OUTLOOK ON NURSING

A snapshot from Canadian nurses on work environments pre-COVID-19

Linda McGillis Hall, PhD, RN Sanja Visekruna, PhD, RN

August 2020 Canadian Federation of Nurses Unions

Photo by Matthew Henry

WE ARE CANADA’S NURSES. We represent close to 200,000 frontline care providers and nursing students working in hospitals, long-term care facilities, community health care and our homes. We speak to all levels of government, other health care stakeholders and the public about evidence-based policy options to improve patient care, working conditions and our public health care system.

Published by Canadian Federation of Nurses Unions 2841 Riverside Drive Ottawa, ON K1V 8X7 613-526-4661

www.nursesunions.ca

Project team Carol Reichert Ben René Oxana Genina

Layout and graphics Alyster Mahoney

ISBN From coast to coast to coast, we acknowledge the ancestral and unceded territory of all the Inuit, Métis and First Nations People 978-1-7753845-8-8 that call this land home. The Canadian Federation of Nurses Unions is located on the traditional unceded territory of the Printed & bound Algonquin Anishnaabeg People. As settlers and visitors, we feel Imprimerie Plantagenet it’s important to acknowledge the importance of these lands, Printing which we each call home. We do this to reaffi rm our commit- ment and responsibility in improving relationships between nations, to work towards healing the wounds of colonialism and Cover images to improving our own understanding of local Indigenous peoples Griffin Wooldridge (front) and their cultures. Matthew Henry (back)

© 2020 Canadian Federation of Nurses Unions

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means without the permission of the publisher. Contents

President’s Message I

Acknowledgements 1

Executive Summary 2

Introduction 4

Background 5

Methods 9

Measures 10

Results 11

Discussion 21

Conclusion 27

Limitations 28

Recommendations 29

References 31

Appendix 37 Photo by Jonathan Borba

InIn thethe midstmidst ofof aa pandemic,pandemic, thethe deepdeep crackscracks inin ourour healthhealth carecare systemsystem areare beingbeing vividlyvividly revealedrevealed foifor toall see.to see. Linda Silas President Canadian Federation of Nurses Unions President’s Message

For decades, the Canadian alongside high patient/resi- nursing offi ce from 2009 to Federation of Nurses Unions dent-to-nurse ratios, nursing 2011 on a series of pilot projects (CFNU) and other health care shortages, generational issues, called Research to Action (RTA). stakeholders have raised and related retention and Projects were rolled out in the alarm. recruitment challenges. provinces across the country to improve the quality of nurses’ Now, in the midst of a pandemic, Studies commissioned by work environments. After the the deep cracks in our health professional associations, success of RTA, the CFNU urged care system are vividly revealed policy groups and indepen- provinces to scale up these for all to see. It has become dent academic research have projects in order to develop glaringly apparent that staffi ng confi rmed CFNU’s fi ndings that long-term nursing strategies to levels in health care facilities are nurses experience heavy work- address nurses’ work and health. dangerously low. loads, lack of suffi cient staffi ng, workplace violence and mental However, this failed to happen. The CFNU says: enough is disorder symptoms arising from Instead, the national nursing enough – we need governments an unhealthy work environment. offi ce was disbanded. to act now! Our message is a simple one: fi x it! In 2001, the Canadian Nursing Collectively, provincial govern- Advisory Committee (CNAC) ments steadily eroded the It’s time for a national strategy was tasked with improving the nursing workforce as they faced to safely staff our health quality of worklife for nurses. budget constraints. care facilities. Nurses are the In 2002, CNAC released its backbone of Canada’s health fi nal report recommending, in What was the result of a decade care system – without frontline part, that the federal govern- of inaction? nurses, our health care system ment fund an annual survey of will cease to function. The nurses’ health. As a result, the A report released this spring nursing workforce, faced with National Survey of the Work by the CFNU, Mental Disorder an unhealthy work environment, and Health of Nurses (NSWHN), Symptoms Among Nurses in unsafe staffi ng and a workforce a collaborative effort between Canada, based on a ground- that is badly eroded, needs the Canadian Institute for Health breaking survey of nurses immediate attention. Information (CIHI), Health in Canada during mid-2019, Canada and Statistics Canada, found alarming rates of mental For decades, the CFNU and was conducted from October disorder symptoms among nurses unions across the 2005 to January 2006. thousands of nurses: one third country have compiled the screened positive for major evidence of the fi nancial costs Following the alarming results depressive disorder and suicidal of excessive overtime coupled of this national survey of 19,000 ideation; more than a quarter with high rates of absenteeism nurses, the CFNU worked screened positive for gene- (close to $2 billion in 2016), with Health Canada’s national ralized anxiety disorder and

CANADIAN FEDERATION OF NURSES UNIONS I clinical levels of burnout. PTSD emerged as a major issue for Prior to the COVID-19 pandemic, symptom rates were consistent nurses. About one quarter the nursing workforce was with those for public safety of nurses surveyed said they aging, with many nurses on the personnel, such as police. experienced physical violence cusp of retirement. Many new from patients or their families nurses were choosing to work The Outlook on Nursing: A ‘once a month or less’, or ‘a few part time, sometimes because of snapshot from Canadian times a month’. About another excessive overtime and unsus- nurses on work environments quarter (26.3%) of the nurses tainable workloads. As a result, pre-COVID-19 builds on CFNU’s said they experienced physical shortages have been experi- research on nurses’ mental violence ‘once a week’ (6.8%), enced in the nursing workforce. disorders. Outlook on Nursing ‘a few times a week’ (11.6%) or is based on a pre-COVID survey ‘every day’ (7.9%). Aggressive recruitment undertaken from late October campaigns to address shortages 2019 until March 17, 2020. The Verbal abuse by patients or their were launched in some juris- survey adds another pillar to families was even more common dictions. Shortages meant that the foundational evidence for than physical abuse. About sometimes, particularly in rural urgent action to address the one in five study participants areas, emergency departments challenges nurses continue to (21.2%) experienced verbal were closed or surgeries were experience on a daily basis. abuse ‘daily’. Another 30% cancelled. Looking ahead to a experienced verbal abuse ‘a few post-COVID world, nothing indi- The survey respondents were times a week’ (20.6%) or ‘once a cates that things will improve. mostly experienced nurses week’ (9%). About another 30% In fact, without proper health (16.7 years on average), working (28.1%) indicated that verbal human resources planning, they full-time (66.7%), and mainly abuse occurred a few times are likely to worsen. women (91.3%) as women during the course of the month continue to make up the or ‘once a month or less’. The Outlook on Nursing Study vast majority of the nursing confirms long-standing issues workforce. The prevalence of physical and with the adequacy of staffing verbal abuse of nurses contri- resources, as well as dissatis- Despite the inherent chal- butes to high levels of emotional faction with the supports and lenges, nurses are working exhaustion among nurses abilities of managers hard to ensure that the quality (65.3%), as well as to high and leaders. of patient care remains rates of work-related physical high – potentially at a cost to injuries: almost 40% of nurses Dissatisfaction with nursing themselves. While almost 70% surveyed (37.8%) experienced work environments means many (68.8%) reported the quality work-related physical injuries on nurses may soon choose to of patient care as excellent or a monthly basis (a few times a leave their current jobs or leave good, two thirds (66.2%) said month or once a month or less). nursing altogether. the quality of the nurses’ work Some participants’ workplaces environment was either put them particularly at risk for Nurses surveyed were asked fair or poor. high rates of work-related phy- about their intention to leave sical injuries: 17% experienced their current job: over half Echoing the results of CFNU’s injuries ‘once a week’, ‘a few (59.7%) planned to leave their 2020 report on mental disorders times a week’ or ‘every day’. current job within the next year in nurses, workplace violence as a result of job dissatisfaction.

II Outlook On Nursing Photo by Matthew Henry

Among these nurses, over a facing discrimination in their care workers in Canada have quarter (27.1%) planned to leave own communities because of become infected is a damning nursing altogether, suggesting their role as health care workers. indictment of Canada’s failure the potential for major attrition to protect those who are from the profession. Even as they grapple with caring for the sick in the enormous stress, they are midst of a pandemic. COVID-19 has brought the also being offered limited long-standing crisis in the access to vacations and This is unacceptable. It hear- nursing workforce to the fore. leaves, with the potential for kens back to a time in the It has exacerbated already forced redeployment. 1800s during the Crimean War, existing issues such as burnout when nurses fought under the and occupational stress injuries Lack of access to appropriate inspiring leadership of Florence related to potentially traumatic PPE needed to keep them safe Nightingale to be respected experiences such as violence has meant further anxiety for and listened to on matters such and abuse, excessive overtime, themselves and their families, as basic hygiene and appro- unsustainable workloads, and is wreaking havoc on priate PPE. unsupportive management nurses’ mental health. Nurses and workforce shortages. have had to fi ght tooth and nail Faced with this daily reality, to receive the protections they where their health and well- For the women who make up deserve. Nurses have resorted being are being placed at risk, most of the nursing workforce, to negotiations, grievances, many nurses may choose to COVID-19 has also made it complaints, work refusals leave their jobs during or soon harder to fi nd daycare, harder and protests. after the pandemic. to educate their school age Many already have. children, harder to manage When all else failed, nurses their work schedules, all of have ended up in court. All in The future of the nursing work- which may contribute to further an attempt to force employers – force is bleak unless action is erosion of the nursing and governments – to provide taken now. Without immediate workforce as women fi nd the appropriate PPE they are action, a post-COVID-19 world their worklife untenable. required to provide under may mean closed hospital provincial occupational health beds, cancelled surgeries, Furthermore, nurses – the and safety laws. shuttered emergency rooms much-lauded “heroes” during and fewer long-term care beds the COVID-19 pandemic – are Currently, health care workers because nurses are not there to being abused on the job by make up about 20% of total staff them. disgruntled patients and their COVID-19 cases in Canada. families, while also sometimes The fact that so many health

CANADIAN FEDERATION OF NURSES UNIONS III Photo credit: Martin Péchy TheThe futurefuture ofof thethe nursingnursing workforceworkforce isis bleakbleak unlessunless actionaction isis takentaken now.now.

