The growing demand in providing healthcare services combined with the effects of the COVID-19 pandemic on healthcare staffing has created a situation where the supply of available nurses is not keeping up with the demand with increasing competition for limited resources. Rural and remote locations face unique challenges in recruiting and retaining skilled staff. Manitoba's Provincial Travel Nurse Team (PTNT) was created as an alternative staffing model with flexible employment options to retain nurses in the public health system. The PTNT's early success has demonstrated that this model can supplement current site staffing models and provide a unique alternative to agency nursing staffing.

Introduction

Providing healthcare in an efficient and sustainable way is complex and requires a multitude of strategies to balance the ever-growing health system needs and provide work environments where staff are engaged and supported in the work they are doing. Recruitment and retention of healthcare providers has been recognized as a key priority within Canada (CIHI 2023a). Healthcare leaders and governments are continuing to look for innovative strategies to address this complex challenge. Nurses in particular are Canada's largest group of regulated health professionals (Health Canada 2024) and play a key role in supporting Canada's healthcare system. The growing demand in providing healthcare services combined with the effects of the COVID-19 pandemic on healthcare staffing has created a situation where the supply of available nurses is not keeping up with the demand. Rural and remote locations face unique challenges in recruiting and retaining skilled staff to support their sites. There is also an increasing reliance on private agency nursing, which offers flexible scheduling and often higher wages but does not always meet the needs of the system.

Manitoba nursing leaders met in the midst of the pandemic during the fall of 2021 to strategize on various approaches to improve nursing recruitment and retention. There was recognition that a multi-pronged approach was needed so the group challenged each other to be creative and innovative, putting every idea forward. Nurses shared how important flexibility in scheduling is to manage the demands of shift work and how that is an incentive to work in private staffing agencies. One of the ideas that came forward to address the immediate staffing gaps, particularly for the rural and remote locations, was to create a provincial staffing pool with that same flexible scheduling while maintaining the benefits of working in the public system. Various nursing leaders had shared their past experiences as travel nurses in other countries, which included the ability to stretch their clinical experiences across various geographical areas and enjoy flexible scheduling and incentives that rewarded their willingness to move to various locations or sites. The vision started to emerge about what could be considered in Manitoba that mimicked those principles. The timing of that vision aligned with the negotiation of a new collective agreement with the Manitoba Nurses Union (Shared Health Employers Organization and Manitoba Nurses Union 2023). In October 2022, the new collective agreement included broad language about how nurses would be incentivized to be part of the provincial nursing float pool and the northern travel locum with the Provincial Health Authority, Shared Health Manitoba. This collective agreement set the wheels in motion to establish an employer-based planning group that developed the implementation plan. Manitoba's Provincial Travel Nurse Team (PTNT) was conceived to operate as a provincial structure with administrative and foundational supports to enhance provincial nursing capacity and address staffing demands in priority service areas. The goal of the Manitoba PTNT team is to support the availability of a skilled, reliable and provincial nursing team engaged and invested in the delivery of care for all Manitobans. The first nurses were hired to the PTNT in December 2022.

Background

Canadian provinces are seeing increasing overtime hours for nurses and an increasing reliance on agency usage to support care needs (CIHI 2023b). There is increasing competition for limited resources. The number of nurses providing direct care for private nursing agencies as well as self-employment also continues to increase (CIHI 2024). As the needs outpace the supply, there has been ample supply of opportunities and shifts available for agency nursing. Agencies are offering flexible scheduling and often higher wages, along with opportunities to work at various sites and gain diverse experiences, which is appealing to some nurses and making it difficult for provincial sites to recruit and retain nurses. In Manitoba, operators report a high degree of cancellation of agency shifts, which results in poor reliability of staffing to support clinical operations. There is also no ability to prioritize scarce staffing resources with a provincial lens. The oversight and prioritization were key priorities for nursing leaders, as well as the reports of different nurses coming each shift, leading to a lack of continuity of care and, at times, a mismatch of skill sets leading to patient safety concerns. These challenges highlight the need for a different model to address this growing trend.

Key design elements in creating the Manitoba PTNT were around flexible scheduling options and accessing the benefits provided by the public healthcare system, including support for orientation, education and continuing professional development as well as comprehensive benefits packages and pension plans. This aligns with two of the eight core themes identified in the newly released Nursing Retention Toolkit (Health Canada 2024) created by nurses for nurses to support nurses in Canada by optimizing their working conditions. Flexible and balanced ways of working can mean different things to different people and while some nurses may appreciate the predictability of their current scheduling rotations and arrangements, others are looking for flexibility in scheduling that supports their own personal interests, hobbies, travel plans or family needs. From juggling daycare demands to backpacking through Europe for an extended period to escaping the Canadian winters to spend a few months somewhere warmer – some nurses are looking for flexibility in scheduling that had not been previously available in the provincial health system. Others are also interested in gaining diverse experiences and love working across different sites, meeting new people, travelling across the province to either small communities close to home or remote fly-in only communities or working at busy high-acuity tertiary care sites and supporting areas with the greatest need. Collaboration with the Manitoba Nurses Union was key to further flushing out what that flexible staffing could look like as the terms were further refined in the collective agreement to match the need. What is clear is that there is no one-size-fits-all approach when supporting the unique requirements of a diverse workforce and a healthcare system that needs to adapt and shift to meet the ever-evolving requirements.

