ASPECTS OF NURSE MANPOWER PLANNING

IN BRITISH COLUMBIA

by

LOREA AMOLEA YTTERBERG

B.N., M c G i l l U n i v e r s i t y , 1967

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF

THE REQUIREMENTS FOR THE DEGREE OF

THE FACULTY OF GRADUATE STUDIES

(Department of Health Care and Epidemiology)

We accept t h i s t h e s i s as conforming to

the required standard

THE UNIVERSITY OF BRITISH COLUMBIA

October, 1980

(c^Lorea Amolea Ytterberg, 1980

MASTER OF SCIENCE

(HEALTH SERVICES PLANNING)

i n

In presenting this thesis in partial fulfilment of the requirements for

an advanced degree at the University of Brit ish Columbia, I agree that

the Library shall make it freely available for reference and study.

I further agree that permission for extensive copying of this thesis

for scholarly purposes may be granted by the Head of my Department or

by his representatives. It is understood that copying or publication

of this thesis for financial gain shall not be allowed without my

written permission.

Department of Health Care and Epidemiology

The University of Brit ish Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1WS

October, 1980 Date

i i

ABSTRACT

A study was undertaken to determine how the planning process for

post-basic c l i n i c a l specialty courses for nurses in Br i t i s h Columbia

could be more effective.

In order to answer this question, i t was decided f i r s t to examine

the present planning process in i t s complexities. In so doing, the

complexities in educational planning were described. The following

agencies are involved: the basic nursing education programs, the

university schools of nursing, continuing education providers, (the com­

munity colleges, the University of Bri t i s h Columbia Division of

Continuing Education, Br i t i s h Columbia Institute of Technology), the

British Columbia Health Association, acute care hospitals, the Nursing

Administrators' Association, the Registered Nurses' Association of

British Columbia, the British Columbia Medical Association, the British

Columbia Ministry of Health, the Br i t i s h Columbia Ministry of Education.

In order to discover why a l l these agencies became involved, the

nursing education issues in Br i t i s h Columbia are considered. The

appropriateness of education and training for present day nursing

functions was reviewed and the importance of c l i n i c a l specialty training

in a developed medical-technological situation discussed.

From time to time since the Second World War the "shortage" of

nursing manpower has been a matter of concern to policy makers and

planners whether groups of nurses, employers, educational bodies or

governments.

Nurse manpower planning as i t now exists is described. It i s argued

that manpower planning and planning for education and training of nurses

can be improved only i f the range of social roles and the behaviour of

i i i

i n d i v i d u a l nurses i n balancing these roles i s taken into consideration.

Understanding where nursing roles f i t together with other roles of

married women i s of c r u c i a l importance. ,

I t would appear that i n d i v i d u a l nurses i n B r i t i s h Columbia have

been making p a r t i c u l a r demands upon employers, represented by the

Directors of Nursing of h o s p i t a l s , namely demands for positions with

greater decision making autonomy and more l i f e style advantages, to f i t

more cl o s e l y with t h e i r other s o c i a l r o l e s .

Judging by the present career choices of nurses, i t seems most do

not want to be employed i n a career structure which offers v e r t i c a l

mobility. Horizontal mobility at the l e v e l of "bedside" nursing care

seems to be more a t t r a c t i v e . However, i n order to be attracted into and

kept i n jobs i n bedside nursing care, nurses need to be provided with

better preparation than at present, through more adequate c l i n i c a l

s k i l l s based on a comprehensive knowledge ba.se.

Recognition of the changing a c t i v i t i e s of nurses and the

implications of the changes should lead to r e v i s i o n of planners' views

about accepted patterns i n education, t r a i n i n g and work organization.

This r e v i s i o n of views could form the basis for:

a) more r a t i o n a l planning of education, t r a i n i n g and manpower

deployment

b) reconsideration of the importance of handling bureaucratic

planning f a i l u r e s more e f f e c t i v e l y and

c) more attention being given to the growing interest of nurses

in trade union bargaining i n order to express t h e i r demands more

f o r c i b l y .

TABLE OF CONTENTS

PAGE ABSTRACT i i - i i i LIST OF APPENDICES v LIST OF TABLES v i ACKNOWLEDGEMENTS v i i

PART I INTRODUCTION 1 A. A Note on Method 5 B. D e f i n i t i o n s and A b b r e v i a t i o n s 5

PART I I PLANNING FOR NURSESEDUCATION AND TRAINING IN BRITISH COLUMBIA 7 A. D e f i n i t i o n s . 7 B. B a s i c Nursing Education Programs 10 C. Degree Programs 13

Bache l o r ' s Programs 13 Master's Program 14

D. Continuing Education 1*4 E. P o s t - B a s i c C l i n c i a l S p e c i a l t y Courses 16

A v a i l a b i l i t y and Adequacy o f E x i s t i n g Programs 16 Funding Issues 19 C l i n i c a l and C l a s s Room Resources 22 Issues i n L o c a t i n g the Courses 22 A v a i l a b i l i t y o f Teaching E x p e r t i s e 22 A v a i l a b i l i t y o f Students 23

F. PRESSURES TO IMPROVE CONTINUING EDUCATION SPECIALTIES: WHO IS CONCERNED? 23 1. Nurses' Concerns About C l i n i c a l S p e c i a l t y Courses . . 24 2. Peer Group Concerns: Competency 26 3. Employers' Concerns - E f f e c t i v e n e s s and E f f i c i e n c y . . 28 4. Government Involvements i n Planning P o s t - B a s i c

C l i n i c a l S p e c i a l t y Courses 32 5. D i s c u s s i o n : Who has the Power to Make

D e c i s i o n s R e l a t i n g to Nursing Education 34 PART I I I HISTORY OF THE NURSING FUNCTION IN THE CONTEXT OF CHANGING

WOMEN'S ROLES 37 A. The Beginnings 37 B. The Depression Years 41 C. The War Years and A f t e r 41

V

TABLE OF CONTENTS (cont'd)

PAGE

D. The Last Two Decades 44 E. Development of C l i n i c a l Specialty Units 45 F. Unionization 49 G. Implications of Changing Attitudes

For Nurse Manpower Training 50

PART IV HOW CAN THE PLANNING PROCESS BE MADE MORE EFFECTIVE? 52 A. From Sectoral Educational Concerns to

Comprehensive Manpower Planning A c t i v i t i e s 52 B. Nursing Manpower i n B.C 56 C. Ineffective Cooperation between Sectoral

Groups i n B.C 63 D. Possible Reasons for Ineffective Planning 65

PART V TOWARDS MORE EFFECTIVE PLANNING 72 A. Rational Planning 72 B. Bureaucratic Planning 76 C. Negotiation Planning 76 D. Conclusions 77 E. Recommendations 78

REFERENCES AND BIBLIOGRAPHY 80

APPENDICES 90

Appendix A Post-Basic Nursing Programs 90

Appendix B Process for Course Approval and Funding i n the Province of B r i t i s h Columbia 98

Appendix C Nursing Administrators' Reaction Paper to Nursing Education: Study Report (Kermacks' Report), (1979) . . 111

Appendix D A c t i v i t i e s i n the 70's i n B r i t i s h Columbia to Support Continuing Education for Nurses 114

Appendix E Th e o r i t i c a l Way to Determine Manpower Needs 125

v i

LIST OF TABLES

TABLE PAGE

1. Number of F u l l Time Equivalent Graduate Nurses i n Spe c i a l i z e d Units i n B.C. Hospitals and as Proportion of Total Employed Graduate Nurses 1976 78

v i i

ACKNOWLEDGEMENTS

T h i s study i n v o l v e d the e f f o r t s o f many people. My thanks go to

those people who c o n t r i b u t e d to t h i s study by o f f e r i n g t h e i r knowledge and

experience p e r s p e c t i v e s i n numerous c o n v e r s a t i o n s , meetings and i n t e r v i e w s .

I would l i k e to thank my committee members; D r . Anne C r i c h t o n , D r .

Annette S t a r k , and Ms. S h i r l e y Brandt f o r t h e i r a s s i s t a n c e and v a l u a b l e

support and a d v i c e .

I am most g r a t e f u l to my n u r s i n g c o l l e a g u e s , who over the years have

shared t h e i r concerns about n u r s i n g with me and helped to i n c r e a s e my

p e r s p e c t i v e s o f n u r s i n g .

My a p p r e c i a t i o n extends to my f e l l o w students i n Health S e r v i c e s

P l a n n i n g , who have added to my understanding o f n u r s i n g i n the context o f the

h e a l t h care system. A s p e c i a l thanks to Mr. K e i t h L o u g h l i n .

I would l i k e to thank John Pousette, S e c r e t a r y - T r e a s u r e r o f the

K i t i m a t Regional D i s t r i c t f o r h i s support and encouragement.

I am indebted to Evangeline Kereluk whose e f f o r t s a s s i s t e d me i n

completing t h i s study.

F i n a l l y , I would l i k e to express my s i n c e r e g r a t i t u d e to Bob and my

mother, who were always understanding, encouraging and s u p p o r t i v e .

PART I

PART 1

INTRODUCTION

As C l i n i c a l Director of Medical Nursing at Vancouver General

Hospital, i t became evident to the author that there were some new

d i f f i c u l t i e s i n nurses' education emerging i n the 1980's. Nurses, with

special c l i n i c a l s k i l l s , were not available i n s u f f i c i e n t numbers to

s t a f f special c l i n i c a l units. Discussions with other nursing admin­

i s t r a t o r s indicated that t h i s was a general problem and, further, l i t t l e

t r a i n i n g was currently available, i n B r i t i s h Columbia, to prepare nurses

to function i n special c l i n i c a l areas.

The professional association, educators and others had been

cognizant of t h i s problem and although a great deal of a c t i v i t y was going

on, very l i t t l e concrete action was being taken to solve t h i s problem.

This s i t u a t i o n led to a question which seemed to need an answer and

i t became the f i r s t theme of t h i s study. The question was: how can the

educational planning process for post-basic c l i n i c a l specialty courses

become more effective?

In order to answer t h i s question, i t was decided to examine the

present educational planning process i n i t s complexities. The following

agencies seemed to be involved: basic nursing education schools (the

community colleges, and the B r i t i s h Columbia In s t i t u t e of Technology),

the University of B r i t i s h Columbia Division of Continuing Nursing

Education, the B r i t i s h Columbia Health Association, acute care

hospitals, the Nursing Administrators' Association of B r i t i s h Columbia,

the Registered Nurses' Association of B r i t i s h Columbia, the B r i t i s h

Columbia Medical Association, the B r i t i s h Columbia M i n i s t r i e s of Health

and Education.

2.

Then, to understand why a l l these agencies became involved, i t

seemed to be necessary to look at the nursing educational issues in

Bri t i s h Columbia, and consider the confusion in planning. This aspect is

examined in Part II.

Because there were a number of different objectives being pursued

by the educational planners — raising the level of basic education and

building upon i t in order to train administrators, educators,

researchers and c l i n i c a l specialists in nursing — i t seemed to be

important to examine two further questions. Were the objectives of

educational planners closely related to nursing functioning? Were

education and training plans likely to cope with nursing shortages?

There has been a concern by the nursing profession and nursing employers,

about the "shortage" of nurses since the Second World War. This

"shortage" seems to come and go but in recent years has been increasing

in British Columbia. During the last few summers, in Vancouver, the

acute care hospitals have closed patient beds, because not enough nurses

have been available to provide staffing for them. But no one really

knows i f there is a shortage of registered nurses or only a shortage of

nurses willing to come into the labour market.

The author, in her capacity as administrator and employer's repre­

sentative, began to consider why the shortage was regarded as a matter

for educational planning. Why did the planners and administrators look

to education of new recruits to resolve the shortages? The reaction of

the Nursing Administrators' Association of the Lower Mainland, at a

meeting in February 1980, had been to look to training programs for the

preparation of nurses for vacant c l i n i c a l specialty jobs.

Do these planners understand the employment demands of individual

nurses in British Columbia? Before committing themselves to being

3.

r e c r u i t e d and agreeing to stay i n a job, the nurses present t h e i r demands

to the Directors of Nursing of s p e c i f i c h o s p i t a l s . These employment

demands appear to be greater for basic bedside care nursing positions

than f o r administrative p o s i t i o n s or for positions i n which coordinating

of the work of the l e s s well trained a s s i s t a n t s i s to be done. However,

basic care nurses (and, more p a r t i c u l a r l y , c l i n i c a l technological

s p e c i a l i s t s among basic care nurses) need to believe themselves to be

well trained and competent to take the r e s p o n s i b i l i t i e s which have to be

handled i n these jobs.

The t r a d i t i o n a l model of a nursing career structure i s pyramidal,

not f l a t , but these i n d i v i d u a l nurses have t h e i r own l o g i c which r e l a t e

to t h e i r view of present day nursing functions and t h e i r perception of

how these can best be f i t t e d i n with t h e i r other s o c i a l r o l e s . They have

made Directors of Nursing aware that they prefer h o r i z o n t a l career

structures. I t seems that there may be misunderstandings about these

employment demands and time lags i n responding to them among manpower and

educational planners.

A number of other questions occurred to the author but only the

f i r s t two of these were educational planning questions. What

competencies or standards should a nurse have i n order to work i n s p e c i a l

c l i n i c a l areas? Do nurses f e e l confident to perform the functions which

they are being asked to do?

Others were more general employment/manpower planning questions.

Have the nursing manpower planners c l e a r d e f i n i t i o n s of nursing

functions f o r s p e c i a l care areas? What e f f e c t does the f a c t that the

majority of nurses are women have on t h e i r a v a i l a b i l i t y f o r work? Have

the planners incorporated adequate demographic information about nurses

i n t o t h e i r planning? Many nurses today seem to be "leaving" nursing for

4.

jobs i n other areas. Have either the employers or planners considered

the work environment and i t s relationship to other roles i n a t t r a c t i n g

and keeping nurses on the job? Is i t clear what the nurses who actually

provide nursing care want? Why are nurses leaving nursing? What effects

to organizational structures and career prospects have on the nursing

manpower situation?

On further thought, questions about the relationship between

nursing manpower planning and nursing education were raised. Why are so

few post-basic c l i n i c a l courses available i n B r i t i s h Columbia? Have the

nurse manpower planners not been able to be sp e c i f i c i n iden t i f y i n g

needs? Why are so many separate groups involved i n th i s issue? How do

they work together to develop the area of manpower planning and

education? Who coordinates the i r a c t i v i t i e s ? Do recommendations from

the interested groups get implemented? I f not, why not? Are resources

available to provide the training needed to meet the manpower require­

ments? How i s i t decided which educational i n s t i t u t i o n w i l l provide

which program where?

These questions caused the author to explore the ove r a l l problem

rather than only a segment of i t . This was begun by reviewing the

evolution of nursing roles and women's positions i n Canadian society and

by r a i s i n g questions about nurses' needs as women with other s o c i a l

r o l e s .

The techniques of nurse manpower planning and application to

B r i t i s h Columbia are described i n Part IV.

In a f i n a l section after following through the questions and

analyzing documentary evidence, prospects for improving nurse manpower

planning (and educational planning as part of that) are reviewed, and

recommendations made.

5.

Since the focus i s upon c l i n i c a l s p e c i a l t i e s i n nursing,

s p e c i a l t i e s p r a ctised i n h o s p i t a l s , l i t t l e a t t ention w i l l be given to

other nursing a c t i v i t i e s such as public health and mental health i n the

discussion which follows.

Beginning with an i n t e r e s t i n post-basic c l i n i c a l s p e c i a l t y courses

fo r nurses, the focus changed to manpower issues since i t seemed that one

could not be corrected without the other being dealt with.

A Note on Method

This i s a study of planning i n the f i e l d of nursing. The following

methods were used:

a) analysis of documents - primary and secondary source

materials,

b) discussion of the issues with planners i n the nursing f i e l d ,

c) discussion of issues with administrators i n the nursing f i e l d ,

d) evaluation of planning a c t i v i t i e s against a s e r i e s of planning

paradigms,

e) development of recommendations for change i n planning

approaches.

D e f i n i t i o n s and Abbreviations

For the purposes of t h i s study the following terms are defined as

follows:

Basic Nursing Education Programs - prepare students to enter the

p r a c t i c e of nursing i n a g e n e r a l i s t r o l e i n a supervised s e t t i n g and

q u a l i f i e s them for r e g i s t r a t i o n . These may be diploma or baccalaureate

degree program

Continuing Education - as a term, can be used broadly to describe

a l l education which occurs following attainment of a basic q u a l i f i c a t i o n .

For the purposes of t h i s discussion i t i s defined as ad hoc or informal

6.

workshops, conferences, seminars, night school courses of l i m i t e d

duration or in s e r v i c e education (that i s up to f o r t y hours of f u l l time

study). I t i s designed to develop or maintain nurses' currency or competency i n any area of p r a c t i c e .

Post-Basic C l i n i c a l Specialty Programs (Part of Continuing Education)

- prepare nurses for positi o n s beyond the basic l e v e l , focus on a

c l i n i c a l s p e c i a l t y r o l e , and are of longer duration than f o r t y hours

( f u l l time).

Post R.N. Baccalaureate Degree, Master's and Doctoral Degree

- prepare nurses for upper l e v e l positions i n c l i n i c a l , administrative,

or educational r o l e s .

The following abbreviations are used:

R.N. - Registered Nurse

RNABC - Registered Nurses' Association of B r i t i s h Columbia

RPNABC - Registered P s y c h i a t r i c Nurses' Association of B r i t i s h Columbia

BCHA - B r i t i s h Columbia Health Association

UBC - University of B r i t i s h Columbia

BCIT - B r i t i s h Columbia I n s t i t u t e of Technology

CNA - Canadian Nurses' Association

BCMC - B r i t i s h Columbia Medical Center

BCMA - B r i t i s h Columbia Medical Association

CMA - Canadian Medical Association

HMRU - Health Manpower Research Unit at UBC

Direct quotes and references are numbered i n the text and l i s t e d

a l p h a b e t i c a l l y at the end of the narr a t i v e .

Appendices include several sections which support the narrative but do

not need to be included i n the argument. Appendices w i l l be referred to by

l e t t e r , when appropriate i n the na r r a t i v e .

PART I I

PLANNING FOR NURSES' EDUCATION AND TRAINING

IN BRITISH COLUMBIA

PART I I 7.

PLANNING FOR NURSES' EDUCATION AND TRAINING IN BRITISH COLUMBIA

The problem which presented i t s e l f t o the author was the shortage o f nurses with adequate c l i n i c a l s p e c i a l t y t r a i n i n g f a i l i n g to come forward f o r employment i n a l a r g e g e n e r a l h o s p i t a l i n Vancouver.

There seemed to be a ge n e r a l agreement among n u r s i n g planners and n u r s i n g a d m i n i s t r a t o r s that t h i s was an e d u c a t i o n a l problem, t h a t the c u r r e n t shortage was a t l e a s t p a r t l y due to the inadequacies o f p r o v i s i o n f o r c o n t i n u i n g e d u c a t i o n i n c l i n i c a l s p e c i a l t i e s .

Although p o s t - b a s i c c l i n i c a l s p e c i a l t y programs were the main focus o f the study i t seemed to be necessary to c o n s i d e r the r e l a t i o n s h i p between the d i f f e r e n t p a r t s o f the system o f n u r s i n g education i n order to show how these c l i n i c a l programs f i t i n t o the whole, how a p p r o p r i a t e they are now and what are the problems a s s o c i a t e d with t h e i r development or l a c k o f development. A. D e f i n i t i o n s

The d i s c u s s i o n o f present p l a n n i n g f o r n u r s i n g e d u c a t i o n must begin with a c l a r i f i c a t i o n o f the uses o f the words "education" and " t r a i n i n g " f o r there are semantic problems.

In g e n e r a l use, "education" i s a broader term which i m p l i e s i n t e l ­l e c t u a l l e a r n i n g . In Canada today i t o f t e n r e f e r s to a minimum o f c o l l e g e or u n i v e r s i t y e d u c a t i o n .

"to develop mentally and mo r a l l y e s p e c i a l l y by i n s t r u c t i o n " (124)

T r a i n i n g i s a term which i m p l i e s l e a r n i n g o f r o l e m o d e l l i n g or l e a r n i n g o f a t e c h n i c a l nature. I t does not mean simply r o t e l e a r n i n g o f ta s k s , but encompasses conceptual t h i n k i n g r e l a t e d to the p r o f i c i e n c y a c h i e v e d .

8.

"to form by instruction, d i s c i p l i n e or d r i l l " "to teach as to be f i t t e d , q u a l i f i e d or p r o f i c i e n t " (124)

Dr. Helen Mussalem (85), Executive Director of the CNA d i f f e r e n t ­

iates between tr a i n i n g and educating the nurse. She says that educating

a nurse equips her mentally to work far beyond the role of a technician

and develops a nurse's a b i l i t y to function at a policy-making and at an

administrative l e v e l . T r a d i t i o n a l l y , i t has been CNA policy to

encourage more emphasis on education of nurses, a policy strongly

supported by the provincial nursing association.

But the majority of nurses do not function at t h i s l e v e l , although

every nurse makes many decisions every working day. Does th i s then imply

that basic beginning l e v e l nurses are trained but not well educated?

Nurses do not l i k e the word training applied to the i r profession. I t has

a negative connotation since i t i s often equated by nurses with the

apprenticeship system of learning, or the rote system of learning to

perform s k i l l s without knowing the conceptual reasons behind them.

Today's nurses are engaged i n strong discussion about minimum entry

q u a l i f i c a t i o n s to practice nursing. One school of thought suggests that

current preparation i s adequate. The other school argues that a univer­

s i t y bachelor's degree should be the minimum q u a l i f i c a t i o n .

The dictionary d e f i n i t i o n of t r a i n i n g , "to be f i t t e d , q u a l i f i e d or

p r o f i c i e n t " does apply to nurses at the beginning l e v e l and t h i s i s often

the goal of nursing schools. Training used i n t h i s way has a very

positive connotation. Possibly too much attention has been given to

education rather than trai n i n g i n recent years for there has been a

recent surge of concern about the adequacy of t r a i n i n g for these c l i n i c a l

nurses, and the numbers available to provide technological nursing

services i n B r i t i s h Columbia.

9.

Who, then, i s responsible for planning education and tra i n i n g of

nurses? Are these education planners i n touch with the employment

situation?

B r i t i s h Columbia has only prepared 35 to 40$ of the t o t a l number of

nurses i t needs i n the work force. I t has depended on immigration from

other countries and transfers from other provinces to provide s u f f i c i e n t

numbers of nurses. As other provinces are reducing the numbers of

students i n the i r nursing programs, t h i s province w i l l have to provide

more of i t s own basic nursing education.

