CRITICAL CARE WORKFORCE PROFILE. Provincial Report

Transcription

1 CRITICAL CARE WORKFORCE PROFILE Provincial Report Critical Care Services Ontario May 2017

2 ACKNOWLEDGMENTS The 2017 Critical Care Workforce Profile (CCWP) reflects data generated between April 1, 2015 to March 31, Critical Care Services Ontario would like to thank all Critical Care Stakeholders who have been instrumental in contributing data to complete the 2015/16 Critical Care Workforce Profile Survey. These contributions are vital to informing CCSO s health human resource planning, efforts and work in identifying emerging challenges and considerations for the critical care workforce. 2 Critical Care Services Ontario May 2017

3 Public Information 2017 Critical Care Services Ontario. All rights reserved. This publication may be reproduced in whole or in part for noncommercial purposes only and on the condition that the original content of the publication or portion of the publication not be altered in any way without the express written permission of Critical Care Services Ontario. To seek this information, please contact: CRITICAL CARE SERVICES ONTARIO LuCliff Place, 700 Bay Street, Suite 1400 Toronto, Ontario M5G 1Z6 Telephone: (416) x info@ccso.ca Website: Critical Care Services Ontario May

4 A Message from Dr. Bernard Lawless and Mrs. Linda Kostrzewa Critical Care Services Ontario (CCSO) is proud to release the 6th edition of survey results in the 2017 Critical Care Workforce Profile (CCWP) Report. Health Human Resource (HHR) planning is a pillar to achieving and sustaining quality healthcare delivery. Since 2007, CCSO has been conducting surveys to track and gain insights into the healthcare workforce to support delivery of critical care. Survey development for the 6th edition, underwent consultation processes resulting in exciting expansions to both the depth and breadth of critical care workforce intelligence captured and presented over the years in this report. Understanding the critical care workforce through comprehensive data increases forecasting accuracy, informs effective staffing practices, and can enhance retention and recruitment strategies to ensure resilient critical care Health Human Resources, which meets current and future system needs. The SARS pandemic in 2003 in particular, highlighted opportunities for improvement in Ontario s critical care system including managing the sufficient supply of critical care HHR. In 2007, CCSO developed the original Critical Care Nursing Workforce Profile (CCWNP), created to focus research on critical care nurse staffing in Ontario. Since then, two cycles of survey refinements occurred. In 2014 changes were made incorporating CCSO s 12 Peer Groups, allowing for comparison of like-units for more accurate trending and benchmaking. In the most recent survey conducted, the focus of the survey was expanded to capture Allied Health Professionals and employee engagement. On behalf of CCSO, we extend sincere thanks and gratitude to all those who have continued to participate in our CCWP survey, year-on-year, without which such robust intelligence could not be produced in return. Finally, we wish to thank those who have thoughtfully contributed to the development over the years and particularly to the 6th edition of the CCWP. We hope our system collaborators will continue to find the insights here within of value to informing an adaptive and resilient critical care system. Sincerely, Bernard Lawless, MD, MHSc, CHE, FRCSC Provincial Lead Critical Care Services Ontario Linda Kostrzewa, RN, BAS Hons., MHSC Senior Director Strategy and System Transformation Critical Care Services Ontario 4 Critical Care Services Ontario May 2017

5 EXECUTIVE SUMMARY The 2017 Critical Care Workforce Profile, Provincial Report provides workforce analytics on critical care nurses and to a lesser degree on allied health professionals working in the Ontario Critical Care System. The report includes comprehensive critical care nurse demographic, workforce utilization, and recruitment and retention indicators with data from the 2015/16 year. Where available indicators have been trended over time from 2007/08, or compared to previous years of data from 2013/14. Where relevant, data is analyzed regionally by LHIN, and by Peer Group. In this report, survey results are presented in two parts: 1. The Provincial Report, which provides both the LHIN and Peer Group level analysis. 2. There are ten Peer Group level reports that have been included in appendices, presenting findings that are unique to Peer Groups and across the individual critical care units for that Peer Group. The provincial executive summary below provides a highlight of the provincial and LHIN-level findings. Highlights of the Peer Group-level findings can be found in the individual executive summaries of each Peer Group Report. 85% SURVEY RESPONSE RATE * * Finance data collection tool Nurse Demographics This section of the report covers experience in critical care, age, and gender. Information on nursing roles can be found in the body of the report. EXPERIENCE IN CRITICAL CARE In 2015/16, almost half (46%) of the critical care nursing workforce had worked in the field for 6 to 20 years. Since 2007, nurses early in their career with 3 to 5 years of experience as well as those late in their career with more than 20 years of experience have decreased by 2-3% while nurses with 11 to 20 years of experience has increased by 5%. Across the province, the level of experience of critical care nurses vary: Central (LHIN 8) and South East (LHIN 10) reported the highest proportions of novice nurses (less than 3 years of experience), both at 32%. In Central West (LHIN 5) and South East (LHIN 10) there are the highest proportions of midcareer nurses with 3-10 years of experience (31% and 28% respectively). The Waterloo Wellington (LHIN 3) has a very high proportion of nurses with 11 to 20 years of experience (37%). Critical Care Services Ontario May