Planning

Several groups needed to come together to ensure that the many different perspectives, considerations and systems could support a program that crossed the boundaries of all health authorities in Manitoba, bridging systems that had historically functioned in silos. A steering committee was stood up to lead this initiative, with representation from the provincial chief nursing officer, human resources, provincial labour relations, senior supplier and digital lead, change management lead and a project manager.

The Manitoba Nurses Union was a key partner in launching this program, and securing a collective agreement for the PTNT that both the employers and the union would support became an important focus in bargaining. Nurses are hired into the Shared Health provincial health authority and, while working shifts in the PTNT, would receive incentive pay at sites not identified as their “home” sites; per diems; accommodations; mileage; flexible scheduling; and support for orientation, education and professional development.

Early on, the steering committee also partnered with the George and Fay Yee Centre for Healthcare Innovation to develop a comprehensive evaluation platform. The goal was to learn about the implementation successes and challenges of the PTNT initiative, including staff, patient and health system level impacts. This mixed-methods evaluation collecting both quantitative and qualitative data includes interviews, focus groups, surveys, observation and analysis of administrative data at three different points in time over the first two years following implementation and is currently in progress.

Due to the pressing staffing needs, there was much pressure to launch and hopeful anticipation that this initiative would provide some relief to a challenged staffing situation provincially. Once preliminary administrative personnel were in place, there were site visits done throughout the province to start to raise awareness and spread the word on the launch of this new initiative providing an opportunity to dialogue, answer questions and flag items for further discussion. The steering committee's initial planning was complete; so, instead, an implementation committee was formed with provincial representatives from nursing, human resources, finance and communications along with representatives from each health authority. The committee was tasked with implementing, supporting and carrying out ongoing assessment of the PTNT, including the systems and processes required to support the new structure, recruitment strategy, staffing prioritization framework and areas for improvement. It was important that throughout all stages of planning and implementation, all health authorities throughout the province had a voice in steering this program.

Implementation

The response to the job posting was overwhelming and positive. It brought a lot of initial relief and excitement that there was interest in this program, but with its early success, other challenges emerged. Proof of concept was quickly established and the small team was immersed in the complexities of scheduling across multiple systems with unique scheduling processes and timelines, working across health authorities while trying to keep up with the high demand of applicants and site launches. It was important that the team met regularly and frequently to continue to build the program and necessary processes and supports.

After only a few months, it was identified that a memorandum of agreement with the Manitoba Nurses Union was needed in order to outline and agree upon further details on operationalizing and managing this new program. There were complexities around nurses who might hold a position in the health system, as well as a position with the PTNT related to sorting out benefit accruals, concurrent employment and incentives around home and away language. Prioritization of allocation of shifts between site nurses and PTNT was also important to clarify early for both nurses and employers. There were also unique considerations around calculating travel time, modes of travel, mileage and per diems. It was a great example of collaboration and partnership with open discussions as the parties came together with the same goals in mind.

The PTNT continued to grow in a strategic and staged fashion, building capacity and processes with each launch. Due to its rapid growth, an analogy commonly used was “building the plane while flying it.” A PTNT toolkit was created to provide information and guidance to sites, including site launch checklists, site versus PTNT manager responsibilities and other general standard operating procedures. There were also many sites requesting PTNT support, so a prioritization matrix was created to objectively score and assess staffing levels, occupancy, risk of service disruption, transport and remote considerations and impacts to the provincial health system. This matrix is what guides site launches as well as ongoing site support and highlights the PTNT's unique model of directing staffing resources based on preferences of the nurse and prioritization of resources for sites with the greatest need based on objective measurements of provincial health system impacts.

Evaluation

After a year and a half, the PTNT consists of 175 nurses and has had over 700 applicants. Seventy per cent of the nurses hired were previously working with a nursing agency. The PTNT currently supports over 32 diverse sites, including medicine, emergency, dialysis, surgery, operating room, obstetrics, community and long-term care sites, and is growing across Manitoba. There has been a steady increase in the number of shifts filled throughout the province each month. Growth has largely been managed in a strategic and staged way in order to ensure that proper agreements and processes are in place to support both nurses and sites as well as build capacity within this small team. As the program has grown so quickly and has been extremely successful with recruitment, there is a recognition that to ensure the ongoing success of the program, there need to be concentrated efforts and resources directed to support retention of nurses. In April 2024, the Manitoba government announced an investment with the necessary resources and supports for recruitment and retention to continue to expand this program for up to 400 nurses.