The Foulkes' Report (60) - a review of health care i n B r i t i s h

Columbia - addressed these issues and recommended expanding the number

of trai n i n g programs i n u n i v e r s i t i e s and community colleges. More

recently, the Open Learning Institute has begun to offer some courses to

students i n isolated areas. Funding for nursing education continues to

be a problem for some potential r e c r u i t s . Whilst the RNABC set aside

some money for bursaries t h i s comes nowhere near meeting demand.

In two phases, 1968 and 1971, the RNABC developed reviews of basic

and post-basic education of nurses i n the province (93, 94). The report

reiterated the continuing need i d e n t i f i e d i n the Weir Report (125) i n

1934 for nurses educated at the university l e v e l . The second report (93)

reviewed the f a c i l i t i e s available for post-basic education (only UBC

School of Nursing) and suggested ways in which more candidates could be

admitted to programs and how nurses could gain degree credits before

entering UBC. I t recommended a collaborative approach by Canadian

u n i v e r s i t i e s to developing nursing Master's programs and also recognized

the need for doctoral programs in Canada.

The educational planning process i n confused and there has grown up

a complexity of bodies responsible for different aspects of providing

10.

education and tra i n i n g or providing funding for the purpose of

evaluating and influencing education and tra i n i n g a c t i v i t i e s . The des­

c r i p t i o n of present day curriculum and course planning which following

i s concerned with explaining these inputs into education and t r a i n i n g

policy making and the gaps and overlaps i n the process of planning

programs.

B. Basic Nursing Education Programs

Entry into the practice of nursing i n B r i t i s h Columbia i s provided

by four kinds of basic education programs. These are: (1) general

nursing programs (diploma or degree)*, (2) psychiatric nursing

(diploma), (3) p r a c t i c a l nursing**, (4) nursing aide***.

Basic nursing programs are offered primarily in post-secondary

i n s t i t u t i o n s * except for general nursing diploma programs at the

Vancouver, Royal Jubilee and V i c t o r i a General Hospitals.

General and Psychiatric Nursing Programs

General and psychiatric programs do not d i f f e r greatly i n

objectives for the i r graduates except i n making them competent i n the

c l i n i c a l areas i n which they are prepared to function. Both types of

programs expect graduates to assess, plan, implement and evaluate

nursing care for individuals of a l l age groups.

*Degree programs are described i n Section C of t h i s chapter. The f i r s t two years of the baccalaureate curriculum at UBC have been similar to the diploma years, but t h i s program has now been revised so that students must complete a l l four years of the program before they are q u a l i f i e d to enter practice and write the r e g i s t r a t i o n examinations. Nurses graduating from diploma programs are accepted for further education i n degree programs i n the province.

* * P r a c t i c a l nursing and aide programs are not discussed further because graduates generally have to s t a r t over i n a general nursing program i n order to advance i n nursing.

.11.

General nursing programs focus on 'providing care for medical,

s u r g i c a l , p e d i a t r i c , post-partum and nursery and psychiatric patients.

Psychiatric nursing programs emphasize the care of patients with

psychiatric i l l n e s s and mental retardation. There are ten general

nursing diploma courses and two psychiatric nursing programs. Programs

vary from two to three years. The current trend i s for programs to be

longer to provide more c l i n i c a l experience i n various forms for the

students.

Graduates of these programs receive a diploma and are e l i g i b l e to

write national r e g i s t r a t i o n examinations.

Responsibility for the control of education rests with the

provinces i n Canada; therefore, a l l educational programs for the

preparation of health manpower must be approved by the p r o v i n c i a l autho­

r i t i e s . I f an agency or i n s t i t u t i o n i s to obtain approval to conduct a

school, the agency (or i n s t i t u t i o n ) , must meet certain standards i n

regard to length of program, curriculum, faculty, and other aspects of

educational administration. Under the health practitioner acts,

authority to control healing arts has been delegated i n most cases to the

respective professional associations in the provinces which have

established c r i t e r i a . The associations set forth minimum requirements

for the conduct of schools to prepare the i r p r a c t i t i o n e r s .

Any educational body can provide a program to t r a i n nurses, but i n

B.C. only nursing students who graduate from a program which has been

approved by the RNABC can write r e g i s t r a t i o n exams.

The graduates of these programs may also write standardized exam­

inations for the purpose of r e g i s t r a t i o n . These are nationally set

examinations, but allow for r e g i s t r a t i o n only within the province i n

which the graduate i s writing the exam.

12.

Curricula of diploma programs are structured i n a variety of

patterns, the most common being a s i x semester program i n two years. The

major part of the f i n a l semester i s usually concentrated c l i n i c a l

practice to consolidate s k i l l s p r i o r to graduation.

A l l diploma programs include instruction i n nursing, the physical

and s o c i a l sciences and most include general education subjects.

Courses i n the physical and s o c i a l sciences and other f i e l d s are usually

taught by faculty i n other d i s c i p l i n e s . Nursing students rarely share

common classes with other students because of scheduling complications,

content needs not shared by other programs and i n s t i t u t i o n a l

organization of separate programs i n self-contained units. Nursing i s

the major component of a l l programs, compromising 72% to 93% of the

content of each program. There are s i g n i f i c a n t variations i n the amount

of time spent i n nursing theory and practice from program to program.

Laboratory and c l i n i c a l time varies from 45.5% to 7&% of the t o t a l

programs i n schools of nursing. The question arises as to whether t h i s

variance has a major effect on the f i n a l product, the graduate, and

whether or not i t i s s u f f i c i e n t when looking at needs for continuing

education.

Entrance requirements for diploma nursing programs vary with the

i n s t i t u t i o n providing the education. A l l schools except Douglas College

require a minimum of grade twelve education, but subject requirements i n

grade twelve vary from college to college.

Funding for these programs i s provided by the sponsoring

i n s t i t u t i o n s through the Department of Education. Students pay a regis­

t r a t i o n fee which i s i n l i n e with that paid by other students i n the

colleges. Most funding i s from the government. Nursing schools are

expensive because of the low r a t i o of pupil to teacher when students are

learning c l i n i c a l s k i l l s or practising i n the c l i n i c a l areas.

.13. C. Degree Programs

1. Bachelor's Programs

The University of B r i t i s h Columbia i n s t i t u t e d the f i r s t degree

program for nurses in 1923. Since then, the program has undergone many

revisions, the l a t e s t being i n 1980. Students w i l l complete a four year

baccalaureate program before entering practice. This, i n essence, adds

a f i f t h type of basic education program.

In 1976, the University of V i c t o r i a began i t s two year Bachelor of

Science i n Nursing degree program for registered nurses.

The ov e r a l l objectives of both B.S.N, programs are s i m i l a r ; to

broaden and enhance knowledge and s k i l l s , p a r t i c u l a r l y i n r e l a t i o n to

problem solving or s c i e n t i f i c method and to develop new s k i l l s ; to

provide nursing care to individuals, families and community groups; to

function within a variety of settings within the community and to

increase a b i l i t y to function interdependently with other health

professionals.

The scheduled time spent i n c l i n i c a l practice varies from 25% to

50%. Students have some choice i n the selection of c l i n i c a l areas within

broad settings.

At both u n i v e r s i t i e s , nursing courses predominate, but courses i n

physical and/or s o c i a l sciences are also required. Basic s t a t i s t i c s and

research methodology are included i n both programs. Students have the

opportunity to choose elective courses and/or independent directed

studies i n a selected area.

The UBC Bachelor Degree must meet the requirements for approval of

schools of nursing by the RNABC. Then students are e l i g i b l e to write the

national r e g i s t r a t i o n exam written by other basic students. Students

from both u n i v e r s i t i e s graduate with a Bachelor of Science i n Nursing

degree.

14. 2. Master's Program

The Master of Science i n Nursing program at UBC began i n 1968.

This program prepares graduates to give highly s k i l l e d care, u t i l i z e the

s c i e n t i f i c method of inquiry, effect change and assume leadership roles.

As w e l l , special courses i n functional areas of administration, teaching

or research or in c l i n i c a l s p e c i a l i z a t i o n are available, depending on

the student's choice. Graduates are expected to assume upper l e v e l

positions i n functional or c l i n i c a l roles.

The M.S.N, program i s two academic years i n length, and consists

almost e n t i r e l y of nursing courses. In the f i r s t year, students

concentrate on systematic approaches to patient care and on research

methodology. C l i n i c a l experience with selected patients i s managed.

Students study and work with individuals of a selected maturational

stage. Students i n the second year select from courses related to

c l i n i c a l nursing, nursing education, nursing service administration,

consultation and c l i n i c a l research. C l i n i c a l experience i s planned with

some courses.

Students graduate with a Master of Science i n Nursing. Evaluation

of the program i s the same as the bachelor's programs.

Funding for these programs i s allocated through University senates.

Nurses pay the same re g i s t r a t i o n fee as the other university students.

D. Continuing Education

1. Continuing Education Programs

Continuing education, as a term, can be used broadly to

describe a l l education which occurs following attainment of a basic

q u a l i f i c a t i o n . For the purposes of t h i s discussion i t i s defined as ad

hoc or informal workshops, conferences, seminars, night school courses

of limited duration or inservice education (that i s up to forty hours of

f u l l time study).

15.

During the e a r l y s i x t i e s , RNABC s t a f f presented c o n t i n u i n g e d u c a t i o n workshops f o r nurses a c r o s s the p r o v i n c e . T h i s became a very expensive undertaking. In 1966, the RNABC changed i t s p o l i c y and began to work to f a c i l i t a t e programs r a t h e r than p r o v i d e them. I t i n v o l v e d h o s p i t a l s , community c o l l e g e s and u n i v e r s i t i e s i n p r e s e n t i n g these programs t o nurses f o r a reasonable fee which u s u a l l y covered the c o s t s o f expenses.

In 1967, the RNABC f a c i l i t a t e d the l i n k i n g o f n u r s i n g c o n t i n u i n g e d u c a t i o n w i t h an e s t a b l i s h e d , powerful U n i v e r s i t y o f B r i t i s h Columbia C o n t i n u i n g M e d i c a l Education body. I t s recommendation was, t h a t " c o l l a b o r a t i o n be undertaken with the Department o f Con t i n u i n g Medical E d u c a t i o n to send a nurse with d o c t o r s p r e s e n t i n g M e d i c a l Continuing Education programs, to provide r e l a t e d n u r s i n g i n s e r v i c e " (104). T h i s was implemented i n the next year when four courses were presented by doc t o r s and nurses.

A f u r t h e r stop i n developing c o n t i n u i n g e d u c a t i o n f o r n u r s i n g was taken i n 1968 i n response t o an Annual Meeting R e s o l u t i o n i n 1967 (104, 105). The r e s o l u t i o n passed by the membership read as f o l l o w s :

That the RNABC o f f e r t o c o n t r i b u t e $5,000.00 per year to UBC f o r a p e r i o d o f f i v e y e a r s , to appoint a f u l l time n u r s i n g f a c u l t y member to the School o f Nursing, s a i d f a c u l t y member to be seconded t o the Department o f Con t i n u i n g M e d i c a l Education to assess the needs and re s o u r c e s f o r c o n t i n u i n g education f o r nurses and to p l a n , develop, implement and coordinate p r o j e c t s f o r c o n t i n u i n g e d u c a t i o n purposes.

N e g o t i a t i o n s ensued with UBC and a f t e r i n i t i a l d i f f i c u l t i e s , an a p p r o p r i a t e appointment was made. The RNABC o b v i o u s l y thought the f u n c t i o n s now being performed by nurses could not continue s a f e l y without i n c r e a s e d e d u c a t i o n but i t had not been s u c c e s s f u l i n making t h i s need known to the funding bodies, so i t provided the funding. The RNABC continued to fund t h i s p o s i t i o n u n t i l 1977.

16.

There has been considerable development within the province i n

continuing education within the l a s t ten yers. The UBC Division of

Continuing Education has provided most courses to nurses, followed by

the University of V i c t o r i a , BCIT and some of the community colleges, but

entrepreneurial groups and special interest groups within nursing have

also undertaken a number of courses.

In general, continuing education programs for nurses are s e l f

funded through r e g i s t r a t i o n fees of participants. I f ind i v i d u a l nurses

or i n s t i t u t i o n s do not see these programs as meeting thei r needs, the

attendance w i l l be low.

Although there are areas of concern to be resolved i n developing

continuing education programs for nurses, such as standards, to most

people with influence i n planning nurse education, t h i s i s not an area of

major concern at t h i s time.

In general, continuing education programs w i l l become more

important i f s p e c i f i c evaluations of nurses' competencies for the

purpose of re-registration are to be undertaken.

E. Post-Basic C l i n i c a l Specialty Courses

i ) A v a i l a b i l i t y and Adequacy of Existing Programs

During the 70's a number of b r i e f s and studies concerning the

need for post-basic c l i n i c a l specialty courses i n B.C. were carried out.

(See Appendix D for complete l i s t i n g ) Although they a l l strongly

recommended that t h i s currently lacking area of nursing training be

provided, there was a l o t of motion but very l i t t l e productive a c t i v i t y .

The RNABC was very concerned about the lack of post-basic c l i n i c a l

specialty courses, so i t decided that i t had a r e s p o n s i b i l i t y to ensure

that nurses received t h i s education.

17.

By 1973 the RNABC had met with the following bodies; the UBC Division of Continuing Nursing Education, the Royal Columbian, St. Paul's, and Vancouver General Hospitals, to develop and sponsor an Intensive and Coronary Care Course. B r i t i s h Columbia Hospital Insurance

provided f i n a n c i a l support for program development and implementation;

W.K. Kellogg Foundation participated i n the developmental funding. The

UBC School of Nursing funded the evaluation of th i s course. This course

was repeated twice, successfully, i n 1975 but further courses were

cancelled because of the lack of funding.

The inadequate supply of nurses prepared to work i n c r i t i c a l care

areas became a serious issue i n early 1980. The provincial Ministry of

Health attempted to id e n t i f y immediate needs so that crash programs

could be developed, but the problem was too complex and involved more

than simply a numbers i d e n t i f i c a t i o n . This attempt was not useful i n

ide n t i f y i n g immediate need.

In a paper e n t i t l e d "RNABC Views on Continuing Basic C l i n i c a l

Nursing Education ( 1 9 8 0 ) " ( 1 0 0 ) the RNABC i d e n t i f i e d current programming a c t i v i t y as follows:

As of February, 198O, there are programs either operating or proposed for a l l the known high need c l i n i c a l areas except neonatal intensive care. There i s almost no information to suggest how many nurses require tra i n i n g i n each category. While there i s evidence that the number of nurses requiring training are considerable, the numbers which can be immediately trained w i l l be limited by a number of factors, including a v a i l a b i l i t y of qu a l i f i e d i n s t r u c t i o n a l personnel, a b i l i t y of agencies to replace s t a f f that can be released for t r a i n i n g , the uncertainties connected with new and untried course offerings, a v a i l a b i l i t y of funds to compensate nurses for salary loss during t r a i n i n g , and a v a i l a b i l i t y of funds for course development and operation. I t appears that the most careful a l B e i t o p timistic, estimates of numbers of nurses that could be trained have been made by providers i n the i r course projections. U n t i l there i s additional and better information which could a l t e r these

18.

estimates, RNABC should support these as immediate post-basic tra i n i n g goals and should caution against overly optimistic planning of "crash programs." The Association should also support the early development of a program for neonatal intensive care.

This same paper also i d e n t i f i e s post-basic programs currently being

presented or i n the planning stages.

In a Post-Basic Nursing Programs Discussion Paper of March, 1980

(121) Dr. Sheilah Thompson, Coordinator of Health and Human Services

Programs, Ministry of Education, l i s t s post-basic courses and adds some

courses i n the planning stages.

These tr a i n i n g programs themselves vary i n length and l e v e l of

sp e c i a l i z a t i o n . For example, the Post-Basic Operating Room Nursing

Course at St. Paul's Hospital i s 24 weeks in length and includes material

on a l l major O.R. services, post-anesthetic recovery room and some

managerial information. The Okanagan College provides a program of 12 to

16 weeks to educate non-specialized Operating Room s t a f f .

Most of the programs do provide some form of c e r t i f i c a t e for t h e i r

graduates and e f f o r t s are underway to standardize the c e r t i f i c a t i o n .

Although most of these post-basic programs now must submit thei r

curriculum to the RNABC Continuing Nursing Education Approval Program,

t h i s i s a voluntary a c t i v i t y , so programs can be taught without external

evaluation mechanisms. ^

Although curriculum approach varies according to the group which i s

presenting the program, as well as what specialty the program i s about,

one thing i n common to a l l c l i n i c a l specialty post-basic courses i s that

c l i n i c a l practice i s seen to be as important as the theoretical aspects

of the course.

Nurses who complete c l i n i c a l specialty courses are accepted by the

employing agencies to work i n the specialty area for which they have been

19.

trained. However, there i s a problem for employing agencies because

nurses from these courses i n B.C., and others i n Canada, may have been

prepared to function at different l e v e l s , therefore, s t a f f orientation

programs have to d i f f e r s i g n i f i c a n t l y - both within the i n s t i t u t i o n s and

between the i n s t i t u t i o n s .

i i ) Funding Issues

Most post-basic courses are expensive. They are estimated to

cost $25.00 to $40.00 per day per student, or from $50,000.00 to

$60,000.00 per course.

Funding for post-basic courses i s variable.* The courses can be

paid for through student r e g i s t r a t i o n fees, through hospital funding, or

by the M i n i s t r i e s of Education, Universities Science and Communication

or Health. In general, continuing education has been paid for by

students but c l i n i c a l specialty courses have sometimes been funded from

other sources.

Hospitals do provide a few post-basic courses, usually out of dire

need. In some hospitals the student has been expected to provide service

to the i n s t i t u t i o n during the post-basic course period as a means of

contributing to the cost of the course, but t h i s type of payment for

education i s on the decline. According to L i s t i n g of Continuing

Education for Nurses, published by the RNABC i n October, 1979, no

post-basic courses i n the province are funded t h i s way. Any B r i t i s h

Columbia hospital providing courses, i s presently supporting these

courses by special grants or out of general hospital budgets. (Appendix

A)

*This information has been taken from published documents. The current si t u a t i o n may be diff e r e n t , since documents were consulted only up to June, 1980.

20.

In educational i n s t i t u t i o n s , the funding problem i s further

compounded by the manner i n which funding i s allocated to community

college nursing departments, BCIT and the UBC Department of Continuing

Education.

Most community colleges with nursing departments are usually

organized i n such a way that a l l nursing education offerings stem from

that department. I f short term continuing education programs or

post-basic nursing programs are to be presented, the resources available

are those from within the department of nursing. F i n a n c i a l l y , these

departments can submit proposals for post-basic courses (through their

internal approval bodies) to the Ministry of Education who w i l l approve

or not approve funding. The d i f f i c u l t y i s two-fold. One, the i n i t i a l

developmental work to present the courses for approval must be provided

by the department's educators. These persons already have major

r e s p o n s i b i l i t i e s for ensuring the adequacy of basic education programs

and have l i t t l e , i f any, time for other a c t i v i t i e s . This problem has

been overcome by the RNABC Board of Directors. In January, 1980, they

approved a policy of providing developmental funds for post-basic

c l i n i c a l specialty programs. Funds have since been made available and

allocated for t h i s purpose.

The second d i f f i c u l t y i s that there are no set c r i t e r i a to determine

whether or not they might receive funding from the Ministry of Education.

This approval process i s an extensive one which can take up to two years

to complete. (See Appendix B) By that time, others may have already met

the i d e n t i f i e d needs, or other resources such as faculty or c l i n i c a l

space may no longer be available.

BCIT d i f f e r s from community colleges i n that i t has a s p e c i f i c

department whose purpose i s to provide continuing educational offerings.

21.

Therefore the resources for basic planning are more available, and

funding sources are more readily accessible from within that

department's budget. I f funding must be obtained from the Ministry of

Education the same process i s engaged i n as the community colleges with

one exception. P r i o r to the l e t t e r of intent being sent to the Minister,

the proposal has to be f u l l y formulated and the proposed programs must be

approved i n t e r n a l l y .

UBC's Continuing Education i n Health Sciences i s funded i n a

different manner. The d i v i s i o n i s composed of an Executive Director of

the d i v i s i o n , Directors for each health science d i s c i p l i n e and support

s t a f f . Each Health Science Dis c i p l i n e i n the Continuing Education

Division provides salary funding for i t s respective Director and one

secretary. The School of Nursing also funds an Assistant Director. The

salary of the Executive Director and other support s t a f f plus any

operating costs are funded from charges to participants i n the various

continuing education presentations, which must be self-supporting.

Therefore, each participant i n a continuing educational program

presented by the Division pays for the costs of the course plus a portion

of the administrative and operating overhead. To sum up, funding for

post-basic courses i n nursing i s haphazard, because p r i o r i t i e s i n need

for programs for c l i n i c a l s p e c i a l t i e s have not been i d e n t i f i e d .

With the lack of i d e n t i f i c a t i o n of program need, the Department of

'Education cannot budget for programs on an ongoing basis, even i f the

department were to accept the r e s p o n s i b i l i t y for funding them as part of

t o t a l nursing education policy. Nor can i t provide guidelines to the

Academic Council as to the p r i o r i t i e s of nursing education over other

educational needs. Consequently, the energy expended i n procuring these

funds on an ad hoc basis, makes these courses very expensive. Teaching

22.

material cannot be planned for continuing education courses but i s

continually being started from "scratch" which i s not cost e f f e c t i v e .

Post-basic courses are expensive to develop and operate, since s t a f f are

required for development, formal in s t r u c t i o n , and on-site c l i n i c a l

supervision. How much more expensive are they when each course begins at

the beginning to r e c r u i t and orientate s t a f f who w i l l have to experience

problems that might have been solved by previous s t a f f had they continued

to teach the course the second and t h i r d time?

i i i ) C l i n i c a l and Class Room Resources

Shortage of c l i n i c a l practice area and classroom resources i s

a problem i n presenting post-basic nursing education, p a r t i c u l a r l y i n

the lower mainland where the c l i n i c a l f a c i l i t i e s which might provide

s u f f i c i e n t experience for the students are located. The lower mainland

agencies already have d i f f i c u l t y i n providing c l i n i c a l spaces for the

current basic courses. Classroom space a v a i l a b i l i t y may create further

problems but these are not as d i f f i c u l t to solve.

iv) Issues i n Locating Courses

The location of courses provides added problems for nurses

l i v i n g outside the d i s t r i c t who must pay extra for board and room as well

as losing pay. This i s d i f f i c u l t to accept when a nurse knows that she

w i l l not be f i n a n c i a l l y rewarded for her e f f o r t s unless she wishes to

acquire geographic mobility.

v) A v a i l a b i l i t y of Teaching Expertise

Another major problem i s the recruitment of teachers with the

c l i n i c a l expertise necessary to instruct i n post-basic programs. Since

there i s not a c l i n i c a l education career ladder, colleges must choose

from educators who do not have c l i n i c a l expertise or practitioners who

lack teaching and programming s k i l l s . This becomes even more d i f f i c u l t

23.

when programs are offered on an ad hoc basis because nurses do not

prepare themselves for t h i s l e v e l of teaching and job security i s lacking

for anyone who might be prepared and interested to teach because of the

nature of the planning.

v i ) A v a i l a b i l i t y of Students

Potential students for specialty courses are often already

working i n special care areas. This i s not desirable, but a fact of

l i f e . Hospitals would have d i f f i c u l t y replacing these s t a f f members for

the period of post-basic courses because they are already short of nurses

in the specialty areas.

