RN/NP Workforce Backgrounder

2019

Executive Summary

This backgrounder compiles data on Ontario nursing registrations, education, employment, and basic demographics, breaking those data down by class of nurse. It includes registered nurses (RN),1 nurse practitioners (NP), and registered practical nurses (RPN), with a focus on RNs and NPs.

The employment data include: the size of the workforce; nurse-to-population ratios; employment status and employment preference; work status (full-time, part-time or casual) and preference for each status; multiple job-holding; employment by sector; and employment by Local Health Integration Network (LHIN) region and by public health unit (PHU). Demographic variables are gender and age distribution. The backgrounder shows recent trends in the above variables and compares Ontario trends with others in the rest of Canada.

Registrations. There was a large drop in the number of RNs eligible to work in Ontario in 2014 (from 112,582 in 2013 to 104,298, it stayed at this lower level for the next three years). This sudden drop was mainly due to a new requirement for nurses to have practised in Ontario within the past three years in order to renew their registration. That affected nurses who lived near Ontario’s borders and practised in other jurisdictions. The College of Nurses of Ontario (CNO) attributed 49 percent of nursing losses to registration revocations and 23.3 percent to movement to the non-practising class. Between 2011 and 2017, the number of RNs registered to practise in Ontario dropped 6.3 percent. Over the same period, the numbers of registered NPs continued to rise steadily, from 1,800 in 2010 to 3,083 in 2017 (71.3 percent), while the number of registered RPNs rose 33.2 percent.

The number of RNs registering in the new non-practising class started at 4,627 in 2014, jumped to 8,417 in 2015, and rose to 8,885 by 2017. For RPNs, 742 registered in the non-practising class in 2014, and that figure rose to 2,055 by 2017. In 2016, the CNO removed “in Ontario” from its practice requirement.2 This could eventually restore the incentive of cross-border nurses to keep their CNO registrations, but so far, the number of non-practising RNs has continued to rise.

Nursing Workforce. The nursing workforce has continued its general increase that began in 2002. After dropping in 2011 and 2012, the RN workforce resumed its growth in 2013, reaching 96,007 in 2015 before dropping to 95,350 by 2017. As the nurse-to-population ratios below show, the increase in RN employment does not always match the growth in Ontario's population. For example, RN employment exceeded population growth between 2012 and 2014, but subsequently lagged it. On the other hand, growth in RPN and NP employment has exceeded population growth, reaching 43,100 and 2,867 positions respectively in 2016. Between 2011 and 2017, when the Ontario population grew 5.4 percent, RN employment rose just 2.2 percent, while RPN employment rose 37.2 percent and NP employment rose 72.1 percent. During that period, 78.3 percent of the gain in nursing positions went to RPNs.

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Nurses-to-population. In the 1990s, Ontario's RN-to-population ratio was low and falling. A low ratio is an indicator for reduced access to RNs and rising nursing workloads. Concerted government action to restore nursing employment reversed that negative trend. In its first mandate (2003-2007), the current government surpassed its nursing employment target of 8,000 more positions (adding a total of 9,669). However, budgetary cutbacks in 2008 stalled that progress, and the government fell short of the 9,000 new nursing positions promised in its second mandate (7,346).

Since 1990, Ontario has lagged behind the rest of the country in its ratio of working RNs per population – by 2017, Ontario had 689 RNs and NPs per 100,000 people (a decline from 725 in 2009), compared to 839 for the rest of the country. As of 2017, this is a gap that would require an estimated 21,052 more RNs and NPs to close. While RN employment growth lagged, RPN employment continued to grow steadily, resulting in a nursing workforce mix that shifted from 21.5 percent RPN in 2005 to 30.5 percent in 2017.

Graduations. Canadian Institute for Health Information (CIHI) data show very sharp growth in the number of Ontario RN graduates between 2005 and 2016 (from 1,619 graduates to 4,127), accounting for 56.1 percent of the reported Canadian growth (from 8,013 graduates to 12,484). Ontario also accounted for 46.6 percent of the growth in NP graduations over the same period. Ontario RPNs also graduated in increasing numbers from 2,125 in 2007 to 3,032 in 2016, ahead of the national pace (amounting to 42.7 percent of the growth over the period). Ontario produces a lower share of Canadian RN graduates than its population share (33.1percent vs. 38.5 percent), and a higher share of NP graduates (52.1 percent vs. 38.5 percent) and a higher share of RPN graduates (40.4 percent vs. 38.5 percent).

After graduation, Ontario RNs have been particularly mobile within Canada as well as internationally. Ontario is a net contributor of RNs to Alberta and B.C. (1,899 Ontario RN graduates are in Alberta and 2,418 are in B.C.), and Ontario is a net recipient from Quebec (2,391 Quebec RN graduates are in Ontario). Quebec employs very few RNs from the rest of the country, whereas Alberta, B.C. and the territories are quite reliant on RNs from other Canadian jurisdictions. Employment status and employment preference. Most registered Ontario RNs (91.3 percent) work in Ontario, while 1.8 percent work in nursing exclusively outside Ontario. Nevertheless, there are 4,541 RNs who do not have nursing positions in Ontario. Of this group, 2,564 (2.5 percent of registrants) are seeking these positions – that number has fluctuated between 2,600 and 3,200 in the recent past. This number can be attributed to the shortage of RN positions in Ontario, and also shows there is a ready source of RNs available to strengthen the RN workforce. 42.3 percent of RNs who are seeking work prefer full-time. There is an even larger body of RPNs seeking nursing employment – 3,242 in 2017, making up 6.7 percent of the RPN labour force. 56 percent of RPNs seeking nursing employment prefer full-time employment. Among NPs, just 1.9 percent were seeking nursing employment in 2017, and about 52.5 percent of those would prefer full-time employment. Full-time employment. In the 1990s, only half of all RNs were employed full time. By 2012, Ontario had reversed the previous downward trend, and 68.1 percent of RNs worked full-time 3 RN/NP Workforce Backgrounder May 2019

(very close to the government’s promise of 70 percent). This put Ontario well ahead of the rest of the country, where RNs had a 54 percent full-time share on average.

In 2013, the full-time share for Ontario RN dropped to below 67 percent. It rose marginally in 2014 and dropped again in 2015 and 2016, down to 66.2 percent. The drop for RNs appears to have been almost entirely borne by younger nurses in the age range 18-20 (who dropped from 71 percent to 57.4 percent full-time between 2011 and 2017). That is turn is strongly correlated with the sharp fall in full-time employment for new Ontario RNs (from 79.3 percent in 2009 to 43.4 percent in 2017). There was some growth in overall nursing employment between 2012 and 2017, but it was shared unequally. For RNs, the growth was almost entirely in part-time positions. RPN employment grew at a much faster rate than RN employment. As with RNs, the bulk of the RPN growth was attributable to part-time positions.

Data released for the first time by CNO in 2014 reveal that Ontario would easily surpass its 70 percent full-time target if all nurses had their preferred employment status. In 2017:  73.1 percent of RNs would prefer full time vs. 66.2 percent who actually worked full time  81.1 percent of NPs preferred full time, while 76.9 percent had full-time work.

Multiple employment. The incidence of individual nurses holding multiple jobs is quite high for all classes of nurse. In 2017, 15.5 percent of RNs and 27.1 percent of NPs worked for at least two different employers at the same time. Those figures rose by 0.3 and 2.7 percentage points respectively between 2014 and 2017. This has implications for continuity of care and continuity of care provider. It is also problematic during pandemics. Moreover, it is a potential indicator that many nurses are cobbling together part-time and casual employment in order to secure the equivalent of a full-time position.

Age distribution. The age distribution within the RN workforce is bimodal, with peaks centered around the age groups 25-29 and 50-54. There is a corresponding trough for the ages 35-39. The age distribution tilts toward the upper age groups, with recent growth in the oldest cohorts. Mid- to-late-career human resource (HR) strategies will remain important for retention. Even with solid retention of all age cohorts, significant retirements can be anticipated, beginning within the next five years. Combined with the shortfall of RN positions, the skewed age distribution places even greater importance on RN education and recruitment. Of late, the share rose for the youngest age groups, indicating some success in renewing the RN workforce.

Gender. The male share of nursing employment has steadily grown since 2002, but the nursing workforce remains overwhelmingly female. For example, the male share of RN employment rose from 3.7 percent to 7 percent between 2002 and 2017, while the RPN share rose from 6 percent to 9.1 percent.

Sector. The RN workforce is employed primarily (more than 60 percent) in the hospital sector. There was very little change in the proportions of the workforce between the major sectors in recent years. In 2017, the shares were: 61.2 percent in hospitals, 19.9 percent in the community, 8.9 percent in long-term care and 10 percent in “Other.”

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Employment by LHIN. Shares of RN/NP employment vary widely from one LHIN to the next, mainly due to the size of the LHIN. However, there is large variation in direct care RN-to- population ratios among LHINs, ranging from 321 to 1246 per 100,000. Part of the differences may be attributable to some LHINs being more rural and remote (and hence requiring more RNs to meet minimum staffing in smaller facilities), or due to some providing hospital services to clients outside their own boundaries. However, the discrepancy is quite large: the LHIN with the lowest ratio had about half (50.2 percent) of the RNs-to-population compared to the provincial average. Budget shares and population shares are poorly aligned, with some LHINs having much higher budget shares than population shares, and others having much lower ones. There was an evident correlation between the budget-to-population ratio and the direct care RN-to-population ratio – the more money per capita allocated to LHINs, the more direct care RNs per capita they had.

Ratios of direct care RNs/NPs to population by public health unit (PHU). As with employment of direct care RNs/NPs by LHIN, there is a large variation in the same nurse-to-population ratios by PHU. For example, in 2017, the PHU with the lowest ratio had just 52.2 percent of the provincial RN-to-population average.

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Table of Contents Executive Summary ...... 2 1. Numbers of Ontario Nursing Registrants ...... 8 1.1 Numbers of Nursing Graduates: Canadian Jurisdictions Compared ...... 9 1.2 Interprovincial Flows of RN Graduates...... 13 2. Size of Ontario Nursing Workforce ...... 14 2.1 Recent Trends in Ontario Nursing Employment ...... 14 2.2 Longer Ontario Employment Trends for RNs ...... 16 2.3 Net Gains in Nursing Employment by Government Mandate ...... 19 3. Changing Skill Mix ...... 20 4. Nurse-to-Population Ratios ...... 23 4.1 Ontario Nurse-to-Population Ratio (Working Nurses/ 100,000 Ontarians) ...... 23 4.2 Ontario Nurse/Population Ratio: Indices Comparing to 1986 Levels ...... 26 4.3 Trend in RN/NP Employment per 100,000 Population: Ontario vs. the Rest of Canada 27 4.4 Canadian NP Workforce-to-Population Ratios ...... 31 4.5 National Nurse-to-Population Ratios ...... 32 5. Employment Status and Preference for Nursing Employment ...... 33 6. Working Status ...... 37 6.1 Ontario RN and RPN Full-Time Ratios ...... 37 6.2 Working Status by Age Group ...... 38 6.3 Ontario Preferred vs. Actual Working Status for RNs and RPNs ...... 40 6.4 How Progress on Ontario Full-Time Employment Was Achieved: Workforce Changes by Work Status ...... 43 6.5 Full-Time Working Status: Ontario RNs/NPs vs. the Rest of Canada RNs/NPs ...... 46 6.6 Full-Time RN/NP Working Status: Ontario vs. Other Provinces ...... 47 7. Multiple Employment ...... 48 8. RN(General Class) Employment by Sector ...... 49 9. Age of Nurses ...... 50 9.1 Average Age of Nurses ...... 50 9.2 Age Distribution ...... 51 10. Gender of Nurses in 2017...... 52 11. RN(General Class) Employment by LHIN Region in Ontario ...... 53

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11.1 Ratios of Direct Care Nurses to Population per LHIN ...... 54 11.2 Distribution of LHIN Per Capita Budgets and Access to Nursing Care ...... 56 11.3 The RN/Population Ratio ...... 56 11.4 Distribution of LHIN Funding ...... 56 11.5 Comparing LHIN Budgets, Populations and Nursing Employment ...... 58 12. Ratios of Direct Care Nurses to Population per Public Health Unit ...... 60 A Note on the Data ...... 63 References and Explanatory Notes ...... 64

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Registered Nurse Backgrounder

This backgrounder provides an overview of Ontario’s registered nurse (RN) workforce, which is broken into RNs in the general class (RN(GC)) and RNs in the extended class (RN(EC)), also known as nurse practitioners (NPs).

