This project, based in Newfoundland and Labrador's Central Regional Health Authority, is the first application of an 80/20 staffing model to a long-term care facility in Canada. The model allows nurse participants to spend 20% of their paid time pursuing a professional development activity instead of providing direct patient care. Newfoundland and Labrador has the highest aging demographic in Canada owing, in part, to the out-migration of younger adults. Recruiting and retaining nurses to work in long-term care in the province is difficult; at the same time, the increasing acuity of long-term care residents and their complex care needs mean that nurses must assume greater leadership roles in these facilities.

This project set out to increase capacity for registered nurse (RN) leadership, training and support and to enhance the profile of long-term care as a place to work. Six RNs and one licensed practical nurse (LPN) participated and engaged in a range of professional development activities. Several of the participants are now pursuing further nursing educational activities. Central Health plans to continue a 90/10 model for one RN and one LPN per semester, with the timeframe to be determined. The model will be evaluated and, if it is deemed successful, the feasibility of implementing it in other sites throughout the region will be explored.

Background

Newfoundland and Labrador (NL) has the highest aging demographic in Canada, partly due to the out-migration of younger adults. This aging population has specific and increasingly complex healthcare needs. Although registered nurses in Newfoundland and Labrador who work in long-term care (LTC) are paid at parity with RNs working in acute care, it is still more difficult to recruit and retain nurses in LTC settings.

The Newfoundland and Labrador Nurses' Union (NLNU), the Newfoundland and Labrador Department of Health and Community Services (DOHCS) and the Central Regional Health Authority (CRHA) recognized the importance of addressing these issues and of taking steps to increase recruitment to LTC and enhance its profile as a place to work. The three partners proposed the adoption of an 80/20 RN staffing model, in which nurse participants are freed from regular resident care for 20% of their paid staff time in order to spend that time pursuing professional development activities. The 80/20 model was developed by the University Health Network (UHN) in Toronto (Bournes and Ferguson-Paré 2007) and had been implemented in units in two large urban settings (the UHN and the Regina General Hospital in Regina, Saskatchewan). Until this project, however, the model had not been implemented in a LTC facility.

Carmelite House was chosen as the implementation site. The 64-bed LTC facility is located in Grand Falls–Windsor, a town of about 15,000 in central NL. Carmelite House is linked to the Central Newfoundland Regional Health Centre (CNRHC), a 120-bed regional hospital that provides a number of healthcare services to a population of approximately 100,000 people and covers a 200-km radius. Carmelite House has its own dedicated nursing staff but also shares some casual and float nurses (RNs and LPNs) with the CNRHC. Nursing staff at Carmelite House comprises an RN team leader who works 8 a.m. to 4 p.m. Monday to Friday, four full-time, two part-time and two casual RNs and a number of full-time, part-time and casual LPNs and personal care attendants (PCAs). The usual RN complement on day shift is two RNs including the team leader, and one RN on night shift. Most LPNs are medication proficient and have completed a health assessment course.

Several other allied health professionals are on staff, and two family physicians visit weekly and are available on an on-call basis.

Residents of Carmelite House generally have a number of medical conditions that require continuous supervision and frequently warrant medical intervention. The majority of residents require assistance with activities of daily living and mobility, and many are incontinent of bowel, bladder or both and have some degree of cognitive impairment.

Objectives

The objectives of the 80/20 project at Carmelite House were to

• provide the time for RNs to develop leadership and clinical skills, to engage in work-related activities and to enhance the resident-centred environment;
• improve the measured indicators of job satisfaction at the project site;
• increase capacity for RN leadership, training and support;
• increase the RN retention rates;
• enhance the profile of LTC as a place to work; and
• provide evidence-based research of 80/20 RN models in LTC.

Overview: Design and Planning

A provincial steering committee composed of representatives from each of the provincial project partners, which included the Department of Health and Community Services, Newfoundland and Labrador Nurses Union, Central Health, project lead and project coordinator, met quarterly. They monitored the project activities and assisted in outreach and communication. The 0.4 FTE project coordinator and the manager of Carmelite House led the project implementation and management of the initiative.

Two nurse educators from CRHA's Professional Development Department were valuable resources for the participants and the project coordinator. They were available on request to provide guidance and encouragement. The Communication Department for the Central Regional Health Authority provided support for media coverage for the pilot project.

The 80/20 project took place over 24 months and included three components: program planning, program implementation and program evaluation. During the planning phase, the project coordinator conducted an assessment to identify how, based on the needs of the participating nurses, the 20% time would best be utilized. Educational resources and supports were then developed. A similar-sized LTC facility within the CRHA was selected as a comparator site for the pilot project for the purposes of the national evaluation.

Two part-time nurses from Carmelite House agreed to increase their hours of work, and one casual nurse was hired to provide the extra coverage needed for the 20% replacement. As a part of succession planning, bursaries were offered to nurses in the float pool to engage in gerontology-focused, distance-based courses.