F. Pressures to Improve Continuing Education Sp e c i a l t i e s : Who i s Concerned?

As the confusion described i n the previous sections must indicate,

there are a number of different individuals and groups concerned about

basic and continuing education for nurses. Their reasons for concern

d i f f e r and w i l l be discussed below. The nurses themselves are concerned

about t h e i r education i n a society where q u a l i f i c a t i o n s are becoming

more and more important for attaining economic rewards and where

educational opportunities are so closely linked with s o c i a l

opportunities. This i s discussed i n F ( i ) .

The second section of the discussion F ( i i ) i s concerned with the

professional association's attitudes. Since other groups have not been

eff e c t i v e i n planning, the nurses' professional association has taken

much of the i n i t i a t i v e i n educational development. Their spokeswomen in

the professional association and unions have struggled to help nurses to

a t t a i n greater recognition as a group, f i r s t l y , through pursuing

professional objectives and more recently through union action.

On the other hand, the employers of nurses are concerned about

standards and cost-effectiveness and e f f i c i e n c y . The t h i r d section

24.

F ( i i i ) considers the employers' attitudes to c l i n i c a l specialty

education. I t must be pointed out that i n B.C. the employers concerned

are the hospitals acting as a consortium (the BCHA), or i n d i v i d u a l l y ; the

Nursing Administrators' Association speaks on behalf of the Directors of

Nursing of the hospitals who are the p r i n c i p a l executive o f f i c e r s

concerned with the deployment of nursing s t a f f s . The BCMA i s included i n

t h i s discussion of employers* attitudes, for whilst doctors are not

employers of nurses they are much concerned about the quality of help

provided by the nurses working with them.

The fourth section F(iv) i s concerned with government planning. I t

has to be recognized that government has been entering the planning scene

gradually as more demands have begun to be made for funding of programs

rather than i n s t i t u t i o n s .

1.) Nurses' Concerns about C l i n i c a l Specialty Courses

Post-graduate c l i n i c a l specialty courses offer both advantages

and disadvantages for nurses. Geographic career mobility i s one

possible outcome for those nurses taking post-basic courses. Nurses

w i l l be able to work i n c l i n i c a l specialty areas i n nursing and can then

transfer to a related c l i n i c a l specialty i n a way that nurses without

post-basic education cannot do. A nurse who must move with her husband

to another town w i l l become immediately sought after by the l o c a l

h o s p i t a l .

Another example of within i n s t i t u t i o n a l mobility i s the nurse

educated i n Coronary Care Nursing who i s more eas i l y able to transfer to

a general intensive care unit, a post-anesthetic recovery room, or a burn

unit than a nurse without such post-basic t r a i n i n g . Unfortunately,

however, once orientated into a special unit, a nurse does not have the

same upward career mobility as nurses taking post-basic administrative

25.

courses since c l i n i c a l career ladders are rare or non-existent i n the

province.

The current c o l l e c t i v e agreement between the Health Labor Relations

Association of B r i t i s h Columbia and RNABC, Labor Relations Division,

does not either encourage or recognize a c l i n i c a l career ladder. Clause

52:01 of the current contract does give f i n a n c i a l reward for special

c l i n i c a l preparation, but only i f the nurse has attended a course, of not

less than s i x months, approved by the RNABC, and i s employed i n the

special service for which she/he has q u a l i f i e d . These nurses w i l l be

paid an additional twenty-five dollars a month i f they have u t i l i z e d the

course within four years prior to employment. At the present time, only

nurses who have completed courses i n Operating Room Nursing at St. Paul's

and the Registered Psychiatric Nursing Course at BCIT qualify for th i s

extra remuneration.

No other post-basic course offered i n B.C. q u a l i f i e s the graduates

to receive t h i s extra monthly stipend.

In operating rooms, therefore, nurses who have taken post-basic

courses other than at St. Paul's Hospital, work for less money even

though they may perform the same functions, accept the same

re s p o n s i b i l i t y and have the same sort of post-basic c e r t i f i c a t e from a

B.C. course. Further, t h i s same contract does not recognize any other

l e v e l of practitioner than general s t a f f nurses. Other positions

i d e n t i f i e d i n the wage schedule c l a s s i f i c a i t d n are either non-registered

general s t a f f nurses or administrative personnel.

T" erefore, i n terms of upward career mobility, the post-basic

courses presently offered do not contribute i n a concrete way towards

nurses' career mobility. They offer the nurse further educational

26.

challenge i n special units, or special status i n the general duty nurse

hierarchy, but nurses are not f i n a n c i a l l y rewarded for t h i s .

2.) Peer Group Concerns — Competency

The RNABC has long been acti v e l y involved i n nursing education

and sees i t as a professional association's r e s p o n s i b i l i t y to be so. In

the l a t e f i f t i e s the Association's concerns shifted from concentration

on basic education to the recognition that continuing education was

essential for nurses. I t became the f i r s t provider of continuing

education i n the province, a role which was f i l l e d u n t i l i t s p o l i c i e s

changed i n the early 1970's. After that time, the Association saw i t s

role as the f a c i l i t a t o r of educational developments for nurses rather

than being the provider. During the 80's, the RNABC has continued to

int e n s i f y i t s e f f o r t s i n pushing for continuing education for nurses.

The RNABC has f a c i l i t a t e d planning of continuing education by

nominating members to serve on committees and planning bodies for

post-basic courses. I t has continued to lobby governments for provision

of post-basic courses for nurses and assists i n developing these courses

i n any other way i t can.

At the January, 1980 meeting of the Board i t was decided that the

remainder of the $100,000.00 unspent for educational loans i n 1979 would

be made available for development of post-basic c l i n i c a l nursing

courses. A maximum of $5,000.00 i s available for each course. Courses

receiving the development funding are the C r i t i c a l Care Level I I for ICU,

PAR, and Emergency Nursing being provided by UBC, and Obstetrical

Nursing Level I I course and General Operating Room Course sponsored by

Okanagan College, an Emergency Nursing Course sponsored by Douglas

College/Royal Columbian, a Psychiatric course sponsored by UBC, a Long

27.

Term Care Course sponsored by UBC, and an Occupational Health Course

sponsored by Douglas College/Royal Columbian. Most of these courses are

planned to start i n late 1980 or early 1981.

At that same Board Meeting, a further decision was made that the

RNABC would undertake a study to id e n t i f y competencies and s k i l l s

required i n a number of c l i n i c a l nursing s p e c i a l t i e s , v i z ; c r i t i c a l

care, maternity, psychiatry, operating room, recovery room, long term

care, emergency, pediatrics, p a l l i a t i v e and neonatal nursing.

Information gathered by the committee from nursing education program

planners indicated that a l i s t of competencies would be useful i n

planning new post-basic nursing courses to ensure greater

standardization i n various educational settings. As a resul t of t h i s

decision, a paper was developed i n A p r i l , 1980. I t was call e d " C l i n i c a l

Specialties Competencies Report" (99). The terms of reference were: to

id e n t i f y major sp e c i a l t i e s and sub-specialties within the practice of

nursing, to specify the competencies required for the i r safe practice,

and to indicate the type of specialty preparation required for practice

i n the major special patient care units and services which exist i n B.C.

Early i n the spring of 1980, the RNABC published a paper called

"RNABC Views on Post-Basic C l i n i c a l Nursing Education" (108). I t

reviewed the state of post-basic courses for nurses and then stated what

was seen as the RNABC's primary r o l e / r e s p o n s i b i l i t y as follows:

As the professional organization and registering body, RNABC i s v i t a l l y concerned with the competencies of R.N.s and hence with the quality and content of th e i r continued professional education.

1) Required competencies for the various c l i n i c a l specialty areas should be set up and regularly reviewed for currency by the professional organization, using consultation with other concerned groups. -

28.

2) A l l p o s t - b a s i c c l i n i c a l courses be reviewed v i a the Continuing E d u c a t i o n a l Approval Program, and one c r i t e r i o n f o r continued funding should be CEAP ap p r o v a l . D e c i s i o n s r e continued funding should a l s o r e s t on r e s u l t s o f post-program e v a l u a t i o n . T h i s approval c o u l d be b u i l t i n t o the CEAP process.

In January, 1979, a c o n s u l t a n t was h i r e d to evaluate the e f f e c t i v e n e s s o f CEAP and i n September, 1979 the board r e f e r r e d her r e p o r t to the J o i n t Continuing Education Approval Committee as k i n g f o r i t s recommendations.

In January, 1980 the Board decided that the Continuing Education Approval Program would continue, t h a t i t be widely a d v e r t i s e d t h a t the c o n s u l t a t i o n s e r v i c e was a v a i l a b l e , and that s i m p l i f i e d approval standards be developed f o r s h o r t courses which do not o f f e r c l i n i c a l i n s t r u c t i o n or award c r e d e n t i a l s .

3.) Employer's Concerns - E f f e c t i v e n e s s and E f f i c i e n c y a) B.C.H.A.

The BCHA as a r e p r e s e n t a t i v e o f employers o f h e a l t h care workers has been concerned about the manpower i s s u e s p a r t i c u l a r l y i n h o s p i t a l care i n B.C.

As a r e s u l t , a Standing Manpower Committee was e s t a b l i s h e d i n l a t e 1979 to address manpower i s s u e s on an ongoing b a s i s , to s e t p r i o r i t i e s f o r the A s s o c i a t i o n and to develop the r o l e o f the A s s o c i a t i o n i n manpower p l a n n i n g . The primary mandate o f t h i s committee i s to ensure that employers are i n v o l v e d i n the d e f i n i t i o n o f manpower needs.

The f i r s t a c t i o n was to i n v e n t o r y r e s e a r c h e f f o r t s o f the BCHA, the Health Manpower Research U n i t , p r o f e s s i o n a l a s s o c i a t i o n s and Managerial E n g i n e e r i n g U n i t s i n order to i d e n f i t y what had to be done and by whom and to a s c e r t a i n any areas o f manpower p l a n n i n g not c u r r e n t l y

29.

being addressed. In May, 1980 the committee published i t s Manpower and

Research Inventory of A c t i v i t i e s and Reports. (20) Included i n t h i s

l i s t i n g are a number of nursing manpower reports and studies. The BCHA

i s working with the Health Manpower Research Unit of UBC on the

d i f f i c u l t - t o - f i l l positions survey. (13)

b) Hospital A c t i v i t i e s

Individual hospitals or groups of hospitals have lobbied

the Health Ministry re the shortage of general duty nurses and i n

p a r t i c u l a r , nurses with post-basic preparation to work i n special

c l i n i c a l areas. . As a r e s u l t , the Ministry of Health circulated a

questionnaire i n the spring of 1980 (19) to attempt to discover what

urgent needs might be, with the hope of establishing some crash courses

for those p a r t i c u l a r s p e c i a l t i e s .

Since hospitals have had to rely on r e c r u i t i n g

inexperienced nurses and providing good orientation, they are discussing

providing t h e i r own specialty courses with support and funding to be

requested from the M i n i s t r i e s of Health and Education. Currently St.

Paul's Hospital i n Vancouver i s providing some post-basic courses i n

Operating Room and Enterostomal Therapy.

A major discussion point i n hospitals i s "who should

control educational a c t i v i t i e s for post-basic courses?" Some comments

indicate that respondents see t h i s as a role f o r hospitals to develop

with seconded assistance from the community colleges and u n i v e r s i t i e s .

c) Nursing Administrators' Association of B r i t i s h Columbia

This organization encompasses other than hospital nursing

administrators but the majority of the membership i s nursing

administrators who are employed i n hospitals. I t has not been a strong

organization but i s presently re-organizing i t s forces.

30.

The nursing administrators presented a "Reaction Paper to

the Nursing Education Study Report." (1979) (Appendix C) The Nursing

Administrators' Association strongly supported recommendations r e l a t i n g

to improving basic standard educational and degree programs and making

degree programs accessible for nurses i n other parts of the province.

Recommendations which dealt with post-basic education were strongly

supported by the Association. The Association also supported

recommendtions which suggest the development of career streams i n

c l i n i c a l nursing. Recommendations which dealt with planning for needs

for nursing were also endorsed.

In October, 1979, the Association presented a b r i e f to

the Minister of Health e n t i t l e d "The Registered Nurse Shortage i n

B r i t i s h Columbia: An Increasing Problem for B r i t i s h Columbia

Hospitals." (88)

The recommendations from t h i s b r i e f are as follows:

The Nurse Administrators urge the M i n i s t r i e s of Education and Health to combine e f f o r t s for implementation of the following recommendations:

I. To provide s u f f i c i e n t separate funding to meet nursing s t a f f orientation and continuing education for job requirements.

I I . To immediately increase the number of seats available to refresher courses.

I I I . To continue funding of the University of B r i t i s h Columbia/Vancouver City College Level I C r i t i c a l Care Course.

IV. To provide funding for the following post-basic courses:

Cardiothoracic Care Coronary Care Emergency Care Gerontology Level I and I I Intensive Care Neurological Care

31.

Neurosurgical Care Obstetrical Care Operating Room Care Post-Anesthetic Recovery Care Renal Care Spinal Cord Injury Care

V. To increase the number of seats for basic nursing programs.

The Nursing Administrators 1 group of the Lower Mainland

invited Mr. R.E. McDermitt, Senior Assistant Deputy Minister,

Professional and I n s t i t u t i o n a l Services, Ministry of Health, to a

special meeting i n March 1980, to discuss with him t h e i r concerns about

the shortage of specialty trained nurses and lack of post-basic courses

to t r a i n nurses i n special c l i n i c a l areas. In meeting with Mr.

McDermitt, t h i s was their attempt to make clear t h e i r consensus to the

Ministry of Health.

d) Colleagues' Concern - Doctors' Attitudes Re Effectiveness

The BCMA has long been interested i n nursing education.

U n t i l recently, i t was highly involved i n pa r t i c i p a t i n g i n nursing

education, i t s members often giving nurses lectures i n anatomy,

physiology, disease pathology and medical treatments. More important to

the physicians of B.C. i s that graduates of nursing programs, i n caring

for patients, work closely with physicians.

Therefore, the physicians are d i r e c t l y affected by the

outcomes of nursing programs.

In December, 1979, i t was brought to the attention of the

Board of the BCMA that a serious shortage of nurses was developing and

also that nursing needed support i n obtaining funding from either the

Ministry of Health or Ministry of Education for post-basic courses.

There had also been concerns expressed by physicians as to the competence

32.

of nurses educated i n the two year programs. As a re s u l t , the BCMA

Hospitals Committee was asked to study the effectiveness of nursing

education i n the province and to report back to the board.

Dr. D. MacPherson, who chairs the Hospitals Committee,

wrote to the RNABC and several directors of nursing to try to ascertain

the scope of the problem. E s s e n t i a l l y , answers he received indicated

that there was a problem but that adequate data had not yet been

obtained. I t was indicated that attempts at corrective action were being

taken through the Health Manpower Research Unit, the RNABC and the BCHA.

The Hospitals Committee presented the following

recommendations to the Board of Directors of the BCMA i n January, 1980

(15):

1) That the Ministry of Education give immediate and serious consideration to the dangerously neglected area of post-basic c l i n i c a l nursing education i n c r i t i c a l care areas.

2) That the Ministry of Education respond to the need for an ongoing dependable source of funding to be u t i l i z e d for the development and implementation of quality post-basic nursing courses.

3) That a source of revenue for consistently a s s i s t i n g hospitals with the cost of s t a f f replacement for nurses attending post-basic courses be i d e n t i f i e d .

H) Government Involvements i n Planning Post-Basic C l i n i c a l Specialty Courses

Since delivery of hospital services i s not a direct

government r e s p o n s i b i l i t y but delegated to the hospitals

themselves, the Health M i n i s t r i e s did not become d i r e c t l y

involved i n the nurse manpower planning u n t i l the seventies

(The development of th i s involvement after the introduction of

National Health Insurance i s discussed i n Part V.)

33.

Equally, the involvement of the M i n i s t r i e s of Education grew slowly, as

was described e a r l i e r i n t h i s chapter. Consequently, u n t i l very

recently, governments were not involved i n supporting post-basic nursing

c l i n i c a l specialty courses. A policy for funding t h i s area of nursing

education on an ongoing basis did not e x i s t , nor had the governments

taken leadership i n coordinating inputs from interested groups so that

ongoing needs could be i d e n t i f i e d . Instead they had moved i n and out of

the planning process as the pressures from the interested groups had

demanded thei r attention or f a l l e n off. The planning focus had only been

on the strongly i d e n t i f i e d program needs not on an o v e r a l l assessment of

needs.

Further, governments had not c l e a r l y i d e n t i f i e d what the roles

of i n s t i t u t i o n s should be i n presenting post-basic c l i n i c a l specialty

courses, so a competition of sorts had developed i n terms of who would

get the ad hoc ind i v i d u a l program funding which was available.

In 1977, i n B.C. a mechanism to review requests for additional

funding for c l i n i c a l specialty programs was set up, but neither on-going

need for programs nor program p r i o r i t i e s was to be on a one time basis.

As a r e s u l t , funding for a program might be approved on a one time basis.

Continuing to present the program meant reapplying through the mechanism

requests for additional courses, for further one time funding. This was

not only time consuming but often resources were dispersed or

unavailable by the time the second approval was granted.

As demands have been increasing for nurses with special

c l i n i c a l preparation, the government has begun to be more involved with

the planning process through attempts to i d e n t i f y needs and, through

funding and guiding the HMRU, i t has begun to play a coordinating r o l e .

34.

5. Discussion: Who Has the Power to Make Decisions Relating to Nursing Education?

The l a s t two decades were the time when most e a r l i e r plans

regarding nursing education were implemented. Basic education programs

came under the control and funding of the pro v i n c i a l education

departments. Baccalaureate nursing courses increased quality and

quantity. Masters' programs were started i n many u n i v e r s i t i e s . Yet

education for spe c i a l i z a t i o n i n nursing i s s t i l l i n the early planning

and implementation stages despite the fact that these two decades were

characterized by increasing technology and spe c i a l i z a t i o n i n nursing.

There i s s t i l l discussion within the profession today about

nursing education needs - about the difference between "service" and

"education." This may well be related to the lack of c l i n i c a l models i n

nursing. Because the practitioner i s not highly regarded or rewarded

within the nursing profession even today, the question of who decides

what nursing practice i s and what education i s needed to f u l f i l t h i s role

i s an important one.

The status i n the nursing profession has not been with those

people who provide nursing service, but, rather, with those who

administer the service and those who educate for i t . To advance i n

nursing, one had to specialize i n education or administration. U n t i l the

l a s t few years, the educators have had the most power. Many nurses who

gained t h e i r higher education chose the teaching role because teachers

tended to have better working conditions, salaries and status than

nursing administrators. They had more freedom to control and make

decisions about the educational environment. They were also i n an

environment where new ideas and concepts are expected. The educators

35.

were able to advance i n thei r thoughts about what nursing should be and

what various educationally prepared levels of nurses should do.

The nursing administrators were looking for nurses who could

perform the established nursing practices w e l l , not nurses who had new

ideas tht the nursing administrators could not possibly implement.

Within the hospitals, many nurse administrators themselves were not

given r e a l power but were often delegated tasks to carry out. They had

l i t t l e control over the i r working environment because hospital

administrators controlled the budget and physicians controlled the

quantity and quality of workload. As a r e s u l t , they were often unable to

do much more than follow orders while trying to advance nursing as best

they could.

But who should determine what nursing r e a l l y i s ? The

educators? The administrators? Or the practitioners who provide daily

care for patients?

Attempts were made by the professional associations to p u l l

together varying views about the objectives of nursing education.

Mussalem (85) for long the Executive Director of the CNA, has put forward

her interpretation of the reasons for slow progress i n attaining the

objectives i d e n t i f i e d by the professional association by quoting King

(76): Throughout the f i r s t part of the century, organized

groups closely associated with health care, for one reason or another, appeared to favour maintaining the narrow custodial image of the nurse. This coupled with the apparent i n a b i l i t y or unwillingness of nurses to interpret developments i n both education and service, further strengthened the accepted image of the nurse. The s i t u a t i o n was a l l the more unfortunate when translated from public confusion to government bewilderment. Since university nursing education has always depended on funds channeled through the provincial government, i t i s essential that the needs of nursing be

36.

interpreted c l e a r l y to their l e v e l of government. I t was inevitable that through the lack of clear interpretation of the need f o r , and the role of the baccalaureate prepared nurses, there would be f i n a n c i a l d i f f i c u l t i e s for university degree programs. The question may well be asked why, i f the general public was confused, nurses were content to accept t h i s s i t u a t i o n . Over the same period other professional groups successfully recognized the need for involving new educational approaches and interpreting these changes to the public. Unfortunately, the mass of nurses were apathetic and lacked understanding of both the need for, and the character of the change i n basic nursing education controlled by the university.

Is t h i s a useful interpretation of the present nursing

situation? Certainly i t focusses attention on the ind i v i d u a l nurse's

reactions to thei r general s i t u a t i o n i n society though these reactions

may well have changed i n recent years.

In the next section the development of nursing functions i n

hospitals and womens' roles i n society are considered, as a basis for

making an assessment of the appropriateness of education and train i n g i n

nursing today and i n interpretation of reasons for the "shortage" of

nurses.

PART I I I

HISTORY OF NURSING FUNCTIONS IN THE CONTEXT

OF CHANGING WOMEN'S ROLES IN CANADA

37.

PART I I I

HISTORY OF NURSING FUNCTION IN THE CONTEXT

OF CHANGING WOMEN'S ROLES IN CANADA

I t would appear that ind i v i d u a l nurses i n B r i t i s h Columbia have

been making particular demands upon employers, represented by the

Directors of Nursing of hospitals, namely demands for positions with

greater decision making autonomy and more l i f e style advantages to f i t

more closely with the i r other s o c i a l roles.

Nursing i s a women's profession. In manpower discussions, t h i s i s

i d e n t i f i e d as a chara c t e r i s t i c of the nursing profession. To explore the

problem of nursing shortages, womens' roles must be examined to under­

stand any impact t h i s c h a r a c t e r i s t i c may have on the a v a i l a b i l i t y of

nurses for the labour market.

A. The Beginnings

Nursing functions today have evolved as a result of many factors.