Definitions and technical notes: For the purposes of this report, the CNO convention of reporting RN(GC)s as RNs will be followed. In contrast, the Canadian Institute for Health Information (CIHI) practice is to combine RN(GC) and NP data together as RN data. RPN refers to registered practical nurses, except in national comparisons, when RPN refers to registered psychiatric nurses. Licensed practical nurses (LPNs) are the national equivalent of Ontario’s RPNs. Employment figures are snapshots of data from the CNO3 taken at registration renewal time, which takes place over several months around the beginning of each year.

Cross-Canada comparisons are performed using the latest data from CIHI,4 which give slightly different figures for Ontario than CNO data (see notes at the end of the document). Data in this backgrounder are the latest available as of October 2018. 1. Numbers of Ontario Nursing Registrants There was a very large drop in the number of RNs eligible to practise in Ontario in 2014. As CNO explained in its 2014 report, this was due to the introduction of a new requirement in 2013 that nurses must have practised in Ontario within the past three years. As a result, "Of the 12,273 losses [of RN registrants], 49 percent were a result of revocations and 23.3 percent were a result of members moving to the Non-Practising Class."5 It is important to note that the numbers of RN and RPN registrants includes those in the nursing workforce and those who aren’t. That is in addition to the RNs and RPNs who elect to register as non-practising. In 2015, the number of non-practising RNs almost doubled, but the number of RNs registered to practise did not decline. Notwithstanding the change in regulations, the numbers of RPNs and NPs eligible to work in nursing in Ontario continued to climb. In 2016, the CNO removed “in Ontario” from its practice requirements,6 which means that nurses can meet the practice requirement through practice in other jurisdictions. RNAO had hoped this would restore the incentive for cross-border nurses to maintain their CNO registrations. So far, the numbers of non-practicing RNs continues to rise. While the 2014-17 growth rate of non-practicing RPNs (40.4 percent) was faster than that of non-practicing RNs (24.3percent), a much higher share of registered RNs in 2017 (7.9 percent) was non-practicing than for RPNs (4.0 percent).

1(a). Numbers of Nurses Registered to Practise in Ontario7

2014-17 Nursing Annual Category 2011 2012 2013 2014 2015 2016 2017 % Change

RNs8 111,532 112,194 112,582 104,298 104,401 104,140 104,483 -0.1%

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NPs 1,800 2,020 2,242 2,362 2,567 2,822 3,083 9.3%

Non-Practising 4,627 8,417 8,830 8,885 24.3% RNs9

All RNs and 113,332 114,214 114,824 111,287 115,385 115,792 116,451 1.5%% NPs

RPNs 36,588 38,845 41,996 42,018 44,195 46,888 48,748 5.1%

Non-Practising 742 1,623 1,889 2,055 40.4% RPNs10

All RPNs 36,588 38,845 41,996 42,760 45,818 48,777 50,803 5.9%

All nurses 149,920 153,059 156,820 154,047 161,203 164,569 167,254 2.8%

Over the period 2011-17, there was a pronounced shift away from RN registrations (-6.3 percent) and towards NPs (+71.3 percent) and RPNs (+33.2percent).

1.1 Numbers of Nursing Graduates: Canadian Jurisdictions Compared Ontario showed sharp growth in numbers of RN graduates between 2005 and 2016, according to CIHI data. Most of growth in Canadian RN graduations over that time period was due to Ontario, and Ontario’s share of Canada’s graduations rose from 20.2 percent to 35.3 percent in 2009, before dropping back to 33.1 percent by 2016. That reflected the slowing in the growth of the number of graduates after 2009. Note also that Ontario’s share of the Canadian population is 38.5 percent, so Ontario still graduates less than its expected share of RNs. Ontario’s rapid growth in RN graduates after 2005 is in part due to the introduction of the baccalaureate entry-to- practice requirement, which terminated all diploma RN graduations in 2005; this requirement went into effect on January 1, 2005.11 That caused an abrupt drop in RN graduations in 2005, and the subsequent rise is in part due to nursing students shifting to degree programs from diploma programs.

1(b). Numbers of Canadian RN Graduates per Year12 [CIHI]

Ont Ont Yr NL PEI NS NB Que Ont Man Sask Alta B.C. YT NWT Nun Can % % grads pop

05 197 51 244 276 3,003 1,619 430 224 1,077 892 n/a .. .. 8,013 20.2 38.9

06 188 56 257 270 2,965 2,015 405 214 1,130 854 n/a 20 5 8,379 24.0 38.9

07 221 56 283 259 2,667 2,828 466 259 1,248 1,132 n/a 13 15 9,447 29.9 38.8

08 201 55 287 256 2,344 2,797 456 319 1,328 1,048 n/a 17 5 9,113 30.7 38.7

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09 197 46 302 263 2,309 3,409 450 355 1,227 1,087 n/a 12 5 9,662 35.3 38.7

10 166 54 302 303 2,375 3,571 583 315 1,204 1,307 n/a 14 5 10,199 35.0 38.6

11 223 67 265 291 2,689 3,731 498 387 1,396 1,370 n/a 16 1 10,934 34.1 38.6

12 253 62 325 344 2,848 3,941 351 409 1,689 1,534 n/a 13 2 11,771 33.5 38.6

13 237 61 366 235 3,171 3,992 492 407 1,465 1,312 n/a 26 6 11,770 33.9 38.6

14 250 73 370 256 3,330 4,038 437 446 1,383 1,404 n/a 13 2 12,002 33.6 38.5

15 247 63 391 268 3,297 4,141 470 590 1,741 1,352 n/a 16 3 12,579 32.9 38.5

16 228 64 400 260 3,319 4,127 471 508 1,609 1,481 n/a 11 6 12,484 33.1 38.5

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Between 2011 and 2013, the numbers of Ontario NP graduates dropped from 249 to 172, before rebounding to 239, 277 and 246 in the years 2014 to 2016 respectively. Nevertheless, Ontario continues to graduate well over 40 percent of Canada’s NPs, and well above its share of the Canadian population (38.5 percent).

1(c). Numbers of Canadian NP Graduates per Year13 [CIHI]

Ont % Ont % Yr N.L. PEI N.S. N.B. Que Ont. Man Sask Alta B.C. Y.T. NWT Nun Can grads Pop

05 x n/a 16 6 8 76 9 9 25 25 n/a x n/a 178 42.7 38.9

06 14 n/a xx 6 8 88 8 11 30 31 n/a x n/a 204 43.1 38.9

07 13 n/a xx 14 10 158 12 13 66 28 n/a x n/a 328 48.2 38.8

08 10 n/a xx 0 4 159 .. 6 55 29 n/a 0 n/a 271 58.7 38.7

09 0 n/a 10 7 20 216 6 8 94 33 n/a 0 n/a 394 54.8 38.7

10 6 n/a 9 5 44 135 14 6 105 48 n/a 7 n/a 379 35.6 38.6

11 10 n/a n/a 8 43 249 5 x 72 26 n/a x n/a 421 59.1 38.6

12 xx n/a 16 14 47 197 7 9 71 24 n/a x n/a 394 50.0 38.6

13 6 n/a 15 x 59 172 n/a 11 59 33 n/a n/a n/a 359 47.9 38.6

14 8 n/a 12 x 53 239 n/a 13 91 31 n/a n/a n/a 450 53.1 38.5

15 5 x 16 18 73 277 11 20 97 36 n/a x n/a 559 49.6 38.5

16 11 x 19 14 69 246 16 31 102 31 n/a n/a n/a 543 45.3 38.5

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Since 2009, the numbers of RPN graduates in Ontario (called LPNs in the rest of Canada) rose sharply from 1,859 to over 3,000, outpacing growth in the rest of the country, and exceeding (at over 40 percent) Ontario’s share of Canada’s population (38.5 percent).

1(d). Numbers of Canadian LPN Graduates per Year14 [CIHI]

Ont Ont Yr NL PEI NS NB Que Ont Man Sask Alta B.C. YT NWT Canada %grads %pop

07 79 21 193 147 1,889 2,125 131 78 475 902 — — 6,040 35.2 38.8

08 78 0 140 75 1,870 1,984 138 79 221 1,038 — — 5,623 35.3 38.7

09 99 24 136 90 2,136 1,859 133 178 371 515 — — 5,541 33.5 38.7

10 99 22 287 128 2,556 2,425 149 96 705 576 11 — 7,054 34.4 38.6

11 176 31 110 234 2,498 3,076 62 187 844 623 0 — 7,841 39.2 38.6

12 143 29 229 188 2,565 3,140 119 88 920 533 13 — 7,967 39.4 38.6

13 68 38 99 243 2,528 3,322 137 194 987 350 0 — 7,966 41.7 38.6

14 — 44 193 215 — — — 174 — — — — — — 38.5

15 118 27 155 170 2,279 3,500 126 130 964 553 — — 8,022 43.6 38.5

16 127 36 267 130 1,848 3,032 154 108 1,134 651 13 — 7,500 40.4 38.5

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1.2 Interprovincial Flows of RN Graduates There is considerable flow of Canadian RN graduates from one province to the other, with some provinces being much more reliant on their own graduates than others. The following 2017 data consider RNs educated in Canada only.

1(e). Jurisdiction of Canadian RN Graduation vs. Jurisdiction of Registration, 201715 [CIHI]

Registration Location

Grad Prov N.L. P.E.I. N.S. N.B. Que. Ont. Man. Sask. Alta. B.C. Y.T. N.W.T.

N.L. 5,604 36 496 80 10 571 38 36 479 196 8 91

P.E.I. 7 1,118 136 41 † 54 † 8 79 33 † 15

N.S. 142 155 7,269 307 13 613 31 56 427 247 20 89

N.B. 45 125 594 7,090 227 747 41 35 334 153 5 37

Que. 15 10 58 232 66,741 2,391 47 19 340 437 15 36

Ont. 149 85 486 182 424 86,905 397 283 1,899 2,418 125 262

Man. 17 8 47 24 22 515 11,026 286 581 796 27 50

Sask. † 6 24 10 † 184 168 8,131 1,328 634 † 33

Alta. 57 24 117 45 27 593 190 881 25,815 2,729 93 91

B.C. 14 8 72 1† 13 418 73 123 1,072 24,169 104 94

Y.T. — — — — — — — — — — — —

N.W.T./Nun. † 0 14 † 0 11 † 12 7 19 † 174

% from 7.4% 29.0% 21.9% 11.5% 1.1% 6.6% 8.2% 17.6% 20.2% 24.1% 100.0% 82.1% outside prov

Net % 20.9% -5.6% 0.6% 15.1% 3.8% 0.7% 10.4% 6.2% -5.5% -21.7% -140.9% Contribution16

Quebec is the most self-reliant, with 98.9 percent of its RN workforce educated in Quebec. In Ontario, that share was 93.4 percent RNs graduated in-province. Ontario contributes slightly more nurses to other provinces than it gets back (net contribution of 0.7 percent). Ontario is a major net recipient from Quebec and a net contributor to B.C. and Alberta. On the other hand, B.C. only graduated 75.9 percent of its Canadian-educated RNs. For Alberta, the figure was 79.2 percent. Newfoundland, for its size, was a major net contributor of RNs (equal to 20.9 percent of all Newfoundland-trained RNs working elsewhere in Canada). B.C., Alberta, the Yukon and the NWT/Nunavut are heavily or (in the case of the Yukon) totally dependent on nurses from other provinces. 2. Size of Ontario Nursing Workforce 2.1 Recent Trends in Ontario Nursing Employment The number of Ontario RNs working in nursing dropped in 2012 but rose again in the following three years before dropping slightly in 2016 and dropping more sharply in 2017 (-654 RNs). Both RPN and NP employment continued to rise steadily – much faster than that for RNs. For example between 2016 and 2017, RN employment fell 0.7 percent, but RPN employment grew 3.8 percent (see Figure 2(b)). RPNs had 81.4 percent of the total nursing employment growth in 2015, 90.7 percent in 2016, and 138.6 percent in 2017 (see Figure 2(c)).

2(a). Ontario Nursing Workforce17

Nursing Employment Nursing Category / 2016- Class 2011 2012 2013 2014 2015 2016 2017 17

RNs 93,315 92,879 94,386 95,787 96,007 96,004 95,350 -654

NPs 1,666 1,874 2,056 2,209 2,407 2,657 2,867 210

All RNs and 94,981 94,753 96,442 97,996 98,414 98,661 98,217 -444 NPs

RPNs 31,419 32,850 35,286 37,284 39,111 41,506 43,100 1,594

All nurses 126,400 127,603 131,728 135,280 137,525 140,167 141,317 1,150

Looking at Table 2(b), from 2011 to 2017, RN employment grew 2.2 percent – well below the 7.0 percent growth in Ontario population. In comparison, the RPN workforce grew 37.2 percent and the NP workforce grew 72.1 percent over that period. The vast majority of the gain in nursing positions (11,681 of 14,917 – 78.3 percent, Table 2(c)) went to RPNs.