Implementation

Program implementation took place for 12 out of 16 months and was delivered in two phases. In total, six RNS and one LPN participated in the project. In phase one, all five participants were RNs. Three participants engaged in a distance-based university course, one completed a post-basic gerontology diploma program, two attended the Fifth Canadian Conference on Dementia and one developed a falls-prevention program for Carmelite House.

Six RNs (the five from phase one, plus one other RN) and one LPN participated in phase two. Two participants continued work on distance-based university courses, one participant worked on a diabetes educator diploma and the LPN participant worked on courses to transition into a baccalaureate nursing program. Four participants continued work on developing a palliative care policy for Carmelite House.

In addition, participants were able to attend a variety of conferences and workshops, including a palliative care seminar, the 2010 Nursing Leadership Conference, a provincial palliative care conference, a skin and wound care conference, a foot care course and a seminar entitled "A Closer Look at Long-Term Care."

Challenges

Because of nursing shortages, the biggest challenge the project experienced was scheduling the 20% replacement time for participants. This challenge was ongoing, but the participants worked with the manager and one another to accommodate scheduling changes.

At the start-up of the professional development activities, participants experienced tremendous anxiety because of fear of failure. Of note is the fact that the majority of these nurses had not engaged in educational activities for extended periods of time.

Initial efforts to engage float nurses in gerontology-focused professional development activities to support succession planning were unsuccessful. The focus was broadened to include general nursing–related topics; this change generated much more interest. As a result, five nurses pursued a course in a master's program, one pursued a pharmacology course and one attended a seminar, "Alzheimer's, Memory and Dementia." (Of the seven nurses who received professional development support, two were full-time to the Professional Development Department [PDD], three were from the float pool, one was the new team leader at Carmelite House and one nurse was a team leader from one of the medical units at the regional health centre. The two nurses from the PDD provided support to the project participants and project coordinator during the implementation phases and assisted with organization of guest speakers in the absence of the project coordinator.)

Timely financial reporting presented some challenges, likely because of insufficient communication and a change in the original contact person from the finance department.

The reality of having very busy individuals on the provincial steering committee with multiple responsibilities and conflicting schedules created some difficulty with scheduling meetings.

Outcomes

Many of the nurses were initially very anxious about undertaking professional development activities, but when they became engaged and started to experience success, their confidence grew, and they actively requested education relevant to the LTC setting. By the project's end, participants expressed a high level of satisfaction with the staffing model and showed an increased interest in professional development activities.

At the end of the project, four participants expressed an interest in registering for the post-basic program in gerontology for nurses. Two of these individuals did register for the program and are, at the time of this submission, actively engaged in the program. Three project participants have expressed a plan to write the CNA certification exam in gerontology. Central Health will provide financial support to nurses who pursue CNA certification.

There have not been any on-site measured indicators of benefits to resident care. However, the nurse manager at Carmelite House has observed improvement in documentation and assessment skills, and there has been a decrease in the number of resident falls. Family members have provided some very positive feedback on the quality of care received by their loved ones, particularly in relation to the palliative care suite. All this indicates that education has had a positive impact on quality of care.

Project results show evidence of an increase in leadership. The team leader at Carmelite House retired, and her replacement is a float pool nurse who received funding for a master's course through this program. The LPN participant is now enrolled in a baccalaureate nursing program. The nurse who developed the falls-prevention program for Carmelite House had her work integrated into the development of a regional falls-prevention program.

The size and timeline of the project did not permit a formal investigation of its effect on staff retention. However, project steering committee members received positive feedback from nurses who reported greater job satisfaction and increased intention to remain on the job. Nurses felt the project improved the profile of nursing in LTC by recognizing it as a specialty requiring its own set of desired skills and competencies. Finally, the positive outcomes suggest that staffing plans such as the 80/20 model are an effective means to improve work life in the LTC setting.

Lessons Learned

• Provide an opportunity, nurture appropriately and growth will occur. Nurses working in LTC often feel like "poor cousins" who lack opportunity because they are perceived as doing less important work than hospital-based nurses. This project has provided an opportunity to a group of nurses who, by their own admission, would not otherwise have participated in professional development activities for a number of reasons, not the least of which was fear of failure.
• Confidence is developed through success in these efforts. Confident nurses provide high-quality care and improve resident care.
• Unions, governments and employers can sit on the same side of the table to create positive solutions to problems that could adversely affect patients, families and other stakeholders. The ongoing nursing shortage, and the many issues that affect retention and recruitment of nurses, is one such issue.

Sustainability and Transferability

From a financial and human resources perspective, the 80/20 model is not perceived as sustainable. The provincial steering committee has discussed the feasibility of alternative models, such as an 85/15 or a 90/10 format that could be offered to a limited number of nurses, for example, six at a selected facility within the CRHA. This would be done for nurses who express an interest in professional development activities. There has also been some discussion on the types of facilities that could best support such a program from a human resources perspective – that is, rural, urban, LTC and acute care. At this time, Central Health plans to continue an 85/15 model for one RN and one LPN per semester (timeframe to be determined). The model will be evaluated and, if it is deemed successful, the potential to implement it in other sites within the region will be explored.

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