Increasing knowledge and technology are obvious i n themselves. Less

obvious, but very important, are changes i n the values on which nursing

i s based, changes i n roles of women i n our society, and the development

of our society. External, economic and s o c i a l pressures as well as

int e r n a l searchings to adapt to the changes has created a state of

uncertainty i n nursing as to what i s the scope and function of nursing. For the perceptions of nursing today have been determined by i t s

t r a d i t i o n s as well as more recent influences:

Uprichard has i d e n t i f i e d heritages from the past that have tended to i n h i b i t progress i n nursing as a profession. These are: the folk images of the nurse brought forward from the primitive times, the re l i g i o u s image of the nurse inherited from the medieval period, and the servant image of the nurse created by the Protestant C a p i t a l i s t i c ethic of the 16th to 19th centuries.

38.

These images, while appealing to the humanistic side of man's nature, show nursing i n a subordinate position to a l l other professions, omni-present and uncomplainingly dedicated, with l i t t l e thought of personal gain. (78)

The values of the nursing profession are closely intertwined with

those thought to be a part of the woman's rol e . I t i s , therefore,

d i f f i c u l t to separate the two, so they w i l l be discussed together as the

changing values i n nursing are i d e n t i f i e d .

During the period from the early settlements i n Canada u n t i l the

1920's the values i n nursing were simple. Nursing was a servant's role

and thus a duty.

Canadian nursing began i n the early years as a "labor of love" for

the r e l i g i o u s orders i n Canada, family members or neighbours who

volunteered t h e i r services. These nurses were untrained and did what

they could for the comfort of their patients. Rewards for nurses were

based on the value of the dedication to patients. They also valued

praise from the physicians for thei r work.

In t h i s period i n Canada's history, the normal roles of women were

to be wives and mothers staying at home. Women were seen as needing

protection and therefore dependent on men. Their status was much less

than men's and they were not welcome or accepted when working i n society

i n competition with men. However, they were accepted i n jobs as teachers

or as nurses because these were seen to be extensions of the "woman's

ro l e . " Nursing as an occupation was also valued by women, as a way of

putting t i n time, hoepfully, u n t i l they were married.

As Canada became more settled, hospitals were set up and the larger

ones opened schools of nursing. Since women had very few career

opportunities, nursing was a popular choice, and many women considered

themselves fortunate to have been accepted into a train i n g school.

39.

At t h i s time, nursing care was aimed at cleanliness, comfort,

maintenance of n u t r i t i o n , and easing of symptoms for the patient.

Medical care was minimal and often treatments consisted of family

remedies. Very l i t t l e nursing care during t h i s period was aimed at

i l l n e s s prevention or health maintenance. Most care was directed at

those already i l l .

Since most nursing care was provided on an ind i v i d u a l basis to

patients i n the i r homes, nurses, besides providing i l l n e s s care, also

did the cleaning, cooking and generally provided the extra care the

family might need. They tended to l i v e i n when they were with a family

and provided care on a twenty four hour basis.

During most of t h i s period, many nurses worked as independent

entrepreneurs. They were self-employed and accountable to the i r

employers for the quality of care they provided, although the physicians

might oversee some of the i r work. As independent practitioners, they

assumed r e s p o n s i b i l i t y and accountability for t h e i r practice and t h e i r

continued learning to keep s k i l l s up to date, even though there was

minimal increase i n knowledge i n t h i s period. I f one were to review the

c r i t e r i a used to designate an occupation as a self-regulating

profession, nursing at t h i s time probably most c l e a r l y approximates the

description of a true professional group.

A few nurses worked as administrators of hospitals and as such,

usually assumed t o t a l r e s p o n s i b i l i t y for the internal management of

hospitals. These administrators may have had an assistant who helped

them with business and finance matters on behalf of the board, but they

were d e f i n i t e l y i n control. As well as t h e i r administrative functions,

they were often expected to teach the students how to provide nursing

40.

care. L i v i n g - i n , they were responsible for the twenty-four hour

operation of the hospital and were often called upon to a s s i s t with

direct care to to provide "expert advice" to the student nurses who

provided most of the nursing care. They were very attuned to the "real

world" of nursing.

Because the hospitals were staffed mainly by apprentices, most

trained nurses were isolated i n private duty nursing and i n the early

1900's th i s stimulated the graduates of the training programs to band

together i n alumni associations to support one another i n whatever ways

they could, including s o c i a l i z i n g and sharing c l i n i c a l information.

This was t h e i r form of continuing education, and ultimately protection.

I t was i n these groups that nurses began to talk about organizing

themselves, and establishing basic standards for nursing education.

They were not greatly concerned with levels of renumeration. Although

nurses might ask for s p e c i f i c amounts for payment for thei r services,

they often would work for l i t t l e or nothing because "they were needed."

The leaders i n the nursing associations were concerned that anyone

could offer herself for hire as a nurse, whether she was trained or not.

Although many nurses were concerned with the control of quality of

nursing care, others were concerned with the competition for jobs that

the untrained nurses created.

Whatever the reason, most nurses became interested i n developing

some form of control over non-trained nurses. I t became important to

nurses to have formal recognition for thei r t r a i n i n g and they valued

nursing r e g i s t r a t i o n as a way to gain t h i s recognition. So they began to

value the need to be linked together i n professional associations and

they began to work for effective professional organization.

41.

B. The Depression Years

In the period from 1920 to 1940 there were few changes i n womens'

and nurses' values and i n nursing functions except that, i n the

depression years, i t became more acceptable for women to work outside the

home i n order to add to family income.

However, less home nursing care was carried out because, with the

depression, people were unable to afford to pay nurses and they trusted

hospitals more because of the improved infection control (2). More

people went to hospitals when they were i l l , but, there was very l i t t l e

money to pay more nurses for thei r services. This sometimes resulted i n

more students being taken on or sometimes those that were there had to

work harder. Some hospitals began to find students expensive and did

hire a few more trained nurses for hospital work, but, not many were able

to do t h i s because of scarcity of funds.

P r o v i n c i a l associations had formed across Canada and were

struggling to set and improve standards of basic tra i n i n g programs and to

develop higher education programs for nurses. For the f i r s t time the

associations were given control over nursing r e g i s t r a t i o n by the early

twenties. They also began to work to develop public funding for nurses'

t r a i n i n g and thus remove i t from the apprenticeship system. More nurses

were unemployed and could concentrate on further education as a way of

keeping up t h e i r s k i l l s while waiting for employment.

C. The War Years and After

Towards the end of th i s depression period, as war began i n Europe,

many nurses were sent to nurse soldiers i n combat, others sent to

organize nursing services for other countries. This l e f t a shortage of

nurses on the domestic scene. To increase t h i s shortage, many injured

42.

servicemen were sent home for treatment i n government hospitals. The

need for nurses, i n Europe as well as at home, increased faster than

nurses could be trained. A u x i l i a r y nurses were introduced to help

overcome t h i s shortage. The impact of introducing p r a c t i c a l and other

a u x i l i a r i e s was that registered nurses began to practice i n a different

way. Besides being a bedside nurse, the R.N. was now expected to guide

and supervise another category of nurse.

Doctors were also i n short supply at home. Nurses began to take

over procedures which had previously been performed only by doctors. As

wel l , the development of new medical technologies, new drugs, such as the

sulphonamides, meant that more severely i l l patients survived and

required to be nursed through intensive i l l n e s s e s as they had not before.

The increased duties of nursing more patients who were intensively i l l ,

and taking on more medical functions, increased the nursing shortage.

In 19^3, the Heagarty Committee, set up by the federal government,

(69) proposed that Canada should adopt a National Health Insurance

Scheme. Although i t took t h i r t y years for a l l the programs i n the scheme

to be introduced, i t was made clear i n the National Health Survey of 1943

(29) that 90,292 more hospital beds were b u i l t and gradually as the

National Health Scheme was implemented (33), the demand for nurses

increased.

Despite the increase i n the numbers and size of hospitals and

changes i n th e i r technological a c t i v i t i e s , nursing organization

structures i n hospitals did not change at th i s time. C l i n i c a l models of

advancement were not introduced as s p e c i a l t i e s began to develop. Post-

basic specialty courses did allow nurses horizontal mobility but upward

career mobility s t i l l consisted of moving into administration or

43.

e d u c a t i o n . However, nurses a c q u i r e d i n c r e a s e d geographic m o b i l i t y once they had taken a course. To summarize, during the 1940's to 1960's, n u r s i n g f u n c t i o n s i n Canada changed d r a s t i c a l l y . From g i v i n g simple tender l o v i n g care as t h e i r only f u n c t i o n , nurses were r e q u i r e d to engage i n other t a s k s . F i r s t , many became i n v o l v e d i n h i g h l y complex and t e c h n i c a l d i a g n o s t i c and t h e r a p e u t i c procedures. They a l s o moved away from spending time with p a t i e n t s as another category of employees began to a s s i s t them on the wards. The second major change was the f i n a l i z a t i o n o f the move away from i n d i v i d u a l i z e d home n u r s i n g care to i n s t i t u t i o n a l i z e d care f o r groups o f p a t i e n t s . There was a g r e a t demand f o r i n c r e a s e d numbers o f r e g i s t e r e d nurses to take on these new f u n c t i o n s .

Nurses s t i l l saw themselves as d e d i c a t e d to s e r v i n g others but they a l s o began to be aware t h a t they were important to the h e a l t h care system. They began to r e a l i z e that more education was r e q u i r e d and should be p a i d f o r the s o c i e t y which wanted t h e i r s e r v i c e s and that they should be p a i d more a p p r o p r i a t e l y f o r t h e i r work. W i l s t the o l d e r forms o f r e c o g n i t i o n were s t i l l valued, new rewards began to be a p p r e c i a t e d , namely, 'reasonable' monetary renumeration, higher s t a t u s i n s u p e r v i s i o n o f o t h e r s who took over some o f t h e i r tasks and p l e a s u r e i n l e a r n i n g new techniques and working more c l o s e l y with other p r o f e s s i o n a l s .

W h i l s t the p r o f e s s i o n a l groups s t i l l emphasized e d u c a t i o n a l o b j e c t i v e s and n u r s i n g standards as t h e i r p r i n c i p a l concern, they were beginning to become i n t e r e s t e d i n c o l l e c t i v e b a r g a i n i n g . In 1946, f o r example, the RNABC se t i t s e l f up as the b a r g a i n i n g body f o r i t s members.

The r o l e o f women changed d r a s t i c a l l y d u r i n g t h i s p e r i o d . Women were i n the labour f o r c e and expected to be. They now d i d many jobs t h a t

44.

previously had only been done by men. Educational and career

opportunities expanded. The expectation that women who married should

quit work, and stay i n the home faded. Women began to be more involved

with public l i f e at every l e v e l . The status of women was s t i l l below

that of men, but the gap was less wide than i t had been.

D. The Last Two Decades

The 1960's and 1970's were characterized by a major s o c i a l

revolution i n Canada. The prosperity after the war, the explosions i n

knowledge and technology, the increasing educational opportunities and

the demands of minority groups for t h e i r rights a l l combined to create

t h i s revolution. The Women's Movement stimulated discussions of women's

roles i n society and because of the Women's Movement, a l l sectors of

society have attempted to begin to move towards greater equality of the

sexes. Women have gained status and i f nothing else, are no longer taken

for granted as automatically belonging i n the "homemaker r o l e . "

Educational opportunities are now more open to women who are

attending university i n greater numbers than ever before, because of the

s o c i a l value now attached to being a university graduate.

In Canada 9856 of nurses are female, so nurses have been able to echo

women's general goals within t h e i r own profession. As we l l , nurses have

become more assertive and vocal. Gradually they began to see nursing

education and trai n i n g as an expectation rather than a pri v i l e g e and were

no longer w i l l i n g to pay for th i s with service.

Nurses have begun to set great value on university education. I t i s

a way to increase s o c i a l mobility and to meet young men. I t provides

opportunities of moving out of nursing into other occpuations. Nurses

have become unwilling to work i n r e s t r i c t i v e , authoritarian i n s t i t u t i o n s

and they have begun to value recognition of th e i r knowledge and s k i l l s .

45.

Nursing administrators gained strength i n t h i s time period. More

and more they are beginning to be seen as i n s t i t u t i o n a l administrators

with nursing backgrounds becoming involved i n top administrative

decisions. This i s not yet the norm throughout the industry, but the

precedents have been set and i t may now be necessary for more nurses i n

senior positions to prove that they are capable of taking broader

r e s p o n s i b i l i t i e s .

During the seventies, several changes i n health care delivery have

i n t e n s i f i e d s p e c i a l i z a t i o n i n nursing. A few of these s i g n i f i c a n t

trends are:

1) more patients are being treated on an outpatient or day

care basis. Those patients that are admitted to hospital are more

seriously i l l than they have been i n the past.

2) There i s increasing s p e c i a l i z a t i o n resulting from

expanding knowledge and technology, r a d i c a l intrusion into the human

body and treatments which have been developed for severe trauma.

3) S h i f t s i n the population structure with more emphasis on

the elderly and the ramifications of the aging process.

E. Development of C l i n i c a l Specialty Units

Nurses began to value (and to be valued for) technological

a b i l i t i e s rather than basic bedside nursing care. The specialty areas

evolved gradually i n hospitals as new information and technology

developed. As new machines came into use, places were found for them to

be set up i n hospitals and nurses were trained to operate them. These

areas gradually became recognized as "special care areas" or "intensive

care areas" where the sickest patients were gathered for concentrated

nursing care.

46.

The equipment and personnel i n these specialty areas were expensive

to fund. The technological advances might not have come so quickly had

not governments f i r s t taken over payment of c a p i t a l and operating costs

of hospitals and then salaries of physicians.

The 1957 Hospital Insurance Scheme and the 1966 Medicare programs

(33) provided funding for doctors to spend more for "esoteric" areas of

health care. Since the patient no longer had to "foot the b i l l " for

these expensive services, "nothing was spared" to provide patients with

l i f e - s a v i n g care. Physicians with regular payments being received from

governments, had to "donate" less free care to indigent patients and

could afford more time for explore new techniques.

The Nursing Administrators' Association of B r i t i s h Columbia

presented a position paper on budget restraints to the Ministry of Health

i n November, 1979. (86) Although t h i s paper was mainly concerned with

financing, the group described the changed function of nursing.

The l e v e l of sophistication of patient care i n health care f a c i l i t i e s continues to r i s e . This l e v e l of sophistication and increased technology, as well as the continuing "transfer of medical functions" to nursing, increases the workload and demands on nursing.

Physician s p e c i a l i s t s i n most communities are demanding more and more highly sophisticated diagnostic and treatment procedures which require increased costs i n equipment and supplies, and highly s k i l l e d nursing personnel. The nursing role has also expanded i n the areas of patient and family teaching with increased emphasis on ambulatory care and health promotion. Also as well as more sophisticated patient care, the handling and care of expensive diagnostic and treatment equipment must be taught, i . e . c i r c u l a r - e l e c t r i c beds, endoscopes, respirators, monitors.

Today the function of nursing i s extremely complex. Few patients

today have the nursing needs as simple as those provided by nurses prior

to 1950. Even the patients on the general wards have numerous needs that

are complex and those i n special care areas may need two or more highly

47.

knowledgeable and s k i l l e d nurses around the clock to care for their

needs.

Specialized units are increasing i n numbers and si z e . A Ministry of

Education Sub-Committee on Nursing Education, Kermacks' (1979) (73)

reported that:

an examination of the positions i n which R.N.s are employed indicated that approximately 30% of those positions require preparation beyond the diploma l e v e l . Most of these positions would require a preparation at least at the baccalaureate l e v e l because they demand a broader scope of nursing knowledge and a range of complex s k i l l s (teaching, counselling, administration, consultative and research ) not provided i n diploma programs.

The S t a t i s t i c Canada data indicated that at least twenty percent of the f u l l time equivalent positions for graduate and registered nurses i n hospitals are i n specialized areas. Few nurses have or can obtain t h i s preparation.

TABLE 2

Number of Full-Time Equivalent Graduate Nurses Employed i n Specialized Units i n B.C. Hospitals and as Proportion of Total Employed Graduate Nurses, 1976

Full-Time ^ Percentage of Specialized Units Equivalents Total F.T.E.

Intensive Care 367.0 H.k%

Labour and Delivery 187.7 2.256

Operating Room

including PAR 810.0 9.7?

Emergency Department 275.6 3•3%

Total Employed 8,389.5 19.6$ 1

Other specialized units i n medical - s u r g i c a l , psychiatric, nursery and other areas could not be i d e n t i f i e d from data.

2 Full-Time Equivalent - graduate or registered nurses - One F.T.E. i s based on 1,950 hours worked per year (37.5/wk/52 weeks/yr).

48.

Nurses today value different rewards. Conditions of work and

salar i e s are now far more important to nurses. As w e l l , the age of

technology has affected nurses. Understanding machines — thei r

operations and effects — has become very important to nurses. Those

nurses who work i n special care areas have a higher status among nurses

and physicians than do other nurses, although i t i s not because of extra

monetary rewards.

One can look at the reward system to attempt one explanation of the

phenomenon. Physicians have more power, make more money, are more

independent i n functioning than nurses. Nurses seeking to gain some

status with the higher status physician group can do so more easily

through understanding the technology (machines) than i n any other way.

The Age of Specialization i s highly organized i n the physician

group. Many physicians do not understand the i n t r i c a c i e s of the

technology i n the special care areas. They usually refer t h e i r patients

to physicians specialized i n these areas, who are minimal i n numbers and

considered the e l i t e of the profession. Those who a s s i s t these

specialized physicians are the nurses who work i n these areas. The

nurses are not rewarded for the tender loving care they give the patients

i n special care units, but, rather for thei r a b i l i t y to understand and

operate the technological equipment and thus support the s p e c i a l i s t

physician. In developing a partnership with s p e c i a l i s t physicians these

nurses gain recognition and respect that i s not evident i n other nursing

areas. Thus, status i s increased i n the eyes of physicians generally and

p a r t i c u l a r l y with the s p e c i a l i s t physicians. C l i n i c a l specialty nurses

are able to work i n a much more independent manner and have more s o c i a l

power than non-technical nurses who are not educators or administrators.

49.

The rewards are greater for these nurses as the i r s e l f worth i s enhanced

on the job.

There are some concerns i n the profession about whether nurses'

proper functions are to nurse patients or to nurse machines. As we l l , to

some older nurses, the "younger" nurses do not seem to be as dedicated to

nursing. This i s suggested, for example, when these nurses are said to

"leave right on time." This may be a way i n which the older nurses

describe change i n nursing which they find d i f f i c u l t to accept or more

correctly, i s at odds with their values. In today's society, l e i s u r e or

non-work time i s highly valued. To most nurses, nursing i s only one role

among their many varied roles.

F. Unionization

I t took over t h i r t y years for many nurses to accept the idea of

building a strong union for bargaining purposes because of the strong

"vocational" ethic which Nightingale had b u i l t into the idea of nursing.

In B r i t i s h Columbia, around the mid-seventies many nurses would not

admit that they belonged to a union. They did admit to having a

professional labour organization. The idea of professionalism for many

nurses was not i n harmony with the concept of unions and therefore,

unionism was denied.

However, the Labour Relations Division of the RNABC has recently

become very strong. In a s t r i k e vote, taken by nurses i n over eighty

hospitals i n the province, i n 1979, over 90% of the nurses voted to

s t r i k e . This i s a major change i n values by nurses i n the province

within the l a s t few years.

Union a c t i v i t y i s evolving i n another dire c t i o n . Baumgart (8)

suggests that c o l l e c t i v e bargaining i s beginning to and should, become a

50.

vehicle for advancing professional concerns of nurses as well as socio­

economic interests. Nurses, as professionals, have a r e s p o n s i b i l i t y to

safeguard human l i v e s . To accomplish t h i s , the quality of services has

to be assured. Where the r e s p o n s i b i l t i e s of employment and professional

standards are i n c o n f l i c t , nurses have a righ t and a duty to point out

the c o n f l i c t . To negotiate disputes of t h i s nature, c o l l e c t i v e

bargaining can be the instrument which should be used by nursing. In

fact, nurses can be the agency nurses use to promote t h e i r professional

values.

G. Implications of Changing Attitudes

The United States i s i n the midst of a major nursing s t a f f i n g

problem. In a study done by the University of Texas at Austin (1980),

prompted by the acute shortage of nurses i n Texas, i t was found that

undesirable working conditions were the major cause for widespread

shortage (8). The reasons cited by nurses for job d i s s a t i s f a c t i o n

included lack of support by hospital and nursing administration, lack of

autonomy, i n f l e x i b i l i t y of working hours, being "pulled" from a f a m i l i a r

unit to work on short staffed units, need for c h i l d care, c o n f l i c t with

family schedules, frequent overtime with no additional compensation,

lim i t e d help i n keeping up professional s k i l l s , i n d i f f e r e n t or

inadequate personnel and low sa l a r i e s .

Texas nurses are refusing to work for hospitals f u l l time because

hospitals decide the number of hours, s h i f t s and days which the nurses

w i l l work. An alternative has been provided for the nurses by nurse

s t a f f i n g companies. A nurse can sign up to work with a company and she

w i l l then be able to decide how many hours, what s h i f t s and what days she

wishes to work. Nurses have flocked to these companies. Hospitals are

51.

i n dire s t r a i t s and are being forced to offer the nurses remaining on

s t a f f many concessions to retain them.

The aspirations of individual nurses i n the profession are a

challenge to the previous e l i t e groups of educators and administrators.

Are these new-style nurses necessarily those who know the most about and

give the best personal care or, rather, those who play a handmaiden role

i n promoting the technological aspects of caring for the patients? Has

thi s implications for the future nursing structures and reward systems

i n Canada? Are nurses going to continue to seek indi v i d u a l solutions or

contract solutions for t h e i r employment conditions?

I t i s important now to consider whether the nurse manpower planners

have recognized and addressed themselves to these changes. The next

chapter w i l l explore national and l o c a l nurse manpower planning e f f o r t s .

PART IV

HOW CAN THE PLANNING PROCESS BE MADE MORE EFFECTIVE?

52.

PART IV

HOW CAN THE PLANNING PROCESS BE MADE MORE EFFECTIVE?

A. From Sectoral Educational Concerns to Comprehensive Manpower Planning^ A c t i v i t i e s

The present confused si t u a t i o n i n educational planning was outlined

at the beginning of th i s paper and the reasons for the confusions have

been explored, at least to some extent, through considering f i r s t the

issues i n nursing education and second, the development of nursing

functions and t h e i r relationships to nurses' changing roles i n society.

The shortage of nurses, now having become a p o l i t i c a l problem the

administrators i n government have, as their f i r s t step, gone back to the

nursing manpower planners to try to j u s t i f y the need and determine the

scope of the problem, provide the means of r a t i o n a l i z i n g nursing

preparation and the use of nursing s k i l l s . But who are the manpower

planners?

