British Columbia: Improving Retention and Recruitment in Smaller Communities
This pilot project involved the application, in Canada, of the innovative 80/20 staffing model to a hospital in a small rural setting. The model provides the voluntary participants with 20% of their salaried time off from direct patient care in order to pursue various types of professional development activities. The project, overseen by a steering committee, lasted from June 2009 to February 2010 and involved 14 nurses on the pediatric unit of Royal Inland Hospital in Kamloops, British Columbia. It entailed a collaborative partnership of the British Columbia Nurses' Union, Interior Health Authority, Thompson Rivers University and the British Columbia Ministry of Health, and aimed to demonstrate how professional development opportunities can improve recruitment and retention of nurses, quality of work life and quality of patient care.
This project was based in the pediatric unit of the Royal Inland Hospital (RIH), which is part of the Interior Health Authority, one of five geographically based health authorities in British Columbia. The RIH is a 216-bed tertiary referral hospital in Kamloops, a city in the interior of the province, with a population of about 85,000. The RIH had been finding it increasingly difficult to recruit needed healthcare providers, including nurses. As in other parts of the country, the nursing workforce is aging, and many junior nurses feel inadequately equipped to deal with workplace stresses.
The 80/20 staffing model was introduced as a pilot project to improve recruitment and retention of nurses and hence help to address the current issues with nursing shortages. This model had previously been implemented in Canada in units in two larger urban settings (the University Health Network in Toronto, Ontario and the Regina General Hospital in Regina, Saskatchewan), but not in a smaller institution such as the RIH. Under the model, nurses spend 80% of their salaried time in direct patient care and 20% in various professional development pursuits such as education, mentoring and work-related activities to enhance patient-centred care. When it was introduced in other hospitals, the model led to a number of positive outcomes, such as enhanced nurses' satisfaction with their practice, a decrease in sick time and overtime, and enhanced patient satisfaction scores.
This project set out to demonstrate how a model that promotes professional development opportunities for both new and experienced nurses in one unit will enhance their work experience and leadership capacity, create a positive work environment and lead to better recruitment and retention of nurses.
The local-level objectives were numerous and included the following: (a) to improve the retention of existing staff and enhance the profile of the RIH as a desired workplace in order to attract staff; (b) to provide time for nurses to develop leadership and clinical skills and to engage in work-related professional development and mentoring outside of time spent directly on clinical care; (c) to introduce staff to research and allow time for engaging in relevant research; (d) to have a positive impact on measured indicators of job satisfaction and staff engagement within the project site; (e) to identify effective practices for collaboration among different sectors/partners; (f) to have a positive impact on work environment indicators such as decreased overtime, absenteeism and sick leave; and (g) to identify the elements of a program that are suited to other health professionals.
Overview: Design and Planning
In addition to senior management of the Interior Health Authority and Royal Inland Hospital, interested provincial partners were secured – the BC Ministry of Health, the BC Nurses' Union and Thompson Rivers University (TRU).
To launch the project, a project charter and budget were developed, and ethics approval was obtained from the Interior Health Authority and TRU. A hospital unit, which had leadership and nursing staff interested in participating on a voluntary basis, was selected. Eleven registered nurses (RNs) and four licensed practical nurses (LPNs) participated.
A project coordinator (0.5 FTE) was hired to coordinate communications between the national and local steering committees as well as to complete a needs assessment and reports and to work with the RIH program leader and participants to arrange work schedules. Other hires were a clinical educator (0.4 FTE) and clinical support staff (0.2 FTE). The project had three phases – planning, implementation and evaluation – undertaken over a period of 24 months (November 2008 to October 2010). Duration of the implementation phase of the project was originally to be 12 months. However, a delay in starting the project – it began in June 2009 instead of March 2009 – led to a loss of funding from one partner (see "Challenges," below), and the implementation phase was shortened to nine months.
Two backfill (temporary) RN positions and one LPN position were created in order to accommodate the 20% time off from regular clinical duties accorded to participating staff nurses. The backfill positions were quickly filled – a contrast from the pre-project challenges to fill vacant positions – and the nurses who were hired for these positions were given, and accepted, the opportunity to participate in the 80/20 project.
A kick-off event was held, and group events during the project included team development activities and discussion of project activities.
The nurse participants worked with the TRU School of Nursing assistant professor, who was on the provincial steering committee, to create individual learning plans. The clinical nurse educator assisted the nurses in carrying out their learning plans, revising them as needed and locating specific professional development activities.
Participating nurses received 20% of their paid time to engage in professional development activities and were also able to access up to $2,500 each to pay for some or all of their activities. This additional funding provided reimbursement for actual expenses that nurses incurred related to their activities, including tuition, supplies and travel expenses.