6 NURSING EXPERIENCE TRENDS: Years 3% 5% Years >20 Years 3% Since 2007, nurses early in their career with 3 to 5 years of experience as well as those late in their career with more than 20 years of experience have decreased by 2-3% while nurses with 11 to 20 years of experience has increased by 5%. AGE When the CCWP work was initiated in 2007, there were fears of an aging workforce and threats to sustainability from retirements. Since 2007, there has been a 4.5% increase in the proportion of nurses under age 30 and there has been an 8.8% decrease in the proportion of nurses aged 40 to 49. In 2015/16, the median age of critical care nurses in Ontario was between 30 and 39 years, representing 28% of all critical care nurses. In contrast, in 2007/08, the median age was 40 to 49, representing 34% of the workforce. This change over time may be showing a favorable demographic shift. MEDIAN AGE OF CRITICAL CARE NURSES 2007/ % of workforce 2015/ % of workforce Some notable differences to these overall provincial trends include: Paediatric units (PG6) had the youngest nursing demographic with close to 70% of the nurses under the age of 40. Central East (LHIN 9) and South West (LHIN 2) have the largest proportion of nurses aged 50 to 59, representing 27% and 25% of their respective LHIN critical care nurse populations respectively. GENDER Since 2007, the proportion of male nurses in critical care, reported in the CCWP, increased from 7.5% to 10.2%. This is higher than the overall proportion of males in nursing in Ontario, which was 5.2% in Notable exceptions to this in the province include the South West (LHIN 2) which reported the lowest percentage of male nurses at 7.1%, in 2015/16 while North West (LHIN 14) reported the highest proportion of critical care male nurses at 14.7%. 6 Critical Care Services Ontario May 2017

7 Nurse Staffing Practices This section covers employment status, overtime, sick time and managing short term nursing shortages, as well as nurse productivity. All other information on overtime hours and education time can be found in the related section in the body of the report. EMPLOYMENT STATUS In 2015/16, 66% of Ontario s critical care nurses were employed full-time which is consistent with findings from previous years of the CCWP. The largest group of part-time staff can be found in nurses under 30 years old. Across the province, there are some exceptions to this however: North Simcoe Muskoka (LHIN 12) has the lowest proportion of full-time staff with only 53% of their critical care nursing workforce being from full-time staff. Some of the less urban LHINs have a greater reliance on earned hours from part-time staff, particularly Erie St. Clair (LHIN 1) and North Simcoe Muskoka (LHIN 12) where the proportion of earned hours from part-time staff is about 30%, far higher than the 17.5% provincial average. OVERTIME, SICK TIME AND MANAGING SHORT TERM NURSING SHORTAGES Provincially, the overtime rate for front-line staff in critical care units was 3.9%. In the South West (LHIN 2), the overtime rate is very low at 1.7%. At the other end of the spectrum, the Central West (LHIN 5) has the highest overtime rate for critical care units at 9.0%. OVERTIME RATE 2007/ /16 4.9% 3.9% Since 2007, the CCWP sick rate for critical care nurses has been decreasing. The provincial sick rate in critical care units for bedside nurses in 2015/16 is 4.8% whereas in 2007/08 it was 7.0%. SICK RATE 2007/08 7.0% 2015/16 4.8% Critical Care Services Ontario May

8 To manage short-term nursing shortages, whether from staff absences or surge in demand, critical care units deploy a number of strategies. Expanded patient assignments is the most frequently used approach to address these short-term nursing shortages in the province, with 22% noting this is frequently used and 43% noting it is sometimes used. Relying on internal critical care nursing pools or using agency staff were the next most frequently used approaches, used frequently or sometimes by 36% and 32% of units respectively. NURSE PRODUCTIVITY One way to view nursing productivity, or the resource intensity of care, is to consider the number of nursing hours worked per patient day. Provincially, in 2015/16 critical care nurses worked 17.1 hours per patient day, which was similar to the findings in 2013/14. There was variation across peer groups however, with level 3 units having more than 15 hours of nursing care per patient day while level 2 units had less than 12 hours of nursing care per patient day. NURSING CARE HOURS PER DAY h6 Nurse Training This section covers educational attainment, and specialized critical care training. All other information on internationally educated nurses, life support training and professional development investments can be found in the related section in the body of the report. 12 EDUCATIONAL ATTAINMENT Coinciding with the provincial policy shift in 2000, requiring a baccalaureate degree in nursing for entry to practice (Council of Ontario Universities Position Paper on Collaborative Nursing Programs in Ontario 2010 ), the proportion of nurses with diplomas has decreased since 2007/08 from 71% to 38% in 2015/16. Over the same period, critical care nurses with Bachelor of Nursing (BNs) or Baccalaureates has doubled from 27% in 2007/08 to 55% in 2015/16. Regionally, Waterloo Wellington (LHIN 3) had the smallest percentage of nurses with an undergraduate nursing degree (28%) and Toronto Central (LHIN 7) had the greatest (67%). In addition, Central East (LHIN 9) although suburban in nature, reported only 38% of their nurses to having an undergraduate degree in nursing. 8 Critical Care Services Ontario May 2017

9 CRITICAL CARE NURSE TRAINING STANDARDS ** 2013/14 38% 2015/16 56% SPECIALIZED CRITICAL CARE TRAINING The Ontario Critical Care Nurse Training Standards recommend training completed through an in-house and/or college-based adult and/or paediatric critical care program that is at a minimum 300 didactic and clinical training hours for nurses new to critical care. Provincially almost 40% of critical care nurses have training to these training standards. There were also some variation in training to critical care standards across the province. Waterloo Wellington (LHIN 3) and South East (LHIN 10) each reported less than 10% of their nurses had training to the Ontario Critical Care Nurse Training Standards (300 hours or more of training). North West (LHIN 14) reported the most nurses who have not completed specialized critical care training (39%). ** Completed a minimum of 300 didactic clinical training hours for nurses new to critical care Critical Care Services Ontario May