Alford, i n Health Care P o l i t i c s , (1) has suggested that there are

three groups of planners involved i n hospital planning i n New York — the

entrepreneurs, the corporate planners and,advocacy planners. This way

of dividing planning interests provides a helpful indication of how

sectoral planning approaches i n nursing i n Canada may be viewed. In

manpower planning i n Canada and B r i t i s h Columbia we can id e n t i f y :

1) the "entrepreneurs" who were at f i r s t the trained nurses who

set up i n private practice from the e a r l i e s t days u n t i l approximately

1940. Thereafter, t h i s group disappeared. They, or their successors,

became employees and began to be represented by the professional

association speaking on their behalf. Although the nurses are no longer

self-employed, the association s t i l l represents the nurses' interest.

53.

Because of the heavy 'vocational' overload, these representatives

of nurses concerned themselves with discussions about education and

tra i n i n g more often than about rewards i n the period up to the mid

seventies. Now that nurses have become unionized, and are beginning to

push more strongly for improved economic standards, the relations

between professional (standards) and union (economic) a c t i v i t i e s has

become a r e a l issue for the associations to manage.

2) the corporate planners who have been consortia of employers,

i n s t i t u t i o n a l interest groups or government sponsored groups i n Canada

and i n B r i t i s h Columbia. The a c t i v i t i e s of corporate planners have been

sporadic and ad hoc u n t i l very recently. For example, the shortage of

nurses i n World War I I , led the federal government i n 1946, to set up the

"Joint Commission of Nursing" (30) with representation from the Canadian

Hospital Council, Canadian Mental Health Association, Department of

National Health and Welfare and the Department of Veterans' A f f a i r s to

consider the acute shortage of hospital personnel.

Much of the planning by i n s t i t u t i o n a l interest groups or employers'

representatives has continued, as was shown i n the narrative above, but

i t has not been very effective since the p r i n c i p a l l o y a l t y of committee

members has been to thei r sponsoring organizations and not to the ad hoc

planning groups.

Corporate planning was given a major boost by the federal

government deciding to fund health services. In 1948, the pro v i n c i a l

governments had to produce hospital plans before they could tap the

national health grant funds and at about t h i s time they also reviewed

th e i r public health and mental health programs and developed plans. But

at that time there were no strong administrators who were employed by the

54.

provincial governments (available to implement plans) except in

Saskatchewan, and outside consultants' plans tended to be pushed aside

by provincial politicians who had different objectives than the v i s i t i n g

planners.

The National Health Grant Program (1948) provided for hospital

construction grants which greatly expanded the number of hospital beds.

This in turn, created great problems in raising enough funds to keep

these hospitals operating. The Hospital Insurance and Diagnostic

Services Act (1957) further increased access to health care for

Canadians and uti l i z a t i o n of hospitals continued to rise. The passage of

the Medical Care Act (1966) continued government's involvement in

funding health care. Before this act could be implemented, costs had

risen alarmingly and the governments became concerned. The Task Force on

the Costs of Health Care in Canada (32) was established in 1969. This

committee made recommendations which can be summarized as:

1) change the federal-provincial funding system to close the

open-ended "funding of health care" system.

2) try to move away from treating so many persons in hospitals by

closing beds and moving towards more outpatient care.

3) investigate other methods of organizing health care systems.

The main d i f f i c u l t y with government planning i s that the delivery

of services i s usually delegated to groups authorized by legislation and

funded by government to provide services - groups which are only

indirectly controlled.

Judge (1978) (71) was distinguished between financial and service

rationing. Governments can only control the legislation and funding of

direct services, although they have been trying to find ways of making

55.

the i n d i r e c t service deliverers more accountable. However, the service

deliverers have been resistant to these controls.

Consequently, the Task Force recommendations were very threatening.

Obviously, the f i r s t two recommendations had special implications

for nursing and they were strongly supported by a l l i e d health

professionals.

The medical establishment and hospitals resisted both of these

recommendations as i t would mean a major change i n a structure with which

they were comfortable.

Alford (1) states:

Groups are usually reluctant to y i e l d rights and privileges that they have exercised, and w i l l r e s i s t s i g n i f i c a n t restructuring unless i t appears that there i s something i n i t for them.

Closing hospital beds was not conducive to the status of the

hospitals, nor to the practice potential of the physicians, who had

become used to treating th e i r patients i n the now-sophisticated hospital

environment.

The t h i r d recommendation led to other a c t i v i t i e s . The federal

government ca l l e d two Health Manpower Conferences i n 1969 and 1971 (23)

(24). Following t h i s , federal-provincial manpower committees were set

up i n 1972 and gradually, inventories of health personnel and th e i r

d i s t r i b u t i o n were b u i l t up.

As w e l l , the government began to look at ways of u t i l i z i n g current

health care manpower more e f f e c t i v e l y , nursing manpower included.

Physicians wished to remain the primary contact with th e i r patients and

work on a fee-for-service basis. Ambulatory care was not at t r a c t i v e

since the physicians have had f a i r l y ready access to more convenient

.56.

hospital beds. The Community Health Centres Concept i s at odds with

concepts of physician control over the work s i t u a t i o n . Although some of

the physicians seemed to support the recommendations of the Boudreau

Report to develop nurse practitioners, i n general the medical profession

has strongly resisted t h i s concept and after demonstrations had

succeeded, no more was done to develop the position except i n the far

north.

3) advocacy groups are groups of consumers who come together

because of s p e c i f i c concerns. They attempt to u t i l i z e public support to

cause changes. In the health care system i n B r i t i s h Columbia the Social

Planning and Review Committee performs t h i s role but i t has not been

interested i n nursing problems. Professional interest groups may also

seek public support for the i r concerns. The nurses from the Vancouver

General Hospital i n 1978, played t h i s role. They successfully used

public support to gain changes at the Vancouver General Hospital.

Generally though, the public i s asked to support so many different

causes and issues that the role of advocates i n planning i s effective

usually only i n " c r i s i s " types of situations. On an ongoing long term

planning basis they have l i t t l e effect i n B r i t i s h Columbia.

B. Nursing Manpower Planning i n B r i t i s h Columbia

In B r i t i s h Columbia, manpower planning began i n 19^9 with studies

by Hamilton and E l l i o t (65) (18). The government did not implement these

studies immediately because i t did not have a strong c i v i l service to

follow through and p o l i t i c a l decisions were incremental decisions rather

than planned decisions.

In 1959 - 60, Dr. J. McCreary, Dean of Medicine, managed to find

resources to finance the Metropolitan Hospital Planning Council and two

57.

epidemiologists working out of the Department of Health Care and

Epidemiology prepared reports on hospital u t i l i z a t i o n . I t was hoped

that the Minister of Hospital Insurance would pick up th i s a c t i v i t y

(after i t had shown i t s e l f to be useful), and provide funding to carry on

with i t , but there was no help forthcoming and the Council went out of

existence. The government moved more ' e f f e c t i v e l y into health care

planning i n 1966 when the Regional D i s t r i c t s Act was passed together with

a Regional Hospital D i s t r i c t s Act to control hospital f a c i l i t y planning.

In 1966, Dr. McCreary persuaded the Honourable Judy LaMarsh,

Federal Minister of Health of the necessity to set aside some funding for

the development of health manpower training f a c i l i t i e s . B r i t i s h

Columbia was slow to pick up i t s share of the money. The provincial

government showed a great reluctance to get into planning so voluntary

planning bodies continued to act. In 1968, the RNABC joined the B r i t i s h

Columbia Medical Association, the B r i t i s h Columbia Pharmacy Association

and the B r i t i s h Columbia Dental Association to form the Council on Health

Resources and Manpower. Subsequently, the RNABC supported a study by

Williamson ca l l e d the "Nursing Manpower Study i n the Province of B r i t i s h

Columbia" (126). The goal was to attempt to id e n t i f y what nursing

manpower was available. The other d i s c i p l i n e s were studying t h e i r

profession's manpower a v a i l a b i l i t y at the same time. The name of the

council was subsequently changed to the B r i t i s h Columbia Health

Resources Council. I t was closely related to the Department of Health

Care and Epidemiology and l a t e r to the Division of Health Services

Research and Development at UBC which was headed by Dr. D.O. Anderson.

(The Division of Health Services Research and Development i s the s i t e of

the current Health Manpower Research Unit.) Although not i n any way

58.

effective i n introducing changes, the council had made people aware of the issues.

Dr. Anderson continued to research health manpower issues on

research grant funding from the federal government, and established the

Health Manpower Research Unit (HMRU) i n the Division. When the federal

government became involved i n health manpower planning i n 1972

(following the two national conferences i n 1969 and 1971), they involved

the p r o v i n c i a l government as wel l . The Federal government formed four

continuing committees, one of which was the Federal/Provincial Health

Manpower Committee, to advise the Council of Ministers, and Conference

of Deputy Ministers of Health for Canada.

Dr. Anderson was asked to represent the province on the

Federal/Provincial Health Manpower Committee.

When the NDP government came into power i n 1973, they set up the

BCMC which was meant to do teaching hospital f a c i l i t y planning

primarily, but i t got involved i n sorting out the students' practicum

placements and therefore into manpower planning.

The Division of Health Services Research and Development under Dr.

D.O. Anderson, then became involved with the BCMC i n a formal way.

F i r s t the Pr o v i n c i a l Council, responsible for advising the Mi n i s t r i e s of

Health and Education on f a c i l i t i e s and programs for health manpower

production, was established under the l e g i s l a t i o n which created BCMC.

Second, the Health Manpower Working Group, consisting of senior

o f f i c i a l s i n the Mi n i s t r i e s of Health and Education, was created to

advise the Ministers on health manpower requirements for the pro v i n c i a l

health care system.

Each of these bodies has a special research and development unit.

The P r o v i n c i a l Council was supported by the Division of Educational

59.

Planning reporting to the Council through an Educational Conimittee of

Deans and Academic Directors. The Health Manpower Working Group was

supported by the HMRU at UBC. These two units, dealing respectively with

production and requirements were linked by cross appointments. The

Director of Health Research and Development played an o f f i c i a l r o l e ; i t s

director Dr. D.O. Anderson, was secretary to the Health Manpower Working

Group, the representative of health o f f i c i a l s on the Education Committee

of the BCMC, and the p r o v i n c i a l representative to the Federal/Provincial

Health Manpower Committee (3). Thus the director became the corporate

planner for the manpower section.

The Division of Health Services Research and Development was given

the r e s p o n s i b i l i t y to study and model nursing manpower requirements of

a l l types of nurses, taking into account population needs, nursing

functions and categories, positions available, vacancies, unemployment

rates and labour force p a r t i c i p a t i o n . The goal was to advise on location

and size of new schools of nursing (3).

Meanwhile the RNABC had published a report i n 1973 e n t i t l e d

"Registered Nurse Manpower i n B r i t i s h Columbia" (110). This was i n

response to public concern i n 1970 and 1971 that there was an oversupply

of nurses re s u l t i n g i n unemployment for nurses. In the summer of 1972

and 1973 the press again were concerned with the supply of nurses and

t h i s time, there was a shortage.

This reports states i n summary:

The data presented i d e n t i f y current needs i n r e l a t i o n to the present health care system and as such should provide a st a r t i n g point for manpower planning to meet future needs as the system begins to change.

60.

The problems i d e n t i f i e d by th i s examination of the registered nurse manpower si t u a t i o n i n B.C. emphasize the need for further study i n the context of t o t a l health manpower and t o t a l health care for the people of the province.

This recommendation from the RNABC had not yet been carried out.

The RNABC became involved i n provincial manpower planning through

the BCMC. The past president of the association, Margaret Neylan, became

an employee of BCMC. The association was asked to send a representative

to the f i r s t planning meeting and other nurses sat on planning committees

for specialty areas.

But i n 1975 the government changed, BCMC was dissolved and the

manpower planning process was considerably diminished i n scope. The

nursing study was not completed although some information was useful

l a t e r on to determine school of nursing locations.

The Director of Health Services Research and Development Division

of UBC resigned and the unit took some time to be reorganized.

The concern with shortages of nursing personnel continued.

The Kermacks Report (73) states:

As was discussed e a r l i e r , the demand for R.N.s i s increasing. Cycles of very short supply and then adequate supply seem to characterize this work force. Indications are that the province i s now moving toward another short supply period. Two cycles have occurred since 1970. These findings d e f i n i t e l y indicate the need for serious manpower planning as registered nurses represent a large portion of the health care workers. Their absence creates a c r i s i s i n health care. The number of nurses prepared for administrative, teaching and specialized c l i n i c a l positions presents an even greater problem. The lack of q u a l i f i e d nurses for these positions has been a persistent concern of nurses and employers for years. An immediate and defined course of action i s required.

61.

Shortages of nurses have obviously affected the health care system.

The effect Is most obvious during the summer months when f u l l time

nursing s t a f f are taking vacations and when many nurses tend to transfer

to other positions. For the past several summers, beds have had to be

closed i n hospitals i n B.C. This has been most noticeable on the Lower

Mainland.

The current 1980 si t u a t i o n i n B.C. i s that there i s concentration at

thi s time on nursing requirements and supplies. This concern i s with

quantity but also with quality of nurses needed and available.

Many groups have made th e i r concerns known to the Ministry of Health

through reports, br i e f s and meetings.

Experience i n the current summer has only supported these concerns

as hospitals throughout the province have closed beds for the summer or

u n t i l they have s u f f i c i e n t nursing s t a f f to re-open these areas. Some

areas have not closed beds but have encouraged t h e i r medical s t a f f to

admit only urgent cases as they are "working short", which means they are

stretching t h e i r nursing s t a f f to dangerous l i m i t s . Vancouver General

Hospital, the major t e r t i a r y care r e f e r r a l hospital i n the province,

closed 200 patient care beds from June 1 to September 15, 1980. As we l l ,

special areas have reduced some of their services. The heart surgery

unit has reduced beds and some of the O.R.s are not open for the summer.

Dr. M. Petreman, President of the BCMA, i n the association's b r i e f

to the Hal l Commission, March 11, 1980 stated: that the BCMA i s aware of

inadequate hospital funding with i t s resultant deterioration of care.

He maintained that whenever hospital budgets get 'clamped on' there i s an

immediate cut-back on nurses. He claimed there i s inadequate

remuneration for nurses i n B.C. and a shortage of nurses i s developing.

62.

In the same b r i e f the BCMA also recommended a review of current

nursing tra i n i n g and continuing education programs; reasonable working

conditions and compensation for nurses.

These n o t i f i c a t i o n s of problems with manpower supply of nurses are

useful to help i d e n t i f y and focus on the problem. They are not useful to

help solve the problem because objective data i s not provided i n the

submission.

I t has not yet been i d e n t i f i e d how many nurses with what expertise,

knowledge and s k i l l s are needed where i n the province.

Not only has t h i s current need not been i d e n t i f i e d , but predictors

for future needs are only beginning. Since considerable time i s required

to plan and provide nursing education programs, current trends may be

indicat i v e of future c r i s i s .

Recent development i n manpower planning have occurred on three

fronts. The Social Credit government, concerned with cost saving,

i n i t i a t e d a study on physician manpower which was carried out by the Hon.

W. Black (former Minister of Health), (11) recommending cut-backs i n

training of physicians. The Minister of Universities, Science and

Communication, the Hon. Dr. P. McGeer, i s extremely interested i n

developing technology. As Minister of Education before the Ministry was

divided (See Appendix B), he recommended increasing the size of the

medical school at UBC to provide more physicians. In the l a s t few years,

the Ministry of Education has become increasingly involved i n health

manpower development. The Ministry of Education, through Dr. Sheilah

Thompson, coordinator of the Division of Health and Human Service

Programs, has begun to sort out the nursing care system, by i d e n t i f y i n g

the various levels of nurses and the competencies which these levels must

63.

have. Major concentration to th i s point i n the d e f i n i t i o n of

competencies has been on nursing aides and p r a c t i c a l nurses, although as

mentioned previously, funding i s now being sought to work on post-basic

c l i n i c a l specialty courses for registered nurses.

The post-basic specialty courses have become an issue because of

demands by entrepreneural groups that something be done to solve

problems i n t h i s area and the HMRU for the Health Manpower Working Group

has been delegated the task of sorting out nursing manpower issues

related to c l i n i c a l s p e c i a l t i e s . The group has begun two major

a c t i v i t i e s . The f i r s t i s the Health Manpower Vacancy Monitoring Project

(13). This project i s being undertaken by the BCHA and the HMRU. A

monthly survey i s conducted which c o l l e c t s data on the d i f f i c u l t - t o - f i l l

positions. These are positions which have been vacant for t h i r t y days or

more. The purpose of t h i s survey i s to id e n t i f y the s h o r t f a l l on a

monthly basis of R.N.s and other occupational groups i n acute care

settings. This i s a beginning attempt to determine what current demands

are for registered nurses and others.

The second a c t i v i t y i s being carried out by the HMRU for the

Manpower Working Group. I t i s a project to review the post-basic nursing

problems i n the province (123). A Steering Committee has been set up and

a preliminary questionnaire designed to ascertain the numbers of R.N.'s

providing special care services i n acute care hospitals i s i n the process

of tabulation.

C. Ineffective Cooperation Between Sectoral Groups i n B r i t i s h Columbia

Alford (1) has argued that the ideologies of the sectoral interest

groups i n New York Hospital Planning were so much i n c o n f l i c t that the

planning which went on was "dynamics without change." I t seems that i n

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B.C., interest groups were prepared to get together from time to time to

pursue common objectives. But planning of nursing manpower i n B r i t i s h

Columbia has never r e a l l y evolved to satisfactory l e v e l s . On the one

hand models for nursing manpower planning have not been c l e a r l y

i d e n t i f i e d , or i f i d e n t i f i e d , not c l e a r l y shown to f i t the circumstances

of B r i t i s h Columbia. In nursing manpower there has not been a clear

i d e n t i f i c a t i o n of the need for numbers and levels of nurses required for

B r i t i s h Columbia. Part of the problem i s the lack of standards for the

various levels of nurse and the various employment areas.

Another reason why nursing manpower planning i s not highly

developed i n B r i t i s h Columbia may have been the lack of commitment by the

government to u t i l i z e the data generated, possibly because those

concerned have not seen where best to.

I t has been pointed out to the provincial government i n many br i e f s

over several years that t h i s province only graduates forty per cent of

the nurses registered i n B r i t i s h Columbia because i t i s an intake

province, but no one has determined what the requirements actually are.

As w e l l , nurses with post-basic c l i n i c a l expertise have been i d e n t i f i e d

as scarce i n t h i s province.

Very l i t t l e has been done to date about either s i t u a t i o n . I t may

not be p o l i t i c a l l y expedient to promote nursing manpower planning i n

B r i t i s h Columbia or the funding may not be available to u t i l i z e the data.

The educational bodies involved have not sorted out who should be

providing either education or training or when, how and where th i s should

be provided. These groups are part of the corporate government group but

have not been properly incorporated into the planning a c t i v i t i e s . Nor

has a coordinated approach been developed either i n long term planning or

65.

i n those involved i n the planning. Plans, to now, have not been

developed, over a period of time i n an orderly way. Rather there have

been "starts and stops" or ad hoc plans developed, often i n i s o l a t i o n

from what has gone before or i n r e l a t i o n to future needs.

Interested groups remain uncoordinated. There are s t i l l many

groups, entrepreneurial, corporate and advocacy, trying to solve the

nursing manpower planning program i n the i r own ways or from thei r own

interest bases, but up to now they have been i n e f f e c t i v e .

D. Possible Reasons for Ineffective Planning

Marmor (83) i n the " P o l i t i c s of Medicare", suggests another model

for planning. He suggests that timing i s important and at a s p e c i f i c

time, one of three decision making methods may be most appropriate. He

describes the three methods as Rational Inputs, Bureaucratic Adjustments

and Negotiation Adjustments. Rational Inputs are obvious - as pointed

out above, there i s a lack of models, standards, clear objectives i n

nurse manpower planning. Rational planning implies i d e n t i f i c a t i o n of

goals and purposes, because decisions regarding which actions should be

undertaken are related to the optimal means i n reaching those goals and

purposes. Are the purposes and goals of entrepreneurs, corporate and

advocate groups the same for nursing manpower planning? Have they ever

been c l e a r l y i d e n t i f i e d by any or a l l of the groups? Can they be and

should they be the same? Can some goals and purposes be the same and yet

others d i f f e r ? W i l l short term and long term goals of various groups

d i f f e r ? Further involved i n r a t i o n a l planning i s a cha r a c t e r i s t i c model

of description, explanation, prediction and evaluation. Are these areas

i n which a l l three interest groups can agree on these a c t i v i t i e s so that

nursing manpower planning can proceed?

66.

Before r a t i o n a l planning can develop basic facts and data must be

available. Are these data available now? Can the Rational Inputs,

Bureaucratic Adjustments and Negotiation Adjustments groups cooperate i n

developing t h i s data base? Do they want to develop a simi l a r or the same

data base?

The concern with adequate numbers and q u a l i t i e s of nurses i s a North

American problem at th i s time. An a r t i c l e i n the American Journal of

Nursing, March 1979 (5), states loudly and cl e a r l y that there i s a

serious shortage of both quantity and quality of nurses. I t further

states that enrolments i n schools of nursing i s declining. The a r t i c l e

l i s t s four d i s t i n c t problem areas:

1) there i s a geographic maldistribution of nurses

2) expanding health care operations have created a need for

registered nurses with additional education

3) certain positions remain u n f i l l e d (those i n which there have

always been less than desirable working conditions)

4) the number of volunt a r i l y inactive nurses i s high.

These same problems are present i n the B r i t i s h Columbia nursing

scene.

These are negative statements. Positive models are less frequently

discussed but one which has had considerable currency i s the pyramidal

model considered by the WHO/ICS/MCU (128) group as the right model.

In B r i t a i n and i n Aust r a l i a , a ra t i o n a l plan for delivery of nursing

care has been developed. I t involves the use of equivalents of p r a c t i c a l

nurses for a great deal of nursing care delivery. In Canada, nurses have

not accepted t h i s delegation role and have not been forced to do so

because the government funds hospitals by global budgets and does not

67.

determine what l e v e l of nurse the hospital must hir e . Further, the

government has not had a r a t i o n a l plan for i t s introduction. Do the

"entrepreneurs" - the professional association planners -understand and

accept the implications of asking for a r a t i o n a l plan?

Since a l l three groups have a different interest base, do any of

these groups r e a l l y want r a t i o n a l planning? The "entrepreneurs" have

been trying to i n i t i a t e or develop a manpower plan for years. I f there

were a surplus of nurses would they s t i l l be committed to r a t i o n a l

planning? Would a r a t i o n a l plan remove f l e x i b i l i t y of the profession's

development?