Participants applied for their 20% professional development time based on the available backfill. Restrictions on leaves were relaxed in order to facilitate the additional leave requirements created by this project. The nurses completed leave request forms for their time off, the program leader approved the leaves and the scheduling office at Royal Inland Hospital ensured that the appropriate backfill relief was entered in the work schedule. Occasionally, there was a mismatch in required 20% release time and available relief. In these situations, the participants often cooperated to facilitate one another's release time.
Participants had scheduled professional development time during the summer, but most had difficulty finding formal educational opportunities during summer months because the bulk of professional development activities did not begin until September 2009. As a result, professional development time and the availability of backfill staff did not always match when the time off was required. However, participants were flexible and willing to support colleagues to overcome scheduling challenges.
Even in the fall, there were limited formal education opportunities available in the local, mostly rural, area, especially for the LPNs in the project. However, this circumstance led participants to be creative in their activities and also to explore online and distance education opportunities of which they had not previously been aware.
There were three site visits to the project from representatives of other Research to Action projects. In response to participant concerns, reporting requirements were reduced and certain activities (such as meeting site visitors) were deemed optional. The project ended with a wrap-up group event for participants.
There were three main categories of challenges – resource challenges, staffing challenges and challenges for participating nurses.
Owing to a delay in starting the national program delivery phase until after the government's fiscal year-end (March 31, 2009), $100,000 from the BC Ministry of Health that was earmarked for the project in the 2009–2010 fiscal year was unusable. The duration of the project was scaled back to accommodate this financial change, and nurses were given nine months instead of 12 months to complete their learning activities.
A staffing challenge arose when the original project coordinator, who was hired in fall 2008, resigned in May 2009. The new project coordinator required time to familiarize herself with the project participants, program leader, clinical educator, principal investigator and the provincial steering committee. The transition occurred smoothly, although it caused some continuity concerns for participants.
The shortening of the project from 12 months to nine months meant that some of the nurses had to complete their learning activities in a condensed timeframe or complete their learning activities after the project came to a close. Many said they were just getting immersed in their project/professional activities when the project ended.
The project took place in a relatively small community in which formal educational opportunities, particularly for LPNs, were limited. Because of Kamloops's geographic location, nurses often have to travel to other cities, such as Kelowna or Vancouver, for educational opportunities, necessitating the use of professional development funds for travel costs. As well, nurses had difficulty coordinating their work schedules with course start dates and with course demands. Nurses had the freedom to choose professional development activities that fit their learning needs. Although most of the participants viewed this flexibility as a very positive aspect of the project, a few experienced this freedom as challenging and would have preferred to choose from a pre-established list of activities that would be available or possible to undertake. The original requirement for participants to report every two weeks proved onerous for them; therefore, reporting time was reduced to once a month.
In addition to participating in the Research to Action initiative's national evaluation, this project was also evaluated provincially. The design of the national research followed action research principles, and the local research continued with this approach.
The local research team, led by principal investigator Marion Healey-Ogden, was composed of five members of the project's provincial steering committee. The local research team collected and analyzed qualitative data from individual phone interviews with 14 of the 15 participating nurses.
All the interviews followed a semi-structured interview guide and were typed during the interview process. The data were immediately read back to the participants to ensure that what was recorded was an accurate reflection of their comments. The participants' names were replaced with codes before the interviews were analyzed by the local research team.
The interviews gave the nurses an opportunity to describe the experience of participating in the 80/20 pilot project. In order to provide a breadth of data, the program leader and clinical educator were also interviewed about their experiences of working with the nurses who were participating in the project.
In total, participants spent about 4,000 hours in professional development/learning activities. The majority of that time (approximately 2,414 hours) was spent in the pursuit of specialty certification – in chemotherapy, Canadian Vascular Access Association (CVAA) and pediatric – and in obtaining academic credentials towards BSN degrees. The balance included time spent in acquiring technical skills (computer skills and a photography course to aid in creation of a brochure for patients), individual (self) study, mentoring, providing and attending workshops and other project-related activities.
The research showed that nurses' learning experiences positively affected their personal growth as well as the work environment on the unit and their working relationship with all staff on the unit.
Many of the nurses discovered that a variety of different career possibilities exist for them, within the RIH and within nursing. Job satisfaction and staff engagement improved, and many of the nurses indicated that because of the project they intended to remain employed at the RIH. As well, there was a significant increase in interest from candidates seeking to work at the hospital: "I am asking people not to apply anymore because [despite the nursing shortage] people want to work here," the unit manager told the project's Knowledge Transfer Conference, held March 9–10, 2011 in Ottawa.