Photo by Shopify Partners

IV Outlook On Nursing Therefore, the Canadian Federation of Nurses Unions recommends that federal and provincial governments renew their commitment to the nursing workforce and immediately enact and provide dedicated funding for the following recommendations.

We recommend that the Federal government establish a permanent National nursing bureau/offi ce and appoint a 1 nurse leader in the federal government to: Build and advise the federal government on nursing and a health care policy in Canada;

Liaise with provincial and territorial principal/chief b nurses to present a unifi ed nursing voice on political and policy agendas to inform public and population health policies and programs; and

Lead a national advisory committee committed to plan- c ning and securing Canada’s nursing health and human resource needs across sectors to support the health and health care needs of all people living in Canada.

We recommend that the federal government commit to conducting annual standardized assessments of the quality 2 and safety of health care work environments for Canada’s nurses to: a Inform the development of a national action plan and sustainable strategy to support the physical, mental and social health of Canada’s nursing workforce, as well as mitigate the impact of the more recent COVID-19 pandemic on the nursing workforce;

Identify systems and processes requiring investment b to support the mental, physical health and wellbeing of Canada’s nursing workforce; and c Implement plans for investment in supports for the ongoing educational development of Canada’s nursing workforce through a dedicated funding envelope to ensure nurses are appropriately prepared for the changing health care needs of all people living in Canada.

CANADIAN FEDERATION OF NURSES UNIONS V Acknowledgements

Photo by Andrew Neel

The authors would like to thank Canada’s regulated nurses who generously gave their time to assist in this project by completing the surveys that provided the data reported herein. We would TheThe majoritymajority ofof also like to acknowledge the genuine interest and support for this study, provided by the findingsfindings inin thisthis CFNU, its provincial member organizations and other orga- nizations (FIQ, BCNU) which studystudy underscoreunderscore promoted this study to their members. In addition, we thank the members of the CFNU Advisory Committee for this thethe importanceimportance ofof project, including Cathryn Hoy, Marie-Ève Viau, Maura MacPhee, Judith Grossman, Paul Curry and thethe environmentenvironment inin Carol Reichert, for their ongoing guidance throughout the study process. Finally, we would also whichwhich nursesnurses work...work... like to acknowledge the assis- tance of Dr. Sarah Brennenstuhl for her contribution to the data analysis.

1 Outlook On Nursing Executive Summary

The Outlook on Nursing Study turnover intent and burnout). with evidence of commu- was a national survey that Participants came from across nication concerns between aimed to assess Canadian all provinces and territories in management and staff nurses, nurses’ perceptions of their the country, although a quarter staffi ng inadequacy and poor work environments. The study were from Alberta, followed by workplace climates. was conducted across all health higher numbers from Quebec, care sectors in the country, British Columbia and Ontario. Nurses reported a high including hospitals, long-term Most were registered nurses prevalence of verbal abuse care settings, home care and working in full-time positions in and complaints from patients other health care workplaces. hospitals. and/or families, with half of Approximately 7,153 regulated study participants subjected Canadian nurses, including The majority of fi ndings in to verbal abuse and a quarter registered nurses (RNs), this study underscore the receiving complaints on a licensed practical nurses (LPNs), importance of the environment daily to weekly basis. While registered psychiatric nurses in which nurses work, and the less prevalent, physical abuse (RPNs) and nurse practitioners challenges faced by nurses in from patients and/or families (NPs), participated in the study. current work settings across was experienced from daily Data was obtained through a Canada. While perceptions of to once a month. In addition, secure online survey platform. patient safety and the quality half of the study participants of care being provided in had experienced injuries from Nurse participants were asked Canada’s health care settings daily to once a month. Both to provide their perceptions were positive overall, system the prevalence and nature of on a variety of aspects of gaps such as nurse-to-nurse these occurrences is a cause their work, including patient communication during care for concern for the profession. care quality, safety, nursing transfers and shift changes were work environments, profes- highlighted as quality-related Dissatisfaction with current sional practice environments, concerns. Ratings on the quality work was identifi ed by just as well as nurse outcomes of the work environments were over half of the study partici- (work and career satisfaction, predominantly poor overall, pants, with close to two thirds

CANADIAN FEDERATION OF NURSES UNIONS 2 Photo by Shopify Partners

planning to leave their current Nurse participants in this study nursing leadership and policy job within the next year as a reported high levels of burnout leaders in the future needs to result of job dissatisfaction. Of overall, in particular with high go beyond attention to the those leaving their jobs, the levels of emotional exhaustion. supply of nurses available to majority plan to seek another Burnout has consistently been provide care. Understanding the nursing job, reflecting perhaps identified as a major concern complex state of nursing work the high satisfaction with for nurses in Canada for several environments in which Canadian nursing as a career reported by years, a point substantiated nurses work and the impact of most of the study participants. further in a recent report on these work environments on However, over a quarter of the mental health of nurses in the health and work outcomes those planning to leave their Canada, where over a quarter experienced by nurses is cri- jobs within the next year aim to of study participants reported tical to ensuring a sustainable seek work outside of nursing, clinical burnout symptoms that nursing workforce in the future. representing a substantial loss required attention.1 to the profession at a time when experienced nurses are in In summary, the results of this great need. study highlight that the focus of nursing issues taken on by

3 Outlook On Nursing Introduction

For at least two decades that nurses suffer from heavy Canadian nurse researchers workloads, perceptions of lack and policy leaders have drawn of support from management, attention to concerns expe- insuffi cient staffi ng, job dissa- rienced by nurses in health tisfaction, workplace violence, care work environments, and burnout and mental health the impact of these on nurses, issues. Yet Canadian nurses patients and Canada’s overall continue to experience these health system. While sporadic same workplace issues as efforts were undertaken to demonstrated in this current address these challenges, no study report. systematic approach has been adopted and maintained over time. Studies commissioned by various nursing professional and policy groups, unions, as well as independent research, have generated consistent evidence

CANADIAN FEDERATION OF NURSES UNIONS 4 Background

Photo by Jonathan Borba

The essential role of nurses to to focus on improving the about nurses’ work, working Canada’s health care system quality of worklife for nurses. In conditions, staffing concerns, has been acknowledged by addition, provincial-territorial as well as physical and mental health policy leaders for several nursing officers were advised well-being.6 Key findings identi- decades.2 Fueled by concerns to “identify and support the fied the high physical demands of a nursing shortage related implementation of retention of nursing work, exposure to to health system reforms in strategies for their respective verbal abuse and workplace the 1990s, the Conference of workforces, which focus on assault, and subsequent physical Deputy Ministers/Ministers of improving the quality of the and mental health issues experi- Health in 1999 directed the work lives of nurses.”5 enced by nurses.7 Advisory Committee on Health Human Resources (ACHHR) to Developed in 2001, CNAC Also beginning in 2001, the create a pan-Canadian strategy released a final report a year Nursing Sector Study group for nursing to prepare options later, which recommended was developed and produced for consideration related to increasing the number of 15 technical research reports developing the nursing work- nurses in Canada, improving over a five-year period, aimed at force.3 Further support for the education and maximizing creating “a long-term strategy nursing was evidenced in 1999 the scope of practice of nurses, to ensure that there was an when the federal health minister and improving working condi- adequate supply of skilled and established an Office of Nursing tions for nurses.6 One of the knowledgeable nurses to meet Policy in Health Canada to report recommendations was the evolving health care needs ensure that the views of nurses that the federal government of all Canadians”.8 One of these and the nursing profession were should fund an annual survey reports presented findings integrated into health policy.4 of nurses’ health. As a result, from the Canadian Survey of the National Survey of the Nurses from Three Occupational One of the first reports to Work and Health of Nurses Groups – registered nurses emerge from these initiatives (NSWHN), a collaborative effort (RNs), registered psychiatric was the 2000 report of the between the Canadian Institute nurses (RPNs) and licensed nursing strategy group, which for Health Information (CIHI), practical nurses (LPNs) on identified plans aimed primarily Health Canada, and Statistics nurse perspectives of factors at addressing nursing supply Canada, was conducted from in their work environments issues.5 Two of the eleven strat- October 2005 to January 2006. that influenced the nature and egies recommended, related The first of its kind in Canada, effectiveness of nursing care.9 to nursing work environments, this groundbreaking survey had Responses were obtained from included the immediate devel- close to 19,000 nurse respon- 13,620 Canadian nurses (36% opment of a Canadian Nursing dents (80% response rate) response rate), highlighting the Advisory Committee (CNAC) and highlighted information aging nursing workforce at the

5 Outlook On Nursing time, the importance of strong Similar initiatives in the area nursing leadership in reducing of nursing work environments turnover, and key linkages and nurses’ health have not between professional practice occurred. A national focus on environments, empowerment work environments emerged and job satisfaction.9 Job dissa- with the development of the tisfaction was associated with Quality Worklife – Quality workplace violence experiences, Healthcare Collaborative the most common being verbal (QWQHC) in 2005, which aggression from patients.9 A recommended that all health 2002 report of key informant care settings adopt and monitor interviews with health care a set of quality worklife indi- stakeholders, aimed at identi- cators tied to performance fying major work-related health agreements and accountability problems faced by Canadian reporting.11 Currently, one of the nurses, further validated these nine national standards of excel- concerns, concluding that lence identifi ed in Accreditation “it is clearly time for a strong, Canada’s QMentum accredita- focused and dedicated effort tion program relates to a safe to establish a method for moni- and healthy worklife where toring the health and individual employers monitor work environment”.10 indicators of the work envi- ronment and are expected to Despite these infl uential and address any issues that arise.13 formative initiatives, ongoing large-scale projects focusing Throughout the early part of on nurses’ health and work that decade, numerous studies environments in Canada were and reports on nursing were not sustained. Substantial work commissioned as federal was undertaken to develop a organizations continued to nursing database through the examine key issues confronted pioneering work of CIHI, which by the nursing workforce in began collecting and reporting practice and policy contexts. data on the supply, distribution Until 2009, the Canadian and practice characteristics Nurses Association (CNA) of Canada’s regulated nursing led a series of reports on the health professionals in 2002.11 nursing shortage in Canada that

CANADIAN FEDERATION OF NURSES UNIONS 6 Photo by Kelly Lacy

OngoingOngoing large-scalelarge-scale projectsprojects focusingfocusing onon nurses’nurses’ healthhealth andand workwork environmentsenvironments inin CanadaCanada havehave notnot beenbeen sustained.sustained.

