said.
Some, however are more critical of the tool. Tourangeau argues that tools like the PCNA “try to use the research to justify substitution” of other professionals for RNs. She says that “the tools should be about the patients, and not about staffing.”
Can nurses working together help manage the risks, and politics, of substitution?
Dianne Martin, who has training as an RPN and RN, is the Executive Director of the Registered Practical Nurses Association of Ontario. She characterizes the research linking more RNs to better patient outcomes as “dated” noting that “we don’t really know how that evidence applies today.”
Martin says more research needs to be done to understand how a mix of staff, including RNs and LPN/RPNs rather than just one particular group, impact patient outcomes. “What we need is an ongoing level of evaluation related to the best staff mix of today’s nurses and other regulated members of the health care team,” she says.
Deb Gordon, an RN and Chief Nursing and Health Professions Officer at Alberta Health Services described a pilot project underway where increased numbers of LPNs were being brought on to busy hospital units. She describes how AHS has struggled with how to interpret the research linking RN numbers to patient outcomes, noting “the research doesn’t describe other supports in place to help nurses work better together.”
This pilot project, part of Alberta Health Services’ Work Force Transformation strategy, was motivated by a sense that patient care was suffering because RNs were overloaded with tasks other than providing complex care to patients. LPNs were brought in to work with RNs to “safely and competently provide care as part of a team.”
Hospital decision makers are tasked with the difficult job of deciding what nursing skill mix is needed to maintain quality patient care, while at the same time trying to meet their organizations’ bottom line.
Gordon says, “If money was no object, I could pick all RNs to provide that care, because their scope is all encompassing… but unfortunately none of us live in an environment where we have an endless supply of resources, you do have to make some choices.”