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2(b). Net Change in Ontario’s Nursing Employment

Nursing Category / Class 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2011-17

-436 1,507 1,401 220 -3 -654 2,035 RNs (-0.5%) (1.6%) (1.5%) (0.2%) (0%) (-0.7%) (2.2%)

208 182 153 198 250 210 1,201 NPs (12.5%) (9.7%) (7.4%) (9.0%) (10.4%) (7.9%) (72.1%)

-228 1,689 1,554 418 247 -444 3,236 All RNs and NPs (-0.2) (1.8%) (1.6%) (0.4%) (0.3%) (-0.5%) (3.4%)

1,431 2,436 1,998 1,827 2,395 1,594 11,681 RPNs (4.6%) (7.4%) (5.7%) (4.9%) (6.1%) (3.8%) (37.2%)

1,203 4,125 3,552 2,245 2,642 1,150 14,917 All nurses (1.0%) (3.2%) (2.7%) (1.7%) (1.9%) (10.9%) (11.8%)

Pop. Growth Rate per 1.1% 1.1% 1.0% 0.8% 1.4% 1.6% 7.0% Period

2(c). Shares of Change in Ontario’s Nursing Employment by Nursing Class

Nursing Category / 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2011-17 Class

RNs -36% 36.5% 39.4% 9.8% -0.1% -56.9% 13.6%

NPs 17.3% 4.4% 4.3% 8.8% 9.5% 18.3% 8.1%

All RNs -19% 40.9% 43.8% 18.6% 9.3% -38.6% 21.7% and NPs

RPNs 119.0% 59.1% 56.3% 81.4% 90.7% 138.6% 78.3%

All nurses 100% 100% 100% 100% 100% 100.0% 100.0%

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2.2 Longer Ontario Employment Trends for RNs The 1990s saw stagnation in the growth of the Ontario RN workforce, with employment falling in the late 1990s. At the same time, the population of Ontario continued to grow and age rapidly. This meant the need for nursing services was growing while RNs were being laid off (see Figure 2(d) below). The 1999 Nursing Task Force report18 outlined these problems and their implications for the nursing profession and client outcomes. Since that time, concerted efforts by successive governments have reversed the downward trend in nursing employment. RN employment has been trending upwards since that time, but it dropped in 2011 and 2012 when the loss of RN positions outweighed the gains by NPs. Between January 2010 and January 2012, RNs lost 1,037 positions while NPs gained 388, for a net loss of 649 RN and NP positions. Between 2012 and 2017, there was a net gain of 3,464 RN and NP positions – about a 3.7 percent gain, less than the 5.8 percent population growth that occurred over that period (Figure 2(d)). In contrast, RPN employment rose 31.2 percent during that time (Figure 2(g)). Over a longer period, RPN employment rose dramatically from 24,428 to 43,100 between 2004 and 2017, after a period of stagnancy. This represented a 76.4 percent rise. NP employment rose 440.9 percent over the same time period and RN employment rose 14.0 percent. Since Ontario's population rose 14.6 percent over the period, RN employment lagged slightly behind population growth while RPN and NP employment markedly exceeded population growth.

2(d). Trend in Ontario RN and NP Employment 1986-2017 105,000

100,000

95,000

90,000 Number of RNs and 85,000 NPs

80,000 # RNs and NPs Employed NPs andRNs # 75,000

70,000 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06 '08 '10 '12 '14 '16

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2(e). Trend in Ontario RN Employment 1986 - 2017 100,000

95,000

90,000

85,000 RN(GC)s

80,000 # RN (GC)s Employed (GC)s RN #

75,000

70,000 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06 '08 '10 '12 '14 '16

2(f). Trend in Ontario NP Employment 1999 - 2017 3500

3000

2500

2000

1500 NPs

1000 # NPs Employed NPs #

500

0 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06 '08 '10 '12 '14 '16

Ontario NP data start in 1999.

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2(g). Trend in Ontario RPN Employment 1986 - 2017 45,000

40,000

35,000

RPNs

30,000 # RPNs Employed RPNs #

25,000

20,000 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06 '08 '10 '12 '14 '16

18 RN/NP Workforce Backgrounder May 2019

2.3 Net Gains in Nursing Employment by Government Mandate During its first mandate (October 2003-October 2007), the current government promised to create 8,000 new nursing positions. In the corresponding CNO data period (2004-2008),19 9,669 nursing positions were created. Thus, we can say that the government met its commitment. In its second mandate, the government promised to create 9,000 additional nursing positions. According to CNO data, the government fell short on its promise. Between the start of 2008 and 2012, Ontario gained just 7,346 nursing positions. Alarmingly, nursing gains slowed dramatically in the last two years of the second mandate, as the nursing workforce lagged behind population growth. From 2010 to 2012, Ontario lost 649 RN and NP positions (RNs lost 1,037 positions, while RPNs gained 2,416 positions), for a net gain of 1,767 nursing positions. Overall, there was very little growth in RN positions in the general class during the provincial government’s second mandate. There was some growth in nursing employment between 2012 and 2017 in all categories. Yet for RNs, the growth (2.7 percent) was almost entirely in part-time positions. RPN employment grew (31.2 percent) at a much faster rate than RN employment. As with RNs, the bulk of the RPN growth was attributable to part-time positions (see section on working status).

2(h). Net Changes in Ontario Nursing Employment By Government Mandate, 2004-2017

Nursing Employment Net Gains in Nursing Employment Nursing Category / 2004-08 2008-12 2004-12 2012-17 Class 2004 2008 2012 2017 First Second First 2 Third+ mandate mandate mandates mandate

RNs 85,638 91,965 92,879 95,350 6,327 914 7,241 2,471

NPs 530 868 1,874 2,867 338 1,006 1,344 993

All RNs and 86,168 92,833 94,753 98,217 6,665 1,920 8,585 NPs 3,464

RPNs 24,428 27,432 32,858 43,100 3,004 5,426 8,430 10,242

All nurses 110,596 120,265 127,611 141,317 9,669 7,346 17,015 13,706

19 RN/NP Workforce Backgrounder May 2019

3. Changing Skill Mix The slow growth in RN employment since 2005, and its ultimate decline from 2010 to 2012, occurred in tandem with a rapid growth in NP and RPN positions over the same period. Accordingly, the skill mix in the nursing workforce has shifted, with RNs' share of nursing employment falling since 2005 from 78.0 percent to a new low of 67.5 percent in 2017 (Graph 3(b)). The RPN share over that period rose from 21.5 percent to 30.5 percent. Graphs 3(a) to 3(d) show the striking shift in skill mix. The NP share of nursing employment has grown quickly since NPs’ broader scope of practice was recognized in legislation.

3(a). RN and NP Share of Ontario Nursing Employment

81%

79%

77%

75%

73%

RN and NP Share

71%

69%

2000 2014 1986 1988 1990 1992 1994 1996 1998 2002 2004 2006 2008 2010 2012 2016

20 RN/NP Workforce Backgrounder May 2019

3(b). RN Share of Ontario Nursing Employment

80%

78%

76%

74%

72%

70% RN Share

68%

66%

1986 2010 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2012 2014 2016

3(c). NP Share of Ontario Nursing Employment

2.5%

2.0%

1.5% NP Share

1.0%

0.5%

0.0%

1990 2014 1986 1988 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2016

Ontario NP statistics start in 1999.

21 RN/NP Workforce Backgrounder May 2019

3(d). RPN Share of Ontario Nursing Employment

32%

30% RPN Share 28%

26%

24%

22%

20%

1990 1986 1988 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016

22 RN/NP Workforce Backgrounder May 2019

4. Nurse-to-Population Ratios 20 4.1 Ontario Nurse-to-Population Ratio (Working Nurses per 100,000 Ontarians) Ontario's plunging RN-to-population ratio provides a direct measure of access to registered nursing services. As the ratio falls, the number of people each RN must care for increases. Figure 4(b) shows a striking pattern from 1986 to 2017: the RN workforce plummeted from more than 800 RNs per 100,000 people to less than 680 in 2001. The sharp drop was caused by a declining nursing workforce and a rising population. This trend was reversed when the growth in RN employment exceeded population growth, which caused the ratio to trend upward and peak at 716.8 in 2009. The biggest nursing gains under the current government occurred after the first year of its first mandate, when the ratio reached 710.8.21 Since that time, the ratio has fluctuated in that range. It rose again in 2013 and 2014, with virtually all of the gains coming in the form of part-time employment (2,734 of 2,908 net positions gained). Between 2014 and 2017, the ratio again declined, to 671.8/100,000, in synch with reports of RN layoffs. These trends for RN employment contrast with those of NPs and RPNs. The ratio of NPs per 100,000 population rose from 2.6 to 20.2 between 1999 and 2017 (Figure 4(c)), while the ratio of RPNs per 100,000 rose from 195.4 to 303.78 between 2005 and 2017 (Figure 4(d)).

4(a). Ontario Trend in RNs+NPs/100,000 Population 1986-2017 850

830

810

790 RNs+NPs/100,000 770

750

730

710

690

670

650 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06 '08 '10 '12 '14 '16

23 RN/NP Workforce Backgrounder May 2019

4(b). Ontario Trend in RNs/100,000 Population 1986-2017 850 830 810 790 RNs/100,000 770 750 730 710 690 670 650 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06 '08 '10 '12 '14 '16

4(c). Ontario Trend in NPs/100,000 Population 1999-2017 25

20

NPs/100,000 15

10

5

0 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06 '08 '10 '12 '14 '16

Ontario NP statistics start in 1999.

24 RN/NP Workforce Backgrounder May 2019

4(d). Ontario Trend in RPNs/100,000 Population 1986-2017 310

290 RPNs/100,000 270

250

230

210

190 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06 '08 '10 '12 '14 '16

25 RN/NP Workforce Backgrounder May 2019

4.2 Ontario Nurse-to-Population Ratio: Indices Comparing to 1986 Levels The chart below represents an index of nurse-to-population ratios with the base year (1986) set to 100, which allows for a ready comparison of percentage changes from the base year. It provides a vivid statistical picture to explain the sharp rise in workloads reported by many RNs. In percentage terms, the ratio for RNs deteriorated to 16 percent below 1986 levels twice – in 1999 and again in 2001. A subsequent deterioration in the RN-to-population ratio followed spending restraints announced in October 2008 as part of the government’s attempt to deal with a recession-driven deficit.22 It recovered to about 10.9 percent below 1986 levels by 2009, and fluctuated since that time, ending up at 16.5 percent below in 2017 (see Figure 4(e)). RNs have not regained the ratios that prevailed in the 1980s, but the recovery in the early 2000s was substantial. RNAO continues to hear concerns about workload, and this is reflected in the data that show that ratios are considerably less favourable than they were in the late 1980s, when the provincial client base was younger, and population health-care needs were less complex. The nurse-to-population ratio fell faster for RPNs after 1986 than it did for RNs – bottoming out at 28.3 percent below 1986 levels in 2005. However the rebound for RPNs was much sharper. By 2012, RPNs had recovered more of their losses than RNs had. By 2017, the RPN ratio was 11.4 percent above its 1986 level, while the RN ratio was 16.5 percent below its 1986 level. This coincides with widespread reports RNAO has received of replacement of RN positions by RPNs.

4(e). Indices of Nurse/Population Ratios for RNs and RPNs 1986 = 100

115

110

105 RN/Pop Index

100 RPN/Pop Index

95

90

85

80

75

70 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06 '08 '10 '12 '14 '16

26 RN/NP Workforce Backgrounder May 2019

23 4.3 Trend in RN/NP Employment per 100,000 Population: Ontario vs. the Rest of Canada Ontario’s RN/NP-to-population ratio ranks well below the rest of the country, with a gap that opened up in the early 1990s. In 2017, Ontario had 689 RNs and NPs per 100,000 population (a decline from 725 in 2009).24 That compares with 837 in the rest of the country. An upward trend in Ontario between 2012 and 2014 was followed by a decline in 2015, 2016 and 2017. In 2015, Ontario moved into last place among the provinces and territories in terms of its RN/NP-to-population ratio, and this deficit has risen since that time. This inevitably has significant implications on workload and patient outcomes.25 26 27 28 29 30 31 For Ontario to catch up with the rest of Canada (ROC), it would have to add an estimated 21,052 more RNs and NPs to its workforce – an increase of 21.5 percent. In response to this growing concern, RNAO is recommending that the government seek to close the gap as quickly as reasonably possible, while continuing to advance policy that focuses on utilizing the most effective care provider for each patient and advancing continuity of care and caregiver.