10 Nurse Turnover This section covers nurse separations by age group and nurse employee turnover. Information on nurse exit destinations and changes in employment status can be found in the related section in the body of the report. EMPLOYEE TURNOVER The overall turnover of direct care nurses was 8.7% in 2015/16, which is lower to the rate noted in a 2008 pan-canadian study (9.5%) (Hayes, 2012). Nursing turnover is lower for full-time staff in critical care, which was reported in the 2015/16 CCWP at a provincial average of 5.7%. The distribution of employee exits from the organization by age group noted that there are higher volumes of exits (excluding retirement) from younger age groups. Nurses under 40 years old represented 57% of exits, while exits from ages represented 42%. Regarding exits due to retirement, the greatest number of nurses retiring are in the age group (30%), although there are also a large number of retirements in the age group (24%) and the age group 65+ (16%). When considering tenure within an organization, nurses with less than 3 years of employment with an organization are the largest groups leaving for both the under 30 and 30 to 39 age groups. This group with less than 3 years with the organization represents almost 30% of exits for the 40 to 49 age group as well. WHERE NURSES GO Across Ontario for nurses changing employment status or nursing positions, most remain within an ICU environment (43%) while 21% move out of the ICU environment but stay within nursing. For those nurses who leave an ICU care environment but remain in nursing, most remain at the same hospital. VACANCY RATE Between the years 2007/07 to 2015/16, the vacancy rate has ranged from a low of 3.4% in 2013/14 to a high of 6.3% in 2010/11, and overall is showing a decreasing trend over time. Most recently, as of March , the provincial vacancy rate for nursing in critical care units was 5.0%. 10 Critical Care Services Ontario May 2017

11 Retention and Employee Engagement This section covers employee engagement. Information on recruitment such as recruitment strategies, new hires and vacancy rate can be found in the Recruitment section of the Report. Retention indicators such as retention strategies can be found in the Retention and Employee Engagement section in the body of the report. EMPLOYEE ENGAGEMENT Respondents to the 2015/16 CCWP were asked if their units participated in hospital-led employee engagement surveys, with over 90% of units reporting this was in place. Units were also asked to identify the top employee engagement improvement opportunities identified in these surveys. The most frequently identified improvement opportunity, noted by almost 50% of units, included dimensions of job characteristics (e.g. flexibility in schedule/work hours; balance of family/personal life with work; having adequate resources/equipment to do work; having time to carry out all work demands; getting recognition for good work). Allied Health Professionals in Critical Care This section of the report covers Allied Health Professionals and reports on the use of the different professions covering: Chaplains/Spiritual Carers/Pastors Dietitian/Nutritionists Occupational Therapists Physiotherapists Respiratory Therapists Social Workers Pharmacists Weekday and weekend support hours, and on-call provision for Pharmacists, Physiotherapists and Respiratory Therapists are provided in the body of the report. ALLIED HEALTH SUPPORT IN CRITICAL CARE Percentage of critical care units using allied health professionals. 92% 90% 88% 87% Pharmacy Physiotherapy Dietician /Nutritionists Respiratory Therapists Critical Care Services Ontario May

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13 TABLE OF CONTENTS 1. INTRODUCTION Objectives and Scope of the Critical Care Workforce Profile (CCWP) Data Collection Methods Structure of Report and Analysis Peer Groups Local Health Integration Networks (LHINs) Report Considerations SURVEY RESPONSE RATE Number of Nurses Represented in the CCWP NURSE ROLES AND DEMOGRAPHICS Nursing Roles Level of Experience Age Gender NURSE STAFFING PRACTICES Employment Status Employment Status by Headcount Employment Status by Earned Hours Distribution of Earned Hours Overtime Hours as a Proportion of Productive Hours Sick Time Education Time Managing Short-Term Nursing Shortages Expanded Assignments Critical Care Nursing Pool Agency Staffing Nurse Productivity 57 Critical Care Services Ontario May

14 5. NURSE TRAINING Internationally Educated Nurses Educational Attainment Specialized Critical Care Training Life Support Training Advanced Cardiac Life Support (ACLS) Training Paediatric Advanced Life Support (PALS) Training Professional Development Investments In-services Paid Courses and Certificates Ministry of Health and Long-Term Care Support NURSING TURNOVER Scope of Nursing Turnover Analysis Separations by Age Group Employee Turnover Where Nurses Go Destination of Exits Changes in Employment Status NURSING RECRUITMENT Recruitment Strategies New Hires Vacancy Rate RETENTION AND EMPLOYEE ENGAGEMENT Retention Strategies Participation in Hospital-Led Engagement Surveys Employee Engagement Improvement Opportunities Critical Care Services Ontario May 2017

15 9. ALLIED HEALTH PROFESSIONALS IN CRITICAL CARE Use of Allied Health Professionals in Critical Care Pharmacists Physiotherapists Respiratory Therapists (RT) FTE Allocation CONCLUSION GLOSSARY OF TERMS PROVINCIAL REPORT APPENDICES 111 Appendix A. Ontario s Local Health Integration Networks 111 Appendix B. Calculations Table 112 Appendix C. Additional Response Rate Details 114 Appendix D. Online Data Collection Tool BIBLIOGRAPHY 127 Critical Care Services Ontario May

