The recent editorial, "Waiting Lists? What Waiting Lists? Not Nursing's Problem" (Pringle 2005), challenges nurses to "step up to the plate" with a pithy and solid analysis of the waiting list issue from a nursing perspective and with recommendations for ameliorating it. Although we are not nurses, and are thereby disqualified from stepping up to the plate, we believe that our experience of working for over a year to implement Ontario's Wait Time Strategy qualifies us to comment on the game.

On November 17, 2004, the Minister of Health and Long-Term Care, George Smitherman, officially announced Ontario's Wait Time Strategy. The strategy is designed to improve access to healthcare services in the public system by December 2006 by reducing the time that adult Ontarians wait for services in five areas: MRI and CT, cancer surgery, cardiac revascularization, cataract surgery and total hip and knee joint replacements. "Wait time" is defined as the time elapsed between the decision to order a scan or surgery and completion of the procedure.

Expert panels - comprising clinicians, administrators, researchers and others - are being used to help achieve this strategy. In addition to the five expert service panels, two other panels have focused on efficient surgical practices to increase patient flow and critical care services to support timely access to surgical care. Ongoing input has also been sought from organizations and professional associations including the Registered Nurses' Association of Ontario, which has provided invaluable advice since the strategy began.

Underlying Human Resources Principle: Healthcare Providers Should Deliver Services to the Maximum Level of Their Training and Skills

Over the past year, hundreds of healthcare leaders and providers, including nurses, have advised government on how to improve access and reduce wait times in the face of increasing demands for the five services. Although everyone has emphasized that a sufficient number of appropriately qualified human resources is needed to reduce wait times, a consistent message has been that we need to work better and smarter with the people that we do have. The underlying human resources principle is that healthcare providers should deliver services to the maximum level of their training and skills.

We believe that non-physician healthcare providers - including nurses - have a significant role to play in resolving many of the wait time issues. There are two main messages here for nursing.

First, many services being performed by specialists and family physicians could and should be provided by nurses with appropriate changes to their scope of practice. This will free specialists and family physicians to concentrate on delivering skilled medical services commensurate with their training. The Wait Time Strategy's expert panels have identified a number of expanded roles for nurses that would help improve access and reduce wait times.

• Registered nurse first assistants (RNFAs) can have a significant impact on reduced waits for surgery, especially in community hospitals that do not have post-graduate trainees such as fellows and residents. Although all the regulatory nursing colleges in Canada have acknowledged that the RNFA functions within the scope of nursing practice, the role has been growing at a snail's pace in Canada (unlike the United States). The Registered Nurses' Association of Ontario has informed us that the RNFA role remains relatively new to Ontario and must be more fully integrated into healthcare.
• Nurse anaesthetists can help address the shortage of anaesthesia services, one of the main limiting factors to achieving Ontario's wait time targets. Although Ontario has just begun to move in the direction of training anaesthesia assistants, who will be an important part of an anaesthesia team, nursing must actively promote specialized training in anaesthesia. In Ontario, both the Registered Nurses' Association and the College of Nurses support an expanded practice role for registered nurses at the graduate level with additional anaesthesia skills. Nurse anaesthetists are widely accepted in other jurisdictions, with good results. They can make an important contribution to resolving wait time pressures in Ontario.
• Advanced practice nurses can play an important role in anaesthesia teams. A number of Ontario hospitals use teams for cataract surgery in which an anaesthesiologist covers two rooms and provides clinical support to nurses who establish IVs, provide sedation and monitor patients. This team model has doubled the throughput of cataract patients while maintaining patient safety.
• Although acute care nurse practitioners are widely used in Ontario's acute care hospitals, they do not play a prominent role in peri-operative services except for pre-operative screening and pain management. Highly skilled nurses have an important expanded role to play in the pre-, intra- and post-operative phases of surgical wait time services. For example, the expert panel on total hip and knee joint replacement has recommended that multidisciplinary joint clinics be established to assess whether a surgical consultation is warranted, to provide pre-operative education and screening and to conduct post-operative assessments and follow-up. (The proposed model is similar to the Alberta Hip and Knee Replacement Project.) Nursing has a pivotal role to play in these proposed clinics, which may be an appropriate model for all surgeries in Ontario.
• Nurses have an important role to play in peri-operative improvement coaching teams, which were recommended by one of the Wait Time expert panels. The teams, made up of peers with experience in effective management of peri-operative resources, will coach hospitals on effective peri-operative management techniques such as planning, mapping processes and determining optimal human resources use and scheduling.

The second message for nursing is that many services being performed by nurses could and should be provided by other healthcare workers. This will free highly trained nurses, many with baccalaureate degrees, to concentrate on delivering skilled nursing services commensurate with their training. The Wait Time Strategy's expert panels identified a number of examples.

• A standardized peri-operative technician role should be open to registered practical nurses and other healthcare personnel with appropriate basic healthcare education, including foreign-trained healthcare providers who are not able to gain employment in their specialty.
• Hospitals need to support the development of innovative interdisciplinary peri-operative teams that use other healthcare providers in addition to surgeons, anaesthesiologists and nurses. These providers could include technical assistants and others who would increase efficiencies while maintaining safety and quality, and help minimize nurses' performance of non-nursing duties.

How Well Is Nursing Equipped to Be Part of the Solution?

Hundreds of healthcare leaders and providers see nursing as part of the solution to improving access and reducing wait times. But how well is nursing equipped to be part of the solution?

The shortage of nurses in Ontario is well known and has contributed to surgical cancellations and longer wait lists. It is estimated that Canada will lose about 29,746 RNs aged 50 or older to retirement or death by 2006, an amount equivalent to 13% of the 2001 Canadian nursing workforce (CIHI 2003). In Ontario, it is predicted that by 2008, hospitals could experience a projected shortfall of up to 12,897 full-time registered nurses and 4,025 registered practical nurses (O'Brien-Pallas et al. 2003). Furthermore, about 45% of RNs and 52% of RPNs are not employed to their full potential, choosing to work either casually or part time. It has been estimated that if these nurses worked full time in 2001, the equivalent of 2,592 full-time positions would have been available. If Ontario is to succeed at reducing wait times, efforts must be made to recruit and retain nurses. It is hoped that supporting nurses to work to the maximum level of their training and skills, and developing nursing specialties, will enrich the career paths of new and established nurses and help keep them in the profession.

The Wait Time Strategy has highlighted the need for incentives to support innovative roles for nurses and other staff. Generally, Ontario hospitals use their global budgets to pay for RNFAs and acute care nurse practitioners and to support innovative team models, whereas physicians who fulfill surgical and anaesthesia roles generally bill the Ontario Health Insurance Plan. Hospitals are reluctant to use their limited resources to pay for hospital staff, preferring physicians to do the work and bill fee-for-service. These physician costs remain "invisible" to the hospital even though they may cost the system significantly more than using other appropriately trained providers. Alternative funding programs encourage the use of other providers. The expert panels call for the Ministry of Health and Long-Term Care to review how surgical services are funded and how staff are compensated, with the goal of aligning incentives to support the efficient and effective use of human resources.

Conclusion

Nursing has a significant and vital role to play in improving access and reducing wait times within the public healthcare system. Ontario's Wait Time Strategy has identified a number of important contributions for nursing. Considering that the five service areas are just the beginning of an ongoing process to improve access to, and reduce wait times for, a broad range of healthcare services beyond 2006, the demand for nursing will continue to increase. Since the strategy was initiated over a year ago, we have become well aware of the problems in nursing as well as potential solutions. We look forward to working with nursing leadership and front-line nurses to make these solutions a reality.

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