7 Outlook On Nursing highlighted supply requirements Columbia, Alberta and Ontario England, Finland, Germany, for the future. More recently, reported job dissatisfaction and Greece, Ireland, the Netherlands, CNA as the professional burnout levels above the norm Norway, Poland, Spain, Sweden voice for nurses in Canada for health care personnel.25,26 and Switzerland), the US and has focused on articulating Further analysis of data from three additional countries and enhancing the role of this study demonstrated that (Botswana, China and South nurses in the Canadian health factors in professional nursing Africa) went on to survey nurses care system.14 The Canadian work environments, such as and patients in about 500 Federation of Nurses Unions staffing adequacy and use of general acute care hospitals in (CFNU) led a number of initia- a nursing model of care, had 2009-2010.30 Numerous publi- tives over the past two decades a direct impact on burnout,27 cations resulting from this work directed at issues facing nurses and reinforced that nursing report the effects nurse staffing over time, including overtime leadership played a fundamental and working environments and absenteeism, workload, role in the quality of worklife have on nurse and patient safe staffing, generational and burnout experienced by outcomes, and other countries issues, workplace safety and, nurses.28 In addition, an in-depth have since replicated the study most recently, mental health examination of the data from including Portugal (2014), Italy disorders. Alberta demonstrated that (2015-2016) and Cyprus (2015- hospitals that had nurses with 2016).31,32 In Canada, work is Individual academic researchers higher nurse education levels, currently underway in Ontario have also conducted a great a richer nursing skill mix, better to replicate the RN4Cast study. deal of research on nursing nurse-physician relationships Initial results of the nurse work environments, much of and lower use of casual and survey in Ontario identified which explored the relationships temporary staff were associated ongoing concerns with the work between nurse staffing, work with lower patient mortality.29 environment, burnout and job environments and outcomes in This international study has dissatisfaction. As no national acute care hospital settings.15-24 since formed the basis for the studies have been completed While substantive in nature, largest body of research under- in recent years on this area, most of these studies focused taken in the world examining the CFNU commissioned a on a single province. An excep- linkages between organizational researcher from the University tion was the 1999 international features of hospital care, nurse of Toronto who led the Ontario study comparing hospital nurse recruitment, nurse retention and project to administer the staffing, organization and patient outcomes.30 RN4Cast nurse survey across all quality of care across five coun- health care sectors in Canada to tries, including Canada, where Known as the RN4Cast study, a obtain a snapshot from nurses just under half of nurse partic- consortium of researchers from of their perceptions of current ipants (n=17,450) from British 12 European countries (Belgium, work environments.

CANADIAN FEDERATION OF NURSES UNIONS 8 Methods

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Study data were collected survey of nurses are presented through an online survey in this report using valid from October 22, 2019, until percentages. March 17, 2020, hosted on the well-established Qualtrics secure Approval to conduct the survey platform. Data collection study was obtained from the was suspended on March 17, University of Toronto’s Health 2020, following consultation Sciences Research Ethics Board. with the CFNU after the WHO A multimodal recruitment declared that the coronavirus strategy was used by the CFNU COVID-19 outbreak was a global to recruit participants via pandemic. Participants had the email and various social media option of completing the survey routes (e.g., Facebook, Twitter, in English or French. A set of virtual events with the CFNU extensively validated measures president through their eight used in the international RN4Cast member unions as well as the studies made up the online non-CFNU member nurses’ nurse survey.30-32 As the online unions in Quebec and British survey had been used primarily Columbia, and other relevant in hospital settings in previous nursing professional associ- research, the survey was adapted ations. Potential participants by the research team with input were provided with the URL for from an Advisory Committee led the online survey. All currently by the CFNU to include wording practising regulated nursing that was relevant for all health care providers, including regis- care work sectors in Canada. tered nurses (RNs), licensed The survey took approximately practical nurses (LPNs), nurse 20 minutes to complete and practitioners (NPs) and regis- contained 112 questions that tered psychiatric nurses* (RPNs) focus on the nursing work across the 13 provinces and environment, job satisfaction, territories in Canada and across nurse-perceived quality of care, health sectors (e.g., hospital, burnout, career satisfaction, long-term care, community/ turnover intent as well as a demo- home care and other), charac- graphics section. Results of this terized the study sample.

*NOTE: in Western provinces only

9 Outlook On Nursing Measures

Demographics

The online survey included a demographic section to capture characteristics of individual nurse participants (e.g., gender, age, education, language spoken and category of regu- lated nursing professional) as well as characteristics of their work (e.g., work experience, work status, work setting and province of employment).

Patient Care Quality, Safety, Work Environments and Outcomes

Participants completed the online survey comprised of well-validated measures that capture nurse perceptions of patient care quality, safety, nursing work environments, professional practice envi- ronments, as well as nurse outcomes (work satisfaction, career satisfaction, turnover intent and burnout). Early versions of some of the measures from this survey were also used in the 1999 interna- tional nurse study25,26,27,33,34 as well as some components of the 2005 NSWHN,7 both of which had large samples of Canadian nurse participants. See Appendix for detailed information on the validated study measures.

CANADIAN FEDERATION OF NURSES UNIONS 10 Results

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Individual Nurse Table 1. Individual Nurse Demographics Demographics

Study participants were Gender Study Participants primarily female (91.3%), with Female 91.3% an average age of 41.97 years. Close to half of participants Male 5.5% were under the age of 40, with Prefer not to say/prefer to 3.1% 18.9% under the age of 30 years self-describe and 27.8% between the ages of 30 and 39 years (see Table 1). Age Of the remainder, 21.2% were Under 30 years of age 18.9% between the ages of 40 and 30 to 39 27.8% 49 years, and 24.3% from 50 40 to 49 21.2% to 59 years of age. Fewer were over the age of 60 (7.8%). Close 50 to 59 24.3% to half (47.6%) held a nursing 60 to 69 7.3% baccalaureate degree, while 70 years and above 0.5% 40% were diploma-prepared, and the remainder held other Education degrees. Most were educated Diploma 40.0% in Canada (96.6%) and English- speaking (84.5%), while 15.5% Nursing baccalaureate 47.6% spoke French. The majority of Non-nursing baccalaureate 6.3% study participants were Masters 3.8% registered nurses (83.8%), followed by licensed practical Regulated nursing professional provider category nurses (12.8%), while far fewer Registered nurse 83.8% were registered psychiatric nurses (1.9%) or nurse prac- Licensed practical nurse 12.8% titioners (1.5%), for an overall Registered psychiatric nurse 1.9% response number of 7,153 regu- Nurse practitioner 1.5% lated Canadian nurses.

11 Outlook On Nursing Work Characteristics Table 2: Work Characteristics

Over 80% of study participants provided information on the Gender Study Participants Work experience Study participants length of their experience in Female 91.3% nursing. Of those who provided 1 to 10 years 41.2% Male 5.5% this information, over 40% had 11 to 20 years 24.6% Prefer not to say/prefer to 3.1% less than ten years of work 21 years or more 34.2% self-describe experience, and the average length of work experience for Work status all study participants was 16.7 Age Full-time 66.7% Under 30 years of age 18.9% years. Over two thirds (66.7%) of study participants were Part-time 26.3% 30 to 39 27.8% employed full-time, while 26.3% Casual 7.0% 40 to 49 21.2% reported they were working 50 to 59 24.3% part-time, and the remaining Location of employment 60 to 69 7.3% 7% in casual positions. Over Hospital 69.6% two thirds of participants 70 years and above 0.5% Home care/community 15.1% worked in the hospital sector (69.6%). Fewer respondents Long-term care 11.4% Education were employed in community/ Other 3.9% Diploma 40.0% home care (15.1%), long-term Nursing baccalaureate 47.6% care (11.4%), or other sectors Province of employment Non-nursing baccalaureate 6.3% (3.9%). The ‘other’ category Alberta 25.2% includes nurses employed in Masters 3.8% Quebec 16.7% business, industry, occupational health, private nursing agencies, British Columbia 11.9% Regulated nursing professional provider category self-employed, physicians’ Ontario 11.6% Registered nurse 83.8% offi ces, family practice units, Nova Scotia 10.1% Licensed practical nurse 12.8% educational institutions, Manitoba 6.6% Registered psychiatric nurse 1.9% associations, government 11 Newfoundland and Labrador 6.2% Nurse practitioner 1.5% and correctional agencies. One quarter of the survey Saskatchewan 5.8% participants came from Alberta New Brunswick 4.6% (25.2%), followed by Quebec Prince Edward Island 1.0% (16.7%), British Columbia (11.9%), Northwest Territories 0.1% Ontario (11.6%), and Nova Scotia Nunavut 0.1% (10.1%). The remainder of partic- ipants came from the other Yukon 0.0% provinces/territories as outlined in Table 2.

CANADIAN FEDERATION OF NURSES UNIONS 12 Photo by Matthew Henry

Quality of Care and Table 3: Quality of Care and Patient Safety Patient Safety

When asked to describe the quality of nursing care delivered Quality of patient care to patients in the area that Excellent 22.6% they worked, over two thirds of Good 46.2% study participants responded Fair 24.7% positively, with 22.6% reporting the care to be ‘excellent’, while Poor 6.5% another 46.2% rated it as ‘good’. Of the remainder, a quarter Patient safety (24.7%) rated the quality of Excellent 8.3% nursing care as ‘fair’, with 6.5% Very good 30.2% providing a ‘poor’ rating (see Acceptable 38.9% Table 3). Nurse participants were also asked to give their Poor 16.4% place of work an overall grade Failing 6.2% for patient safety. The largest proportion of nurses (38.9%) indicated the midpoint rating of ‘acceptable’. An additional 30.2% ranked patient safety as ‘very good’, and 8.3% gave an ‘excellent’ rating. Less than a quarter of study participants rated patient safety in their workplace as ‘poor’ (16.4%) or ‘failing’ (6.2%).