16 LIST OF FIGURES Figure 1: CCWP Data Collection Tool Response Rate, Trend Over Time 25 Figure 2: Critical Care Nurses, by LHIN 28 Figure 3: Length of Nurse Experience in the Critical Care Unit, Trend Over Time 31 Figure 4: Length of Nurse Experience in the Critical Care Unit, by Peer Groups 32 Figure 5: Length of Nurse Experience in the Critical Care Unit, by LHIN 33 Figure 6: Age Group Distribution of Critical Care Nurses, Trend Over Time 34 Figure 7: Age Group Distribution of Critical Care Nurses, by Peer Group 35 Figure 8: Age Group Distribution of Critical Care Nurses, by LHIN 36 Figure 9: Gender Distribution of Critical Care Nurses, Trend Over Time 37 Figure 10: Age Group Distribution of Male Critical Care Nurses, Provincial 38 Figure 11: Gender Distribution of Critical Care Nurses, by Peer Groups 38 Figure 12: Gender Distribution of Critical Care Nurses, by LHIN 39 Figure 13: Employment Status Distribution of Critical Care Nurses, 2013/14 and 2015/16 41 Figure 14: Employment Status Distribution of Critical Care Nurses by Age Group, Provincial 42 Figure 15: Employment Status Distribution of Critical Care Nurses, by Peer Group 43 Figure 16: Employment Status Distribution of Critical Care Nurses, by LHIN 44 Figure 17: Employment Status Distribution of Critical Care Nurse Earned Hours, by Peer Group 45 Figure 18: Employment Status Distribution of Critical Care Nurse Earned Hours, by LHIN 46 Figure 19: Distribution of Critical Care Nurse Earned Hours by Type, Provincial 47 Figure 20: Overtime Hours as a Proportion of Productive Hours for Critical Care Nurses, by Peer Group 48 Figure 21: Overtime Hours as a Proportion of Productive Hours for Critical Care Nurses, by LHIN 49 Figure 22: Sick Rate for Critical Care Nurses, Trend Over Time 50 Figure 23: Sick Rate for Critical Care Nurses, by Peer Group 51 Figure 24: Education Hours as a Proportion of Total Earned Hours for Critical Care Nurses, by Peer Group 52 Figure 25: Approaches to Manage Short-Term Nursing Shortages, Provincial 53 Figure 26: Use of Expanded Assignments to Manage Short-Term Nursing Shortages, by Peer Group 54 Figure 27: Use of Critical Care Nursing Pool to Manage Short-Term Nursing Shortages, by Peer Group 55 Figure 28: Use of Agency Staff to Manage Short-Term Nursing Shortages, by Peer Group 56 Figure 29: Critical Care Nurse Worked Hours (including Overtime) per Patient Day, by Peer Group 57 Figure 30: Critical Care Nurse Worked Hours per Patient Day in 2013/14 and 2015/16, by Peer Group 58 Figure 31: Percent of Internationally Trained Critical Care Nurses, Trend Over Time 60 Figure 32: Percent of Internationally Trained Critical Care Nurses, by Peer Groups 60 Figure 33: Percent of Internationally Trained Critical Care Nurses, by LHIN 61 Figure 34: Educational Attainment Distribution of Critical Care Nurses, Trend Over Time Critical Care Services Ontario May 2017

17 Figure 35: Educational Attainment Distribution of Critical Care Nurses, by Peer Groups 63 Figure 36: Educational Attainment Distribution of Critical Care Nurses, by LHINs 64 Figure 37: Proportion of Nurses that completed a Minimum of 300 Clinical or Didactic Critical Care Training Hours, 2013/14 and 2015/16 66 Figure 38: Critical Care Training Attainment Distribution of Critical Care Nurses, by Peer Group 67 Figure 39: Critical Care Training Attainment Distribution of Critical Care Nurses, by LHIN 68 Figure 40: Advance Cardiac Life Support Training Attainment Distribution of Critical Care Nurses, by Peer Group 69 Figure 41: Paediatric Advanced Life Support (PALS) Training Attainment Distribution of Critical Care Nurses in Paediatric Critical Care Units 70 Figure 42: Approaches to Professional Development Investment in Critical Care Units, Provincial 71 Figure 43: Use of In-services for Professional Development (PD) in Critical Care Units, by Peer Group 72 Figure 44: Use of Paid Courses and Certificates for Professional Development (PD) in Critical Care Units, by Peer Group 73 Figure 45: Use of MOHLTC Support for Professional Development (PD) in Critical Care Units, by Peer Group 74 Figure 46: Critical Care Nurse Exits by Category and Age Group, Provincial 76 Figure 47: Critical Care Nurse Turnover by Age Group, Provincial 77 Figure 48: Critical Care Nurse Turnover for Full-Time Staff by Age Group, Provincial 78 Figure 49: Critical Care Nurse Exits from the Organization by Age Group and Tenure with Employer, Provincial 79 Figure 50: Destination of Critical Care Nurses Leaving the Unit or Changing Employment Status, by Peer Group 80 Figure 51: Destination of Critical Care Nurses Changing Position and Remaining in ICU, by Peer Group 81 Figure 52: Destination of Critical Care Nurses Leaving ICU and Remaining in Nursing, by Peer Group 82 Figure 53: Changes in Employment Status for Critical Care Nurses, by Peer Group 83 Figure 54: Vacancy Rate for Critical Care Units, Trend Over Time 87 Figure 55: Vacancy Rate for Critical Care Units, by Peer Group 88 Figure 56: Vacancy Rate for Critical Care Units, by LHIN 89 Figure 57: Critical Care Unit Participation in Hospital-Led Engagement Survey, by Peer Group 93 Figure 58: Critical Care Unit Participation in Hospital Led Engagement Survey, by LHINs 94 Figure 59: Employee Engagement Improvement Opportunities for Critical Care Units, Provincial 95 Figure 60: Routine Use of Allied Health Professionals in Critical Care Units, Provincial 98 Figure 61: Pharmacist Support Hours per Day in Critical Care Units, by Peer Group 100 Figure 62: Pharmacist Provision of On-Call Support in Critical Care Units, by Peer Group 101 Figure 63: Physiotherapist Support Hours per Day in Critical Care Units, by Peer Group 102 Figure 64: Physiotherapist Provision of On-Call Support in Critical Care Units, by Peer Group 103 Figure 65: Respiratory Therapist Support Hours per Day in Critical Care Units, by Peer Group 105 Figure 66: Respiratory Therapist Provision of On-Call Support in Critical Care Units, by Peer Group 106 Figure 67: Respiratory Therapist FTE Allocation in Critical Care Units, by Peer Group 107 Critical Care Services Ontario May