The bureaucratic planning model i s concerned with the present

si t u a t i o n over which any planning group has control and ways of moving

incrementally towards change whilst making the best use of i t s existing

departments or sectors. The bureaucratic planners have to consider what

implications a r a t i o n a l plan would have i n nurse manpower planning.

Shortages i n nursing, p a r t i c u l a r l y c l i n i c a l specialty prepared nurses

e x i s t s . I f the bureaucratic planners were to develop a r a t i o n a l plan

adjusted to f i t existing i n s t i t u t i o n s would they have to commit the

resources and/or would they be able to, to implement the plan? The

corporate planners involved i n nurse manpower planning are at a

disadvantage because no one group has attained the power to provide an

overview of the si t u a t i o n and to pursue i t .

The Ministry of Health, through the Health Manpower Working Group

can i d e n t i f y service needs for nurses, but the Ministry of Education may

have different p r i o r i t i e s for spending the budget for educating nurses

for these services. The Ministry of Health controls the manpower

deployment i n operating i n s t i t u t i o n s only through the budget and use of

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consultancy advice. Therefore, the Health Ministry i s limited i n i t s

a b i l i t y to pursue manpower planning and implement recommendations.

The Ministry of Education, through various educational

i n s t i t u t i o n s , whose roles i n nursing education have not yet been

c l a r i f i e d , may i d e n t i f y and plan for educational needs for nurses but i f

these do not meet the p r i o r i t i e s of the Ministry of Health approval w i l l

not be given.

C i r c l e s run i n c i r c l e s . The confusion which exists today results i n

large part because of the vested interests of these corporate planners

and the lack of an overall coordinating mechanism which has the power to

force them to plan together. The negotiations adjustments model i s

concerned with seeking bargained solutions between parties with power to

plan. The bureaucratic planning model i n B.C. seems to be almost more of

a negotiations adjustment model, for the corporate planners have

developed mechanisms within t h e i r groups for negotiation and discussion.

An example i s the Health Manpower Working Group which has representation

from the Ministry of Education and the Ministry of Labour. Members of

th i s group have worked reasonably well together to try to solve nursing

manpower problems. By contrast, i n the Education Ministry, approval for

funding of programs i s through the Academic Council, which i s not part of

the c i v i l service, reports only to the Minister of Education and i s not

represented on the Health Manpower Working Group (although there i s some

attempt at cross referencing discussion since the chairman of the Health

Manpower Working Group attends the Education Health Committee of the

Academic Council). But the Health Manpower Working Group can not be sure

that i t s recommendations w i l l be carried out by that Ministry.

The effectiveness of t h i s inter-Ministry group i s questionable

o v e r a l l because i t s members do not have control of the i n s t i t u t i o n a l or

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professional resources and have not set up a formal negotiation system

with the "entrepreneurial" (professional association) groups.

Marmor (83) says that t h i s model develops from the position and

power of the principals and focuses on the understandings and

misunderstandings which determine the outcome of the games.

In planning for nursing manpower, which group has the greatest

power? Since advocacy groups are not active i n supporting nursing man­

power, they have only potential power at t h i s time.

The "entrepreneurs" - the professional association - have attempted

to i d e n t i f y the needs and to lobby for nursing manpower planning since

1973, but up to now have not been very e f f e c t i v e . However, t h i s group

has been successful i n r a i s i n g consciousness about the issue and i n

focusing the current interest on post-basic c l i n i c a l specialty courses.

Apart from t h e i r general concern about r a i s i n g the general educational

standards of the i r members, professional organizations, have i n the

past, tended to react to external pressures. As a r e s u l t , they have

planned on a short term basis for immediate c r i s i s needs. Therefore the

o v e r a l l directions i n which they see nursing progressing have not

c l e a r l y been determined. To develop a plan for nursing manpower, the

interest of a l l levels and groups of nurses must be considered, which i s

d i f f i c u l t to do i f the current c r i s i s relates to only one area of nursing

(the R.N.'s). The vested int e r e s t s , then of the professional

association, being focused on c r i s e s , have less force i n nursing man­

power planning. This group does gain strength i n the short term because

i t can concentrate i t s energies i n a bounded area of concern, but i t s

long term s e l f interests may be compromised.

The government corporate planning group, sometimes working with

employers' organizations (or HMRU), i s the most powerful group since i t

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controls the funding and the approval mechanisms. But government

interest has not, u n t i l recently, focused on nursing manpower. This

government corporate planning group i s made up of at least two separate

pr o v i n c i a l m i n i s t r i e s , each of which has interests other than nursing

manpower planning. This group has never been sure that i t wanted to

grasp manpower planning u n t i l recently and there are s t i l l many

discussion within the ranks. The Health Manpower Working Group has not

been unduly concerned with nursing manpower u n t i l 1980 and therefore i t s

resources have not been focused i n th i s area.

Since corporate planning i n B.C. must be concerned with bargaining

with the "entrepreneurs" what mechanisms have been set up to f a c i l i t a t e

t h i s a c t i v i t y for manpower planning? Have they been effec t i v e

mechanisms?

There has not been a formal mechanism set between the professions

and the corporate planners to deal with nursing manpower. The RNABC

meets with the Minister of Health on a regular basis, but to discuss a l l

concerns related to nursing not just the manpower planning issue;

however through t h i s mechanism the association has been able to bring the

manpower issue forward as a concern. The RNABC i s now represented on

several planning groups, but tends to act as a consultant about needs and

standards rather than as a policy setter because i t does not control

resources. The RNABC i s the agency which keeps the register of nurses,

thus i t has available some of the information about the supply of nurses

which i t w i l l i n g l y contributes.

Because the RNABC has decided that standard setting i s i t s respon-

s i b l i t y (approval of programs for continuing education), and th i s seems

to be accepted by corporate planners, i t has a subtle power to shape the

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planning, and to determine i t s effectiveness or ineffectiveness. In

1980, the UBC Health Manpower Research Unit was delegated the task of

nursing manpower planning for post-basic nursing. A steering committee

for t h i s group has been set up. The RNABC has appointed two members to

t h i s steering committee. This group provides a mechanism for formal

discussion among different planning interests but i s just beginning i t s

task.

The negotiation adjustments between the groups i s i n i t s infancy.

Although the corporate planners should be able to lead negotiations, i t

has been hampered because of i t s internal competing interests.

To be e f f e c t i v e , these groups must be aware of th e i r r e l a t i v e

powers, and become p o l i t i c a l l y astute re thei r bargaining bases. They

must also recognize each other as actors i n t h i s a c t i v i t y and set up

formal mechanisms, with decision making powers, to begin progress i n

manpower planning.

PART V

TOWARDS MORE EFFECTIVE PLANNING

72.

PART V

TOWARDS MORE EFFECTIVE PLANNING

Marmor's thesis (83) i s that at certain times one type of plan i s

more effective than another.

1) When i s the appropriate time, i f any, for r a t i o n a l decision

making to occur i n nurse manpower planning a c t i v i t i e s ?

2) Can bureaucratic planning be improved?

3) What i s l i k e l y to be the future of negotiated planning?

A. Rational Planning

Should nursing manpower planning continue without discussion and

decisions related to ra t i o n a l planning?

The customary way of making change i n democratic societies i s by

incrementalism. This may be shapeless and incoherent unless the policy

makers can draw upon a plan. Donnison (56) has argued that i t i s helpful

for policy makers to know of a standing r a t i o n a l plan. That plan may

change or be implemented i n a different manner once the p r a c t i c a l

application i s begun but that can only happen i f there i s a basis of

understanding. In applying t h i s to nursing manpower planning, a

ra t i o n a l plan should be the, foundation for any decisions on trade o f f s .

I f such a plan were developed i t should be the sta r t i n g point to

solve the confusions and disorganization i n nursing manpower planning.

Various models have been used i n the past to predict nursing needs.

(79) (See Appendix E) The measure of their lack of success can be seen

i n the current arguments about whether or not there i s a shortage of

nursing personnel. Although t h e o r e t i c a l l y , many of these models have

73.

indicated that there should not be a shortage, i n practice, Directors of

Nursing who are not able to r e c r u i t nurses indicate that there i s a

severe shortage.

Nursing manpower planning has been going on i n the province, but the

resu l t s of t h i s work have not been d e f i n i t i v e enough to f a c i l i t a t e

action.

No clear picture of current or future supply has been i d e n t i f i e d for

general or special c l i n i c a l areas. This can be related to the fact that

s p e c i f i c d e f i n i t i o n s of levels of hospitals and health care are not yet

established. Nevertheless there are some commonly accepted specialty

areas where work could begin. Presently there i s no clear picture of

current demand or predicted demand for nurses. The h a r d - t o - f i l l

positions survey i s an attempt to try to determine what the current

nursing needs are i n general nursing areas as well as i n special c l i n i c a l

areas.

The pro v i n c i a l government provides operating costs for hospitals i n

the province. I t should be possible to id e n t i f y the number of f u l l time

equivalent positions the province i s currently supporting. This could

then be broken down by nurses employed i n general nursing areas and those

employed i n special c l i n i c a l areas. In Canada, the average percentage of

nurses needing education for special c l i n i c a l areas i s 20%. The B r i t i s h

Columbia average i s currently unknown.

Standards of competency for nurses working i n special care areas

have not been determined. Perhaps nurses could be provided for the lower

l e v e l special care areas more easily by means other than post-basic

courses, were these standards set. The demand for specialty c l i n i c a l l y

educated nurses might then be clearer.

74.

The pro v i n c i a l government has developed a Bed Matrix Model for the

province.^ (62) This i d e n t i f i e s the beds which are to be i n operation and

the types of services which are to be offered for 1981 and 1986 by

pro v i n c i a l hospitals. These data could provide a basis for estimates of

current and future demand for nurses. To date these data have not been

used i n nurse manpower planning.

The current supply of general duty and special c l i n i c a l nurses i s

unknown. I f evaluations of competencies were to occur t h i s would provide

a beginning base.

The following information was taken from the Kermacks' Report (73).

The majority of nurses are women. Only 1-6% of the registered nurses

employed i n 1978 were men. The majority of nurses are between the ages

of 25 to 34 years. Most nurses are married. Only 36.3% of the R.N.s are

single. Most married R.N.s are employed on a part time basis

p a r t i c u l a r l y between the ages of 30 and 39. The highest percentage of

f u l l time employees are single, between the ages of 20 to 24 and 55 to

64. A t o t a l of 76.7% of a l l R.N.s are employed on a f u l l time basis.

Characteristics of nurses should be considered when discussing

supply and integrated i n the planning information. The s o c i a l

c h a r a c t e r i s t i c s of nurses have an impact on how, why, and where they

remain i n the nursing work force or why they might be leaving nursing.

By reviewing these ch a r a c t e r i s t i c s , s p e c i f i c factors can be i d e n t i f i e d

which should be considered i n manpower planning, p a r t i c u l a r l y i n

ide n t i f y i n g supplies of nurses.

The new graduates provided by the education system are a part of

supply information. The nursing schools have a certain number of

"places" for entry of students. Should t h i s number be increased to make

75.

up for the high a t t r i t i o n rate ( 3 0 to H0%) of nursing students, so that

schools designed to provide 100 graduates for the system are able to do

so? Is i t necessary to increase the "spaces" or merely to oversubscribe?

Can t h i s province continue to count on others to provide "up to 60%"

of our nursing manpower? The schools of nursing should be included i n

discussions on supply of nursing manpower.

The preparation of nurses to work i n specialty c l i n i c a l units i s one

area that has lacked concrete attention. The Ministry of Health has not

o f f i c i a l l y recognized the need for inclusion of post-basic nursing

courses as a part of publicly funded education. This i s partly because

the specialty and sub-specialty care units, where these nurses work,

have not yet been c l e a r l y i d e n t i f i e d . This w i l l be d i f f i c u l t to

determine u n t i l the roles of hospitals, and the l e v e l of a c t i v i t y to be

provided i n each, i s c l e a r l y defined.

The government, i n a l l o c a t i n g funds to hospitals, has neglected to

consider the orientation and inservice costs for nurses i n hospitals.

Nurses i n special care units have often not had s u f f i c i e n t on-the-job

tr a i n i n g and orientation to perform e f f e c t i v e l y the competencies

required of them i n special care units. As a r e s u l t , there i s not at the

present time a pool of knowledgeable and well q u a l i f i e d nurses available

to work i n these ares, nor i s there money available to prepare new nurses

i n t h i s way for t h e i r r e s p o n s i b i l i t i e s . Even i f money were available for

t h i s a c t i v i t y , i t may not be the most desirable method of preparing

nurses. Standards would vary greatly from one hospital to another and

cost effectiveness could be questioned.

One other area of funding i s currently lacking. Support of nurses

to attend post-basic courses and costs of replacing s t a f f while they are

f

76.

at courses has not yet been sorted out. This i s an important question

which needs to be addressed before planning for post-basic courses can

proceed.

B. Bureaucratic Planning

A number of problems i n bureaucratic nurse manpower planning i n

B r i t i s h Columbia were i d e n t i f i e d . The f i r s t i s that of commitment to

planning, the second j u r i s d i c t i o n a l boundaries and f a i l u r e s to resolve

the d i f f i c u l t i e s associated with these.

C. Negotiation Planning

Whilst government involvement i n nurse manpower planning i n B r i t i s h

Columbia can be c r i t i c i z e d for i t s ineffectiveness, i t can be applauded

for i t s openness i n negotiating with other interest groups. However,

these negotiations tend to be i n e f f e c t i v e , because of the current

planning models and also because of the different values that nursing

administrators, nursing educators and practitioners have. In the past,

educators were most powerful because they had the most education, time to

think, time to develop support networks and the status given them by the

nurses themselves. Nursing administrators have begun to overtake that

power, as they are now becoming more educated and are much closer to the

r e a l world of nursing and the dispensation of dollars to provide nursing

care. Practitioners have had least, i f any, power because of the i r

submissive employee status, but today they have begun to r e a l i z e that

they have a great deal more power, simply by withholding t h e i r work. I t

i s important to ask i f these three groups involved i n the negotiations

have thought about or i d e n t i f i e d where the power l i e s or what th e i r power

base i s . I f so, have they c l e a r l y i d e n t i f i e d t h i s rather than working on

assumptions which may have derived from t r a d i t i o n a l stereotyping?

77.

D. Conclusions

The f a i l u r e of nurse manpower planning i n B r i t i s h Columbia can be

attributed to lack of a r a t i o n a l basis against which to measure

performance, bureaucratic ineptness, and f a i l u r e s i n negotiation.

Although nursing i s regarded as an important a c t i v i t y i n health

care, nursing i n B r i t i s h Columbia has not been considered c a r e f u l l y

enough. International models for nurse manpower planning may be quite

inappropriate for planning here.

Stereotyped characteristics of nurses are commonly described i n

writings about nursing manpower planning. Rarely do authors come to

grips with what effects changing characteristics of the occupational

group actually have on nursing manpower, because i t i s not easy to do so.

What does i t mean to nursing manpower planning i n B r i t i s h Columbia

that nursing i s almost t o t a l l y a woman's profession? What effect does

most nurses being married have? What do the ages of nurses mean? I t i s

important to know about part time and f u l l time employees but what does

t h i s mean i f we are trying to plan for nurses' manpower here?

One of the concerns of nursing, described e a r l i e r i n t h i s paper, i s

the different interpretation or d e f i n i t i o n of nursing made by nursing

educators and nursing service people. The educators are seen to i d e n t i f y

and teach nursing according to one set of standards. The nursing

administrators and practitioners seem to say "that's not how i t i s . "

Does the same type of si t u a t i o n exist i n manpower planning?

The practitioners provide the majority of nursing manpower. Have

we examined the basic value system of practitioners? Since most

practitioners are women, and married, they often have competing roles of

wives and mothers. Have we looked at commitments of practitioners to

78.

these varying roles? Have we asked them what they want and what they are

prepared to give i n nursing? Have they been able to communicate

e f f e c t i v e l y enough with the planners? Have we understood and been able

to u t i l i z e t h i s information i n manpower planning? Would i t be valuable?

These questions remain to be answered.

The practising nurse, i n the past has had l i t t l e , i f any formal

power except to work or not to work — she could vote with her feet but

not make herself heard. Do the changing values and roles of the nurses

who actually provide the care now begin to matter as they increase t h e i r

formal power with the development of unions which no longer p u l l t h e i r

punches for 'vocational* reasons?

In the past the nursing practitioner has negotiated d i r e c t l y with

the hospital Directors of Nursing about available jobs and her

willingness to f i l l them. She has made i t clear that what she wants i s

not a pyramidal structure of power with promotion upwards and delegation

downwards. She wants to be a primary care nurse i n charge of her own

patients with the potential for horizontal movement within the same

hospital or within the l o c a l i t y (or i f her husband moves she wants to be

able to pick up a job i n the l o c a l hospital i n the new location). She

wants to know she i s competent to do th i s work. I f she feels

uncomfortable she w i l l move out into some other sphere. Directors know

t h i s . Do health planners?

E. Recommendations

I t i s recommended that:

A model of r a t i o n a l planning, that considers the current si t u a t i o n

of nurses i n B r i t i s h Columbia, be i d e n t i f i e d for nurse manpower

planning.

79.

a. A ra t i o n a l plan for nurse manpower planning i n B r i t i s h

Columbia be developed and implemented. This plan should include

attention to post-basic c l i n i c a l specialty courses.

b. The bureaucratic negotiation process for nursing manpower i n

B r i t i s h Columbia be sorted out and a l l involved parties be made aware.

c. The negotiating process involved i n nursing manpower planning

be continued, but a l l parties be aware that with increasing union

involvement t h i s process w i l l become more f i e r c e .

80.

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108. Registered Nurses' Association of B r i t i s h Columbia, Views on Post Basic C l i n i c a l Nursing Education, Vancouver, Registered Nurses' Association of B r i t i s h Columbia, 1980.

109. Registered Nurses' Association of B r i t i s h Columbia, Views on Continuing Basic C l i n i c a l Nursing Education, Registered Nurses' Association of B r i t i s h Columbia, 1980.

110. Registered Nurses' Association of B r i t i s h Columbia, Registered Nurse Manpower i n B r i t i s h Columbia, Vancouver, Registered Nurses' Association for B r i t i s h Columbia, 1973.

111. Registered Nurses' Association of B r i t i s h Columbia, Statements on Certain Recommendations on the Report of the Royal Commission on Health Services, Vancouver, Registered Nurses' Association of B r i t i s h Columbia, 1965.

88.

112. Research Group, Metropolitan Hospital Planning Council, Hospital Use i n the Metropolitan Area of the Lower Mainland, Vancouver, Metropolitan Hospital Planning Council, 1961.

113. Robertson, R. Rocke, Health Manpower Output of Canadian Educational I n s t i t u t i o n s , Ottawa, Association of Universities and Colleges of Canada, 1973.

114. Roemer, Ruth and Roemer, Milton, Health Manpower Policy Under National Health Insurance - The Canadian Experience. United States Department of Health Education and Welfare, Washington, D.C, 1977.

115. Sackett, D.L. et a l , "The Burlington Randomized T r i a l of the Nurse Pra c t i t i o n e r , Health Outcomes of Patients", Annals of Internal Medicine, Vol. 80, February, 1974, pp 137 - 42.

116. Saskatchewan, Royal Commission on Government Administration, Regina, Queens Pri n t e r , 1965.

117. So c i a l Planning and Review Council of B r i t i s h Columbia, Members B u l l e t i n s , 1970 - 1980.

118. Stevens, Barbara J . , Mandatory Continuing Education for Professional Nurse Relicensure; What are the Issues? Journal of Nursing Administration, September/October, 1973.

119. Street, Margaret M., Canadian Nursing i n Present, Past and Future, University of Alberta, 1974.

120. Street, Margaret M. Watchfires on the Mountains: The L i f e and Writings of Ethel Johns, Toronto, University of Toronto Press, 1973.

121. Thompson, S., Post Basic Nursing Programs Discussion Paper: Vancouver Health and Human Services Program, B r i t i s h Columbia Ministry of Education, pp 1 - 30 , 1976.

122. University of B r i t i s h Columbia, Health Manpower Research Unit, R o l l C a l l , 1978, 79.

123. University of B r i t i s h Columbia, Human Manpower Research Unit, Review of Post Basic Nursing Problems i n the Province, ongoing 1980.

124. Webster, M., Seventh New Collegiate Dictionary, Thomas Allen Limited, Toronto, 1963.

125. Weir, G.M., Survey of Nursing Education i n Canada, Toronto, University of Toronto Press, 1932.

126. Williamson, Eva. M., Nurse Manpower Study i n the Province of B r i t i s h Columbia, B r i t i s h Columbia Health Resources Council, 1970.

89.

127. Williamson, L., Future Prospects, Nursing Mirror 144, February 10, 1977, pp 50 - 1.

128. White K.L. et a l . , International Comparisons of Medical Care: (WHOICSMCU) The Milbank Memorial Fund Quarterly, Vol. L No. 3, July, 1972, Part I I .

129. Winegard, W., Commission on University Programs i n Non-Metropolitan Areas, B r i t i s h Columbia Ministry of Education, pp 1 - 30, September, 1976.

130. Zimmer, Marie J . , Rationale for a Ladder for C l i n i c a l Advancement i n Nursing Practice, Journal of Nursing Administration, November/December, 1977.

90.

APPENDIX A

POST-BASIC NURSING PROGRAMS

Table A: Post-Basic Nursing Programs Based i n Education In s t i t u t i o n s

Table B: Post-Basic Nursing Programs Based i n Health Care F a c i l i t i e s

Table C: Proposals for New Post-Basic Nursing Programs

Source: Kermacks, Clair e ; A Report to the Health Education Advisory Council: Nursing Education Study; Ministry of Education, Science and Technology, Province of B r i t i s h Columbia, Vancouver, A p r i l , 1 9 7 9 .

TABLE A: POST-BASIC NURSING PROGRAMS BASED IN EDUCATION INSTITUTIONS

REPORT FOR BRITISH COLUMBIA, 1979

PROGRAM INTAKES SOURCE STUDENT R INTAKES OF PROG. FINANCIAL or PER STU- ADMISSION CERTIFICATE OPERATING SUPPORT

NAME & DESCRIPTION LOCATION LENGTH D YR DENT CRITERIA ISSUED BY TUITION FUNDS AVAILABLE

Advanced Nursing Care of Hospitalized Child

VCC 14 wks (p.t.) & 4 wks full-time C l i n i c a l Practice

R 1 12 Jan

6 mos. acute care experience s a t i s , c l i n . evaluation

VCC $200.00 VCC Ministry of Ed.

Diploma i n Psychiatric Nursing

BCIT

Program spe c i a l l y designed for R.N.s Includes practicum i n acute and long term psych., Mental Retardation and Psycho-g e r i a t r i c s

34 wks min. a 17 wk pre-ceptorship may be required

2 de-Jan pend Aug on

seats

P r i o r i t y B.C. BCIT $505.00 BCIT Ministry of Ed.