13 Outlook On Nursing Perceptions of specifi c dimen- Table 4: Patient Safety sions of patient care quality and safety were explored further in this study. Half of Staff feel mistakes are held against them the nurse participants in this Agree or strongly agree 45.1% Quality of patient care study reported that things Neither agree nor disagree 29.5% Excellent 22.6% ‘fall between the cracks’ when Good 46.2% transferring patients between Disagree or strongly disagree 25.3% Fair 24.7% units (50.7%), while another 39.4% noted that important Important patient care information is lost during shift changes Poor 6.5% patient care information gets Agree or strongly agree 39.4% lost between shift changes. Patient safety Neither agree nor disagree 22.7% Prevention of future errors was Disagree or strongly disagree 37.9% Excellent 8.3% a focus of discussion for 62.3% Very good 30.2% of study participants, although Things ‘fall between the cracks’ when transferring between units Acceptable 38.9% only 36.9% indicated that they were made aware of changes Agree or strongly agree 50.4% Poor 16.4% being implemented as a result Neither agree nor disagree 23.0% Failing 6.2% of patient safety event reports. Disagree or strongly disagree 26.6% At least half (50.2%) of the nurses participating in this study Staff feel free to question decisions/actions of those in authority do not feel free to question Agree or strongly agree 32.5% decisions or actions made by those in positions of authority, Neither agree nor disagree 17.3% while 45.1% feel their mistakes Disagree or strongly disagree 50.2% are held against them. Finally, similar numbers of participants We discuss ways to prevent errors from happening again felt that management actions Agree or strongly agree 62.3% in their workplace refl ect that Neither agree nor disagree 15.6% patient safety is a priority (38.8%), and 39.0% disagreed. Disagree or strongly disagree 22.1% For most of these specifi c patient safety dimensions, close Feedback on changes implemented based on event reports is given to a quarter of nurses partici- Agree or strongly agree 36.9% pating in this study had neutral Neither agree nor disagree 21.4% perceptions, indicating that they Disagree or strongly disagree 41.7% neither agreed nor disagreed that the event occurred Actions of management show patient safety is a priority (see Table 4). Agree or strongly agree 38.8% Neither agree nor disagree 22.2% Disagree or strongly disagree 39.0%

CANADIAN FEDERATION OF NURSES UNIONS 14 Photo by Matthias Zomer

Quality of Work Interactions with Environments Patients and Families

In contrast to quality of care Study participants were asked and patient safety, which the to comment on the frequency majority rated favourably, the of occurrence of different types work environment was rated of incidents that are related to ‘poor’ by over a quarter of study interactions with patients and participants (27.3%), another families, with response options 38.9% rated it as ‘fair’, while ranging from ‘never’ to ’every 27.7% gave it a ‘good’ rating, day’. These include complaints and only 6.1% rated it as from patients or their families, ‘excellent’ (see Table 5). as well as verbal or physical abuse towards nurses by patients and/or families. Over Table 5: Quality of Work Environment a quarter of study participants received complaints from patients and families ‘every Work environment day’ (8.7%), ‘a few times a week’ (10.5%) or ‘once a week’ Excellent 6.1% (7.6%). Another 18.1% received Good 27.7% complaints from patients and/ Fair 38.9% or their families ‘a few times a Poor 27.3% month’, while 17.5% noted these complaints occurred ‘once a month or less’. Over a third of study participants experienced limited complaints from patients and families – ‘a few times a year or less’ (31.4%) or ‘never’ (6.2%) (see Table 6).

Verbal abuse towards nurses from patients and/or families was much more prevalent than complaints. Just under a quarter of study participants (21.2%)

15 Outlook On Nursing experienced verbal abuse daily, Table 6: Interactions with Patients and Families while a similar number (20.6%) noted it occurred ‘a few times Complaints from patients/families a week’, and 9% reported weekly occurrences. Another Never 6.2% 16.4% reported verbal abuse A few times a year or less 31.4% from patients and/or families ‘a Once a month or less 17.5% few times a month’, and 11.7% A few times a month 18.1% reported it ‘once a month or Once a week 7.6% less’. Fewer experienced verbal abuse from patients and/ or A few times a week 10.5% families ‘a few times a year or Every day 8.7% less’ (17.3%) or ‘never’ (3.6%). Verbal abuse from patients/families Experiences of physical abuse Never 3.6% from patients and/or families A few times a year or less 17.3% were less common than expe- rience with verbal abuse, with Once a month or less 11.7% 19.3% of nurse participants A few times a month 16.4% ‘never’ experiencing it, and Once a week 9.0% 29.2% reporting having experi- A few times a week 20.6% enced it ‘a few times a year or less’. Another 12.2% of partici- Every day 21.2% pants reported physical abuse from patients and/or families Physical abuse from patients/families occurred ‘once a month or less’, Never 19.3% and 13.0% indicated it happened A few times a year or less 29.2% ‘a few times a month’. The Once a month or less 12.2% remaining study participants reported experiencing physical A few times a month 13.0% abuse from patients and families Once a week 6.8% daily (7.9%), ‘a few times a week’ A few times a week 11.6% (11.6%) or ‘once a week’ (6.8%). Every day 7.9%

CANADIAN FEDERATION OF NURSES UNIONS 16 Photo by Shopify Partners

Work-Related Injuries Table 7: Work-Related Physical Injuries

Work-related physical injuries were also reported, with only Work-related physical injuries 9.4% of nurse participants in this Never 9.4% study ‘never’ experiencing one (see Table 7). Of the remainder, A few times a year or less 35.7% over a third of participants Once a month or less 19.8% (35.7%) had a work-related A few times a month 18.0% physical injury ‘a few times Once a week 5.6% a year or less’, while 19.8% reported these injuries occurred A few times a week 7.2% ‘once a month or less’, and Every day 4.3% another 18.0% noted injuries happened ‘a few times a month’. The remainder of participants reported work-related physical injuries occurred ‘once a week’ (5.6%), ‘a few times a week’ (7.2%) and ‘every day’ (4.3%).

17 Outlook On Nursing Professional Practice relations (2.93) and nursing reporting being ‘very or a little Environments foundations for quality of care dissatisfi ed’ (52.4%) with their (2.64) were rated as favour- current job. The remainder of able, whereas the subscales of respondents reported feeling Nurse participants were asked staffi ng and resource adequacy ‘moderately or very satisfi ed’ to describe their perception of (2.08), nurse participation in (47.6%) (see Table 8). Turnover the professional practice envi- hospital affairs (2.15) and nurse intention was also examined, as ronment across different health manager ability, leadership and participants were asked if they care settings in relation to a set support for nurses (2.37) were would leave their workplace of factors that have been linked rated as unfavourable by because of job dissatisfaction. to nurse job satisfaction, patient study participants. Over half of the study parti- safety and quality of care in cipants (59.7%) indicated that previous research.35,36 Mean they planned to leave their scores reported, that are above Work Satisfaction and current job within the next year the scale midpoint of 2.5, indi- Turnover Intent as a result of job dissatisfaction. cate a favourable nursing work Most planned to seek another environment, while scores below Perceptions of work satisfaction nursing job either in a hospital represent an unfavourable were relatively evenly split (45.6%) or elsewhere in nursing environment.35 The subscales with just over half of nurses (27.3%), while 27.1% plan to seek of collegial nurse-physician participating in the study other employment.

Table 8: Work Satisfaction and Turnover Intent

Work satisfaction Moderately or very satisfi ed 47.6% A little to very dissatisfi ed 52.4%

Turnover intent Yes 59.7% No 40.3%

Plans for next work role Hospital nursing role 45.6% Nursing role outside of a hospital 27.3% Non-nursing role 27.1%

CANADIAN FEDERATION OF NURSES UNIONS 18 Satisfaction with work was Table 9: Job Satisfaction explored in greater depth with participants asked to identify Work schedule fl exibility their level of satisfaction with particular aspects of their Moderately or very satisfi ed 56.5% work. Nurse participants in this A little or very dissatisfi ed 43.5% study were most satisfi ed with their level of independence at Opportunities for advancement work (78.8%) and professional Moderately or very satisfi ed 35.9% status (77.4%), while sick leave A little or very dissatisfi ed 64.0% (60.7%), salary (57.2%), work schedule fl exibility (56.5%) and vacation (53.1%) were Independence at work ranked closer to the midline. Moderately or very satisfi ed 78.8% Educational opportunities, A little or very dissatisfi ed 21.1% educational leave and opportu- nities for advancement were the Professional status dimensions where nurse partici- Moderately or very satisfi ed 77.4% pants reported having the most dissatisfaction (see Table 9). A little or very dissatisfi ed 22.6%

Salary Career Satisfaction Moderately or very satisfi ed 57.2% A little or very dissatisfi ed 42.7% Participant satisfaction with choosing nursing as a career Educational opportunities was largely positive. Close to Moderately or very satisfi ed 42.5% two thirds (61.8%) of study respondents were moderately or A little or very dissatisfi ed 57.5% very satisfi ed with their career choice. Just over a quarter Vacation of the participants expressed Moderately or very satisfi ed 53.1% feeling a little or very dissatis- A little or very dissatisfi ed 46.9% fi ed (28.2%) with their choice of nursing as a career Sick leave (see Table 10). Moderately or very satisfi ed 60.7% A little or very dissatisfi ed 39.3%

Education leave Moderately or very satisfi ed 42.2% A little or very dissatisfi ed 58.7%

Table 10: Career Satisfaction

Career satisfaction Moderately or very satisfi ed 61.8% A little to very dissatisfi ed 28.2%