18 LIST OF TABLES Table 1: Data Elements Captured Over CCWP Survey Evolution 21 Table 2: Ontario s Critical Care Unit Peer Groups 23 Table 3: CCWP Response Rate by LHIN 26 Table 4: Critical Care Nurses Reported in Data Collection Tools 27 Table 5: Headcount by Nursing Role Type 29 Table 6: Headcount Distribution by Nursing Function 30 Table 7: Classification of Employment Status 40 Table 8: Data Collection Tools for Nursing Turnover Capture 75 Table 9: Use and Effectiveness of Recruitment Strategies, Provincial 84 Table 10: Use and Effectiveness of Recruitment Strategy Mentorship, by Peer Group 85 Table 11: New Critical Care Nurse Hires by Category, 2013/14 and 2015/16, by Peer Group 86 Table 12: Use and Effectiveness of Retention Strategies in Critical Care Units, Provincial 90 Table 13: Use and Effectiveness of Recruitment Strategy Education/Training Events, by Peer Group 91 Table 14: LHIN Rural Population 111 Table 15: Calculations Used in Data Collection for Workforce Profile 112 Table 16: CCWP Response Rate by Peer Group 114 Table 17: Critical Care Nurses Reported in Data Collection Tools, by LHIN 115 Table 18: Critical Care Nurses Reported in Data Collection Tools, by Peer Group Critical Care Services Ontario May 2017

19 1. INTRODUCTION Healthcare continues to face increasing demand pressures from both population growth and shifting demographics in Ontario. According to the 2016 population estimate by Statistics Canada, Ontario s population has increased by over half a million residents (4%) since 2011 with the province s metropolitan centers, such as Toronto, Hamilton, Kitchener-Waterloo and London having absorbed the bulk of these increases ( Estimates of population by census metropolitan area, sex and age group., 2016). More importantly however, the proportion of Ontarians 65 years and older has increased by 16.8% per cent during the same time frame ( Population by sex and age group, by province and territory, 2016), which is particularly relevant when planning for critical care needs as the majority of critically-ill patients are over the age of 65 years (Needham et al., 2005). This Critical Care Workforce Profile Report works to understand and profile the workforce in critical care, as an enabler to effective human resource planning and to capture any shifts in the composition of the workforce which may present sustainability risks for the system. The 2017 Critical Care Workforce Profile Report is the 6th edition of a provincial survey looking into the demographics, staffing practices, and supports to critical care nursing in Ontario, across more than 160 critical care units. The original Critical Care Nursing Workforce Profile (CCNWP) developed in 2007 was created to focus research on critical care nurse staffing in Ontario. Enhancements to the data collection in the recent iteration of the survey (now called the Critical Care Workforce Profile (CCWP)) have expanded to include some data collection on the resourcing of allied health professionals in critical care, although much of the survey remains focused on nursing. The survey generally, and with its expansion to include allied health resourcing, is undertaken recognizing that Health Human Resource (HHR) planning is a system pillar to achieving and sustaining quality healthcare delivery. In this report we examine HHR resourcing and trends for nurses and allied health professionals in the critical care workforce. While there has been jurisdictional data collected broadly on nursing and other professional groups, there has been relatively scarce data available to reflect upon the precise challenges and demand on a workforce in specialty services such as critical care, outside of this work undertaken by Critical Care Services Ontario (CCSO). Critical Care Services Ontario May

20 1.1 Objectives and Scope of the Critical Care Workforce Profile (CCWP) The Critical Care Workforce Profile (CCWP) aims to provide critical care service providers, the Ministry of Health and Long-Term Care (MOHLTC) and other critical care stakeholders insights into the availability, utilization and adequacy of critical care HHR at provincial, Peer Group, and regional levels (Local Health Integration Networks (LHINs)) to ensure a resilient critical care workforce which meets current and future system needs. Comprehensive workforce data increases forecasting accuracy, informs effective and efficient staffing practices, identifies and strengthens useful retention strategies and ensures workforce continuity. Up-to-date information about demographics, staffing practices, turnover, recruitment and retirement, workplace stressors, and professional development trends of the critical care workforce is essential for informing these efforts. Thus, the CCWP aims to: Track and trend demographics of the nursing workforce to identify emerging trends and pressures across the province; Understand the existing resourcing of the critical care nursing and allied health professional workforce in depth; Understand the training and development practices for the critical care nursing workforce; Assess recruitment and retention through staff departure rates and the number of new hires/trainees at the provincial, LHIN and Peer Group levels required to staff existing and proposed expanded capacity; Assess retention and recruitment challenges at the provincial, LHIN-level and track the impact of initiatives designed to improve retention and facilitate recruitment; and, Understand employee engagement pressures in critical care (new in 2017). 20 Critical Care Services Ontario May 2017

21 1.2 Data Collection Methods The survey recipients identified to populate the 2017 CCWP Report have been expanded to include hospital human resources department and finance department submissions of standardized data sources as well as a survey to nurse managers as has occurred in previous surveys. A summary of the data elements and data sources captured over time is represented in Table 1 below. Table 1: Data Elements Captured Over CCWP Survey Evolution Subject Area Survey Target Nursing Roles and Demographics Nurse Staffing Practices Nurse Training Nursing Turnover Nursing Recruitment Retention and Employee Engagement Allied Health Professionals (AHP) Focus of Questions 2007/ /11 Unit Managers 2013/ /16 Unit Managers Unit Managers Human Resources Finance Number of staff by discipline Length of time on the unit Number of staff by age group and gender Staff by employment status Staffing statistics (worked hours, overtime hours, sick hours etc.) Strategies for short-term nursing coverage Worked hours per patient day Highest level of education; proportion of internationally educated nurses Type of training (critical care certificates, ACLS, paid education hours etc.) Support strategies for nursing professional development Number of exits Reasons for exits (where known) Recruitment strategies New Hires Vacancies Retention strategies Use of employee engagement surveys by hospitals Opportunities for engagement improvement at the unit level Allied health disciplines involved in regular care Approximate FTE allocations of AHP by discipline Coverage for weekdays, weekends, and call for AHP Critical Care Services Ontario May