4(f). RNs+NPs/100,000 Population: Ontario vs. Rest of Canada

900

850

800

750

700

Ontario RNs+NPs/100,000 Population RNs+NPs/100,000 650

ROC

600

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016

27 RN/NP Workforce Backgrounder May 2019

As previously noted, CIHI combines its NP data with its RN data when reporting RN employment. When NPs are removed from the equation, the gap between Ontario and the rest of the country is even larger than detailed above. In 2017, there were 828 RNs per 100,000 population in the rest of Canada compared to just 669 in Ontario.

4(g). RN(GC)s/100,000 Population: Ontario vs. Rest of Canada

850

830

810

790

770 Ontario

750 ROC

730

710

RN(GC)s/100,000 Population RN(GC)s/100,000 690

670

650

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

28 RN/NP Workforce Backgrounder May 2019

Figure 4(h) shows provincial RN/NP-to-population ratios for 1994 and 2017. Between those two periods, Ontario's ratio dropped the most of any Canadian jurisdiction. In 2015, Ontario overtook B.C. for the lowest ratio in the country and the gap has continued to widen. The third data column is an index (Ontario = 100) that shows proportional differences. For example, Newfoundland had 65.2 percent more RNs/NPs per capita than did Ontario. The ratio for Canada outside of Ontario was 21.5 percent above Ontario’s indexed ratio, which is a large discrepancy.

4(h). Comparison of RN/NP Workforce per 100,000 Population Across Canada

Province / 2017 Index: 1994 2017 Territory Ontario = 100

N.L. 901 1,138 165.2

P.E.I. 871 1,033 150.0

N.S. 988 968 140.4

N.B. 1,014 1,037 150.5

Que. 851 821 119.2

Ont. 751 689 100.0

Man. 898 930 135.0

Sask. 841 913 132.5

Alta. 809 812 117.9

B.C. 750 738 107.0

Y.T. 684 1,144 166.0

N.W.T./Nun 854 1,271 184.5

Rest of 842 837 121.5 Canada

Canada 808 780 113.2

29 RN/NP Workforce Backgrounder May 2019

Figure 4(i) shows provincial RN-to-population ratios for 1994 and 2017, by removing NP data from the previous table. Between those two periods, Ontario's ratio dropped the most, and in 2015, overtook B.C. for the lowest ratio in the country (in 2017, at 669/100,000, it sat well below rest of the provinces). The third data column is an index (Ontario = 100) that shows proportional differences. For example, Newfoundland had 65.5 percent more RNs per capita than did Ontario. The rest of Canada had a ratio that was 23.8 percent above Ontario’s.

4(i). Comparison of RN Workforce per 100,000 Population Across Canada

Province / 2017 Index: 1994 2017 Territory Ontario = 100

N.L. 901 1,107 165.5

P.E.I. 871 1,018 152.1

N.S. 988 951 142.2

N.B. 1,014 1,021 152.7

Que. 851 816 122.0

Ont. 751 669 100.0

Man. 898 918 137.2

Sask. 841 895 133.8

Alta. 809 802 119.8

B.C. 750 731 109.3

Y.T. 684 1,128 168.7

N.W.T./Nun 854 1,205 180.1

Rest of 842 828.0 123.8 Canada

Canada 808 766.5 114.6

30 RN/NP Workforce Backgrounder May 2019

4.4 Canadian NP Workforce-to-Population Ratios Figure 4(j) shows the number of NPs per 100,000 population for each province from 2008 to 2017.32 Ontario has substantially more NPs per 100,000 population (20) than the rest of Canada (9). Newfoundland, however, has a higher ratio than Ontario with 31 NPs per 100,000 people. Note that Newfoundland also has the highest RN-to-population ratio. Nunavut/Northwest Territories have a much higher ratio, at 67.33

4(j). Comparison of NPs per 100,000 Population Across Canada 34

Province / Territory 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

N.L. 19 18 18 20 23 24 24 26 28 31

P.E.I. 2 2 3 3 3 3 8 10 15 16

N.S. 9 9 11 12 14 14 15 15 15 16

N.B. 7 7 9 10 14 13 14 14 15 16

Que. 0 0 1 1 2 2 3 4 5 5

Ont. 7 9 11 12 14 15 16 17 19 20

Man. 4 5 8 8 8 8 9 11 12 12

Sask. 10 11 12 12 13 14 15 15 17 18

Alta. 6 7 7 7 8 8 9 9 10 11

B.C. 2 3 3 3 4 4 5 5 6 7

Y.T. * * * * * 14 16 13 11 16

N.W.T./Nun. * * * * * 77 51 56 46 67

Rest of Canada 4 4 5 5 6 7 7 8 8 9

Canada 5 6 7 8 9 10 11 11 13 14

* Indicates small cell size, meaning data suppressed to meet CIHI privacy standards, or data does not exist.

31 RN/NP Workforce Backgrounder May 2019

4.5 National Nurse-to-Population Ratios35 Ontario fares worse in comparison to other provinces in terms of overall nurse-to-population ratios. For 2017, Ontario’s ratio was 992 per 100,000 versus 1,146 per 100,000 in the rest of the country. As with the RN-to-population ratio, Ontario has the lowest nurse-to-population ratio in Canada. In the final column of Figure 4(k), all ratios are compared via an index with Ontario set to 100. The rest of Canada had ratios 15.5 percent higher than Ontario's, ranging from 1.9 percent more in B.C., up to 58.6 percent more in Newfoundland. Ontario has caught up and passed the average of the rest of the country with respect to numbers of licensed practical nurses (LPNs).36 Ontario leads all jurisdictions except Newfoundland and NWT in NP-to-population ratios.

4(k). 2017 Comparison of Nurses per 100,000 Population Across Canada

Index Province / Reg Psych RNs NPs LPNs37 All Nurses Ontario = Territory Nurses38 100

N.L. 1,107 31 436 0 1,574 158.6

P.E.I. 1,018 16 395 0 1,429 144.0

N.S. 951 16 419 0 1,386 139.7

N.B. 1,021 16 414 0 1,451 146.2

Que. 816 5 288 0 1,109 111.8

Ont. 669 20 303 0 992 100.0

Man. 918 12 237 75 1,242 125.2

Sask. 895 18 291 73 1,277 128.7

Alta. 802 11 286 30 1,128 113.7

B.C. 731 7 221 52 1,011 101.9

Y.T. 1,128 16 28939 0 1,144 115.3

N.W.T. 1,205 67 129 0 1,389 139.9

Rest of 828 8 283 25 1,146 115.5 Canada

Canada 767 13 291 15 1,087 109.5

32 RN/NP Workforce Backgrounder May 2019

5. Employment Status and Preference for Nursing Employment Table 5(a) shows that in 2017, the vast majority of Ontario RNs (91.3 percent) work in the province, including about 0.7 percent (743, not shown) who are employed in nursing both inside and outside Ontario, working in different nursing jobs on both sides of the border. That leaves 1.8 percent who work in nursing exclusively outside Ontario. Nevertheless, there are still 4,541 RNs without nursing positions in Ontario (not shown), and 2,564 of them (2.5 percent of registrants) are seeking these positions. That number has fluctuated between 2,600 and 3,300 in the recent past. The shortage of RN positions in Ontario helps to explain the number of RNs seeking nursing employment.

5(a). Employment Status of Ontario RNs in the General Class40

2013 2014 2015 2016 2017

Status # % # % # % # % # %

Nurse in 94,386 83.8 95,787 91.8 96,007 92.0 96,004 92.2 95,350 91.3 Ont

Nurse outside 4,801 4.3 1,423 1.4 1,285 1.2 1,470 1.4 1,910 1.8 Ont

Seek 3,269 2.9 2,639 2.5 2,746 2.6 2,640 2.5 2,564 2.5 Nursing

Not Seek 6,448 5.7 1,928 1.8 1,913 1.8 1,944 1.9 1,977 1.9 Nursing

On 3,671 3.3 2,508 2.4 2,450 2.3 2,082 2.0 2,682 2.6 Leave

Not 0 0.0 6 0.0 0 0.0 0 0.0 0 0.0 Spec.

Total 112,582 100 104,298 100 104,401 100 104,140 100 104,483 100

33 RN/NP Workforce Backgrounder May 2019

Table 5(b) shows the employment preferences of those seeking nursing employment. 42.3 percent of RNs seeking employment prefer full-time. These 2,564 RNs constitute a supply that is immediately available for nursing employment.

5(b). Employment Preference of RNs Seeking Nursing Employment41 in Ontario

2013 2014 2015 2016 2017

# % # % # % # % # %

Full-time 1,474 45.1 1,118 42.4 1,279 46.6 1,192 45.2 1,084 42.3

Part-time 951 29 785 29.7 787 29 760 28.8 801 31.2

Casual 842 25.8 736 27.9 678 24.7 686 26 877 26.4

Not specified 2 0.1 0 0 2 0.1 2 0.1 2 0.1

Total 3,269 100 2,639 100 2,746 100 2,640 100 2564 100

A smaller percentage of NPs (1.9 percent) is seeking nursing employment, as shown in Table 5(c). NPs seeking nursing employment moderately prefer full-time employment (53.3 percent), as indicated in Table 5(d).

5(c). Employment Status of NPs42

Status 2013 2014 2015 2016 2017

# % # % # % # % # %

Nurse in Ont 2,056 91.7 2,209 93.5 2,407 2.3 2,657 94.2 2,867 93.0

Nurse outside Ont 69 3.1 38 1.6 44 1.7 41 1.5 50 1.6

Seek Nursing Job 30 1.3 36 1.5 32 0.0 45 1.6 59 1.9

Not Seek Nursing 22 1.0 15 0.6 13 0.0 16 0.6 18 0.6 Job

On Leave 65 2.9 61 2.6 73 2.8 63 2.2 89 2.9

Total 2,242 100 2,362 100 2,567 100 2,822 100 3,083 100.0

34 RN/NP Workforce Backgrounder May 2019

5(d). Employment Preference of NPs Seeking Nursing Employment43 in Ontario

2013 2014 2015 2016 2017

# % # % # % # % # %

Full-time 16 53.3 21 58.3 17 53.1 24 53.3 31 52.5

Part-time 9 30 14 38.9 9 28 13 28.9 19 32.2

Casual 5 16.7 1 2.8 6 18.8 8 17.8 9 15.3

Total 30 100 36 100 32 100 45 100 59 100

35 RN/NP Workforce Backgrounder May 2019

As shown in Table 5(e), 6.7 percent of the RPN labour force is seeking nursing employment (3,242 in 2017). Table 5(f) shows that RPNs seeking nursing employment are reasonably likely to prefer full- time employment (56 percent).

5(e). Employment Status of RPNs44

Status 2013 2014 2015 2016 2017

# % # % # % # % # %

Nurse in Ont 35,286 84.0 37,284 88.7 39,111 88.5 41,506 88.5 43,100 88.4

Nurse outside 408 1.0 274 0.7 291 0.7 375 0.8 449 0.9 Ont

Seek Nursing 3,079 7.3 2,762 6.6 3,112 7.0 3,302 7.0 3,242 6.7 Job

Not Seek 1,799 4.3 560 1.3 548 1.2 649 1.4 540 1.1 Nursing Job

On Leave 1,423 3.4 1,133 2.7 1,133 2.6 1,056 2.3 1,417 2.9

Not Specified 0 0 3 0.0 0 0.0 0 0.0 0 0.0

Total 41,996 100.0 42,018 100.0 44,195 100.0 46,888 100.0 48,748 100.0

5(f). Employment Preference of RPNs Seeking Nursing Employment45 in Ontario

2013 2014 2015 2016 2017

# % # % # % # % # %

Full-time 1,869 60.7 1,645 59.6 1,857 59.7 1,947 59.0 1,817 56.0

Part-time 813 26 771 27.9 850 27 954 28.9 969 29.9

Casual 391 12.7 346 12.5 401 12.9 394 11.9 449 13.8

Not specified 6 0.2 0 0 4 0.1 7 0.2 7 0.2

Total 3,079 100 2,762 100 3,112 100 3,302 100 3,242 100

36 RN/NP Workforce Backgrounder May 2019

6. Working Status 6.1 Ontario RN and RPN Full-Time Ratios There was an upward trend in full-time employment for RNs between 1998 and 2012. Beginning this period below 50 percent, the share of full-time employment for RNs rose to 68.1 percent by 2012. In 2013, it dropped to 66.3 percent, where it stayed until edging down slightly to 66.2 percent in 2016 and 2017. The full-time share of employment for NPs rose from 76.9 percent in 2004 to 84.7 percent in 2013, after which it dropped to 76.7 percent by 2017. That gave a weighted average of 66.5 percent of full-time employment for RNs and NPs overall in 2017. RPN employment followed a similar pattern to RNs, falling to 47.4 percent full-time in 1999, but hitting a new high of 61 percent in 2011. After that, the full-time share for RPNs has fallen steadily to 53.9 percent in 2017. Until 2012, Ontario was well on the way to achieving its objective of 70 percent full-time status for RNs and RPNs, as requested in RNAO’s previous election platform46 and as committed to by the government.