19 Outlook On Nursing Burnout Table 11: Burnout

Burnout, considered to be a syndrome that occurs from Burnout chronic interpersonal stressors High levels of emotional exhaustion 65.3% on the job, is often exhibited High levels of depersonalization 50.2% through three dimensions: emotional exhaustion – High levels of decreased personal achievement 42.5% ‘overwhelming exhaustion’, depersonalization – ‘feelings of cynicism and detachment from the job’ and decreased personal achievement – ‘a sense of ineffectiveness and lack of accomplishment’.37 Almost two thirds (65.3%) of study respon- dents reported high levels of emotional exhaustion, while half (50.2%) reported feeling high levels of depersonalization (see Table 11). Higher scores on these two subscales correspond to higher degrees of experienced burnout.36 Less than half (42.5%) of study participants had high levels of effi cacy or personal achievement, where lower scores on this subscale refl ect higher degrees of burnout.37

Photo by Vladimir Fedotov

CANADIAN FEDERATION OF NURSES UNIONS 20 The overall aim of this study was to obtain a description from Canada’s nurses of their perceptions of current work environments. Participants in this study came from across 13 provinces/territories, although a quarter were from Alberta, and Discussion more than 10% came from each of Quebec, British Columbia, Ontario and Nova Scotia. The demographic profi le of nurse participants in this study is similar in age, gender and work experience to that of Canada’s regulated nursing professionals as outlined in a recent report on Canada’s nursing workforce.38 The majority of study partici- pants were Anglophone nurses educated in Canada, with close to half having a baccalaureate degree in nursing. Most were registered nurses working in full-time positions in hospitals, with higher percentages of study participants coming from these categories in comparison to Canada’s overall workforce.38

Quality of Care and Patient Safety

Nurse perceptions of patient care have been reported to be a reliable indicator of quality when compared with process of care and patient outcomes.39 The majority of nurses in this study had positive perceptions about the overall quality of care being provided in their work setting, although over a quarter gave it a fair or poor rating. However, twenty percent more nurses in this study provided unfavourable ratings for quality of care than Canadian nurse respondents to the international study (11%) conducted two decades ago.40 Similarly, close to 20% fewer study respon- dents participating in the 2005 cross-sectoral Canadian NSWHN Photo by Oladimeji Ajegbile (11.9%) rated the care delivered by their team as fair to poor

21 Outlook On Nursing than in this study.7 In addition, nurses appears to be more satisfaction.35,36 This was rein- just over a third of respondents problematic in this study as just forced in Canada’s NSWHN, in the earlier international study over a third of participants were which reported that nurse rated the quality of care as made aware of changes being perceptions of working relations excellent,26 much higher than implemented as a result of with physicians were over- participants in this study, where patient safety event reports, and whelmingly positive: with over less than a quarter gave high half do not feel they are working three quarters reporting good rankings. This difference may in a culture that allows them to relations, a lot of teamwork, and suggest that although positive ask questions of management collaboration between nurses overall, a shift in nurse percep- about decisions or actions being and physicians.7 tions of the quality of care being made. Of greatest concern is provided in Canada’s health care that close to a half of study Factors considered to have an settings has occurred over time. respondents report working in unfavourable influence on work a punitive workplace culture environments by participants Perceptions of patient safety as they feel their mistakes are in this study were the extent were quite positive in this held against them. As further to which nurses participate in study, with over three quarters evidence of the discord in how their work environments of participants ranking it as management and staff relations, are managed, the supports acceptable, very good or study participants were rather and abilities of their managers excellent. Less than a quarter of evenly split on whether the and leaders, and the adequacy nurse participants rated patient actions of their management of staffing resources available safety in their workplace as poor team reflect a priority towards to them. Previous Canadian or gave it a failing grade. This patient safety. research also reported concerns is in between the prevalence with resource adequacy, reported in a US study using this Quality of Work including the earlier interna- survey instrument conducted tional work conducted in 1999,26 across four states from 2005- Environments where more than one-third of 2008, where almost a third of respondents reported problems nurse respondents provided an Two thirds of study participants with inadequate staffing. A 2012 unfavourable grade on patient rated the overall quality of report by the CFNU on nursing safety,41 and the European Union the work environment where workload and patient care RN4Cast studies, where just 7% they were employed as fair emphasized the need to develop provided poor/failing patient or poor, with over a quarter safe staffing models.42 More safety grades for their work of these ratings being poor. recently, in a 2013 Canadian settings.31 Differences between Specific aspects of the work Broadcasting Corporation (CBC) the results between countries environment that support survey of nurses examining may be attributed to variations nursing professional practice Canada’s health care, ‘about 60 in systems and practices of care environments that were favour- per cent of nurses responding delivery across countries. ably rated by nurses in this said there was not enough staff study included having collegial for them to properly do their The specific aspects of patient working relationships between jobs’.43 A newly released study care quality that concerned nurses and physicians and an commissioned by the CFNU study participants the most environment that emphasizes examining nurses’ mental health were communication-oriented, the nursing-based foundations in Canada also reported that with half reporting nurse-to- of patient care. Both of these nurses described the regular nurse communication issues dimensions of care have staffing levels of health care such as things falling between been identified in previous staff in their workplaces were the cracks when patients are Canadian studies as important ‘insufficient or inappropriate in transferred between units characteristics of positive meeting the needs of patients’.1 and information getting lost work environments,7,9,28,29 with during shift changes. At the similar scoring on the subscales Perceptions of nurse manager same time, close to two thirds reported in the international ability, leadership and support noted having communication comparative study.28 Decades for nurses received unfavourable systems in place to discuss ways of research conducted on ratings by participants in this of preventing future errors in Magnet hospitals in the US have study. Participants highlighted patient care. Communication demonstrated that positive lack of support from manage- between management and nurse-physician relationships ment for pursuit of ongoing are related to nurses’ job

CANADIAN FEDERATION OF NURSES UNIONS 22 education, including leave for conducted in 1999 indicated snapshot of the scope of educational purposes, as well that just under half of Canadian this issue, using reports from little or no opportunity for nurse participants reported the provincial and territorial advancement. In contrast, the that complaints from patients nursing unions.46 More broadly, majority of nurses who partic- or families were not infrequent, in CFNU’s (2017) membership ipated in the 2005 NSWHN while close to two thirds survey, almost two thirds of had a positive view of their reported frequent verbal abuse respondents reported experi- supervisor, with close to three to nurses from patients or fami- encing at least one workplace quarters reporting that their lies.26 Canada had the highest violence incident such as phy- nurse manager or immediate percentage of nurses from sical assault, verbal or emotional supervisor was a good manager across three countries in that abuse, bullying and racial/sexual and leader.7 A 2014 CFNU study reporting verbal abuse.26 harassment in the previous report on work redesign within year.46 Aimed to be a call for the context of patient safety Physical abuse was less prev- action to stop nursing work- reinforced the need for health alent in this study, although place violence in health care care organizations to strive for half of the participants had in Canada, it is clear from the Magnet-like work environments, experienced physical abuse fi ndings from our current study emphasizing effective nursing from patients and/or families that frequent problems with leadership as well as staffi ng ranging from daily to once verbal abuse and complaints adequacy.44 Recent work a month. This is higher than continue to persist today, as well emerging from the RN4Cast reported in the 2005 NSWHN, as physical abuse. consortium has reported links where just over a quarter of between nursing and hospital nurse respondents reported Work-related physical injuries management, perceptions of that they had been physically were also less prevalent than quality of care and the personal assaulted by a patient in the verbal abuse in this study, accomplishment dimension previous year.7 The 2005 report yet half of the participants of burnout.45 of nurses from across different reported experiencing injuries occupational groups in Canada from daily to once a month. also reported verbal aggres- This is substantially more than Interactions with sion, physical assault, threat of the 9% who reported having Patients and Families assault and emotional abuse been injured on the job in across all health care work the past year in the NSWHN.7 Concerns related to interactions sectors – the majority coming Ongoing assessment of with patients and families were from patients and/or families.9 work-related physical injuries also noted by nurses partici- A 2015 study examining the will be important to monitor in pating in this study, with more workplace violence experiences the future to determine if this than a quarter indicating they of nurses in British Columbia report is an anomaly, or whether received daily to weekly patient found that nurses were exposed further trends emerge that complaints. Of greater concern to workplace violence a few would benefi t from was the identifi cation by half times a year, reported high in-depth examination. of study participants of verbal levels of emotional exhaustion, abuse occurrences as daily to experienced musculoskeletal Work Satisfaction, weekly. These fi ndings are not injuries and anxiety at least new, as close to four out of ten monthly, and sleep disturbances Turnover Intent and nurse participants in the 2005 a few times a month.23 Career Satisfaction NSWHN reported occasional or frequent complaints from A discussion paper released by Over half of nurses partici- patients/patient families, as the CFNU in 2017 highlighted pating in the study reporting well as close to half reported the escalation in violence dissatisfaction with their current emotional abuse.7 Findings that nurses are experiencing job, and close to two thirds from the international study in Canada and provided a indicated that they planned to

23 Outlook On Nursing leave their current job within the next year as a result of job dissatisfaction. Satisfaction with work is comprised of factors relating to the job itself as well as the work environment. Over two thirds of participants in this study were satisfied with the professional concepts of the nursing role, such as control and independence in work as well as the professional status of the nursing role. At the same time, just over half of participants were satisfied with remuneration and flexibility of work schedules. Less than half of nurse partici- pants in this study were satisfied with educational opportunities, educational leave and oppor- tunities for advancement. Reports of job dissatisfaction were higher in this study than reported in the 1999 interna- tional nursing survey, where a third of Canadian nurse partici- pants were not satisfied,40 while just over ten percent of parti- cipants in the NSWHN in 2005 reported being dissatisfied with their work.7

Intent to leave was substantially higher in the current study with over half of participants planning to leave their position in the next year. Of these, the majority plan to seek another nursing job, although over a quarter expect to seek work outside of nursing. In comparison, in the previous international study it was reported that less than 20% of the Canadian nurse respondents were planning to leave work in the upcoming year.25 Reports of turnover intention by European nurses across ten countries in the 2010 RN4Cast study were lower, with only 9% indicating they intended to leave.47

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CANADIAN FEDERATION OF NURSES UNIONS 24 Photo by Shopify Partners

Nurses do the same amount of work in a shorter period of time, and the cycle of admissions and discharges is more rapid...