22 1.3 Structure of Report and Analysis The 2017 CCWP Report provides workforce profiling of critical care nurses including some trending analysis where possible for data captured from 2007/08 to 2015/16, and snapshot analysis for data representing the nursing and allied health workforce from April 1, 2015 to March 31, Each section will present the provincial trending analysis where possible, as well as Ontario, Peer Group or LHIN perspectives where relevant findings are noted PEER GROUPS Peer-level groupings were first launched by CCSO in July 2013, outside of the CCWP work, to facilitate comparison of a unit s performance with like units. Assignment to a specific Peer Group (PG) took into account factors such as unit designation (Level 2 or Level 3), academic affiliation, and severity of illness of patients managed in the units. The Peer Groups can be used for comparing similar units or comparing one Peer Group with others. The Peer Groupings list was re-evaluated without change in December For this 2017 CCWP Report, two smaller PGs have been merged with larger PGs to assist with comparison of results. In order to best represent these units data for Peer Group analysis, they were merged with the next closest Peer Group based on acuity of patients and hospital type. PG7 (two units) has been merged with PG1; and, PG12 (one unit) has been merged with PG10. The list of Peer Groups and a summary of the criteria used to define each Peer Group is outlined in Table Critical Care Services Ontario May 2017

23 Table 2: Ontario s Critical Care Unit Peer Groups Peer Group # Criteria Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8 Group 9 Group 10 Group 11 Group 12 Level 3 Teaching Hospitals (Medical Surgical ICU) Level 3 Community Hospitals (Medical Surgical ICUs with Ventilator Patient Day Rate above the mean rate of 46.95%) Level 3 Community Hospitals (Medical Surgical ICUs with Ventilator Patient Day Rate equal to or less than the mean rate 46.95%) Level 3 and Level 2 Cardiac/Cardiovascular Unit Level 3 and Level 2 Coronary Care Units Paediatric Units Level 3 Burn Units Level 2 Small - Low Acuity Units Level 2 Large - Low Acuity Units Level 2 Small - High Acuity Units Level 2 Large - High Acuity Units Miscellaneous NOTES: For Groups 2 and 3, the data used to generate Mean Ventilator Patient Day Rate is based on fiscal For Groups 4 and 5, identification of cardiac/cardiovascular unit is based solely on the unit name provided by each hospital For Groups 8-11, criteria Identified using mean values for total beds and MODS (6 and 1.1, respectively). Values equal to or below the means were defined as small (total beds 6) or low acuity (MODS 1.1). The data used to generate the mean MODS is based on fiscal LOCAL HEALTH INTEGRATION NETWORKS (LHINS) The LHIN-level analysis offers regional perspectives that can inform evaluation, planning and resource allocation. Rural and urban areas in particular can have unique workforce demographics and needs, which can be informed by examining LHIN-level analysis. The compositions of LHINs, as well as the numbers and types of critical care units within each of them, limits direct comparison of the critical care nursing workforce across LHINs. As well, it should be noted that a considerable proportion of patients cross LHIN borders to receive care for sub-specialty programs. The list of LHINs and the proportion of each LHIN that is considered rural can be found in Appendix A. Critical Care Services Ontario May

24 1.4 Report Considerations When reviewing the report and analysis, the reader should be aware of the following considerations: Analysis may be at the staff-level or unit-level, depending on the focus of analysis. In figures and tables throughout the report, N denotes the provincial sum of respondents (nurses or units) who reported to the indicator, and n refers to the total number of respondents (nurses or units) in each Peer Group or LHIN as represented by the variable. Not all units that responded to the 2015/16 CCWP Survey completed all three data collection tools. For this reason, the number of units included in analysis may shift depending upon the data source. N, or the provincial sum of respondents, may be different for each question, as the same number of units may not have responded to each question. Percentages are therefore calculated from the number of responses to each question. In one instance combined results were submitted for human resource submissions (CCIS030 and CCIS217) and for the finance data submissions this occurred in two instances (CCIS030 and CCIS217 as well as CCIS126 and CCIS127). Each pair of these units are treated as one unit in the analysis; assigned to the higher-level acuity Peer Group. The calculations for different analyses presented in figures and tables throughout the report can be found in Appendix B. 24 Critical Care Services Ontario May 2017

25 2. SURVEY RESPONSE RATE Critical Care Services Ontario (CCSO) has been tracking and profiling the critical care nursing workforce since In the summer of 2016, CCSO disseminated the Critical Care Workforce Profile Survey to Chief Nursing Officers, Vice Presidents responsible for ICU, ICU Directors, and ICU Nurse Managers with detailed instructions as well as invitation to CCSO-led webinars to assist with data collection requirements and survey completion. The approach to data collection was revised in the 2015/16 survey. The revisions aimed to make the analysis more robust, adding collection of data from hospital Human Resources (HR) departments and Finance departments to allow for more comprehensive analysis. The completion of all three data components was internally managed and submitted to CCSO by Hospitals. The CCWP has had consistently successful response rates since 2007, collecting data from the majority of Ontario s critical care units. Since 2007, survey response rates have ranged from 73% to 87% as identified in Figure 1. In the 2015/16 data collection process, response rates varied between 75% and 85% from the three data collection tools, with the newly implemented finance department data collection tool having the highest response rate from hospitals at 85% compliance (170 out of a total 199 Ontario critical care units). Figure 1: CCWP Data Collection Tool Response Rate, Trend Over Time Response Rate 100% 85% 80% Online Survey 87% 87% HR Data Collection Tool Finance Data Collection Tool 85% 83% 81% PERCENTAGE 60% 40% 73% 75% 20% 0% 2007/08 (216) 2008/09 (200) 2009/10 (200) 2010/11 (200) 2011/12 YEAR (N) 2012/ /14 (206) 2014/ /16 (199) Critical Care Services Ontario May

