Eliminating the shortage of registered nurses in Canada: An exercise in applied needs-based planning
Introduction
Policy makers in Canada and other countries have considered various policy interventions in response to perceived shortages of various types of Health Human Resources (HHR). These policies have tended to be narrow in scope, often focusing on a single determinant of HHR supply such as enrolments in education or training programs without consideration of the impact of such changes on shortages in the context of other determinants of supply and requirements for HHR. The result of this type of intervention in Canada is that the HHR situation across the country remains uncertain.
Claims of HHR shortages imply awareness of both the supply of and requirements for HHR. However, estimates of HHR requirements across countries continue to use simple age and gender standardized provider-to-population ratios [1], [2], [3], [4], [5], [6]. Although such ratios are easily calculated and compared across jurisdictions [7], they are of limited value from a planning perspective [8], [9], [10]. Estimating HHR ‘requirements’ in this way assumes that the number of providers alone determines the supply of services, that current levels of service provision are (a) optimal and (b) will not change in the future, and that neither the health needs of the population nor the productivity of HHR in delivering services will change in the future [11], [12], [13]. Contrary to these assumptions, improvements in productivity associated with new technologies, team compositions, and methods of service delivery [14], [15], [16] mean that fewer providers are required to deliver the same level of service. Similarly improvements in age- and gender-specific levels of health in populations [8], [17], [18] mean that fewer services per capita are needed further reducing the number of providers per age-standardized population. The need for more comprehensive approaches to HHR planning is being increasingly recognized [13], [19], [20], [21], [22].
Beyond provider-to-population ratios, other methods of HHR planning largely involve the application of current or target levels of utilization – sometimes by age and gender – to future estimates of population size. The target levels of utilization are rarely based on independent measures of population need, however, and hence are unable to adjust for under or over provision of services in relation to needs. Instead, requirements are estimated using measures of demand for care. But this distinction between need and demand is important, because demand for health care is not independent of supply [13], [22], [23]. As a result demand-based approaches will perpetuate any existing inefficiencies and inequalities in access to care and lack capacity to plan – let alone respond to – changes in the levels and distribution of health and risks to health within the population.
Needs-based approaches to HHR planning require the explicit consideration of population health needs – that is, direct measures of levels of health that give rise to need for care – and the planned number and type of services to be provided to address those needs. The number of providers required is therefore given by the product of the size and age distribution of the population (demography), the average levels of age-specific health within that population (epidemiology), the planned number and type of services to be delivered in relation to those health levels (level of service), and the number and type of providers required to deliver those services (productivity). In traditional approaches, epidemiology, level of service and productivity are all treated as invariant and incorporated implicitly in the chosen provider-population ratio. Needs-based approaches are more appropriate when health authorities are able and willing to take an active role in shaping health care [23].
We describe an analytical framework for informing HHR planning from which we derive a simulation model that allows policy makers to evaluate the relative effectiveness of different determinants of supply and requirements as methods for addressing HHR shortages. Explicitly incorporating measures of population health and linking these to planned levels of service delivery in estimating HHR requirements distinguishes this approach from others where, for example, requirements for RNs are estimated based on nurse–population or nurse–patient ratios [24], or where utilization of health care services is used as a proxy for health care needs (e.g. the HRSA model [25]). Because this approach derives HHR requirements explicitly from estimated requirements for services it allows policy makers to consider different models of service delivery involving different mixes of health care workers in an integrated way. In this way it represents a significant departure from the silo- or single profession-based planning that, as noted elsewhere [18] has been typical worldwide. The approach has been applied to multiple professions and jurisdictions [26], [27], but never at the national level nor with so much data available.
Some studies have aimed to incorporate measures of health care need independent of service use to estimate HHR requirements, in order to distinguish demand from need. However the measures of need remain demographically focussed (e.g. birth rates) rather than epidemiological (e.g. prevalence of high-risk pregnancy) [28]. Other approaches have been proposed but not applied [29] or have focused attention on explicit types and levels of care in relation to particular need groups (e.g. mental health) but these have not accounted for changes to supply, needs, levels of service or productivity in estimating future shortages [30].
The objective of this paper is to demonstrate the application of the needs-based approach to the problem of the shortage of RNs in Canada. Given the breadth of evidence on the relationship between nursing care and patient outcomes [31], [32], [33], failure to plan the number of RNs in relation to the needs for care to which RNs contribute can be expected to result in inefficient levels of nursing input that compromise patient (recovery), provider (burnout, retention) and system (efficiency) outcomes.
Section snippets
Methods
This approach is based on a conceptual framework [34] that considers the dynamic nature of the relationships among the many components of the health care system. In traditional approaches to planning, these components have been treated, often implicitly, as separate, independent and in many cases invariant over time. The framework is based on the following principles:
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HHR planning must occur within, as opposed to independent of, broader health system planning.
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Requirements for HHR are derived
Results and discussion
The results of simulations for different policy scenarios are presented below. Throughout this section RNs are referred to in units of FTEs. The status quo scenario (i.e. one in which there are no changes to existing RN HHR policies) is used as a ‘baseline’ against which to compare alternative policy scenarios.
Results indicate that as of 2007, Canadians required the services of approximately 198,000 RNs. Looking to the future, the data show that if the profile of health continues to change in
Conclusions
HHR planning has traditionally been developed without consideration of population health needs, the way in which health care services are delivered, or the effects of these policies on the productivity of the health workforce. To eliminate inequities and inefficiencies in health systems, HHR planning must explicitly consider the health needs of populations and the specific services planned to respond to those needs. Further, it is imperative that HHR planning be done iteratively on a continuous
Next steps
Ongoing work on this approach will focus on three fronts. The first will involve examining alternative scenarios to those included as examples in this paper. These scenarios might consider, for example, the effect of increasing the scope of medication prescribing of RNs – which would increase RN requirements – or delegating RN tasks to auxiliary nursing categories – which would reduce RN requirements, other things equal. Second, we will seek to refine the analytical approach – for example, by
Acknowledgement
This work was funded by the Canadian Nurses Association.
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Cited by (0)
- 1
Now at: Department of Community and Health and Epidemiology, Dalhousie University, 5940 University Ave, Halifax, NS, Canada B3H 1V7.
- 2
Now at: 11953 Cloverdale Road, Winchester, ON, Canada K0C 2K0.