25 Outlook On Nursing The majority of study partic- has been identifi ed as a major job outcomes, including job ipants were satisfi ed with concern for nurses in Canada, satisfaction and turnover their choice of nursing as a with earlier reports from the intention.45,49 Further research career, while just over a quarter international study indicating comparing nurse data from nine expressed some dissatisfaction that almost half of Canadian countries suggests that higher with their career choice. In nurse participants had burnout burnout scores from Canadian comparison, far fewer nurse above the norms for medical nurses may be a result of short- participants (9.7%) in the personnel, with ratings for the ened average length of hospital NSWHN expressed dissat- specifi c burnout dimensions stays as “nurses do the same isfaction with nursing as a quite similar to respondents in amount of work in a shorter profession.7 this study.25,26 Further research period of time, and the cycle of using the Canadian nurse data admissions and discharges is Burnout from the international study more rapid”, placing substantial found that emotional exhaustion burden on nurses.49 was directly related to staffi ng Three dimensions of burnout adequacy.27 A 2008 study of Public awareness of nurse were examined in this study – 667 nurses across four provinces burnout in Canada was high- emotional exhaustion, deper- in Atlantic Canada also found lighted in a 2013 report on sonalization and personal that burnout was a predictor of hospital health care, led by accomplishment.37 Emotional turnover intention as emotional the Canadian Broadcasting exhaustion assesses nurse exhaustion predicted deperson- Corporation (CBC), where over participant feelings of being alization, which predicted the 40% of the over 4,500 nurse emotionally extended and feeling of ineffi cacy in study respondents indicated that exhausted from work, while participants.48 In addition, a 2015 they were burned out.43 More depersonalization captures study examining the workplace recently, in a Canadian survey of when they are becoming violence experiences of nurses nurses mental health, conducted unfeeling or impersonal towards in British Columbia found that in 2019, close to two thirds of their patients, and personal higher levels of emotional study respondents reported accomplishment refl ects the exhaustion were associated with having some symptoms of feelings of competence with intention to leave, and workload burnout, while over a quarter successfully accomplishing was the most frequent reason more had burnout symptoms and achieving their work cited for intention to leave.22, 23 that needed intervention.1 goals.37 Participants in this study reported high levels of These fi ndings correspond with experienced burnout overall, results of a number of studies with high levels of emotional from the international RN4Cast exhaustion and moderate consortium, confi rming that levels of depersonalization and burnout is related to quality personal achievement. Burnout of nursing care and nursing

CANADIAN FEDERATION OF NURSES UNIONS 26 Conclusion

Photo by Claudia Barbosa

Canadian nurses are expressing as a career remains strong, it is acute respiratory syndrome greater concern with the quality clear from these study results (SARS).51 The virus impacted of patient care than seen in that the trends being seen in health workers in Canada previous studies, a change nursing work environments in greatly as it compromised which have evolved over time. this study cannot continue for their safety as well as caused Patient safety issues are less the workforce to be maintained. burnout and psychological evident, although an awareness distress.52 Nearly two decades of health systems gaps such as The supply of nurses is a later, another debilitating coro- nurse-to-nurse communication concern for health systems navirus, COVID-19, emerged that during care transfers and shift globally, as identified in required the WHO to declare a changes was highlighted. Of the recent World Health global public health pandemic concern was poor communica- Organization (WHO) report, on March 11, 2020.53 The tion between management and which projected a shortage COVID-19 pandemic has drawn staff nurses and the resulting of 5.9 million nurses in 2018, a great deal of public attention punitive culture that ensues. particularly in low- and to health care, and in particular Given this climate, the quality middle-income countries.50 An to nurses and nurses’ health and of workplace environments was aging nurse workforce in the safety in workplaces. noted to be quite poor, with WHO American region, where concern expressed related to Canada falls, and the European This study was conducted just management capability and region may also affect supply before the COVID-19 pandemic subsequent supports provided longitudinally. Canada’s nursing was declared. Study findings to nurses, especially related supply grew by 1.9% from 2018 provide a disturbing picture of to ongoing educational devel- to 2019, although a downward nursing work environments in opment and opportunities trend is evident over the past Canada, one that has, no doubt, for advancement. Of greatest five years and may continue due worsened during the pandemic. concern in this study is the to an aging workforce.38 These While primarily related to the high level of verbal abuse and numbers only capture one supply of nurses, the WHO complaints, as well as an aspect of nursing in Canada, the report on the state of the escalating picture of physical supply of regulated nurses. They world’s nursing, released in April assault occurrences – all coming do not account for the very of this year, identifies that coun- from patients and families. real challenges experienced tries need to invest in enabling Not surprisingly, high levels of by nurses in Canada’s system working conditions for nurses.50 burnout exist with these nurses, of care delivery during normal The year 2020 was designated along with high levels of dissat- times – challenges that are by the WHO as the international isfaction and large numbers compounded during disasters year of the nurse and midwife, planning to leave their position and unexpected health events. so the time to address these and/or the profession. While This was apparent in 2003 with concerns is now. overall satisfaction with nursing the global epidemic of severe

27 Outlook On Nursing Limitations

This study provides a snapshot obtained based on nurses latter groups of nurses may of Canadian nurses’ perspec- volunteering to participate, as experience different work envi- tives at one point in time. It is opposed to random sampling. ronment challenges, it will be likely that work environment As a result, it is likely that important that nursing sectors perceptions change over time the sample was affected by are sampled proportionately in due to contextual infl uences self-selection. For example, future research. ranging from local working some nurses may have been conditions, structural health more motivated to complete Just under two thirds of the system changes, and global the survey given different sample provided complete data factors such as the COVID-19 political and contextual factors on all the variables measured public health pandemic. in various provinces at the time in the survey. As a result, the Comparison with studies of the study, including cutbacks sample composition changes obtained in different historical to health care funding during from variable to variable, contexts or countries should be the study period (e.g., Ontario, making comparisons across the interpreted with this in mind. Alberta). These factors could different indicators challenging. have equally discouraged other Nurses in this study may not nurses from participating due Finally, data collection was be representative of all nurses to the survey time commitment halted earlier than planned at a national or provincial and their increasing workloads. when the WHO announced level in Canada. The sampling Future research should consider that the COVID-19 corona- frame consisted of all working using methods that allow for virus outbreak was a global regulated nurses who were the construction of a random pandemic, thus the sample may members of nursing unions sample. In addition, the nurse have been larger had subject across the country that are survey was administered to recruitment continued. affi liated with the CFNU, as Ontario nurses in early 2019 as well as the non-CFNU member part of a different study, thus nurses unions in Quebec and the number of responses from British Columbia, and other Ontario at this time may be relevant nursing professional lower than normal. associations – which may have excluded nurses not A disproportionately higher currently practising or on leave percentage of nurses in the from work (e.g., maternity or study were full-time registered disability leave) and those not nurses in hospitals, compared represented by a nursing union. to the proportion found across As the names and contact Canada, which means that information of the nurses were nurses working in the long-term not available to the researchers, care and community sectors a convenience sample was were underrepresented. As the

CANADIAN FEDERATION OF NURSES UNIONS 28 Recommendations

We provide two recommendations from this report:

We recommend that the Federal government establish a permanent National nursing bureau/offi ce and appoint a nurse 1 leader in the federal government to:

Build and advise the federal government on a nursing and health care policy in Canada;

Liaise with provincial and territorial principal/ b chief nurses to present a unifi ed nursing voice on political and policy agendas to inform public and population health policies and programs; and

Lead a national advisory committee committed to c planning and securing Canada’s nursing health and human resource needs across sectors to support the health and health care needs of all people living in Canada.

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29 Outlook On Nursing We recommend that the federal government commit to conducting annual standardized assessments of the quality 2 and safety of health care work environments for Canada’s nurses to:

Inform the development of a national action plan and a sustainable strategy to support the physical, mental and social health of Canada’s nursing workforce, as well as mitigate the impact of the more recent COVID-19 pandemic on the nursing workforce;

Identify systems and processes requiring investment b to support the mental, physical health and wellbeing of Canada’s nursing workforce; and

Implement plans for investment in supports for the c ongoing educational development of Canada’s nursing workforce through a dedicated funding envelope to ensure nurses are appropriately prepared for the changing health care needs of all people living in Canada.