26 Table 3 offers a snapshot of the response rate to our three data collection tools by LHIN. Two of the LHINs, South West (LHIN 2) and North Simcoe Muskoka (LHIN 12) had low response rates for at least two of the survey collection tools, suggesting an opportunity for greater engagement with these LHINs to support survey participation in future surveys. Survey response by Peer Group did not demonstrate similar wide variation in response rates. Response rates ranged from 70% to 100% among all Peer Groups across survey data collection tools. Table 3: CCWP Response Rate by LHIN LHIN Total # of Critical Care Units Number of Critical Care Units Responded Online Survey Human Resources* Finance* Online Survey Response Rate Human Resources Finance Ontario % 75% 85% 1. Erie St. Clair (ESC) % 86% 86% 2. South West (SW) % 55% 79% 3. Waterloo Wellington (WW) 4. Hamilton Niagara Haldimand Brant (HNHB) % 82% 82% % 86% 89% 5. Central West (CW) % 83% 100% 6. Mississauga Halton (MH) % 78% 100% 7. Toronto Central (TC) % 88% 85% 8. Central (C) % 90% 90% 9. Central East (CE) % 77% 100% 10. South East (SE) % 90% 80% 11. Champlain (CH) % 55% 95% 12. North Simcoe Muskoka (NSM) % 43% 43% 13. North East (NE) % 77% 69% 14. North West (NW) % 67% 67% * Where units submitted combined data, both units are included in this count. When results are discussed in later sections, these combined units are treated as one. Details on response rate for each data collection tool by Peer Group can be found in Appendix C. 26 Critical Care Services Ontario May 2017

27 2.1 Number of Nurses Represented in the CCWP Of the three data collection tools used, the online survey submissions provided information on the highest number of critical care nurses from a headcount perspective. Information requested on nursing headcount was omitted for a number of units in the finance data collection tool which led to this result. The number of nurses represented in each of the data collection tool submissions is identified in Table 4 below. Table 4: Critical Care Nurses Reported in Data Collection Tools Total # of Critical Care Units Online Data Submission Human Resources Submission Finance Submission* Total Units Responded: Ontario Total Number of Units Providing Headcount Data Total Number of Critical Care Nurses (Headcount) Represented: Ontario ,414 8,224 8,576 * Where units submitted combined data, both units are included in this count. When results are discussed in later sections, these combined units are treated as one. The online survey responses, submitted by 83% of Ontario s critical care units, collected information on 9,414 registered critical care nurses of the total 97,418 overall registered nurses in Ontario. While this accounts for 10.3% of all registered nurses employed in 2015 (College of Nurses of Ontario, Membership Statistics Highlights., 2015), there is believed to be some degree of inflation in this figure as some nurses may be employed by more than one organization. Critical Care Services Ontario May

28 Figure 2 shows the total number of critical care nurses represented by the online survey data collection tool from each of Ontario s LHINs. Toronto Central (LHIN 7) has approximately 25% of the critical care nurses represented by the survey across all the Ontario LHINs. This highlights the centralization of many specialized services, which rely upon critical care in the Toronto area. Figure 2: Critical Care Nurses, by LHIN TOTAL NUMBER ESC 1 SW 2 WW 3 HNHB 4 CW 5 MH 6 TC C 7 8 LHIN CE 9 SE 10 CH 11 NSM 12 NE 13 NW 14 Source: 2015/16 CCWP Online Data Collection Tool, Question 1B 28 Critical Care Services Ontario May 2017

29 3. NURSE ROLES AND DEMOGRAPHICS This section presents an overview of the nursing roles in critical care units and the demographic characteristics of Ontario s current critical care nursing workforce. A view of current demographics offers insight into the current and potential demands for training and recruitment in critical care (Kabene, Orchard, Howard, Soriano, & Leduc, 2006). A clear understanding of these factors provides guidance for effective planning, utilization, and management of the critical care nursing workforce. In addition, this data provides important contextual insights to inform recruitment and retention of the critical care nursing workforce. 3.1 Nursing Roles Over 90% of nurses working in critical care are working in registered nurse roles. This is consistent across both the information submitted by nurse managers in the online survey data collection tool as well as with the headcount information submitted by Finance departments. There are discrepancies between nurse manager and finance department reporting of nursing support roles however (see Table 5). This difference, including reporting numbers of nurse managers, nurse educators, clinical nurse specialists and others seems to suggest that these roles are not uniformly captured within the critical care functional centres (which was the source of the finance data), or that the information was not fully disclosed in the information provided in the survey. Table 5: Headcount by Nursing Role Type Nursing Role Online Data Submission (N= 165 units) Finance Data Submission* (N= 160 units) Number Percent Number Percent Registered Nurse 8, % 8, % Other Nurse / Undefined Nurse % % Permanent Charge / Nurse without Assignment % Nurse Manager % % Nurse Educator % % Clinical Nurse Specialist % % Registered Practical Nurse % % Nurse Practitioner % % TOTAL 9,414 8,576 * Where units submitted combined data, both units are included in this count. When results are discussed in later sections, these combined units are treated as one. Critical Care Services Ontario May