6(a). Percent Full-time Share of Employment for Ontario RNs, NPs and RPNs 1986-2017

90

85

80 RN(GC)

75 NP

70 RPN

65 Time Share ofEmployment Share Time - 60

55

Percent Full Percent 50

45 86 88 90 92 94 96 98 00 02 04 06 08 10 12 14 16

Ontario NP statistics start in 1999

37 RN/NP Workforce Backgrounder May 2019

6.2 Working Status by Age Group Shares of full-time employment have become more unequally distributed between age groups in recent years. The drop in full-time employment share is mainly due to losses experienced by younger RNs. Younger RNs have seen their full-time share dwindle from 71 percent to 57.4 percent between 2011 and 2017. The situation is even worse for new RNs. The proportion of new RNs who reported overall full-time employment decreased from 79.3 percent in 2009 to 43.5 percent in 2016 (see graph 6(b2)). 47 48 "New RNs" are RNs registering with the CNO for the first time after successfully meeting Ontario requirements.49 In contrast, both early and mid-career RPNs suffered significant losses in full-time shares of employment, while RPNs over the age of 54 have had recent gains in full-time shares of employment.

6(b1). Full-time Shares of Employment by Age Group50

RNs

2011 2012 2013 2014 2015 2016 2017

18-29 71.0 69.6 66.8 64.6 61.6 59.2 57.4

30-54 71.4 72.0 70.6 70.8 71.1 71.4 71.6

55+ 58.1 58.5 56.6 57.4 58.2 58.5 59.2

RPNs

18-29 46.1 47.4 42.1 40.6 39.1 36.9 36.3

30-54 65.0 64.8 60.5 59.7 59.1 58.2 58.0

55+ 62.7 62.7 60.9 60.6 61.2 61.7 62.3

38 RN/NP Workforce Backgrounder May 2019

6 (b2) Working Status for New Ontario RNs

90 Full-time %

80 Part-time % 70 Casual % 60

50

40

30

20

PercentageofRMMew Workforce 10

0

2009 2003 2004 2005 2006 2007 2008 2010 2011 2012 2013 2014 2015 2016 2017

39 RN/NP Workforce Backgrounder May 2019

6.3 Ontario Preferred vs. Actual Working Status for RNs and RPNs In 2014, CNO started publishing data comparing nurses' stated preference for work status with their actual work status. While most nurses are working according to their preferred status, a significant minority are not, and the bulk of those are part-time or casual nurses who would prefer full-time employment. In 2016:  66.2 percent of RNs were employed full time, while 73.1 percent of RNs preferred full-time work (Table 6(c))  76.9 percent of NPs worked full-time, while 81.1 percent of NPs preferred full-time work (Table 6(d))  53.9 percent of RPNs were employed full time, while 76.5 percent of RPNs preferred full-time work (Table 6(e)) If all nurses had their preferred work status, Ontario would easily surpass its 70 percent full-time objective for nurses. Reading the table: The full-time row shows that of RNs who work full-time, 60,390 prefer full-time, which is 95.6 percent of all the full-time RNs. By comparison, 8,189 part-time RNs (32.5 percent of all part-time RNs) would prefer to work full time. If we look at the part-time column, we see that 65.3 percent of part-timers prefer part-time, while 32.5 percent would prefer full-time and 2.2 percent would prefer casual employment.

6(c1). Ontario RNs: Preferred vs. Actual Work Status 201751 Actual Work Status

Preferred Full-time Part-time Casual

# % # % # %

Full-time 60,390 95.6 8,189 32.5 1,135 16.2

Part-time 2,332 3.7 16,460 65.3 995 14.2

Casual 413 0.7 548 2.2 4,882 69.6

Not Specified 3 0.0 0 0.0 0 0.0

Total 63,138 100.0 25,197 100.0 7,012 100.0

40 RN/NP Workforce Backgrounder May 2019

6(c2). Ontario RNs: Preferred vs. Actual Work Status 2017: Summary52 Status Preferred Actual

# % # %

Full-time 69,716 73.1 63,138 66.2

Part-time 19,788 20.8 25,197 26.4

Casual 5,843 6.1 7,012 7.4

Not Specified 3 0.0 3 0.0

Total 95,350 100.0 95,350 100.0

6(d1). Ontario NPs: Preferred vs. Actual Work Status 201753 Actual Work Status Preferred Full-time Part-time Casual

# % # % # %

Full-time 2,080 94.3 203 36 42 42.9

Part-time 117 5.3 352 62.4 13 13.3

Casual 8 0.4 9 1.6 43 43.9

Total 2,205 100 564 100 98 100

6(d2). Ontario NPs: Preferred vs. Actual Work Status 2017: Summary54 Status Preferred Actual

# % # %

Full-time 2,325 81.1 2,205 76.9

Part-time 482 16.8 564 19.7

Casual 60 2.1 98 3.4

Total 2,867 100.0 2,867 100.0

41 RN/NP Workforce Backgrounder May 2019

6(e1). Ontario RPNs: Preferred vs. Actual Work Status 201755 Actual Work Status Preferred Full-time Part-time Casual

# % # % # %

Full-time 22,485 96.8 8,653 55.1 1,849 44.5

Part-time 615 2.6 6,880 43.8 878 21.1

Casual 139 0.6 169 1.1 1,431 34.4

Not Stated 0 0 0 0 0 0

Total 23,239 100.0 15,702 100.0 4,158 100.0

6(e2). Ontario RPNs: Preferred vs. Actual Work Status 2017: Summary56 Working Status Preferred Actual

# % # %

Full-time 32,987 76.5 23,239 53.9

Part-time 8,374 19.4 15,702 36.4

Casual 1,739 4.0 4,158 9.6

Not Stated 0 0.0 1 0.0

Total 43,100 100.0 43,100 100.0

42 RN/NP Workforce Backgrounder May 2019

6.4 How Progress on Ontario Full-Time Employment Was Achieved: Workforce Changes by Work Status Tables 6(f) to 6(j) estimate the progress toward full-time employment during recent government mandates.57 The 2004-08 period of CNO data corresponds closely to the Liberal government’s first mandate (2003-07), while the 2008-12 period of CNO data corresponds closely to the second mandate (2007-11). It should be noted the CNO data pertains to January 1 of each year, while the mandates commenced in October of 2003 and 2007.

2004-2008 In the present government’s first mandate (2004-2008),58 the number of full-time RN/NP positions increased significantly (+9,106 positions), while part-time positions dropped (-2,464) and casual positions were virtually unchanged (+23), as seen in Table 6(h). The overall number of RN/NP positions increased by 6,665.

2008-2012 In the government’s second mandate – using CNO data for 2008-2012, Table 6(h) – there was very little growth in RN/NP positions (+1,920) and more than half were NPs (1,006), as seen in Table 6(g). Much of the gain in full-time positions (+4,620) was offset by drops in part-time (-2,557) and casual (- 143) positions.

2012-2017 The 2012-17 period reversed the pattern of the previous period. RN/NP employment grew by 3,464 positions, though the majority (3,128) were part-time (Table 6(h)). RNs actually lost 92 full-time positions over the period (Table 6(f)). New Ontario RNs were particularly affected, with their full-time status dropping from 79.3 percent in 2009 to 42.9 percent in 2017.59

1995-2017 Over the entire 1999-2016 period (from the low point to the most recent data; Table 6(h)), RN/NP full- time employment increased by an estimated 26,070 positions. A loss of 2,374 part-time and 3,577 casual positions brought the net gains to approximately 20,120 positions. It should be noted the reduction in part-time and casual positions reflected in part the conversion to full-time positions as a part of Ontario's 70 percent full-time policy for RNs. Over the same time period, the combination of a rise in full-time positions and a drop in part-time/casual positions resulted in a dramatic hike in the share of full-time employment from about 50 percent to 68.4 percent in 2012 before it fell back to 66.5 percent by 2017.

43 RN/NP Workforce Backgrounder May 2019

6(f). Estimated Workforce Changes: Ontario RNs

2004-08 2008-12 2012-17 2004-17 1999-2017

Full-Time 8,812 3,730 (92) 12,450 24,036

Part-Time (2,510) (2,660) 2,818 (2,352) (2,856)

Casual 25 (156) (255) (386) (3,625)

Total 6,327 914 2,471 9,712 17,555

6(g). Estimated Workforce Changes: Ontario NPs

2004-08 2008-12 2012-17 2004-17 1999-2017

Full-Time 294 890 614 1,798 2,034

Part-Time 46 103 310 459 482

Casual (2) 13 69 80 49

Total 338 1,006 993 2,337 2,565

6(h). Estimated Workforce Changes: All Ontario RNs and NPs

2004-08 2008-12 2012-17 2004-17 1999-2017

Full-Time 9,106 4,620 522 14,248 26,070

Part-Time (2,464) (2,557) 3,128 (1,893) (2,374)

Casual 23 (143) (186) (306) (3,577)

Total 6,665 1,920 3,464 12,049 20,120

44 RN/NP Workforce Backgrounder May 2019

In contrast, RPNs steadily gained employment through all three recent time periods, including full- time, part-time and casual positions. The full-time gains outweighed the part-time and casual gains in the first two mandates, meaning that the full-time ratio improved during that period. In the third four- year period, RPNs gained more part-time and casual positions, meaning that the full-time ratio deteriorated. RPNs did not see the same hike in full-time share as RNs (47 percent to 61 percent from 1999 to 2011, before dropping off), but the RPN full-time share of total nursing employment hit a record high in 2011.

6(i). Estimated Workforce Changes: Ontario RPNs

2004-08 2008-12 2012-17 2004-17 1999-2017

Full-Time 2,390 4,576 3,218 10,183 11,314

Part-Time 475 458 5,615 6,548 6,484

Casual 139 384 1,417 1,940 159

Total 3,004 5,418 10,250 18,672 17,957

When RN/NP and RPN employment are added together, an estimated 37,384 full-time nursing positions have been added from 1999 to 2017. Part-time positions grew more slowly, while the number of casual positions fell. The three factors worked together to raise the full-time share of nursing employment. Recently, rapid growth in RPN employment has dominated changes to total nursing employment.

6(j). Estimated Workforce Changes: All Ontario Nurses

2004-08 2008-12 2012-17 2004-17 1999-2017

Full-Time 11,496 9,196 3,740 24,431 37,384

Part-Time (1,988) (2,099) 8,743 4,656 4,110

Casual 162 241 1,231 1,634 (3,417)

Total 9,669 7,338 13,714 30,721 38,077

45 RN/NP Workforce Backgrounder May 2019

6.5 Full-Time Working Status: Ontario RNs/NPs vs. the Rest of Canada RNs/NPs CIHI statistics show Ontario and the rest of Canada experienced similar patterns with respect to shares of full-time employment over time, but a wide gap opened after 1999. Both were well above 60 percent in 1980, and both followed a general downward trend after that time, falling below 50 percent by 1999. After that, both trended upwards, with Ontario rising much more quickly than the rest of the country. As of 2017, 66.8 percent of Ontario RNs were working full-time as compared to only 55.6 percent of RNs in the rest of Canada.

6(k). Percentage Full-Time Work Share for RNs/NPs: Ontario vs. Rest of Canada (ROC) 1980-2017

70.0

65.0 Ontario ROC 60.0

55.0

Time Share for RNs/NPs for Share Time -

50.0 Percent Full Percent 45.0 80 82 84 86 88 90 92 94 96 98 0 2 4 6 8 10 12 14 16

46 RN/NP Workforce Backgrounder May 2019

6.6 Full-Time RN/NP Working Status: Ontario vs. Other Provinces In 2017, the percentage of RNs/NPs working in full-time positions across the country varied considerably from province to province. Percentages ranged from 43.9 percent in the Yukon, 45.3 percent in Alberta and 45.6 percent in Manitoba to 71.1 percent in Newfoundland and 68.9 percent in the NWT/Nunavut. The other two western provinces had full-time rates between 50 and 60 percent. Joining Ontario in the 60-67 percent range were Nova Scotia, and New Brunswick, with Quebec marginally below that range. Newfoundland demonstrates that a goal of 70 percent full-time employment is achievable, while also having the highest RN-to-population ratio in the country. This is a strong indication its residents have access to more hours of RN services per capita than the rest of Canada.

