Staffing Crisis Hits The North

Patients lined in hallways. Shortages of specialty educated nurses leading to agonizingly long surgical wait times. Hospitals that are chronically short-staffed and overcapacity, putting nurses and their patients at risk. It's a picture that's been painted many times in media stories about the staffing challenges our health-care system faces. Not surprisingly, these reports often come from major cities and centres where the majority of the province's population lives and works. But nurses in rural and remote communities – the majority of which are in northern BC – have long been calling attention to difficulties they and other health-care workers face when it comes to providing care where there are fewer resources and the nurse-to-population ratio is wider than in urban areas.

BCNU's advocacy on behalf of members working in rural and remote communities is ongoing. In 2015 the union delivered thousands of personally signed postcards to then-health minister Terry Lake calling for improved rural health services. The union also made a detailed submission to the provincial government's all-party Select Standing Committee on Health that contained a series of policy recommendation on how to best improve rural health care.

Now, the province's Auditor General has weighed in, issuing a report this February entitled, An Independent Audit of the Recruitment and Retention of Rural and Remote Nurses in Northern BC, which found that the northern nursing shortage now constitutes a full-blown staffing crisis within the Northern Health Authority, impacting thousands of residents.

The report, based on an audit of records going back to 2012, provides a sober assessment of the health authority's performance. "We looked to see if Northern Health was effectively recruiting and retaining enough registered nurses and nurse practitioners to fill these positions. We concluded that it was not," said Auditor General Carol Bellringer.

Her report outlines the factors that have contributed to the north's endemic shortage of RNs and NPs, and make a series of recommendations that, if implemented, could effectively address the crisis.

"Northern Health is not effectively recruiting and retaining enough RNs to fill the rural and remote positions identified in its HHR plan."

- Auditor General Carol Bellringer

Northern Health is responsible for planning and delivering health services to approximately 300,000 northern BC residents across a largely rural and remote territory the size of France. In that outlying geographic area, it is nurses who play a critical role in sustaining health services for residents. They deliver the majority of direct patient care, and in some communities, they are the only resident health-care provider.

According to Bellringer's report, as of April 2017, the health authority was short 121 RN full-time equivalent positions (FTEs), or 15 percent of its rural and remote workforce, and at least six NP FTEs. The report also found that seven local areas were short more than 20 percent of their workforce; these included the areas of Upper Skeena, Nechako, Smithers, Prince Rupert, Fort Nelson, Peace River North and Terrace.

The audit found that half of all vacant shifts were staffed with nurses working on a casual basis or by existing nursing staff working overtime, and that between 2012 and 2016, Northern Health's use of overtime hours increased by 30 percent. The audit also found that the remaining shifts were left unfilled or staffed by expensive external agency nurses, who are paid a higher wage. In 2016 the workload equivalent of 16 nurse positions were filled by agency nurses.

"These findings will come as no surprise to nurses working in the north," says BCNU President Christine Sorensen, who met with Northern Health executives in March following the report's release. Sorensen notes that BCNU has consistently been working to raise awareness of the nursing shortage in rural and remote communities. "This issue has been prioritized at the bargaining table, and with Northern Health executives, whom we will meet again this year," she says.

FACTORS AT PLAY

Bellringer cites many external factors that have contributed to Northern Health's inability to fill all of the RN and NP positions in its 2016/17 health human resources plan.

Northern weather, long distances between communities, and limited amenities can affect the willingness of RNs and NPs to move to rural and remote areas of northern BC or prompt them to leave after a short while.

Housing can be expensive and difficult to find in parts of the north. High salaries in the resource industry can drive up rents, and in communities where there is a market for tourism, some owners are opting to list their properties on short-term rental sites (e.g., AirBnB), reducing the supply of long-term rentals and driving up prices.

Other costs, such as for heat, internet and cellphone service, can be relatively expensive. As RN compensation is roughly the same across the province, higher costs may be a deterrent for some potential recruits and cause others to leave if they are having difficulty achieving their financial goals.

RNs and NPs who chose to work in rural and remote communities may experience a number of challenges related to family life, found the report. For those in a long-term relationship, finding the right employment for a partner can be tough. And for parents, daycare can be difficult to find, particularly for RNs doing shift work and education may be a concern. Social opportunities may also be limited. All of these challenges may cause some RNs and NPs to look to bigger centres for employment, and lead to departures, especially when children reach school age.

The report authors acknowledge that all of these factors are beyond Northern Health's control.

However the audit also cites several internal factors that the health authority is responsible for or can reasonably influence that have also contributed to the RN and NP shortages.