30 In both the finance data submission as well as the human resource data submission units were asked to identify whether roles were associated with direct care (e.g. Unit Producing Personnel (UPP) in finance terminology) or with support roles (e.g. Management and Operational Support (MOS) in finance terminology). As indicated in Table 6, more than 97% of staff was identified as performing direct care / UPP functions. Again, the lower number of MOS staff identified through the finance data submission seems to indicate that these roles are not uniformly captured within the critical care functional centres, or that the information was not fully disclosed in the information provided in the survey. Table 6: Headcount Distribution by Nursing Function Nursing Role Direct Care Nurses / Unit Producing Personnel (UPP) Support Nurses / Management and Operational Support (MOS) Finance Data Submission* (N= 160 units) Human Resource Data Submission (N= 150 units) Number Percent Number Percent 8, % 7, % % % Nurse Practitioners (NP) % TOTAL 8,576 8,224 * Where units submitted combined data, both units are included in this count. When results are discussed in later sections, these combined units are treated as one. Due to inconsistencies in the completeness of data on support roles in the human resource and finance data collection tools compared with the online data collection tool, as well as the core interest in profiling front-line care workers, the remainder of analysis from the human resources and finance data sources in this report will restrict focus to the information provided for direct care and/or UPP staff. 30 Critical Care Services Ontario May 2017

31 3.2 Level of Experience The 2015/16 CCWP online survey data collection tool introduced a set of nuanced questions pertaining to length of experience in nursing. Survey respondents were asked to report on the following: Length of experience as an RN; Length of experience in Critical Care; Length of experience in the Unit. Due to some inconsistencies in information reported across the three questions (e.g. length of experience as an RN less than length of experience on the unit), for the purpose of the 2015/16 CCWP, only nursing length of experience in unit is reported and remains consistent with information collected in previous surveys. Length of experience on the unit has been linked with influencing various patient outcomes (Dunton, 2007). As shown in Figure 3, almost half (45.6%) of the critical care nursing workforce have worked in the unit for 6 to 20 years. Since 2007, the percentage of critical care nurses working on the unit with over 20 years of experience has decreased slightly by 1.6%. As reported in this year s CCWP, almost a quarter (23.9%) of critical care nurses working on the unit has less than 3 years of experience. Figure 3: Length of Nurse Experience in the Critical Care Unit, Trend Over Time 30% Experience <3 yrs 3 5 yrs 6 10 yrs yrs >20 yrs PERCENTAGE 25% 20% 15% 10% 26% 26% 22% 21% 21% 18% 2007/08 (7309) 17% 2008/09 (6237) 24% 21% 21% 23% 14% 15% 15% 15% 15% 2009/10 (8389) 23% 23% 21% 18% 19% 2010/11 (8510) 2011/12 YEAR (N) 2012/13 24% 23% 23% 22% 22% 19% 2013/14 (8268) 2014/15 23% 18% 13% 2015/16 (9414) Source for 2015/16 Data: CCWP Online Data Collection Tool, Question 2A Critical Care Services Ontario May

32 Novice RNs are defined as those with less or equal to 3 years of experience, mid-career as those with 3 to 10 years and experienced RNs as those with over 11 years of service in a critical care unit (Ontario, ). The Peer Group snapshot in Figure 4 displays subtle differences between the level of experience among nurses across Peer Groups. The combined PG1+7 (Level 3 units in teaching hospitals) has the highest number of experienced nurses, where 20.9% of nurses had over 20 years of experience on the unit. Paediatric critical care units (PG6) tend to have a greater number of younger nurses (as shown in Section 3.3), which informs the greater presence of novice nurses, with 28.5% of respondents having < 3 years of experience on the unit. In contrast, the lowest number of novice nurses was reported in PG4 at 12.0% Figure 4: Length of Nurse Experience in the Critical Care Unit, by Peer Groups Length of Experience <3 yrs 3 5 yrs 6 10 yrs yrs >20 yrs 100% % PERCENTAGE 60% 40% 20% % ON (9414) PG1+7 (1912) PG2 (1794) PG3 (842) PG4 (574) PG5 (603) PG6 (428) PEER GROUP (N) PG8 (554) PG9 (424) PG10+12 (448) PG11 (831) Source: 2015/16 CCWP Online Data Collection Tool, Question 2A 32 Critical Care Services Ontario May 2017

33 A LHIN breakdown of length of experience in unit in Figure 5 shows some regional variation across the province. Central West (LHIN 5) has a low proportion of novice RNs, (<3 years experience on the unit) while the Central (LHIN 8) and South East (LHIN 10) have high proportions of novice nurses. For mid-career nurses (3-10 years experience on the unit), South West (LHIN 2) and Waterloo Wellington (LHIN 3) have a lower proportion of these nurses, while Central West (LHIN 5) and South East (LHIN 10) have quite high proportions of mid-career nurses. For experienced nurses, those with more than 10 years of experience, Waterloo Wellington (LHIN 3) has a very high proportion of these nurses, while Central (LHIN 8) and South East (LHIN 10) have relatively low proportions of these highly experienced staff. Figure 5: Length of Nurse Experience in the Critical Care Unit, by LHIN 100% Length of Experience <3 yrs 3 5 yrs 6 10 yrs yrs >20 yrs PERCENTAGE 80% 60% 40% % 22 0% ON ESC (9104) (372) SW (920) WW (272) HNHB CW (1245) (541) MH (573) TC (2221) C (617) LHIN (N) CE (453) SE (251) CH (988) NSM (119) NE (422) NW (110) Source: 2015/16 CCWP Online Data Collection Tool, Question 2A Critical Care Services Ontario May