The Registered #Nurses’ Association of Ontario (#RNAO) says government reforms that are expected to radically change the way health services are delivered in the province won’t succeed unless they include a comprehensive health human resources (HHR) strategy.

To inform the conversation on how that strategy might look, representatives of RNAO were at Queen’s Park on May 9 – the first day of National Nursing Week 2016 – to release a report that outlines what must happen if Health Minister Eric Hoskins wants to achieve his goal of putting patients first – an initiative RNAO supports.

Mind the safety gap in health system transformation: Reclaiming the role of the RN takes an extensive look at recent trends in nursing employment and sheds light on how the minister’s priorities to improve the system are completely at odds with the reality of how nursing human resources are deployed today.

RNAO says developing a comprehensive and well-thought-out interprofessional HHR plan is a must for any major health system transformation, which is why it is the report’s first recommendation.

“Given that nurses make up the largest share of regulated health professionals in the province, we are advancing the HHR agenda by issuing this report,” says RNAO President Carol Timmings, adding that “nurses play a central role in delivering health services, and statistical trends in nursing skill mix and organizational models of care delivery don’t bode well for patient safety and health outcomes.”

“How can we drive the important changes outlined in the health minister’s Patients First report without the fuel to make these changes happen?” asks Timmings. “It makes no sense that at a time when patient acuity is increasing in hospitals and in the community sector, #RNs are being replaced by less qualified personnel.”

RNAO is urging the minister of health and the Local Health Integration Networks (LHIN) to issue an immediate moratorium on the replacement of RNs, a trend associated with increased morbidity and mortality. “RNs are being replaced simply to cut costs, but this practice flies in the face of well-documented evidence that shows employing more RNs actually costs less. This is because a higher proportion of RNs results in lower complication rates, and fewer hospital re-admissions,” says Timmings.

And yet, data shows that between 2005 and 2010, the ratio of RNs to diploma-prepared registered practical nurses (RPN) was 3:1. By 2015, the ratio had shockingly dropped to 2.28:1. In fact, Ontario has the second-worst RN-to-population ratio in Canada.

RNAO CEO Doris Grinspun says “these statistics must trigger alarm bells, because if the government’s goal is to shorten lengths of stay in hospital and re-orient the system towards greater community care, a large influx of RNs is needed to respond to rising acuity levels, especially those of hospital patients deemed the sickest of the sick.” That’s why RNAO is calling on the ministry to mandate an all-RN nursing workforce in acute care, teaching, and cancer care hospitals within two years, and in large community hospitals within five years.

Given that acuity will continue to increase in home care and long-term care, the report also includes recommendations for these sectors. For example, RNAO welcomes the health minister’s promise to move more care into the community. But as patients are discharged from hospital earlier and with more complex care needs, the report recommends every first home care visit be conducted by an RN.

The association says the minister’s vision of a more person- and family-centred system also needs to take full advantage of the expertise and authority of nurse practitioners (NP). To that end, RNAO’s report includes specific recommendations aimed at removing all barriers that handcuff NPs’ ability to fully care for Ontarians, including those who reside in long-term care homes.

Changes in nursing skill mix are not the only concern highlighted in RNAO’s report. The way nurses are increasingly being forced to deliver care is another troubling trend. Grinspun says more and more hospitals are resorting to functional or team-based organizational models of nursing care delivery that result in fragmented care where no one is in charge of the comprehensive care needs of the patient. These models, in which patient care is broken down into a series of tasks that are delegated to various members of the nursing team, have huge implications in terms of quality of care and safety, says Grinspun. “Imagine being a patient or family member and not knowing who your nurse is.”

She says some hospitals are relying on these models to meet bottom line pressures. “Not only are they ineffective, there is no continuity of care. They are the furthest thing from putting the patient first,” says Grinspun. RNAO’s report recommends that hospitals use primary nursing as the most effective model, where one nurse is in charge and takes full responsibility for planning and delivering all of the care needs of a patient throughout their stay.

Grinspun says RNAO applauds Minister Hoskins for his desire to revamp the health system. “If we are going to shake up the system, we must make sure that it’s set up to succeed,” she says, adding the most important element in the delivery of health services is front line staff. “Those who provide care day-in and day-out are the ones who will help us deliver the necessary changes Ontarians have been waiting for, and we will do our part to ensure their experiences and health outcomes are the best.”

To read the report, and the full list of eight recommendations proposed by RNAO, visit RNAO.ca/mindthesafetygap