CANADIAN FEDERATION OF NURSES UNIONS 30 References

1. Stelnicki, A., Carleton, Government of Canada. Industry, December 2006. N., & Reichert, C. (2020). Retrieved June 8, 2020, Retrieved June 8, 2020, Mental Disorder Symptoms from: https://www. from: https://secure. Among Nurses in Canada. canada.ca/content/dam/ cihi.ca/free_products/ Ottawa, ON: Canadian hc-sc/migration/hc-sc/ NHSRep06_ENG.pdf Federation of Nurses hcs-sss/alt_formats/ Unions. Retrieved June hpb-dgps/pdf/nurs-in- 8. O’Brien-Pallas, L., Pringle, 8, 2020, from: https:// firm/2006-mandat-eng. D., Tomblin Murphy, nursesunions.ca/wp-con- pdf G., Birch, S., White, S., tent/uploads/2020/06/ McGillis Hall, L., Hayes, OSI_report_final.pdf 5. Advisory Committee on L., Kephart, G., Baumann, Health Human Resources. A., Wang, S. & Higgin, 2. Canadian Institute for (2000). The Nursing A. (2004). Building the Health Information Strategy for Canada. Future: An integrated (CIHI). (2001). Future Ottawa, ON: Government strategy for nursing human Development of of Canada, October 2000. resources in Canada Information to Support Retrieved June 8, 2020, – Research Synthesis the Management of from: https://www.canada. Report of Research Nursing Resources: ca/content/dam/hc-sc/ Findings. Ottawa, ON: Recommendations. migration/hc-sc/hcs-sss/ The Nursing Sector Study Ottawa, ON: CIHI. alt_formats/hpb-dgps/ Corporation/Canadian Retrieved June 8, 2020, pdf/pubs/2000-nurs- Nurses Association. from: https://secure. infirm-strateg/2000-nurs- Retrieved June 8, cihi.ca/free_products/ infirm-strateg-eng.pdf 2020, from: https:// FutureDev.pdf www.researchgate.net/ 6. Health Canada (2002). publication/271645730_ 3. Canadian Our Health, Our Future: Building_the_future_ Intergovernmental Creating Quality An_integrated_strategy_ Conference Secretariat. Workplaces for Canadian for_nursing_human_ (2000). News Release: Nurses. A Report of the resources_in_Canada_ First Ministers Meeting Canadian Nursing Advisory Research_Synthesis_ Communique on Health Committee. Ottawa, ON: Report (800-038). Ottawa, ON: Health Canada. Retrieved Government of Canada, June 8, 2020, from: 9. O’Brien-Pallas, L., Tomblin September 20, 2000. https://www.canada. Murphy, G., Laschinger, Retrieved June 8, 2020, ca/content/dam/hc-sc/ H., White, S., Wang, S. from: https://scics.ca/ migration/hc-sc/hcs-sss/ & McCulloch, C. (2005). en/product-produit/ alt_formats/hpb-dgps/ Canadian Survey of Nurses news-release-first-minis- pdf/pubs/2002-cnac- from Three Occupational ters-meeting-communi- cccsi-final/2002-cnac- Groups. Ottawa, ON: The que-on-health/ cccsi-final-eng.pdf Nursing Sector Study Corporation. 4. Government of Canada 7. Shields, M. & Wilkins, K. (2006). Nursing Issues: (2006). Findings from 10. Kerr, M.S., Laschinger, H.S., Mission, Mandate, the 2005 National Survey Severin, C.N., Almost, J.N., Functions, Key Activities of the Work and Health Thomson, D., O’Brien- and Current Priorities of Nurses (NSWHN). Pallas, L., Shamian, J., of the Office of Nursing Ottawa, ON: Statistics McPerson, D., Koehoorn, Policy. Ottawa, ON: Canada/Ministry of M. & LeClair, S. (2002).

31 Outlook On Nursing Monitoring the Health of Ottawa, ON: Canadian care delivery model and Nurses in Canada. Ottawa, Nurses Association, patient care quality. ON: Canadian Foundation September 2012. Journal of Nursing Care for Innovation (formerly Retrieved June 8, 2020, Quality, 19 (1) 27-33. Canadian Health Services from: https://www.cna-aiic. Research Foundation). ca/-/media/cna/files/en/ 20. Doran, D., Harrison, M.B., nec_report_e.pdf?la=en& Laschinger, H., Hirdes, 11. Canadian Institute for hash=3659EA41A22369A J., Rukholm, E., Sidani, Health Information (CIHI). F14FFD057284414B264F S., McGillis Hall, L., (2013). Regulated Nurses D58E0 Tourangeau, A., & Cranley, Database Data Element L. (2006). Relationship List. Ottawa, ON: CIHI; 15. Doran, D., McGillis Hall, between nursing inter- 2013. Retrieved June 8, L., Irvine, D., Baker, ventions and outcome 2020, from: https://www. G.R., Pink, G., Sidani, achievement in acute cihi.ca/sites/default/files/ S., O’Brien Pallas, L., & care settings. Research document/nursing_data_ Donner, G. (2001). Nursing in Nursing and Health, 29, element_en.pdf staff mix and patient 61-70. outcome achievement: 12. Canadian Council The mediating role of 21. Laschinger, H., Wong, of Health Services nurse communication. C. & Greco, P. (2006). Accreditation (CCHSA). International Nursing The impact of staff (2007). Within Our Grasp: Perspectives, 1 (2-3), nurse empowerment on A Healthy Workplace 74-83. person-job fit and work Action Strategy for engagement/burnout. Success and Sustainability 16. McGillis Hall, L., Doran, Nursing Administration in Canada’s Healthcare D., Baker, G.R., Pink, G., Quarterly, 30 (4), 358-367. System. Ottawa, ON: Sidani, S., O’Brien Pallas, CCHSA. Retrieved June L., & Donner, G. (2003) 22. MacPhee, M., Dahinten, 8, 2020, from: https:// Nurse staffing models S. & Havaei, F. (2017). www.cna-aiic.ca/-/media/ as predictors of patient The impact of heavy cna/page-content/ outcomes. Medical Care, 41 perceived nurse workloads pdf-en/17---2007_qwqhc_ (9), 1096-1109. on patient and nurse within_our_grasp_e. outcomes. Administrative pdf?la=en&hash=8BEF5F- 17. McGillis Hall, L. (2003). Sciences, 7,(7);7010007. 33B0C28F333D5CC6AC- Nursing staff mix models 8DC0C02AD1BECB6D and outcomes. Journal of 23. Havaei, F., MacPhee, M. Advanced Nursing, 44 (2), & Dahinten, S. (2016). 13. Accreditation Canada. 217-226. RNs and LPNs: emotional (2020). The Qmentum exhaustion and intention Accreditation Program. 18. McGillis Hall, L., Doran, D., to leave. Journal of Nursing Ottawa, ON: Accreditation & Pink, G. (2004). Nurse Management, 24, 393–399. Canada. Retrieved June staffing models, nursing 8, 2020, from: https:// hours and patient safety 24. Havaei, F., Astivia, accreditation.ca/accredi- outcomes. Journal of O.L.O. & MacPhee, M. tation/qmentum/ Nursing Administration, 34 (2020). The impact of (1), 41-45. workplace violence on 14. Canadian Nurses medical-surgical nurses’ Association. (2012). A 19. McGillis Hall, L., & Doran, health outcome: a moder- Nursing Call to Action. D. (2004). Nurse staffing, ated mediation model

CANADIAN FEDERATION OF NURSES UNIONS 32 of work environment 30. Sermeus, W., Aiken, 33. Aiken, L.H., Clarke, S.P., conditions and burnout L.H., Van den Heede, K., Sloane, D.M., Sochalski, using secondary data. Rafferty, A.M., Griffiths, J., & Silber, J.H. (2002). International Journal of P., Moreno-Casbas, M.T., Hospital nurse staffing Nursing Studies, 109, Busse, R., Lindqvist, R., and patient mortality, 103666. Scott, A. P., Bruyneel, L., nurse burnout, and job Brzostek, T., Kinnunen, dissatisfaction. JAMA, 25. Aiken, L.H., Clarke, S.P. J., Schubert, M., 288,1987-1993. & Sloane, D. M. (2002). Schoonhoven, L., Zikos, 34. Aiken, L.H., Clarke, S.P., Hospital staffing, organi- D. and the RN4Cast Sloane, D.M., Lake, E.T., zation, and quality of care: consortium. (2011). Nurse & Cheney, T. (2008). cross-national findings. forecasting in Europe Effects of hospital care Nursing Outlook, 50, (RN4Cast): Rationale, environment on patient 187-194. design and methodology. mortality and nurse BMC Nursing, 10 (6), 1-9. outcomes. Journal of 26. Aiken, L.H., Clarke, S.P., Nursing Administration, 38, Sloane, D. M., Sochalski, 31. Aiken, L.H., Sloane, D., 223-229. J.A., Busse, R., Clarke, H., Griffiths, P., Rafferty, A.M., Giovannetti, P., Hunt, J., Bruyneel, L., McHugh, 35. Lake ET. (2002). Rafferty, A.M., & Shamian, M., Sermeus, W. for the Development of the J. (2001). Nurses’ reports RN4Cast Consortium. practice environment on hospital care in five (2016). Nursing skill mix in scale of the Nursing Work countries. Health Affairs, European hospitals: Cross- Index. Research in Nursing 20 (3), 43-53. sectional study of the & Health. 25 (3),176-88. association with mortality, 27. Laschinger, H.S. & Leiter, patient ratings, and quality 36. Lake, E. (2007). The M.P. (2006). The impact of care. BMJ Quality and nursing practice environ- of nursing work environ- Safety, 26, 559-568. ment. Measurement and ments on patient safety evidence. Medical Care outcomes. Journal of 32. Aiken, L.H., Sloane, D.M., Research and Review, 64 Nursing Administration, 36 Bruyneel, L., Van den (2), 104S-122S. (5), 259-267. Heede, K., Griffiths, P., Busse, R., Diomidous, 37. Maslach, C., & Jackson, 28. Leiter, M. P. & Laschinger, M., Kinnunen, J., Kozka, S.E. (1981). The measure- H. (2006). Relationships of M., Lesaffre, E., McHugh, ment of experienced work and practice envi- M., Moreno-Casbas, burnout. Journal of ronments to professional M.T., Rafferty, A.M., Occupational Behaviour, 2, burnout. Nursing Research, Schwendimann, R., Scott, 99-113. 55 (2), 137-146. P.A., Tiscelman, C., van Achterberg, T., & Sermeus, 38. Canadian Institute for 29. Estabrooks, C., Midodzi, W. for the RN4Cast Health Information (CIHI). W.K., Cummings, G.G., Consortium. (2014). Nurse (2020). Nursing in Canada, Ricker, K.L. & Giovannetti, staffing and education 2019. Ottawa, ON: CIHI. P. (2005). The impact of and hospital mortality in Retrieved June 8, 2020, hospital nursing character- nine European countries: from: https://www.cihi.ca/ istics on 30-day mortality. A retrospective observa- en/nursing-in-canada-2019 Nursing Research, 54 (2), tional study. Lancet, 383 74-84. (9931), 1824-1830. 39. McHugh, M. & Stimpfel, A., W. (2012). Nurse reported