6(l). Percent Shares of RN/NP Full-Time Employment, 2017 Across Canada

Province/Territory Full-time Share

NFLD 71.1

NWT 68.9

NS 67.1

Ont 66.8

NB 62.5

Canada 59.5

Sask 59.0

Que 58.2

BC 56.0

Rest of Canada 55.6

PEI 53.0

Man 45.6

Alta 45.3

Yukon 43.9

47 RN/NP Workforce Backgrounder May 2019

7. Multiple Employment A significant number of nurses work for more than one employer: 15.5 percent of RNs, 27.1 percent of NPs and 19.9 percent of RPNs. Between 2013 and 2015, the incidence of multiple job holding rose for nurses in all three categories. It increased in 2016 for RNs and NPs, and dropped for RPNs. In 2017, multiple job holding rose for nurses in all three categories.

7. Percentage of Nurses with Multiple Employers in Ontario

Number RNs60 NPs61 RPNs62 of Employers 2014 2015 2016 2017 2014 2015 2016 2017 2014 2015 2016 2017

One nursing 84.8 84.8 84.7 84.5 75.6 74.8 74.0 72.9 80.3 79.8 80.2 80.1 employer

Two nursing 13.3 13.4 13.3 13.5 20.1 20.7 21.3 22.3 17.7 17.8 17.5 17.6 employers

More than two 1.9 1.9 1.9 2.1 4.3 4.5 4.6 4.8 2.3 2.3 2.3 2.3 nursing employers

Total 100 100 100 100 100 100 100 100 100 100 100 100

48 RN/NP Workforce Backgrounder May 2019

8. RN(General Class) Employment by Sector By numbers of positions, hospitals remain the largest employer of RNs. Between 2014 and 2016, there was no pronounced trend change in sectoral shares. In 2017, there was a slight shift into the hospital sector from the other sectors. Please note that these are counts of RN positions, which are more numerous than the number of RNs. A significant number of RNs were counted at least twice as they had multiple employers.

8. Employment Sectors for RNs in Ontario63

2015 2016 2017 Sector # % # % # %

Hospital 68,607 60.9 68,607 60.9 68,755 61.2

Community 22,602 20.1 22,602 20.1 22,361 19.9

Long-Term Care 10,135 9.0 10,135 9.0 10,044 8.9

Other 11,347 10.1 11,347 10.1 11,270 10.0

Total 112,691 100.0 112,691 100.0 112,430 100.0

49 RN/NP Workforce Backgrounder May 2019

9. Age of Nurses

9.1 Average Age of Nurses The average age of RNs fell in 2015 after trending upwards in previous years and it continued to fall through 2017. This reflects gains at the lower end of the age spectrum. The average age of NPs continued its decline. The average age of an RPN resumed its decline in 2014 after being unchanged in 2013. That decline is consistent with expanding RPN employment.

9(a). Average Age of Nurses in Ontario

Nurse Category / 2002 2014 2015 2016 201764 Class

RN 44.8 45.4 45.1 45.0 44.8

NP 43.5 44.6 44.5 44.3 44.0

RPN 44.2 41.9 41.4 41.0 40.8

50 RN/NP Workforce Backgrounder May 2019

9.2 Age Distribution The RN workforce continued to get older in 2017 compared to 1999, with the percentage of those age 60 and older growing from less than 5 percent to 13 per cent. The percentage of nurses between 35 and 49 plunged, while there was growth in the percentage of the youngest nurses age 29 or less. The 2017 age distribution is bimodal, with peaks for the age groups 25-29 and 50-54. The rise in the share of younger RNs indicates that the effort to recruit and educate new RNs is already yielding gains. The dramatic decrease over time in the share of RNs ages 35 to 49 suggests a need to develop a strategy to retain mid-career nurses. The rise in the share of RNs over 55 may indicate that efforts to retain late- career RNs are bearing fruit, but further recruitment and retention efforts are needed to ensure sufficient replacements for the many RNs who will retire over the next 10 years.

9(b). Trends in Distribution of Age Groups among Ontario RNs

1992 1999 2017 Age Group # % # % # %

18 - 24 1,801 2.2 810 3.5 3,888 4.1

25 - 29 10,246 12.5 5,548 9.1 11,034 11.6

30 - 34 11,129 13.6 8,809 9.1 10,451 11.0

35 - 39 14,086 17.2 12,002 10.6 9,378 9.8

40 - 44 14,427 17.6 12,379 12.3 10,685 11.2

45 - 49 12,480 15.2 14,823 14.9 11,964 12.5

50 - 54 8,771 10.7 11,902 13.6 13,652 14.3

55 - 59 5,512 6.7 7,905 14.3 11,215 11.8

60 - 64 2,835 3.5 3,019 8.6 8,542 9.0

65+ 806 1.0 597 4.0 4,541 4.8

Not Specified 12 0 1 0 0 0

Total: 82,105 100 77,795 100 95,350 100.0

51 RN/NP Workforce Backgrounder May 2019

9 (c). Ontario RN Age Distribution by Percent, 1992-2017

25 1992 20 1999

15 2017

10

5

0 18 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 65+

10. Gender of Nurses in 2017 The gender ratio of Ontario nurses in the nursing workforce has been stable over time, and heavily balanced toward females, with a slow increase in the percentage of males in the workforce.

10. Percentage of Ontario Nursing Workforce that is Female

2002 2012 201765

RN 96.3 94.6 93

NP 95.4 94.5 93.5

RPN 94 92.6 90.9

52 RN/NP Workforce Backgrounder May 2019

11. RN(General Class) Employment by LHIN Region in Ontario RN employment shares between Ontario LHIN regions show modest shifts. The counts from 2011 and after are not comparable to those in previous years because they consist of the total number (or percent) of positions and not the total number (or percent) of RNs, as in previous years. (See endnotes for each year.) There is considerable variation in RN employment between different LHINs.

11(a). Comparison of RN Employment by LHIN

LHIN Region 2005 201366 201767

# % # % # %

Central 6,596 7.4 9,306 8.4 10,055 8.9

Central East 7,704 8.7 9,325 8.5 9,163 8.1

Central West 2,506 2.8 3,614 3.3 4,173 3.7

Champlain 9,637 10.8 11,894 10.8 12,085 10.7

Erie St. Clair 4,252 4.8 5,053 4.6 4,891 4.4

Hamilton Niagara Haldimand Brant 10,330 11.6 11,832 10.7 12,083 10.7

Mississauga Halton 5,104 5.7 7,474 6.8 7,920 7

North East 4,968 5.6 6,005 5.4 6,131 5.5

North 2,971 3.3 3,743 3.4 3,658 3.3

North West 2,344 2.6 2,897 2.6 2,872 2.6

South East 4,379 4.9 5,128 4.6 5,038 4.5

South West 8,361 9.4 9,735 8.8 9,594 8.5

Toronto Central 14,840 16.7 19,128 17.3 19,847 17.7

Waterloo Wellington 3,884 4.4 4,949 4.5 4,919 4.4

Not Specified 1,178 1.3 222 0.2 1 0

Total 89,054 100 110,305 100 112,430 100

53 RN/NP Workforce Backgrounder May 2019

11.1 Ratios of Direct Care Nurses to Population per LHIN CIHI data reveal large discrepancies in ratios of direct care nurses to population between the different LHINs. For example, in 2017, the lowest concentration of direct care nurses was in the Central West LHIN, which had 321 RNs/NPs per 100,000 population (51.2 percent of the provincial average of 638, and 25.8 percent of the highest LHIN) (see Figure 11(c) and 11(d)).

11(b). RNs/NPs in Direct Care Per 100,000 Population (by LHIN), Ranked from Lowest to Highest for 2017

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Ontario 642 648 650 632 638 644 648 646 639 627

Central West 284 292 298 282 281 287 295 325 324 321

Central 375 380 386 370 361 366 369 375 375 363

Central East 458 455 459 441 446 445 443 436 431 420

Mississauga Halton 471 468 464 451 472 478 478 456 462 467

Waterloo Wellington 504 504 503 507 522 528 542 528 515 498

North Simcoe Muskoka 625 622 623 618 609 630 633 616 607 589

Erie St. Clair 628 644 623 632 636 648 650 647 632 603

Hamilton Niagara 687 692 689 674 677 679 683 677 674 662 Haldimand Brant

Champlain 747 750 759 746 748 758 753 754 745 728

South West 839 847 861 829 839 838 840 842 822 806

South East 825 831 831 816 831 849 858 841 821 818

North East 796 815 823 834 848 866 877 886 874 877

North West 892 917 947 944 983 998 1000 1027 1023 1015

Toronto Central 1238 1276 1288 1216 1239 1245 1269 1273 1260 1246

Canada 688 696 691 678 678 680 697 701 699 702

Rest of Canada 718 726 717 706 704 703 728 735 736 748

54 RN/NP Workforce Backgrounder May 2019

At the high end, the Toronto Central LHIN had a ratio of 1,246, which was almost double the provincial average. Joining it in the higher range were the North West and North East LHINs at 1,015 and 877 respectively. LHINs with largely rural and remote populations can be expected to require higher RN ratios, as one would also expect for LHINs that provide extensive hospital services to people from outside their boundary (e.g., Toronto Central). However, the size of the discrepancy among LHINs is a red flag of potentially unequal access to RN/NP services. This is particularly compelling in Ontario, given that the province already compares badly to the rest of the country in terms of RN/NP- to-population ratios. It suggests that RN/NP staffing in LHINs with low ratios should receive particular attention. Regions that have had rapidly growing populations in recent decades appear to be particularly at risk of having low direct care RN/NP-to-population ratios. The bar chart below demonstrates the significant spread of RN/NP density between LHINs. Also included is an RNAO estimate of the ratio for the rest of Canada outside Ontario.

11(c). Ontario 2017 Direct Care RNs/NPs Per 100,000 Population

1400

1200

1000

800

600

400

200

0

55 RN/NP Workforce Backgrounder May 2019

11.2 Distribution of LHIN Per Capita Budgets and Access to Nursing Care There is significant variation across the province in per capita operational funding allocated to the 14 LHINs. In particular, the rapidly growing LHINs outside of Central Toronto receive significantly less provincial dollars per capita than the Ontario average. This backgrounder also shows that the RN-to- population ratio is much lower in these underfunded LHINs. Here, the following data are compared: the per capita 2017-18 operating budgets for the LHINs as reported in the 2017-18 Ontario Expenditure Estimates;68 direct care RN-to-population ratios by LHIN;69 population shares by LHIN;70 and shares of RN71 and RPN72 employment. The information reveals large differences in funding on a per capita basis, with a corresponding large difference in LHIN shares of Ontario RN employment. The data show that the more generous the budget, the higher the share of RN employment. 11.3 The RN-to-Population Ratio Table 11(d) shows a striking discrepancy in per capita RN employment (first data column) across the different LHINs. The second data column creates a corresponding index that compares per capita employment to Toronto Central LHIN, set at 100. The Central West LHIN has the lowest RN employment compared to Toronto Central (25.8 percent of the Toronto Central per capita RN employment), while the North West LHIN is next highest after Toronto Central at 81 percent. Seven LHINs have half or less of the Toronto Central per capita RN staffing. This discrepancy is all the more important given that Ontario lags behind all provinces as an employer of direct care RNs (in 2017, Ontario had 627.3 RNs and NPs per 100,000 population, while the ratios for the other provinces ranged from 676 in BC to 1,019 in both Newfoundland and the Yukon and 1,102 in the Northwest Territories).73 Ontario also lags all provinces as an overall RN employer, requiring 19,126 more RNs to catch up with the rest of the country.74 11.4 Distribution of LHIN Funding Operating budget shares in LHINs align poorly with their population shares. One would expect equity, albeit with allowances for more funding for rural and remote LHINs and for LHINs that host disproportionate shares of teaching hospitals. Indeed, Toronto Central, North East and North West LHINs all have budget shares that substantially exceed their population shares. On the other end of the spectrum are seven LHINs that budget shares that fall short of their population shares. Notably, Central West LHIN has 6.8 percent of the population, but only 3.5 percent of the budget.