The initial evaluation provided important key insights into initial successes and challenges. Nurses reported that they had joined the PTNT to travel and gain experience in different sites and with different teams; for benefits, including pay, sick time and pension contributions; for union membership; and for flexibility. Challenges were flagged by nurses related to complexities and timelines in onboarding, scheduling, payroll and expense claim processes particularly when compared with agencies.

Sites reported that PTNT nurses were more accountable for the level of care they provided and reliable (e.g., not cancelling shifts at the last minute) compared with agency staff as they are part of the public healthcare system and employed by Shared Health. Sites also reported that it has taken longer than expected to implement the PTNT across all health authorities and not all sites are currently able to access PTNT nurses. They were hopeful about the PTNT's potential to address shortages and move nurses into the public healthcare system, thereby increasing accountability of travel nurses.

Discussion

There were several key enablers that have contributed to the early success of the PTNT. Partnerships and support across health authorities were integral to ensure that all perspectives were considered. These included nursing as well as operations, human resources, digital systems, finance and communications. These partnerships helped navigate the complexities of building a program across health authorities with many different teams and systems that have historically been structured and functioned in silos.

As with many new initiatives, strong and engaged leadership was absolutely essential to provide the oversight needed to develop this program. The PTNT leadership team truly embodied the LEADS in a Caring Environment capabilities framework (Dickson and Tholl 2020). They showed great character, resilience and creativity when navigating challenges; advocated for and fostered the development of nurses; demonstrated a commitment to customer service and built relationships with sites; and encouraged and supported innovation. Their continued commitment to this program and to thinking strategically for the future was integral to the results achieved.

Encouraging and creating space for feedback from front-line nurses as well as the leads at the sites also allowed for the ability to adapt when needed to ensure that the right processes and supports are in place. Collaboration and ongoing open dialogue with the nursing union was also key to working through solutions and coming to agreements that would be amenable to both the employer and the union. Taking the time to intentionally work through and talk through the challenges with open dialogue allowed both parties to think creatively in generating ideas to address the unique attributes of this program.

Orientation to and education of clinical areas is not something that is currently standardized provincially within Manitoba. PTNT nurse orientation, education and support have been positively received by both PTNT nurses and receiving sites, particularly in comparison with orientation to and education of agency nurses. The skill set of PTNT nurses is quite varied, which has allowed units delivering a range of clinical services to be supported. This is also an area for planned future development with much opportunity for professional development and standardization of practices across sites and shared learnings that occur when nurses from sites of various acuity levels work and learn together.

As the Manitoba PTNT continues to expand, there are ongoing barriers and challenges related to implementing a program across health authorities with siloed structural, technical and governance systems. Recommendations to teams who may be embarking on this work would be to assess in advance the ability to support a scheduling and hours preparation process, including digital resources across the sites to be implemented. A single provincial payroll and scheduling system with standardized hours preparation processes across all health authorities would greatly reduce the workload of PTNT scheduling and site launching, as well as the risk of errors. This has by far proven to be the largest and most significant challenge in implementing the PTNT in Manitoba to date.

Without attention to retention, education, ongoing communication and support of nurses, the program faces significant risk for continued success in supporting a large number of staff who are geographically distributed throughout the entire province. This has been a main driver in controlling the growth of the program and staging the increase in hiring to ensure that there is operational capacity and processes to support nurses who are geographically spread throughout the province. It is not easy to slow growth when sites are asking for help and there is a steady stream of applicants, but applying due process to evaluate applicants and ensure that supports are in place will set the program, sites and nurses up for success; promote high-quality care; and support nurses to be engaged in their work as they experience many different sites and opportunities within the province.

Conclusion

It is exciting to hear about the work underway throughout the country, listening to the voices of nurses and working together to build stronger and sustainable healthcare staffing models. Navigating the current and upcoming challenges requires a multi-pronged approach, collaboration and open dialogue incorporating different perspectives and an ongoing commitment to evaluate, adapt and improve. The PTNT was one of Manitoba leaders' solutions to address the limited resources and the desire to retain nurses in the public health system. The PTNT's early success has demonstrated that this model can supplement current site staffing models and provide a unique alternative to agency nursing staffing. The PTNT model reinvests the dollars that we are currently spending on agency nurses into employees of the public system who will be supported and accountable in directing resources where they are most needed. In order to continue to build and expand the program, the PTNT team recognizes that they must focus on all eight themes outlined in Canada's Nursing Retention Toolkit (Health Canada 2024) that impact a nurses' day-to-day working life and continue to listen, evaluate and adapt. There have been challenges along the way; however, the vision of flexible nursing opportunities, rewarding work and excellence in nursing – working together to make a positive difference in healthcare for Manitobans – is something the PTNT team is excited to be championing. Hearing the stories of impact and continuing to get to know and work with nurses across the province is energizing and helps to create momentum to advance this great work.

Correspondence may be directed to Nicole Sneath by e-mail at nsneath@sharedhealthmb.ca

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