Specific outcomes included:
- Pre-op teaching brochure for pediatric patients and their families: It is anticipated that this brochure, developed by some participating nurses, will be made available throughout the Interior Health Authority.
- Staff retention: Of the 14 nurses who were interviewed for the provincial evaluation, seven stated that because of their experiences in the 80/20 project, they would definitely remain working at the RIH. Prior to the project, some of those nurses were seriously considering leaving the RIH or leaving nursing altogether. Three of the 14 nurses gave neutral responses regarding the impact that the project had on their decisions to stay or leave their nursing positions, mainly because they were settled in Kamloops. They indicated, however, that the project itself could positively influence their future employment decisions. Four of the 14 nurses stated the project did not have an impact on their decisions to remain working at RIH or in nursing because they had already made specific plans regarding their career.
- Increased quality of care: As the nurses gained knowledge and skills from their professional development activities, they recognized that the quality of their nursing care improved. In turn, they readily shared their new knowledge with the other staff on the unit whether or not they were participating in the 80/20 project. The entire unit benefited from the participating nurses' experiences.
- Intersectoral collaboration: The participating nurses and the leaders on the unit commented favourably about the collaborative partnership between academia and practice that contributed to cohesive and positive working relationships with the staff on the unit and with other staff and departments at Royal Inland Hospital. The nurses highlighted the value of including both registered nurses and licensed practical nurses in this project because this collaboration gave the message that the two groups were being treated equally.
- Profile of Royal Inland Hospital: The 80/20 project itself, and the support the nurses received throughout their nine months of professional development, raised the profile of the hospital in the eyes of the participating nurses. They talked about feeling valued, and they expressed their gratitude for being part of the project.
- Engaging as a team: The nurses' individual professional development activities had a positive influence on the entire team. Over the nine months of the project, the staff coalesced as a team. The high level of staff engagement arose from a foundation of collegial caring, a positive work environment, increased staff morale and a special bonding relationship that developed over the life of the project.
- Personal growth and rewards: The nurses' professional development and related learning journeys involved leaving their comfort zones. The nurses described this experience in positive terms. They gained increased self-esteem, self-worth and self-confidence and, in turn, they experienced a new excitement about nursing. Their personal growth led to experiencing personal rewards such as feeling enriched, respected and satisfied. Specifically, the nurses experienced a work–life balance that had a positive impact on their personal lives and their work environment.
- It would have been better if the implementation phase of the project – when nurses became free to pursue professional development activities – corresponded with academic schedules.
- The introduction of the 80/20 model provided opportunities for nurses to experience professional renewal, resulting in a more engaged and informed workforce.
- The opportunity to participate in employer-supported professional development led directly to the retention of nurses. The RIH benefits from the new competencies and skills of these nurses and adds to the capacity of the health authority.
- The collaborative design of the national model was reflected in the provincial working relationships, financial contributions and overall implementation of the BC project. Collaboration can have a positive impact on organizational culture (Ferguson-Paré et al. 2010), and this impact can potentially promote the retention and recruitment of a range of healthcare professionals.
Sustainability and Transferability
The current 80/20 format is not sustainable within the Interior Health Authority at this time. On the pilot unit, the program leader and the new clinical educator are currently exploring opportunities to maintain the momentum generated by the 80/20 project, within existing resources. Opportunities exist to utilize work that came out of the project. For example, a pre-operative brochure that one nurse developed for children and their families is being utilized throughout the Interior Health Authority. The participants valued the professional development time so highly that they would welcome any amount of formal paid PD time, and they suggested building in such time within regular workloads.
Although the primary focus of this project was nurse retention and recruitment, the overall focus was to improve retention and recruitment of all healthcare professionals. This research set the stage to communicate the value of the 80/20 project to government and management. It also set the stage for future implementation of such a model with healthcare professionals other than nurses. Further, it demonstrated the value of nurse unions, employers, governments and academia engaging in new collaborative partnerships.
About the Author
Marion Healey-Ogden, RN, RCC, PhD, Assistant Professor, Thompson Rivers University, Kamloops, BC
Patricia Wejr, RN, BA, MSc, Senior Policy Analyst, British Columbia Nurses' Union, Adjunct Professor, University of British Columbia, Burnaby, BC
Catherine Farrow, RN, MSN, Project Coordinator, Professional Practice Office, Interior Health Authority, Kelowna, BC
Ferguson-Paré, M., C. Mallette, B. Zarins, S. McLeod and K. Reuben. 2010. "Collaboration to Change the Landscape of Nursing: A Journey between Urban and Remote Practice Settings." Nursing Leadership 23: 90–100.
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