56 RN/NP Workforce Backgrounder May 2019

11(d). Ontario’s LHINS 2017: Budgets, Populations and Nurse Staffing. Ranked from Lowest to Highest RN/Population Ratios

RNs/100,000 Pop Budget RN RPN RNs/100,00075 RPNs/100,000 TorCen=100 Share Share Share Share

Central 321.1 25.8 147.4 6.8 3.5 3.5 3.4 West

Central 363.3 29.2 192.5 13.5 8.0 7.8 8.9

Central East 420.5 33.8 259.3 11.7 8.8 7.9 10.4

Mississauga 466.9 37.5 205.5 9.0 5.7 6.7 6.3 Halton

Waterloo 497.5 39.9 313.1 5.6 4.1 4.5 6.0 Wellington

North Simcoe 589.0 47.3 362.8 3.5 3.4 3.3 4.3 Muskoka

Erie St. 602.8 48.4 386.2 4.6 4.4 4.4 6.0 Clair

Hamilton Niagara 661.9 53.1 341.3 10.4 11.4 11.0 12.1 Haldimand Brant

Champlain 727.6 58.4 300.6 9.6 10.1 11.1 9.8

South East 818.1 65.7 421.1 3.5 4.4 4.6 5.1

South West 806.1 64.7 354.7 7.0 8.9 9.0 8.5

North East 877.1 70.4 493.2 3.9 5.7 5.5 6.6

North West 1014.6 81.5 503.9 1.7 2.5 2.7 2.9

Toronto 1245.7 100.0 315.2 9.1 18.9 18.0 9.7 Central

Ontario 627.3 50.4 293.6 100.0 100.0 100.0 3.4

57 RN/NP Workforce Backgrounder May 2019

11.5 Comparing LHIN Budgets, Populations and Nursing Employment Table 11(e) constructs a series of ratios of the above shares to further explore the relationships between budget, population and nursing employment. The provincial average is 100 for each ratio. There is a large discrepancy in the budget-to-population ratio (first data column) of LHINs, with Toronto Central having more than double the Ontario average and Central West at just 51.8 percent of the provincial average. There is a strong alignment between the budget-to-population ratio and the RN-to-population ratio (comparing the first and second data columns). In other words, the number of RNs per capita in each LHIN are correlated to the LHIN’s per capita funding levels. The third data column measures how well LHINs create RN positions per dollar of budget allocated. There is not a large dispersion of RN/budget shares (third data column). They range from the highest ratio in Mississauga Halton at 117.2 (17.2 percent above the provincial average) and the lowest in Central East, at 89.0 (11 percent below the provincial average). Interestingly, even though Toronto Central strongly leads in the RN-to-population ratio, it is below average (95.6) in its RN-to-budget ratio, indicating a strong disproportionality of funding in its favour. There is quite a spread in RN vs. RPN shares (fourth data column), with a much higher ratio in Toronto Central (185) compared to Waterloo Wellington (74.4). There is no obvious pattern in the relationship between budget-to-population ratios and skill mix (RNs/RPNs). Some LHINs with more generous budget allocations also have high RN-to-RPN ratios, (Toronto Central, South West, and Champlain), while other LHINs with generous budget allocations have low RN-to-RPN ratios (Hamilton Niagara Haldimand Brant, South East, North East, and North West). The situation is equally mixed with LHINs having less generous budgets: some have higher RN-to-RPN mixes (Central West, and Mississauga Halton), while the rest have lower RN-to-RPN mixes (Erie St. Clair, Waterloo Wellington, Central, Central East, and North Simcoe Muskoka). There is a broad dispersion of RPN-to-population share ratios (data column 5), ranging from 50.2 in Central West to 171.6 in North West. There appears to be a direct relationship between budget-to- population ratios and RPN employment, as is the case for RN employment. There is a wide dispersion in the RPN-to-budget share ratio (data column 6), from 51.7 in Toronto Central to 145.6 in Waterloo Wellington. The practice of all-RN staffing in many Toronto hospitals helps to explain the Toronto ratio. The differences in per capita funding between LHINs are striking. They are clearly associated with lower direct RN and RPN care ratios in underfunded LHINs.

58 RN/NP Workforce Backgrounder May 2019

11(e). Ontario’s LHINS 2017: Ratios of Budget Shares, Nursing Shares and Population Shares

Budget/Pop RNs/Pop RNs/Budget RNs/RPNs RPNs/Pop RPNs/Budget

Central West 51.8 51.2 98.9 101.9 50.2 97.0

Central 59.2 57.9 97.8 88.3 65.6 110.7

Central East 75.3 67.0 89.0 75.9 88.3 117.3

Mississauga 63.5 74.4 117.2 106.3 70.0 110.3 Halton

Waterloo 73.3 79.3 108.2 74.4 106.7 145.6 Wellington

North Simcoe 97.7 93.9 96.1 76.0 123.6 126.5 Muskoka

Erie St. Clair 97.2 96.1 98.9 73.0 131.5 135.4

Hamilton Niagara 109.8 105.5 96.1 90.8 116.3 105.9 Haldimand Brant

Champlain 105.4 116.0 110.1 113.3 102.4 97.2

South East 124.0 130.4 105.2 90.9 143.4 115.7

South West 126.7 128.5 101.4 106.4 120.8 95.4

North East 145.2 139.8 96.3 83.2 168.0 115.7

North West 151.9 161.7 106.4 94.2 171.6 113.0

Toronto 207.8 198.6 95.6 185.0 107.4 51.7 Central

Total 100.0 100.0 100.0 100.0 100.0 100.0

59 RN/NP Workforce Backgrounder May 2019

12. Ratios of Direct Care Nurses to Population per Public Health Unit CIHI data on RN/NP-to-population ratios again reveal large discrepancies between different public health units (PHUs). For example, in 2017, York Regional had 328 RNs/NPs per 100,000 population, which was 52.2 percent of the provincial average and 27.8 percent of the highest public health unit (Thunder Bay District). As noted above, Ontario has a very low RN/NP-to-population ratio by Canadian standards, and certain regional centres provide nursing care well beyond their boundaries, so the focus should not be on whether some regions have too much RN/NP care, but on those regions with very low ratios.

12(a). RNs/NPs in Direct Care Per 100,000 Population (by PHU)76

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Ontario 642 648 650 632 638 644 648 646 639 627

York Region 321 328 334 319 315 321 320 327 331 328

Haldimand–Norfolk 386 386 406 387 396 403 398 390 399 378

Peel 371 376 377 367 380 392 392 395 396 397

Durham 411 418 409 403 412 420 421 412 411 405

Halton 443 439 443 425 420 405 409 411 422 423

Haliburton Kawartha, Pine Ridge 443 456 456 442 456 449 452 459 442 427

Wellington–Dufferin–Guelph 485 486 482 477 481 485 490 486 469 443

Brant 519 529 532 503 492 473 463 464 478 455

Elgin–St. Thomas 589 575 557 559 551 541 518 511 508 486

Eastern Ontario 471 459 462 467 471 474 480 479 487 497

Waterloo 509 510 507 513 533 538 555 538 526 514

Niagara Region 509 521 511 513 509 519 521 523 520 525

Oxford County 493 482 481 505 511 533 549 546 540 529

Simcoe Muskoka District 570 570 569 565 555 575 576 561 553 535

Lambton 628 650 634 643 649 647 636 612 574 542

60 RN/NP Workforce Backgrounder May 2019

12(a). RNs/NPs in Direct Care Per 100,000 Population (by PHU)76

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Grey Bruce 617 604 591 588 583 597 599 595 574 581

Leeds, Grenville and Lanark 584 586 589 575 583 594 599 587 597 584

Hastings Prince Edward 601 614 612 612 637 656 654 651 606 587

Windsor–Essex 623 635 608 620 620 640 650 657 643 607

Huron 597 583 600 610 626 598 593 585 601 608

Perth 664 679 693 712 682 654 678 651 639 616

Renfrew 605 624 624 631 657 668 657 643 632 639

Chatham-Kent 646 674 663 666 679 681 665 652 660 660

Northwestern 656 656 694 666 717 737 728 761 748 731

Timiskaming 715 720 712 744 712 728 777 761 758 758

Toronto 795 806 816 773 780 783 796 796 785 769

North Bay Parry Sound 745 757 782 798 762 790 801 792 790 774

Peterborough 798 816 860 791 808 797 804 789 799 788

Ottawa 851 855 865 843 839 849 840 843 829 801

Porcupine 785 792 805 815 809 844 849 868 854 844

Algoma 781 799 787 796 817 821 824 848 830 845

Hamilton 1005 1013 1007 981 996 1000 1018 1007 1000 985

Sudbury and District 862 893 903 908 966 978 992 1002 986 1001

Middlesex–London 1120 1144 1178 1099 1123 1120 1118 1130 1095 1068

Kingston, Frontenac and Lennox 1136 1131 1134 1110 1128 1152 1171 1138 1113 1128 & Addington

61 RN/NP Workforce Backgrounder May 2019

12(a). RNs/NPs in Direct Care Per 100,000 Population (by PHU)76

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Thunder Bay District 1024 1065 1091 1103 1134 1147 1155 1180 1182 1180

ROC 718 726 717 706 704 703 728 735 736 748

Canada 688 696 691 678 678 680 697 701 699 702

12(b). Direct Care RNs per 100,000 Population by Public Health Unit

1400

1200

1000

800

600

400

200

0

ROC

Peel Peel

Kent Kent

-

Essex Essex

Perth Perth

Brant Brant

Huron Huron

–

Halton Halton

Canada

Guelph Guelph

Ottawa Ottawa

Norfolk Norfolk

London London

Ontario Ontario

Algoma

Toronto Toronto

Durham Durham

Renfrew Renfrew

–

–

–

Lambton Lambton

Hamilton Hamilton

Waterloo Waterloo

Porcupine Porcupine

St. Thomas Thomas St. Bruce Grey

York Region Region York

–

Timiskaming Timiskaming

Peterborough Peterborough

Northwestern Northwestern

Chatham

Oxford County County Oxford

Windsor

Niagara Region Region Niagara

Eastern Ontario Ontario Eastern

Dufferin

Elgin

–

Middlesex

Haldimand

Sudbury and District District and Sudbury

Thunder Bay District District Bay Thunder

North Bay Parry Sound Parry Bay North

Hastings Prince Edward Edward Prince Hastings

Simcoe Muskoka District District Muskoka Simcoe

Leeds, Grenville and Lanark Lanark and Grenville Leeds,

Wellington

Haliburton Kawartha, Pine Ridge Ridge Pine Kawartha, Haliburton Kingston, Frontenac and Lennox & Addington Addington & Lennox and Frontenac Kingston,

62 RN/NP Workforce Backgrounder May 2019

A Note on the Data: Ontario-specific nursing data was obtained from the College of Nurses of Ontario (CNO).77 National RN data for interprovincial comparisons was obtained from the Canadian Institute for Health Information (CIHI) RN database. The population data used to help generate the RN-to-population ratios come from Statistics Canada Table 051-0001 and Table 17-10-0086-01 (formerly CANSIM 109-5365). The calculations, analyses, conclusions, opinions and statements expressed herein are those of RNAO, and are not necessarily those of Statistics Canada, CNO or CIHI.