33 Outlook On Nursing quality of care: a measure 40% of respondents, Enough_June1_FINALlow. of hospital quality. CBC survey suggests. pdf Research in Nursing and Ottawa, ON: Canadian Health, 35, 566-575. Broadcasting Corporation. 47. Heinen, M., van Acterberg, Retrieved June 8, 2020, T., Schwendimann, R., 40. Aiken, L.H., Sloane, D.M., from: https://www.cbc.ca/ Zander, B., Matthews, A., Clarke, S.P., Poghosyan, news/health/nearly-25-of- Kozka, M., Ensio, A., Sjetne, L., Cho, E., You, L., canadian-nurses-wouldn- I.S., Casbas, T. M., Ball, J. Finlayson, M., Kanai-Pak, t-recommend-their-hos- 7 Schoonhoven, L. (2013) M. & Aungsuroch, Y. pital-1.1304601 Nurses’ intention to leave (2011). Importance of work their profession: a cross environments on hospital 44. MacPhee, M. (2014). sectional observational outcomes in nine coun- Valuing Patient Care: study in 10 European tries. International Journal Responsible Workforce countries. International of Quality in Health Care. Design. Ottawa, ON: Journal of Nursing Studies 23 (4), 357-364. Canadian Federation of 50, 174–184. Nurses Unions. Retrieved 41. Aiken, L.H., Sloane, D.M., July 20, 2020, from: 48. Leiter, M. & Maslach, C. Barnes, H., Cimiotti, J.P., https://nursesunions. (2009). Nurse turnover: Jarrin, O.F. & McHugh, ca/wp-content/ the mediating role of M. (2018). Nurses’ and uploads/2017/05/ burnout. Journal of Nursing patients’ appraisals show Valuing-Patient-Safety- Management, 17, 331-339. patient safety in hospitals PRINT-May-2014.pdf remains a concern. Health 49. Poghosyan, L., Aiken, Affairs, 37 (11), 1744-1751. 45. Van Bogaert, P., Kowalski, L.H. & Sloane, D. M. C., Weeks, S.M., Van (2009). Factor structure 42. Berry, L. & Curry, P. heusden, D. & Clarker, S. of the Maslach burnout (2012). Nursing Workload P. (2013). The relationship inventory: An analysis and Patient Care: between nurse practice of data from large scale Understanding the Value environment, nurse cross-sectional surveys of of Nurses, the Effects work characteristics, nurses from eight coun- of Excessive Workload, burnout and job outcome tries. International Journal and How Nurse-Patient quality of nursing care: of Nursing Studies, 46, Ratios and Dynamic A cross-sectional survey. 894-902. Staffing Models Can Help. International Journal of Ottawa, ON: Canadian Nursing Studies, 50, 1667- 50. World Health Organization Federation of Nurses 1677. (WHO). (2020a). State of Unions. Retrieved July the World’s Nursing 2020: 20, 2020, from: https:// 46. Canadian Federation Investing in Education, nursesunions.ca/wp-con- of Nurses Unions. Jobs and Leadership. tent/uploads/2017/07/ (2017). Enough Is Geneva, SW: World cfnu_workload_printed_ Enough – Putting a stop Health Organization. version_pdf.pdf to violence in the health Retrieved June 8, 2020, care sector – A discussion from: https://www.who. 43. Hildebrandt, A. (2013). paper. Retrieved March int/publications/i/item/ Nearly 25% of Canadian 25, 2020, from https:// nursing-report-2020 nurses wouldn’t recom- nursesunions.ca/wp-con- mend their hospital: tent/uploads/2017/05/ 51. World Health Organization Burnout plagues about CFNU_Enough-is- (WHO). (2020a). SARS

CANADIAN FEDERATION OF NURSES UNIONS 34 (Severe Acute Respiratory Organization of hospital 59. Swiger, P.A., Patrician, Syndrome). Retrieved nursing, provision of P.A., Miltner, R.S., Raju, April 1, 2020, from https:// nursing care, and patient D., Breckenridge-Sproat, www.who.int/ith/diseases/ experience with care in S. & Loan, L. (2017). The sars/en/ Europe. Medical Care practice environment Research and Review, 72 scale of the Nursing Work 52. Maunder, R.G., Lancee, (6), 643-664. Index: An updated review W.J., Balderson, K.E., and recommendations for Borgundvaag, B., Evans, 56. Aiken, L.H., Sloane, D.M., use. International Journal of S., Fernandes, C.M., … Bruyneel, L., Van den Nursing Studies, 74, 76-84. Masylenki, D.A. (2006). Heede, K. & Sermeus, W & Long-term psychological the RN4Cast Consortium. and occupational effects (2013). Nurses’ reports of of providing hospital working conditions and healthcare during SARS hospital quality of care outbreak. Emerging in 12 countries in Europe. Infectious Diseases, 12 (12), International Journal 1924-1932. of Nursing Studies, 50, 143-153. 53. World Health Organization (WHO). (2020b). WHO 57. Aiken, L. H., Sermeus, Director-General’s W., Van den Heede, K., opening remarks at Sloane, D.M., Busse, R., the media briefing on McKee, M., Bruyneel, L., COVID-19 - 11 March 2020. Rafferty, A.M., Griffiths, Retrieved June 8, 2020, P., Moreno-Casbas, M.T., from: https://www.who. Tishelman, C., Scott, A., int/dg/speeches/detail/ Brzostek, T., Kinnunen, J., who-director-general-s- Schwendimann, R., Heinen, opening-remarks-at-the- M., Zikos, D., Sjetne, I.S., media-briefing-on-covid- Smith, H.L. & Kutney-Lee, 19---11-march-2020 A. (2012). Patient safety, satisfaction, and quality 54. Bruyneel, L., Van den of hospital care: cross Heede, K., Diya, L., Aiken, sectional surveys of L. & Sermeus, W. (2009). nurses and patients in 12 Predictive validity of the countries in Europe and International Hospital the United States. British Outcomes Study question- Medical Journal, 344: e1717. naire: an RN4CAST pilot study. Journal of Nursing 58. Warshawsky, N.E. & Scholarship, 41, 202-210. Havens, D.S. (2011). Global use of the Practice 55. Bruyneel, L., Li, B., Environment Scale of Ausserhofer, D., Lesaffre, the Nursing Work Index. E., Dumitrescu, I., Smith, Nursing Research, 60 (1), H.L., Sloane, D.M., Aiken, 17-31. L.H. & Sermeus, W. (2015).

35 Outlook On Nursing Photo by Nicole De Khors

CANADIAN FEDERATION OF NURSES UNIONS 36 Appendix

The nurse survey used in affairs (8 items); nursing foun- and is internationally the most this study is comprised of a dations for quality of care widely used instrument for comprehensive questionnaire (9 items); nurse manager ability, measuring the phenomenon of for collecting data from nurses, leadership and support of work-related burnout. The MBI that has been used for more nurses (4 items); staffing and captures three dimensions of than two decades in studies that resource adequacy (4 items); burnout: emotional exhaustion, explore the association between and collegial nurse-physician depersonalization and personal nursing work environments, relationships (7 items). The accomplishment. nurse staffing, and nurse as reliability (i.e. Cronbach alpha well as patient outcomes.30, coefficients) of the PES-NWI The survey also includes some 54 It consists of the Practice subscales vary from 0.71 to items that reflect global ratings Environment Scale of the 0.84.34 The subscales have of the dimensions being exam- Nursing Work Index showed to have a high predic- ined, including quality of care, (PES-NWI);35,36 the Maslach tive validity for workforce quality of work environments, Burnout Inventory (MBI);37 stability issues and quality patient safety ratings, job satis- demographic questions; and of care in hospitals.35,36 The faction, career satisfaction and questions on nurses’ job, work PES-NWI is widely used in turnover intent. Global measures and employment, as well as research studies internationally are often chosen when overlap questions about nurse-per- and is endorsed for use by the with independent study scales ceived quality of care, patient US National Quality Forum is a consideration. Along with safety and quality of work as a national standardized these, similar to the approach environments.30 The inter- measure of the nursing practice used in the EU study,30 several national hospital outcomes environment, and by the Joint of these areas were explored study (conducted in 1999 and Commission as a screening indi- with additional questions. led out of the United States) cator of staffing effectiveness in These included satisfaction and the more recent RN4Cast hospital accreditation standards with: specific aspects of the job studies (led out of the European and as part of the NDNQI (e.g., work schedule flexibility, Union since 2010) have utilized (National Database of Nursing opportunities for advancement, this instrument and reported Quality Indicators) annual remuneration); the nursing work reliability and validity of the survey of nurse credentialing for environment (e.g., complaints, measures.25,31,32,54-57 Magnet hospitals.58,59 verbal and physical abuse, work-related physical injuries); The Practice Environment Scale Burnout has been found to have and patient care quality and of the Nursing Work Index important negative effects on safety culture (e.g., manage- (PES-NWI)35,36 was used to job satisfaction, nurse turn- ment of staff errors and related measure elements of nurses’ over and patient satisfaction. policy changes, information work environments. The revised The levels of burnout in this omissions during care transi- PES-NWI consists of 32 Likert- study were evaluated using tions, staff relations type questions (1=“strongly the Maslach Burnout Inventory with management). disagree” to 4=“strongly (MBI).37 The MBI includes 22 agree”), including 5 sub-scales: items scored on a scale from nurse participation in hospital 1=“never” to 6=“every day”

37 Outlook On Nursing Photo by Shopify Partners

ThisThis studystudy waswas conductedconducted justjust beforebefore thethe COVID-19COVID-19 pandemicpandemic waswas declared.declared. StudyStudy findingsfindings provideprovide aa disturbingdisturbing picturepicture ofof nursingnursing workwork environmentsenvironments inin Canada,Canada, oneone thatthat has,has, nono doubt,doubt, worsenedworsened duringduring thethe pandemic.pandemic.

CANADIAN FEDERATION OF NURSES UNIONS 38 NursesUnions.ca