Remarks: Graudates e l i g i b l e for re g i s t r a t i o n as psychiatric nurse (RPNABC)

TABLE A CONT'D

PROGRAM INTAKES SOURCE STUDENT R INTAKES OF PROG. FINANCIAL or PER STU- ADMISSION CERTIFICATE OPERATING SUPPORT

NAME & DESCRIPTION LOCATION LENGTH D YR DENT CRITERIA ISSUED BY TUITION FUNDS AVAILABLE

C r i t i c a l Care Nursing Level I

VCC Lower Mainland

UBC parts of prov. on request

6 wks +

5 wks or

approx 1 yr on p/t basis

R 3- 15 Recent s a t i s . & 6 c l i n i c a l D evaluation.

C.P.R. c e r t i f i c a t e

VCC or UBC

$250.00 VCC Min. of Ed.

UBC

At least 1 yr recent exp. i n acute med/surg. unit.

OR Nursing to prepare beginning l e v e l R.N.s for OR's

BCIT (B'by)

10 wks F.T.

R 3 12 Oct Jan Apr

Recent C l i n , exp. Intent to work i n B.C. Satis med. exam

BCIT BCIT Min. of Ed.

CEIC

TABLE A CONT'D

PROGRAM INTAKES SOURCE STUDENT R INTAKES OF PROG. FINANCIAL or PER STU- ADMISSION CERTIFICATE OPERATING SUPPORT

NAME & DESCRIPTION LOCATION LENGTH D YR DENT CRITERIA ISSUED BY TUITION FUNDS AVAILABLE

Health Care Management

to develop & improve s k i l l s , of department heads, supervisors, head nurses, a s s i s t , head nurses i n hosp. & other health care f a c i l i t e s

Management i n Health Care I n s t i t u t i o n s

BCIT (B'by)

RCH/DC Ed Cent. New West

course designed for nurses & other health workers wanting to prepare for supervisory positions. Includes theory & practice on fundamentals of supervision

3 yrs p/t 3 hrs/ wk 8 units

15 wks p/t 3 hr/wk

R 2 appr no r e s t r i c -Sept 50 tions Jan

BCIT i n $70 BCIT co-opera- per unit tion with BCHA

R 2 appr. p r i o r i t y 15 to B.C.

residents

DC $33 DC

TABLE B: POST-BASIC NURSING PROGRAMS BASED IN HEALTH CARE FACILITIES

REPORT FOR BRITISH COLUMBIA, 1979

PROGRAM INTAKES SOURCE STUDENT R INTAKES OF PROG. FINANCIAL or PER STU- ADMISSION CERTIFICATE OPERATING SUPPORT

NAME & DESCRIPTION LOCATION LENGTH D YR DENT CRITERIA ISSUED BY TUITION FUNDS AVAILABLE

Enterostomal Therapy

to prepare R.N.s to function as enterostomal therapists SPH: St. Paul's Hospital

OR Nursing

SPH Van.

SPH Van

to provide knowledge & s k i l l s so that optimum nursing care can be given to patients before, during and after surg. intervention

Radiotherapy Technology for Nurses

CCABC Van.

8 wks F.T.

R 5

6 mos f . t .

2 yrs

R 2 6 Sept Mar

R 2 June Oct

1 yr exp. & confirm of f . t . job on completion P r i o r i t y : 1. B.C. 2. Canada 3. USA

1 yr nursing exp P r i o r i t y : 1. B.C. 2. Canada 3. USA

SPH approx SPH $1000

SPH $250 SPH

Bursaries available

Remarks: Program lead to e l i g i b i l i t y to s i t national exams for Canadian Assoc. of Medical Radiology Technologists

TABLE B CONT'D

PROGRAM INTAKES SOURCE STUDENT R INTAKES OF PROG. FINANCIAL or PER STU- ADMISSION CERTIFICATE OPERATING SUPPORT

NAME & DESCRIPTION LOCATION LENGTH D YR DENT CRITERIA ISSUED BY TUITION FUNDS AVAILABLE

In d u s t r i a l F i r s t Aid St. John's 10 wks R 2 St. John's $135 C e r t i f i c a t e Amb. or Sept Amb.

i* wks Jan p. t. 2 wks Remarks: a week f u l l time for A & f . t . Ticket Holders only

I n d u s t r i a l F i r s t Aid ABC 2 wks R 20 19 yrs WCB $125 s e l f -Indus­ f . t . wkly of age funding t r i a l 10 wks

Theory & practice Emerg. p.t. i n emergency care Training Remarks: on completion of program equipment & CPR School students e l i g i b l e to s i t WCB exams

Inc. R.N.s e l i g i b l e for B t i c k e t .

TABLE C: PROPOSALS FOR NEW POST-BASIC NURSING PROGRAMS

REPORT FOR BRITISH COLUMBIA, 1979

PROGRAM INTAKES SOURCE STUDENT R INTAKES OF PROG. FINANCIAL or PER STU- ADMISSION CERTIFICATE OPERATING SUPPORT

NAME & DESCRIPTION LOCATION LENGTH D YR DENT CRITERIA ISSUED BY TUITION FUNDS AVAILABLE

C r i t i c a l Care Nursing Level I I

VCC &

UBC advanced knowledge & s k i l l s common to specialized C r i t i c a l Care areas with courses i n s p e c i f i c specialized f i e l d s , e.g. cardiac, spinal injury, emergency, etc.

Obs. Nursing Level I

Normal mother & newborn with emphasis on intrapartum period

3 mos.

VCC 20 wks Van. p.t. + Distance 6-8 wks Educ. f . t .

2 6 C r i t i c a l Care Course I or equiv.

1 16

VCC or

UBC

VCC

VCC Min. of F i r s t Course Ed./UBC Sept/80 or

Jan/81

VCC Min. Of Ed.

Remarks: F i r s t course Sept/80 Two courses at one time -one l o c a l - one distance

TABLE C CONT'D

NAME & DESCRIPTION LOCATION

PROGRAM INTAKES R INTAKES or PER STU- ADMISSION

LENGTH D YR DENT CRITERIA

SOURCE STUDENT OF PROG. FINANCIAL

CERTIFICATE OPERATING SUPPORT ISSUED BY TUITION FUNDS AVAILABLE

Level I I VCC

high r i s k mother & newborn with emphasis on intrapartum period

Psychiatric BCIT Nursing Douglas

as above

1 16 Obs Nrsg Level I or equiv.

VCC VCC Min. of Ed.

Remarks: F i r s t course Sept/81

Infection Control

C e r t i f i c a t e Program i n Gerontology

Occupational Health Nrsg.

UBC

UBC

RCH/ DC Ed. Centre New West

p.t.

i-1 yr

12 mos. p.t. 6 parts of 10 wks

1 20-25 R.N.'s working i n occup. health

DC DC F i r s t course Min. of Sept/80 Ed.

Emergency Nursing RCH/ DC Ed. Centre New West.

16 wks f . t .

15-1st course 30 there­after

2 yrs exp. DC $400 DC F i r s t course Min. of Sept/80 Ed. second course

Jan/81.

APPENDIX B

PROCESS FOR COURSE APPROVAL AND FUNDING

IN THE PROVINCE OF BRITISH COLUMBIA, 1980

99.

APPENDIX B

PROCESS FOR COURSE APPROVAL AND FUNDING

IN THE PROVINCE OF BRITISH COLUMBIA, 1980

To begin to understand t h i s process, i t i s important generally to know the organizational structures of the Ministry of Education and the Ministry of Health as they relate to the approval process and to know s p e c i f i c functions of bodies within the mini s t r i e s .

THE MINISTRY OF EDUCATION

The Ministry of Education i s headed by a Minister of Education.

Reporting to him are three deputy ministers one i f whom i s the Assistant

Deputy of Post-Secondary Education. The post-secondary department has

three d i v i s i o n s : programs services, continuing education and management

services. Each provides support services for the councils i n addition to *

performing i n s p e c i f i c areas outlined.

The program services d i v i s i o n participates i n the development of

new programs for colleges and i n s t i t u t i o n s . I t implements research into

subject areas i n which new needs have been perceived and i f a program

appears desirable, proceeds to curriculum design. I t also regulates

procedures by which i n s t i t u t i o n s develop programs, monitors the i r

effectiveness through regular reviews of the need of both students and

employers, and i n i t i a t e s a five-year review of each i n s t i t u t i o n . The

programs services d i v i s i o n supplies selected support service to the

Academic and Occupational Training Councils. The programs services

d i v i s i o n , again, i s divided into three areas of r e s p o n s i b i l i t y . The

Academic/Technical Directory i s the d i v i s i o n which deals with nursing

programs. This d i v i s i o n has appointed a Coordinator of Health and Human

Services Programs who i s currently Dr. S. Thompson.

100.

One"other important group i n the Education Ministry relevant to the

approval system i s the Councils Advisory to the Ministry. These councils

are three i n number. The one of concern to post-basic nursing education

i s c a l l e d the Academic Council.

At the post-secondary l e v e l , the governing boards of i n s t i t u t i o n s

have complete management authority. P r o v i n c i a l councils have been

delegated r e s p o n s i b i l i t y for recommending levels of support to

government and al l o c a t i n g f i n a n c i a l resources.

The councils are funnels through which the financing requests of

the i n s t i t u t i o n s flow into the Ministry and to the government, which bear

the ultimate f i n a n c i a l and l e g i s l a t i v e r e s p o n s i b i l i t y .

These bodies are the Universities' Council of B r i t i s h Columbia, the

Academic Council, the Occupational Training Council and the Management

Advisory Council.

The intent of th i s system i s to free a l l post-secondary education

i n s t i t u t i o n s from direct government control while at the same time

providing the tools to enable everyone concerned with post-secondary

education to meet two imperatives.

The f i r s t i s the provision of knowledge and s k i l l s to the people of

the province to' enable them to l i v e enriched and useful l i v e s and earn

satisfactory compensation for their contribution to society.

The second i s to accomplish t h i s ideal at a cost that i s reasonable

i n r e l a t i o n to the t o t a l revenue available to the government and, at the

same time, acceptable to the taxpayers of the province.

The appointment of members of the councils and members of the boards

of pr o v i n c i a l i n s t i t u t e s i s the prerogative of the Lieutenant-Governor

i n Council, while the appointment of the members of the governing bodies

101.

of colleges i s the prerogative of the Minister and involved school

d i s t r i c t s . This ensures c i t i z e n involvement i n educational decision

making.

The practice i s to appoint lay people with managerial experience

and a strong sense of f i s c a l r e s p o n s i b i l i t y , who have attained success i n

the i r own part i c u l a r f i e l d s , and who have a broad interest i n , and

dedication'to, education and career t r a i n i n g .

In 1963, a new Universities Act established the Advisory Board to

make recommendations to the government on the al l o c a t i o n of public

monies among the un i v e r s i t i e s and an Academic Board to advise on academic

matters.

In 1974, the functions of the two boards were combined into a single

intermediary body, the Universities Council of B r i t i s h Columbia. This

recognized the need for an even stronger voice between the government's

policy-making and di r e c t i o n a l roles and the three public but

independently-operated u n i v e r s i t i e s . A body with clear l e g i s l a t i v e

authority was required, one that could have the confidence of the

government yet be close enough to the u n i v e r s i t i e s to distinguish

between t h e i r needs and the needs of the province as a whole.

I t could also serve to eliminate unnecessary duplication of

services among i n s t i t u t i o n s i n close physical proximity, and coordinate

t h e i r a c t i v i t i e s on matters of common concern.

Similar reasoning was instrumental i n the decision of the

government i n 1977 to set up three additional councils to l i a s e with the

Ministry and the indiv i d u a l colleges and pro v i n c i a l i n s t i t u t e s which

complete the post-secondary spectrum.

The Universities Council of B r i t i s h Columbia consists of 11 members

who are appointed by the pro v i n c i a l government and employs a f u l l time

102.

director and s t a f f .

The Universities Council reviews the budget proposals and other

requests for funds from the three u n i v e r s i t i e s , examines thei r f i n a n c i a l

requirements, and advises the government on the t o t a l amount of money

they need.

The Council distributes a l l operating funds from the provincial

governments to the indiv i d u a l u n i v e r s i t i e s . The Universities Council

also reviews the Academic Council recommmendations regarding requests

for money from colleges and provincial i n s t i t u t e s to pay for programs for

which the Academic Council i s responsible.

Demands for c a p i t a l funds are assessed by the Universities Council

for the Universities and reommendations are made to the Ministry.

The Universities Council also examines plans for academic develop­

ment, and approves the establishment of new f a c u l t i e s and degree prog­

rams. I t may require the un i v e r s i t i e s to consult with each other to

avoid unnecessary duplication pf f a c u l t i e s and programs and can

establish procedures to evaluate university departments, f a c u l t i e s and

programs.

The Universities Council and the Academic Council work together on

questions of program a r t i c u l a t i o n and course equivalencies between

programs.

The Academic Council consists of f i v e members appointed by the

prov i n c i a l government.

The council i s responsible for coordination and funding of academic

transfer programs offered by the colleges, technological programs

offered by BCIT and various other career programs at colleges and

i n s t i t u t e s .

103.

The programs related to the humanities, s o c i a l and natural

sciences. Included are career programs i n the managerial,

administrative, s e c r e t a r i a l , c l e r i c a l , health, applied art s ,

electronics, aviation technology and such service related aras as

criminology, police training and administration, f i r e f i g h t i n g and leg a l

assistance.

The Academic Council required i n s t i t u t i o n s to provide i t with

proposed budgets for the designated programs. I t makes recommendations

to the u n i v e r s i t i e s Council and the Ministry concerning those requests

and allocates funds provided to i t by government amongst the various

i n s t i t u t i o n s .

The Council also establishes Academic Advisory Committees to as s i s t

the Council and Ministry i n developing program content and standards. I t

depends upon a r t i c u l a t i o n committees to provide advice on the

equivalency of courses given at one i n s t i t u t i o n compared with another.

The Council may require i n s t i t u t e s to accept equivalency decisions,

and may recommend to u n i v e r s i t i e s ' senates that they be accepted by the

u n i v e r s i t i e s . The resulting interchangeability of program credits i s

designed to f a c i l i t a t e movement of students from college to college and

from college to university.

i The Academic Council has a subcommittee cal l e d the Technical

Advisory Committee. Members of t h i s committee are appointed and they are

s p e c i a l i s t s i n a given f i e l d . The Education Health Advisory Committee

reports to the Technical Advisory Committee.

When discussing t h i s process, i t i s important to note that a change

has occurrred i n the education f i e l d i n B r i t i s h Columbia. The B.C.

Government News, Volume 24, Number 9, December 1979 reported that

104.

Premier B i l l Bennett announced major cabinet changes on November 23,

1979. Among these were a d i v i s i o n i n the Ministry of Education into two

min i s t r i e s .

The Ministry of Education was to have r e s p o n s i b i l i t y for public

schools from kindergarten to Grade 12, colleges, vocational schools, the

B.C. I n s t i t u t e of Technology, and the Open Learning I n s t i t u t e .

The newly created Ministry of Universi t i e s , Science and

Communications was to have r e s p o n s i b i l i t y for the administration of the

University's Act and the promotion of science and technology within the

province.

In discussions about the funding process with Sheilah Thompson,

Co-Ordinator of Health and Human Services Programs, Ministry of

Education i n March, 1980, she indicated that j u r i s d i c t i o n a l matters

between thee two ministries were s t i l l being worked on and evolving. For

that reason, very l i t t l e information i s provided about the Ministry of

Univ e r s i t i e s , Science and Communication.

MINISTRY OF EDUCATION STRUCTURES AS IT RELATES TO FUNDING OF ADDITONAL COURSES

MINISTRY OF EDUCATION

K-12

Minister of Education

Deputy Minister of Education

Councils Advisory to the Minister

Post-Secondary I Assistant Deputy Minister

Post-Secondary

Management Services Division

Research and Development Director

Academic Council

(Nursing Courses)

Program Services Division

Technical/Trades Director

Continuing Education Division

Academic/Technical Director

Occupational Training Council

Management Advisory Council

Health and Human Services Programs Coordinator

Dr. Sheilah Thompson Coordinator of Health and Human Services Programs Ministry of Education March, 1980 o

106.

THE MINISTRY OF HEALTH

The Minister of Health i s responsible for the work of the Ministry

of Health. A deput minister reports to the Minister of Health and i s

responsible for seven divisions of the Ministry. One of these divisions

i s the Planning and Development Group. The Health Mannpower Working

Group i s an i n t r a - m i n i s t e r i a l committee of the Ministry which i s chaired

by the Executive Director of Planning and Development and reports to the

Deputy Minister of Health.

HEALTH MANPOWER WORKING GROUP

Terms of Reference

1. To recommend and advise on appropriate policy regarding the growth,

development and control of health manpower i n the Province.

2. To establish p r i o r i t y areas for health mannpower research i n the

Province and arrange for t h i s research to be conducted.

3. To advise the Deputy Minister on appropriate action regarding the

results of research conducted i n the area of health manpower.

4. To address or respond to sp e c i f i c manpower concerns, consulting

with expert committees, professional associations, the Mi n i s t r i e s of

Labour and Education, and other agencies or Mi n i s t r i e s as necessary.

5. To receive reports addressing s p e c i f i c concerns and take action

where necessary or advise the Deputy Minister on appropriate action with

regard to these concerns.

6. To act as l i a i s o n with other M i n i s t r i e s and to discuss with and

recommend action through the Deputy Minister on matters of

i n t e r - M i n i s t e r i a l concern regarding health manpower.

7. Through the chairman and/or his appointees, to provide

representation on behalf of the Provincial Ministry of Health to

107.

federal/provincial, i n t e r - p r o v i n c i a l and i n t r a - p r o v i n c i a l committees

concerned with health manpower, advising the Ministry of Health on

matters of concern and appropriate action.

8. To review proposed health manpower l e g i s l a t i o n for i t s implications

regarding the d i s t r i b u t i o n , control and supply of health manpower stock

and advise the Deputy Minister of any concerns.

9. To advise other M i n i s t r i e s , outside agencies, licensing bodies, and

associations of existing p o l i c i e s regarding health manpower.

10. To be aware of, and where necessary assess, proposed health care

programs for implications for health manpower and where necessary,

advise the Ministry of Health of these implications.

11. To review proposals regarding the establishment of new types of

health care workers and advise on policy with regard to the employment of

these new types of personnel.

MINISTRY OF HEALTH

MINISTER OF HEALTH

Hon. K.R. Mair -Minister's Office

Deputy Minister

Dr. C. Key -Deputy Minister's Office

Executive Director Health Promotion and Information

L. Chazottes

Executive Director Planning and Development

C. Buckley

Senior Administrator Professional and I n s t i t u t i o n a l Services

R.E. McDermitt

Senior Administrator Administrator Chairman Chairman Community Health Services

Dr. G.W. Bonham

Health Manpower Working Group

r Chariman Medical Services Comm. D. Weir

I Emergency Health

Services

I Admin. Hospital Programs

Support Forensic Alcohol Services Psychiatric and Drug

Services Commission J. Bainbridge Commission

Dr. F. Tucker C.B. Hoskins

I Admin. Vancouver Bureau

D. Thompson J. Smith

Admin. Admin. Direct Preventative Care and Special Services Community Services I. Kelly Dr. H. Richards

Dr. P. Ransford

Source: C l a i r Buckley February, 1980

109.

THE APPROVAL PROCESS OF ADDITIONAL NURSING PROGRAMS

The sponsoring i n s t i t u t i o n s determines the need and f e a s i b i l i t y for

a nursing course. The proposing department follows whatever int e r n a l

procedures are appropriate for that i n s t i t u t i o n . Once the sponsoring

i n s t i t u t i o n has accepted the proposal, i t i n i t i a t e s the procedure for

approval of government funding.

F i r s t , a l e t t e r of intent i s sent to the Director of Program

Services Division. Information required i n a l e t t e r of intent i s spelled

out i n the statements of operating policy. From here, i f i t i s deemed

reasonable by the Director of Program Services Division, i t i s sent to

the Academic/Technical Director who delegates i t to the Health and Human

Services Programs Coordinator for preliminary investigation.

The proposal i s assessed at th i s point for duplication and need.

Need i s determined by reference to health Manpower Working Group which

w i l l determine whether or not there i s a need for th i s program i n the

health care system. The HMWG w i l l u t i l i z e the resources of the Health

Manpower Research Unit to legitimize the need for th i s proposal.

I f there i s a need for t h i s program and i t i s not already being

presented, the proposing i n s t i t u t i o n i s n o t i f i e d and a detailed proposal

i s then prepared by the i n s t i t u t i o n .

The process then begins again with the detailed proposal sent to the

Director of Program Services who delegates review of proposal to the

Director of Academic/Technical Programs. Nursing proposals are

automatically referred to the Coordinator of Health and Human Services

Programs who thoroughly investigates the proposal. At th i s point, the

procedure has been adopted that the proposal i s automatically referred

to the RNABC, RPNABC Continuing Education Approval Committee. I f the

110.

committee gives i t approval, a report i s submitted by the Coordinator of

Health and Human Services Programs to the Director of Program Services.

The Director submits the proposal and accompanying report to a Monthly

Program Services Review Committee. Consideration of f i n a n c i a l needs are

reviewed i n t h i s committee. When th i s committee approves the proposal,

t h e i r recommendations i s sent to the Academic Council.

The Academic Council i s responsible for a l l o c a t i n g resources i f i t

approves the proposal'. I f f i n a n c i a l commitments are approved by the

council, the i n s t i t u t i o n i s n o t i f i e d and planning can continue for

implementation of the proposed program.

This i s a very complex and time consuming process. Moreover, the

approval process does not have stated c r i t e r i a for determining

p r i o r i t i e s for any one proposal over any other. As a re s u l t , decisions

approving funding for courses are not based on r a t i o n a l planning but i n

the end are p o l i t i c a l decisions.

Lack of r a t i o n a l i t y of t h i s process i s evident at several points,

because, up to t h i s point, p r i o r i t i e s for programs i n nursing have not

been determined, p o l i c i e s have not been set by the Minister of Education

for a l l o c a t i o n of education dollars to health care and within that to

nursing programs. The Academic Council members are responsible only to

the Minister and therefore they do not have to answer to the public or

any pa r t i c u l a r sector, i f i t i s p o l i t i c a l l y loud enough, could affect the

decision i n the Ministry of Education, Ministry of Health or at the

Academic Council.

111.

APPENDIX C

NURSING ADMINISTRATORS'

REACTION PAPER TO NURSING EDUCATION (1979)

STUDY REPORT (KERMACKS' REPORT)

RECOMMENDATIONS PERTINENT TO CONTINUING EDUCATION

SOURCE: Kermacks, Cl a i r e ; A Report to the Health Education Advisory Council Nursing Education Study; Ministry of Education, Science and Technology, Province of B r i t i s h Columbia, Vancouver, A p r i l , 1979.