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References and Explanatory Notes

1 For the purposes of this report, the CNO convention of reporting RNs in the general class (RN (GC) s) as RNs will be followed. In contrast, the CIHI practice is to combine RN (GC) and nurse practitioner (NP) data together as RN data. 2 College of Nurses of Ontario (2016). FAQs: Declaration of Practice. October 31. http://www.cno.org/en/maintain-your- membership1/declaration-of-practice/. 3 College of Nurses of Ontario. (2013). Nursing Statistics. http://www.cno.org/en/what-is-cno/nursing-demographics/. 4 Canadian Institute for Health Information. (2018). Regulated Nurses, 2017. https://www.cihi.ca/en/regulated-nurses-2017. 5 College of Nurses of Ontario. (2014). Membership Statistics Highlights 2014, p. 10. http://www.cno.org/globalassets/docs/general/43069_stats/43069_membershipstatistics-highlights.pdf. 6 College of Nurses of Ontario (2016). FAQs: Declaration of Practice. October 31. http://www.cno.org/en/maintain-your- membership1/declaration-of-practice/. 7 Based on Data from Table 3.1 of College of Nurses of Ontario. (2018). Membership Statistics Report 2017, http://www.cno.org/globalassets/docs/general/43069_stats/2017-membership-statistics-report.pdf. and earlier versions of the report. 8 This includes practicing RNs and non-practicing RNs who are still entitled to practice in Ontario. 9 The CNO introduced the non-practising class for nurses on January 1, 2013. It reports non-practising data from 2014 onwards. This allowed nurses to keep the nursing designation, while not allowing them to practice in Ontario. College of Nurses of Ontario. (2016). FAQs: Non-Practising Class. http://www.cno.org/en/maintain-your-membership1/nonpractising- class-faq/. 10 See previous endnote. 11 Council of Ontario Universities. (2010). Council of Ontario Universities Position Paper on Collaborative Nursing Programs in Ontario. August. http://cou.on.ca/wp-content/uploads/2015/05/COU-Position-Paper-on-Collaborative- Nursing-Programs-in-Ontario.pdf. 12 Canadian Institute for Health Information. (2018). Regulated Nurses, 2017: RN/NP Data Tables and previous years. Table 1. X .. indicates not available. n/a indicates not applicable. 13 Ibid. X indicates value suppressed to comply with CNA privacy policy cell value between 1 and 4. XX indicates value suppressed to comply with CNA privacy policy, cell value greater than 4. .. indicates not available. n/a indicates not applicable. 14 Canadian Institute for Health Information. (2018). Regulated Nurses, 2017. Table 1 Regulated nurse graduates (entry to practice) by profession and jurisdiction, Canada, 2007 to 2016, and Table 1. and previous years’ reports. .. indicates data is not available. 15 Canadian Institute for Health Information. (2017). Regulated Nurses, 2017: RN/NP Data Tables. Table 13. † indicates number suppressed in accordance with CIHI’s privacy policy. - indicates data is not applicable or does not exist. Data kindly provided by CIHI via special request, as the table was not reported in Regulated Nurses, 2017. 16 The ratio is the net contribution to other provinces divided by the total number of nurses trained in that province and working in Canada. 17 Based on data from Tables 4.4, 6.4, and 8.5 in: College of Nurses of Ontario (2017). 2017 Membership Statistics Report, and Tables 4.4, 6.4, and 8.5 in: College of Nurses of Ontario (2016). 2016Membership Statistics Report 18 Nursing Task Force. (1999). Good Nursing, Good Health: An Investment in the 21st Century. January. http://www.health.gov.on.ca/en/common/ministry/publications/reports/nurserep99/nurse_rep.aspx. 19 Note that CNO data by year refer to January 1 of the stated year, so that October 2003 for example is very close to January 1, 2004. 20 Ratio calculated by RNAO using CIHI RN employment data and Statistics Canada population data (Table 17-051- 0001(formerly CANSIM 051-0001) Estimates of population for July 1, Canada, provinces and territories). 21 The first mandate started near the end of 2003, and CNO data pertain to January 1 of each reported year. Hence, 2005 would represent the end of the first year of the first mandate.

22 The government anticipated $50 million in savings for 2008-09 alone by delaying the completion of the promise to hire 9,000 more nurses. Ontario Ministry of Finance. (2008). Managing Expenditures. http://news.ontario.ca/mof/en/2008/10/managing-expenditures.html. 23 The figures comparing Ontario with the rest of the country are based on CIHI statistics, which are slightly different than those from CNO, as CIHI adjusts statistics from each jurisdiction for nurses registered in multiple jurisdictions. Ratio calculated by RNAO using CIHI RN employment data and Statistics Canada population data (Table 17-051-0001(formerly CANSIM 051-0001) Estimates of population for July 1, Canada, provinces and territories). 24 Note that Ontario’s NPs first appear in the data in 1999, the year after they were able to register in the extended class. Nurse Practitioners’ Association of Ontario. (n.d.). NP History in Ontario. https://npao.org/nurse-practitioners/history/. 25 Aiken, L., Clarke, S. P., Sloane, D. M., Lake, E. T., & Cheney, T. (2008). Effects of hospital care environment on patient mortality and nurse outcomes. Journal of Nursing Administration, 38(5), 223-229. 26 Aiken, L., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA: Journal of the American Medical Association., 288(16), 1987-1993. 27 Estabrooks, C. A., Midodzi, W. K., Cummings, G. G., Ricker, K. L., &Giovannetti, P. (2005). The impact of hospital nursing characteristics on 30-day mortality. Nursing Research, 54(2), 74-84. 28 Hye Park, S., Blegen, M.A., Spetz, J., Chapman, S.A., & De Groot, H. (2012).Patient turnover and the relationship between nursing staffing and patient outcomes. Research in Nursing & Health, 35(3), 277-288. 29 Tourangeau, A., Doran, D. M., McGillis Hall, L., O'Brien Pallas, L., Pringle, D., Tu, J., et al. (2007).Impact of hospital nursing care on 30-day mortality for acute medical patients .Journal of Advanced Nursing, 57(1), 32-44. 30 Twigg, DG., Duffield, C., Bremner, A., Rapley, P., Finn, J. (2012). Impact of skill mix variations on patient outcomes following implementation of nursing hours per patient day staffing: a retrospective study. Journal of Advanced Nursing, 68(12), 2710-2718. 31 Tourangeau, A. (2006). Nurse staffing and work environments relationships with hospital-level outcomes. Ottawa, Ont.: Canadian Health Services Research Foundation. 32 Calculations by RNAO using CIHI nursing employment statistics and Statistics Canada population figures. CIHI has ceased to report nurse/population ratios. 33 CIHI suppressed the NP counts for the territories in 2016 for data privacy reasons. 34 Canadian Institute for Health Information. (2017). Regulated Nurses, 2016. RN/NP Data Tables. Table 24. 35 RNAO calculation using CIHI nursing workforce data and Statistics Canada population data. RNAO’s and CIHI’s calculation of the nurse/population ratio differed because RNAO used more recent population estimates than CIHI did. 36 RPNs/LPNs (RPNs in Ontario are the equivalent to licensed practical nurses (LPNs) in the rest of the country. Ontario RPNs are not to be confused with the registered psychiatric nurses of western Canada. Ontario does not have the latter). 37 LPNs = licensed practical nurses, called registered practical nurses in Ontario (RPNs). 38 RPNs = registered psychiatric nurses in this table, not to be confused with the registered practical nurses in Ontario. Note that Ontario and the other eastern provinces do not have registered psychiatric nurses. 39 2016 data for Yukon was used instead of 2017 data because NP data was suppressed for those territories in the 2017 CIHI report, preventing calculation of NP/population data. 40 Adapted from College of Nurses of Ontario. (2017). Membership Statistics Report 2017. Table 4.1. 41 College of Nurses of Ontario. (2017). Membership Statistics Report 2017. Table 4.2. 42 Adapted from College of Nurses of Ontario. (2017). Membership Statistics Report 2017. Table 8.1. 43 College of Nurses of Ontario. (2017). Membership Statistics Report 2017. Table 8.2. 44 Adapted from College of Nurses of Ontario. (2017). Membership Statistics Report 2017. Table 6.1.

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45 College of Nurses of Ontario. (2017). Membership Statistics Report 2017. Table 6.2. 46 Registered Nurses’ Association of Ontario. (2010). Creating Vibrant Communities. http://rnao.ca/policy/reports/creating- vibrant-communities. 47 College of Nurses of Ontario. (2018). New Members in the General Class 2016. P. 13. http://www.cno.org/globalassets/docs/general/43069_stats/new-members-in-the-general-class-2016.pdf. 48 College of Nurses of Ontario. (2013). Membership Statistics Supplement 2012. P. 5. http://www.cno.org/globalassets/docs/general/membershipstatisticsupplement.pdf 49 College of Nurses of Ontario. (2018). New Members in the General Class 2016. P. 2. . 50 College of Nurses of Ontario. (2016). Membership Statistics Report 2016. And Membership Statistics Report 2017 Figures 9.1 and 10.1. 51 Calculated from College of Nurses of Ontario. (2017). Membership Statistics Report 2017. Table 4.5. Columns for Not Stated actual work status omitted for ease of reading. 52 Ibid.. 53 Calculated from College of Nurses of Ontario. (2017). Membership Statistics Report 2017. Table 4.5. Columns for Not Stated actual work status omitted for ease of reading. 54 Calculated from College of Nurses of Ontario. (2017). Membership Statistics Report 2017. Table 4.5. Columns for Not Stated actual work status omitted for ease of reading. 55 Calculated from College of Nurses of Ontario. (2017). Membership Statistics Report 2017. Table 6.5. Columns for Not Stated actual work status omitted for ease of reading 56 Calculated from College of Nurses of Ontario. (2017). Membership Statistics Report 2017. Table 6.5. Columns for Not Stated actual work status omitted for ease of reading 57 Work status figures prior to 2005 were estimated, due to the fact the CNO only started to make reporting of those figures mandatory in 2005. Before that time, many RNs did not report their work status (almost 11,000 in 2004). The estimation was done by assuming that those whose status was unknown had the same proportions of full-time, part-time and casual employment as those whose employment status was known. 58 CNO data for 2004-2008 is counted from January 1 of each year and closely maps to the first mandate that ran from October 2003 to October 2007. 59 First year of renewal for RNs new to Ontario. College of Nurses of Ontario (2018).New Members in the General Class 2016, and previous editions of the report. Table 5.4. http://www.cno.org/globalassets/docs/general/43069_stats/new- members-in-the-general-class-2016.pdf. 60 College of Nurses of Ontario. (2017). Membership Statistics Report 2017. Table 4.6. 61 College of Nurses of Ontario. (2017). Membership Statistics Report 2017. Table 8.7. 62 College of Nurses of Ontario. (2017). Membership Statistics Report 2017. Table 6.6. 63 College of Nurses of Ontario. (2017). Membership Statistics Report 2017. Table 9.9. 64 College of Nurses of Ontario. (2017). Membership Statistics Report 2017, for 2017. Previous editions supplied the data for previous years. 65 College of Nurses of Ontario. (2017). Membership Statistics Report 2017. Pp. 19, 59, 39. Earlier data from previous editions of the Report. 66 2013 counts in this section are not comparable to those in the previous years because post-2010 counts are for positions while the earlier counts are for RNs. Due to multiple job holding, there were 110,305 positions but only 94,386 RNs. 67 2017 counts in this section are not comparable to years prior to 2011 since they are counts for positions while the earlier counts are for RNs. Due to multiple job holding, there were 112,430 positions in 2017 but only 95,350 RNs.

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68 Calculated by RNAO based on: LHIN operating budgets from Ontario. (2018). Expenditure Estimates for the Ministry of Health and Long Term Care (2017-18): Local health integration networks and related health service providers - vote 1411. https://www.ontario.ca/page/expenditure-estimates-ministry-health-and-long-term-care-2017-18#section-6; and LHIN population estimates for 2017 from Statistics Canada. (2018). Table: 17-10-0086-01 (formerly CANSIM 109-5365). Estimates of population (2011 Census and administrative data), by age group and sex for July 1st, Canada, provinces, territories, health regions (2017 boundaries) and peer groups. https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1710008801. 69 Calculated by RNAO based on direct care RN staffing by LHIN from Canadian Institute for Health Information. (2018). Regulated Nurses, 2017. Table 7, Regulated nursing workforce employed in direct care, by health region, jurisdiction and Canada, 2007 to 2016 https://www.cihi.ca/en/regulated-nurses-2016; and LHIN population estimates for 2017 from Statistics Canada. (2018). Table: 17-10-0086-01 (formerly CANSIM 109-5365). Estimates of population (2011 Census and administrative data), by age group and sex for July 1st, Canada, provinces, territories, health regions (2017 boundaries) and peer groups. https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1710008801 70 Calculated by RNAO from and LHIN population estimates for 2017 from Statistics Canada. (2018). Table: 17-10-0086- 01 (formerly CANSIM 109-5365). Estimates of population (2011 Census and administrative data), by age group and sex for July 1st, Canada, provinces, territories, health regions (2017 boundaries) and peer groups. https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1710008801. 71 Calculated by RNAO from direct care RN staffing by LHIN from Canadian Institute for Health Information. (2018). Regulated Nurses, 2017. Table 7, Regulated nursing workforce employed in direct care, by health region, jurisdiction and Canada, 2007 to 2016 https://www.cihi.ca/en/regulated-nurses-2017. 72 Calculated by RNAO from direct care RPN (LPN in CIHI terminology) staffing by LHIN from Canadian Institute for Health Information. (2017). Regulated Nurses, 2016. Table 7, Regulated nursing workforce employed in direct care, by health region, jurisdiction and Canada, 2007 to 2016. https://www.cihi.ca/en/regulated-nurses-2017. 73 Canadian Institute for Health Information. (2018). Regulated Nurses, 2017. Table 17, Health care providers employed in direct care per 100,000 population, by health region and jurisdiction, for selected provinces/territories, 2008 to 2017. https://www.cihi.ca/en/regulated-nurses-2017. 74 RNAO calculation using CIHI RN employment statistics and Statistics Canada population figures. 75 RNAO calculation using CIHI direct care employment figures and Statistics Canada population figures. 76 RNAO calculation using CIHI direct care employment figures and Statistics Canada population figures 77 College of Nurses of Ontario. (2018).Nursing Statistics. http://www.cno.org/en/what-is-cno/nursing-demographics/.

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