Many RNs whom investigators spoke with said they had major concerns with Northern Health's ongoing process of implementing interprofessional teams in communities across northern BC. The move is part of a larger provincial initiative to improve the quality and accessibility of primary care in the province, and there is good evidence on the effectiveness of interprofessional teams, especially in the context of chronic disease management.

At Northern Health, interprofessional teams work closely with a primary care physician or NP to deliver patient-centred care. Each team is different, but all are generally made up of a team leader, nurses, social workers and allied health professionals (e.g., physiotherapists). They may also be supported by specialist RNs and other professionals in the community.

Under this new model, RN members of primary care teams deliver the full spectrum of primary nursing services —from mental health to home care. This change has had a significant impact on RNs, many of whom previously focused on one area of practice, such as public health or mental health. Some require additional training to feel proficient in providing the full range of primary nursing services.

But the model is leading to recruitment and retention challenges among RNs for a few reasons.

Some RNs told investigators that they are not interested in a more general primary care practice, as they have focused on a particular area (e.g., public health, mental health) for a number of years, and are not interested in, or don't feel comfortable, expanding their practice to other areas.

Training was also a significant concern. Some primary care nurses told investigators they are not able to take timely training in areas they are unfamiliar with, causing some discomfort.

BCNU North East region chair Danette Thomsen represents many of the RNs interviewed for the audit. She explains that after nurses join interprofessional teams they are often unable to access the training and education needed in order to perform all the aspects of their new position because it is not regularly offered. She notes that the ongoing staffing shortage only compounds this problem.

"When education is offered nurses are unable to be replaced from their shifts to take the education," she explains. "Nurses want to support their patients and colleagues, but knowing that their co-workers would then be short staffed leaves them feeling a great deal of moral distress."

In all of the communities investigators visited, primary care nurse workloads were heavy. Some team members told investigators that they lost RN resources in the transition to interprofessional teams. And since not all team members felt comfortable providing the full range of primary care services, the audit found that those with skills and knowledge in certain areas may bear a larger workload burden.

Bellringer's report also noted that nurse managers have a significant impact on the recruitment of rural RNs and NPs, and cited examples of RNs choosing a particular community over another because the hiring manager was quick and attentive throughout the recruitment process.

"These findings will come as no surprise to nurses working in the north"

- BCNU President Christine Sorensen

The audit acknowledges that managers have a huge impact on retention: a poor manager can cause staff to leave, and a great manager can keep people, even if it means a longer commute or fewer opportunities for development.

Thomsen says that nurse managers have very heavy portfolios and often lack the required resources and training need to effectively do their jobs. "The liability issues this creates for them is worrying – they are often doing the best they can with what little training they have but their education needs must be a priority."

The Auditor General found that the lack of accessible education was also a major internal factor affecting nurse recruitment and retention efforts, and notes that nursing programs are only offered in three northern communities: Terrace, Prince George and Quesnel. Many people investigators spoke with pointed out that there is no RN program available in the northeastern part of the province, and saw this as one of the causes of the significant shortage of RNs in this area.

"The union would also be very supportive of an RN program in northeastern BC, where there is a significant population," says Sorensen. "Often, when nurses are not recruited into jobs in or near where they live they leave their home community to find employment elsewhere. This can make it more difficult for smaller communities to recruit nurses, even though they are often the places that are desperately in need of nursing staff."

Thomsen reports that the next BCNU North East region meeting will be hosted in Fort St. John, where she hopes to offer tours for the nurses attending from outside the community. "This is an effort on our part to assist with rural recruitment and retention," she says. "The health authorities and the nurses are in this together to try and attract nurses to this beautiful area of the province, which has many benefits if you enjoy the outdoors."

BETTER EVALUATION NEEDED

Northern Health's recruitment, hiring and retention programs, practices and strategies were a major focus of Bellringer's audit. She acknowledged that Northern Health had already implemented many good practices for recruitment and retention, which include a formal employee referral program, marketing campaigns, staff recognition programs, and student placements at rural and remote locations.

However auditors also found that Northern Health's performance monitoring of its recruitment, hiring and retention functions was minimal and, as a result, it was not able to show that its efforts in these areas had a positive impact on its results.

Thomsen says that this is a problem. "They have not evaluated the effectiveness of key recruitment and retention programs and practices, and neither have they tracked routine performance metrics, so it is unclear if their programs are working."

According to Thomsen, there needs to be an evaluation system of current practices to see what is working and what isn't. "I would like to see exit interviews conducted by an outside source, so members feel free to stat the reasons they are leaving without fear of negative recourse from the employer," she says. "Better yet, why don't we ask the people who are staying what makes them stay and what we could do to ensure they remain. It's the members on the front lines across the north, doing so much—often with so little—that need to be consulted as to their priority needs."