112.

APPENDIX C

RECOMMENDATIONS PERTINENT TO CONTINUING EDUCATION

RECOMMENDATION 32

That highest p r i o r i t y i n nursing education be given to the development of post-basic c l i n i c a l courses.

We strongly support t h i s recommendation, as the need for nurses adequately prepared to work i n specialty areas i s acute i n t h i s province. We sincerely hope that the funding w i l l be consistent and immediately available, and that the courses w i l l be accessible to nurses i n outlying regions.

RECOMMENDATION 33

That developmental work commence immediately on post-basic c l i n i c a l courses for registered nurses i n :

c r i t i c a l care (intensive and coronary care) emergency and trauma care long term care (including extended care and gerontology) o b s t e t r i c a l care ( p a r t i c u l a r l y during labour and intensive care for newborns) operating room and post-anesthetic recovery room care psychiatric care

Our association h e a r t i l y endorses t h i s recommendation.

RECOMMENDATION 34

That innovative approaches be taken i n the development of post-basic courses based on the following p r i n c i p l e s , that courses be:

developed on validated competencies required i n the work setting made more accessible on a province wide basis designed to meet a variety of learner needs i n various geographic areas evaluated through a b u i l t - i n evaluation process.

We h e a r t i l y endorse t h i s recommendation.

RECOMMENDATION 35

That the Ministry of Education award contracts to interested educational i n s t i t u t i o n s for the development of post-basic courses; and that coordination and consultative services be available through the Ministry.

We support t h i s recommendation.

113.

RECOMMENDATION 36

That employer and employee groups given serious consideration to the development of career streams i n c l i n i c a l f i e l d s so that the career progession for c l i n i c a l nurses i s possible without having to s h i f t administration or education.

We agree with t h i s recommendation i n p r i n c i p l e as a method of rewarding c l i n i c a l l y competent nurses at the bedside instead of promoting them away from the bedside.

Studies need to be carried out regarding the f i n a n c i a l implications, labor relations implications and impact on health team relationships.

RECOMMENDATION 37 . .

The Joint M i n i s t e r i a l Health Manpower Planning between the Min i s t r i e s of Health and Education be examined; and that consideration be given to a single organizational structure involving policy makers and planners who w i l l i d e n t i f y the supply and requirements, project future supply and requirements, and effect a balance between supply and requirements.

Our Association endorses t h i s recommendation.

RECOMMENDATION 38 and 39

That the Ministry of Health (and Human Resources where indicated) i d e n t i f y the kind of health care workers required and areas of special need and p r i o r i t y for manpower planning with input from employer groups, unions, professional/licensing bodies, consumers, etc.

That the Ministry of Education i d e n t i f y needs for Health Education programs based on manpower planning and coordinate development, implementation, and evaluation of programs through cooperative planning with educational i n s t i t u t i o n s and organizations, professional/licensing bodies, consumers, etc.

We endorse these recommendations but put emphasis on input from a l l groups affected.

APPENDIX D

ACTIVITIES IN THE 70 fS IN BRITISH COLUMBIA TO SUPPORT

CONTINUING EDUCATION FOR NURSES

115.

APPENDIX D

In 1973, the RNABC published a "Proposed Plan for the Orderly

Development of Nursing Education i n B r i t i s h Columbia, Part I I I :

Continuing Nursing Education." This document provides a comprehensive

review of the problems involved and the resources available. I t

i d e n t i f i e s a plan for continuing education i n B.C. within the context of

the t o t a l nursing education system and recommends several actions which

provided leadership for development i n continuing nursing education.

This document c l e a r l y i d e n t i f i e s that the "professional association

(RNABC) assumes primary and overall r e s p o n s i b i l i t y for planning to meet

the educational needs of nurses." I t goes on to indicate that others, as

the post-secondary educational i n s t i t u t i o n s , health care agencies,

appropriate government agencies and the indiv i d u a l nurses should be

involved i n the planning. I t s p e c i f i c i a l l y states that appropriate

government agencies should provide supportive services plus direct

f i n a n c i a l support for the development of continuing nursing education.

This plan states that "implementation of continuing nursing

education i s largely the business of the educational i n s t i t u t i o n s i n

cooperation with appropriate sponsoring group."

"The professional nurse must be w i l l i n g to invest time, e f f o r t and

money i n continuing education a c t i v i t i e s . "

Shortly before t h i s document was published, the government of the

province changed from Social Credit to NDP. This had a major impact on

the role of the RNABC i n continuing education. The NDP government within

a matter of days of taking o f f i c e , through an Order i n Council, appointed

Dr. Richard G. Foulkes as a special consultant to the Ministry of

116.

Health. His terms of reference were simply to "present recommendations

which could lead to a r a t i o n a l i z a t i o n of the Health Care Services of the

province." The effects of his report "Health Security for B r i t i s h

Columbians" were widespread on nursing through his recommendations on

nursing education but more so for this recommendation of the creation of

the B.C. Medical Center.

The B.C. Medical Center was formed i n July, 1973 to serve for the

teaching of undergraduate and post-graduate students i n a l l professions

including nursing. Foulkes indicated that m u l t i - d i s c i p l i n a r y task

forces should be created and given s p e c i f i c objectives related to the

programs and to provincial needs. One of these committees was an

Education Committee. A sub-committee was the Continuing Education

Sub-Committee. The terms of reference for t h i s committee was appended.

Ess e n t i a l l y , the sub-committee was to recommend to the Education

Committee on appropriate administration mechanisms and adequate and

appropriate educational resources i n continuing education at the BCMC.

The development of a formal government sponsored body responsible

for organizing continuing nursing education allowed the RNABC to

withdraw from the role they had assumed because no one else had.

The RNABC as an association was active i n BCMC Planning for

continuing education. In July i t prepared a paper commenting on the

princi p l e s i d e n t i f i e d by the sub-committee, the terms of reference and

the membership of that committee. In essence, i t reaffirmed the plan and

recommendations i d e n t i f i e d i n Part I I I of the Proposed Plan for the

Orderly Development of Nursing Education i n B r i t i s h Columbia. Standards

for nursing care must be stated;, manpower needs i d e n t i f i e d through

evaluation; learning needs i d e n t i f i e d and met through educational

.117.

programs and programs evaluated and appropriate actions taken. I t

continued to see continuing education as a j o i n t r e s p o n s i b i l i t y of

in d i v i d u a l , health agencies, education i n s t i t u t i o n s , government and the

association. I t indicated that consumers should be members of the

planning committee. \

In October of 1974, the RNABC presented a b r i e f to the sub-committee

on Continuing Education, BCMC dealing with administrative mechanisms

within the BCMC for continuing education planning. I t reviewed the

rati o n a l approach for ident i f y i n g needs on an ongoing basis and

providing appropriate continuing education programs. Evaluation at a l l

levels was also recommended. The RNABC l i s t e d areas i n nursing requiring

continuing education opportunities. These included OR, Maternity,

Extended Care, Psychiatric, C r i t i c a l Care and Primary Nursing.

The BCMC joined with the Health Manpower Working Group to study and

review the nursing education needs. This j o i n t group was call e d the

Advisory Committee on Nursing Manpower. In January of 1976 thi s group

approved a number of recommendations for presentation to the BCMC

Education Committee and the Health Manpower Working Group. These

recommendations dealt with post-basic c l i n i c a l nursing education and

suggested ways of r a t i o n a l i z i n g the system. Before any actions could be

taken on these recommendations, the BCMC suffered a p o l i t i c a l demise

with the defeat of the NDP government. The newly elected Social Credit

government discontinued the concept developed by B i l l 81 of an ove r a l l

planning, organizing and coordinating Medical Center for B r i t i s h

Columbia. Planning for continuing education i n the province was not

ended but seriously set back.

118.

With the change i n government and a new minister of education, a

number of studies were i n i t i a t e d which had a direct impact on nursing.

These commissions were:

1. The Winegard Commission to advise the Minister of Education on

providing higher education i n non-metropolitan areas of the province.

2. The Goard Commission to advise the Ministers of Education and

Labor on vocational, technical and trade t r a i n i n g .

3. The Faris Commission to advise the Minister of Education on

a l l aspects of community education.

4. The Ha l l Commission to enquire into the t r a i n i n g of p r a c t i c a l

nurses and related hospital personnel.

The RNABC presented b r i e f s to a l l these commissions. One point,

reinforced i n t h e i r b r i e f s to the f i r s t three commissions, was the urgent

need to develop a system for post-basic nursing education programs i n the

province.

The Winegard Commission report was delivered i n September to B.C.

Education Minister P.L. McGeer. This Commission developed a series of

twenty-four recommendations. Addressing the o v e r a l l problem of

providing higher education i n non-metropolitan areas, the commission

report recommends that SFU became multi-campus, degree granting

i n s t i t u t i o n to serve the B.C. i n t e r i o r .

S p e c i f i c a l l y discussing nursing, the report states on page 26:

"There i s no question about the demand outside of Vancouver and V i c t o r i a for degree-completion and post-basic courses i n nursing. Since nursing i s offered by the UBC and University of V i c t o r i a i t i s recommended that the u n i v e r s i t i e s cooperate i n the delivery of necessary programs to the non-metropolitan areas. SFU can provide some Arts and Science courses needed for the tr a i n i n g of nurses but the major load must be borne by the other two u n i v e r s i t i e s . "

119.

The report makes no recommendation on continuing education "since

th i s matter i s before the committee chaired by Dr. R.L. F a r i s . " A member

of the Winegard Commission, Faris was named i n July to head a separate

study of continuing education needs.

The Goard Commission, i n i t s report, submitted i n January, 1977,

recognized the need for more c l i n i c a l experience for two year nursing

graduates and p o s t - c l i n i c a l courses, but there were no s p e c i f i c

recommendations related to these concerns. I t was recommended that

consideration be given to providing a supporting grant to a s s i s t i n the

operation of upgrading programs i n nursing but i t was not i d e n t i f i e d i n

what way.

I t may be important to note that the major concern of t h i s

commission was the lack of organization and coordination and o v e r a l l

control for planning these programs. They were concerned about the

number of agencies and people that were involved before a course could

proceed and the o v e r a l l lack of planning.

This same si t u a t i o n exists with the nursing education i n B r i t i s h

Columbia. There may be some implication, from t h i s concern of the

commission, that nursing does not have special problems but i s simply

part of a problem that affects a l l of the education system of the

province.

The Faris Commission Report was presented to the Minister of

Education i n December, 1976. The commission recommended more money for

adult education and higher p r i o r i t y for community and continuing

education.

While i t recommended f i s c a l control of continuing education by the

pr o v i n c i a l government, the commission sought to keep control of

120.

programming with l o c a l school d i s t r i c t s and community college regions.

P r o v i n c i a l input would come with more education s t a f f and a pr o v i n c i a l or

m i n i s t e r i a l council to provide leadership.

In assigning p r i o r i t i e s , the commission report placed career

continuing education below three other v a r i e t i e s i t said have an impact

on "functional i l l i t e r a c y " i n the province: basic education for adults

below grade twelve l e v e l s , language programs for Canadians who have

d i f f i c u l t y with English, and teaching c i t i z e n s about t h e i r roles i n

public a f f a i r s . The needs i n these areas were p a r t i c u l a r l y stressed for

the disadvantaged, the handicapped, women, the elderly and immigrants.

Professional associations should continue to be involved i n career

continuing education, according to the commission, but funds for t h i s

kind of educational a c t i v i t y should also come from the government

ministr i e s most involved, (e.g. Health)

Two separate commission recommendations called for investigation

into the p o s s i b i l i t y of paid educational leaves and into funding for

private organizations which provide educational programs.

Reviewing educational needs outside major B.C. population areas,

the commission recommended government investigation of a pr o v i n c i a l

"open college" that might use radio and t e l e v i s i o n as well as development

on a p r i o r i t y basis of other "distance educational methods" for sparsely

populated areas.

The commission recommended that i n s t i t u t i o n s that provide the

o r i g i n a l entry t r a i n i n g for the profession also be the main provider of

continuing education i n cooperation with the professional association

and where appropriate with the community colleges. This recommendation

did not help i n sorting the roles of continuing education departments at

the UBC and BCIT from nursing departments i n community colleges.

121.

Another a c t i v i t y at the provincial l e v e l was important to nursing.

B.C. Education Minister P.L. McGeer established a Health Education

Advisory Council i n mid-September (1976) to continue some of the

a c t i v i t i e s of the education committee of the now defunct BCMC.

The seven member council was to advise Dr. McGeer on education i n

nursing, medicine and health technologies, make recommendations on new

programs, and study the requirements of a l l health occupations.

In November, 1977, the B.C. Ministry of Education approved a study

of nursing education as proposed by the Health Education Advisory

Council. The s i x month study was to cover the education of registered

nurses, registered psychiatric nurses, licensed p r a c t i c a l nurses, and

other categories of nursing care workers. I t s terms of reference were

establishing with the Ministry of Health long term projections of B.C.'s

nursing needs.

The nursing community was assured when the Ministry of Education

released t h i s study. The Ministry called the study "A Discussion Paper:

Nursing Education Study Report." This report was i n i t i a t e d by the Health

Education Advisory Council and funded by the Ministry of Education. The

report l i s t e d forty-three recommendations dealing with nursing

education. The report attempted to r a t i o n a l i z e the system of nursing

education by organizing a l l nursing personnel into five-part functional

c l a s s i f i c a t i o n system by eliminating the category of registered

psychiatric nurse, by introducing a student competency based core

curriculum for basic nursing education, closing hospital schools of

nursing, developing post-basic continuing education at specified

educational i n s t i t u t i o n s , and by providing baccalaureate l e v e l education

for nurses outside the metropolitan areas, by u t i l i z i n g manpower

122.

planning as a basis for ide n t i f y i n g needs for educational programs and by

supporting the post-basic educational needs for nursing.

The majority of the recommendations, or the concepts involved i n

them, can be supported i n part wholly by policy statements made by the

CNA or the RNABC i n the l a s t ten to f i f t e e n years but the reaction of the

professional body was generally not favorable. The RNABC News

(April/May/June, 1979) page 7, describes the report as follows:

"Educational Bomb S h e l l " "Controversial Nursing Study Released" " I t

burst a l l over the B.C. nursing scene l i k e a bombshell." "Heated

Discussion" "The report by nursing consultant, Claire Kermacks of North

Vancouver was labelled a "discussion paper" by the Ministry of

Education. That i s precisely what has been generated, heated discussion

with l i t t l e apparent middle ground between c r i t i c i s m and praise."

The nurses reacted mostly to the methodology, the lack of precise

supporting data for the recommendations, and the seeming encroachment on

the association's l e g i s l a t e d authority over basic nursing educational

programs.

The ov e r a l l effect of the document was positive, not so much i n what

was recommended, but more because of the generated interest and

discussion about the nursing educational system.

The long term effects of t h i s document are yet to be seen:

The RNABC has contributed i n other ways to continuing nursing

education i n the province. The RNABC Library (1969) was improved for

membership use and a part time l i b r a r i a n was hired. The association was

providing f a c i l i t i e s for s e l f learning rather than providing learning

experiences.

123.

Beginning i n 1959, the RNABC provided yearly loans/bursaries for

nurses seeking to continue t h e i r education. These monies were available

for post-basic courses, c e r t i f i c a t e courses and university education.

They were well u t i l i z e d by the membership.

In 1979, the RNABC increased i t s loan fund for continuing education

to $100,000.00. A non-profit society, the Registered Nurses Foundation

of B.C. was being set up to promote nursing education and research i n

the province. The loans funds have been transferred to t h i s foundation

which i s expected to administer the educational loan program and funding

for c l i n i c a l l y oriented post-basic nursing programs.

The purpose of RNF i s to promote the advancement and improvement of

nursing care, practice and education.

A j o i n t e f f o r t by the RPNABC and RNABC i n i t i a t e d a voluntary

continuing nursing education approval program. The purpose of th i s

program was fourfold. I t was to provide guidelines for those developing

programs, provide a mechanism for evaluation of course plans, a s s i s t

participants and/or employers i d e n t i f y programs most l i k e l y to meet

th e i r needs and provide recognition and c r e d i b i l i t y for the programs

approved and the participants i n them.

This was an important move for the association. The RNABC had

i d e n t i f i e d one of i t s roles i n continuing education as providing

standards and th i s was one way of doing so. I t i s also important to note

the cooperation between the associations.

The Health Education Council created by Education Minister P.L.

McGeer (1976) was to continue some a c t i v i t i e s of the BCMC. The

coordinator of continuing education was not included. In an attempt to

pick up t h i s function a group began to plan to establish a B.C. Council

124.

for Coordination of Continuing Education. The RNABC, RPNABC, the

Licensed P r a c t i c a l Nurses' Association, the P a c i f i c Medical Technicians

Association and representatives of a number of educational i n s t i t u t i o n s

and agency inservice departments were involved as voluntary

participants. They saw the goals of t h i s council as i d e n t i f y i n g learning

needs, setting p r i o r i t i e s , a l l o c a t i n g resources, developing a resource

bank and acting to control the quality of continuing nursing education.

The committee discontinued i n November, 1978, because i t could f i n d

no new ways to attack basic problems. The members did decide to ask the

RNABC to continue publishing i t s l i s t of continuing nursing education

programs, and to authorize an ad hoc committee to "maintain a watching

b r i e f " of the continuing education s i t u a t i o n , and, convene another

conference at i t s discretion.

In March, 1977, the RNABC published a document t i t l e d "Competencies

Required and Recommended for Registration of Re-Entering Nurses." This

was a comprehensive guideline for planners and sponsors of refresher

courses for graduate and registered nurses and a basic standard for

nurses coming back into the work force.

The RNABC Guideline for Orientation of Registered Nurses was

completed i n 1978.

Continuing nursing education developed a great deal i n t h i s period,

although post-basic c l i n i c a l programs are s t i l l not organized or funded.

The RNABC, through i t s various a c t i v i t i e s , provided strong leadership

because of the b e l i e f s of the need for continuing education and the

association's role i n setting standards but most importantly because no

other body was assuming t h i s r o l e . Because of the association, organized

nurses were very powerful i n determining d i r e c t i o n for nursing

continuing education i n B r i t i s h Columbia.

APPENDIX E

THEORETICAL WAYS TO DETERMINE MANPOWER NEEDS

126.

APPENDIX E

Theoretical Ways to Determine Manpower Needs

Levine, i n an a r t i c l e c a l l e d "Measuring Nursing Supply and

Requirements: The State of the Art," indicates that various

methodologies available have generally f a l l e n i n four types.

F i r s t are those that rely onn comparative standards, or c r i t e r i a

based on exi s t i n g practice. These methologies use medians, or averages

of state-nurse population r a t i o s or ratios based on existing practice i n

hospitals.

Second, methodologies are i n effect, that attempt to develop

optimal r a t i o s or levels for use i n determining nursing requirements.

These studies, while interesting have had d i f f i c u l t i e s a r r i v i n g at clear

cut r e s u l t s .

Third, models tend to ide n t i f y requirements based on the supply and

demand model u t i l i z e d by economists. One application i s the counting up

of budgeted positions, which can y i e l d a measure of demand. The problem

i s that the budgeted positions have to be legitimized i n some fashion

since the hospitals may be over-budgeted or under-budgeted to provide

safe nursing care. Many times, these models i d e n t i f y how well o f f or

poor an area i s rather than predicting future needs of nurses.

The fourth approach embraces comparative standards. I t uses demand

and includes attempts to apply optimizing c r i t e r i a by using the results

of certain research studies that measured the relationship between

nursing care and patient welfare. In the conclusion to th i s a r t i c l e ,

Eugene Levine says:

127.

I t must be kept i n mind that determining supply and requirements for health manpower i s not a s c i e n t i f i c exercise. Even the most precise quantitative model involves a certain degree of subjective judgement and i s influenced by personal values. Many scenarios can be written of the future and i n the f i n a l analysis each depends on one's view of the health care system and how nursing w i l l be u t i l i z e d i n i t . "

What methodologies have been used i n the past to determine manpower

needs and what are current proposals for i d e n t i f y i n g needs. In

determining theoretical models to determine manpower needs, supply of

personnel i s usually easily measured. But the essential component to

know whether or not there i s a problem i s to i d e n t i f y the requirements.

Models are currently being looked at to attempt to i d e n t i f y t h i s

component.

The Division of Nursing, U.S. Public Health Services, attempted to

develop models for i d e n t i f y i n g requirements for nursing manpower. They

are described as follows i n an a r t i c l e by Eugene Levine and are described

as follows:

1) System Dynamics Model

This model was developed using a set of techniques known as

system dynamics. The model i s concerned with changes taking place and

l i k e l y to take place i n nursing and i n health care generally by the year

1990. I t focuses on the impact those changes w i l l have on the supply,

demand and d i s t r i b u t i o n of nursing personnel and services. The model

produces simulations that are a sequence of calculations describing how

a system of r e l a t i v e factors w i l l behave over time.

2) Vector Requirement Model

The purpose of this model i s to assess the impact of three

anticipated changes i n the health care system on the requirements for

nurses.

128.

i ) The introduction of national health insurance (NHI)

i i ) the increased enrollment i n HMO's

i i i ) the reformulation of nursing roles

An overview of the model i s shown i n the figure. Beginning with a base

of 1972, projections of R.N. and L.P.N, requirements through 1985 were

made using l i n e a r regression techniques.

Similar to the system dynamics model, various scenarios of the

future are postulated.

The State Planning Process

This method consists of a procedure for a r r i v i n g at decisions

concerning key elements i n current and future nursing resources and

requirements and an integrated data base for as s i s t i n g i n the decision

making process. The method has been developed for use at the state

l e v e l . In the requirement area the process consists of the following

steps:

1) d i f f e r e n t i a t i n g the c l i e n t population

2) assessing the health needs of the population

3) formulating a health strategy

4) choosing the l e v e l and mix of nursing s t a f f

5) s t a f f i n g schools of nursing

The Micro Model

This project i s aimed at developing and testing a model that

incorporates health services u t i l i z a t i o n factors affecting nursing

demand and supply into a framework determining shortages or surpluses.

The model contains s p e c i f i c i n s t i t u t i o n a l c haracteristics and i s capable

of predicting demand and supply for nursing manpower at country and state

l e v e l s .

129.

These models used for manpower planning are examples of some of the

lat e s t techniques u t i l i z e d for manpower planning. In reviewing these

models, the complexity of the problem i s obvious. I t w i l l not be an easy

task to determine what future nursing requirements w i l l be i n B.C.

Nursing supply i s easier to id e n t i f y but there are s t i l l problems

related to t h i s because of the characteristics of nurses.