nursing education in canada: historical review and current capacity

Nursing Education in Canada: Historical Review and Current Capacity

This report is part of an overall project entitled Building the Future: An integrated strategy for nursing human resources in Canada.

Nursing Education in Canada: Historical Review and Current Capacity © 2004 The work in this publication was provided to The Nursing Sector Study Corporation courtesy of/or under licence from the respective authors.

Publisher The Nursing Sector Study Corporation

Authors Dorothy Pringle PhD, MS, BScN Linda Green EdD (c), MEd, BA Stacey Johnson, BScN

Editor Maude Downey

Designer Maude Downey

Cover Zed Communications

Project The Nursing Sector Study Corporation Management 99 Fifth Avenue, Suite 10 Ottawa, Ontario K1S 5K4

Phone (613) 233-1950 E-mail [email protected] Website www.buildingthefuture.ca

Nursing Education in Canada: Historical Review and Current Capacity (English, PDF) ISBN 0-9734932-8-3

Également disponible en français sous le titre: L'enseignement des soins infirmiers au Canada : historique et capacité actuelle (document en français, PDF). ISBN 0-9734932-9-1

This project is funded in part by the Government of Canada. The opinions and interpretation in this publication are those of the author(s) and do not necessarily reflect those of the Government of Canada.


Table of Contents

Preface.......................................................................................................................................................... v Executive Summary .................................................................................................................................... 1 1. Introduction .......................................................................................................................................... 7 2. Methods ................................................................................................................................................. 8

2.1. Consultations with Stakeholders — History of Nursing .............................................................. 8 2.2. Surveys of Schools of Nursing — Capacity of Schools ............................................................... 9

Table 1. Response Rates for RNs, LPNs, and RPNs ..............................................................................11 2.3. Literature Review — Educational Capacity and Trends ............................................................ 11 2.4. Focus Groups — Under-represented Groups.............................................................................. 12

2.4.1. Target Group ................................................................................................................. 12 2.4.2. Data Collection .............................................................................................................. 12 2.4.3. Recruitment ................................................................................................................... 12 2.4.4. Participants .................................................................................................................... 13 2.4.5. Data Analysis................................................................................................................. 14

3. History of Nursing Education in Canada......................................................................................... 15 3.1. History of RN Education in Canada ........................................................................................... 15

3.1.1. Origins in English and French Canada .......................................................................... 15 3.1.2. University-based nursing education .............................................................................. 15 3.1.3. From Hospitals to Education Sector .............................................................................. 16 3.1.4. The Development of the Entry to Practice Initiative ..................................................... 17

3.1.4.a. British Columbia............................................................................................... 17 3.1.4.b. New Brunswick ................................................................................................ 20 3.1.4.c. Prince Edward Island ........................................................................................ 21 3.1.4.d. Ontario .............................................................................................................. 22 3.1.4.e. Quebec .............................................................................................................. 23 3.1.4.f. Other Provinces/territories ................................................................................ 23

3.2. History of LPN Education in Canada ......................................................................................... 24 3.2.1. Phase 1: The Establishment of Educational Programs .................................................. 24 3.2.2. Phase 2: The Evolution of Educational Programs ......................................................... 27 3.2.3. Phase 3: Expansion of Practical Nurses’ Scope of Practice (1990 and onward) ........... 28

3.3. History of RPN Education in Canada......................................................................................... 31 3.3.1. The Pre-nursing Phase, 1886–1920 ............................................................................... 31 3.3.2. The Developmental Phase, 1920–1960 ......................................................................... 32 3.3.3. The Transition Phase, 1960–2000 ................................................................................. 33 3.3.4. The Educational Options Phase, 2000 ........................................................................... 35

4. Nursing Education in Canada and Key Source Countries ............................................................. 39 Table 2. Overview of RN Programs, in Canada and Source Countries.................................................40 Table 3. Overview of LPN Programs, in Canada and Source Countries...............................................41 Table 4. Overview of RPN Programs, in Canada and Source Countries ..............................................41

5. RN Education and Capacity — Survey Findings ............................................................................ 42 Table 5. Regional Response Rates to Survey Questionnaire, RNs.........................................................42

5.1. Types of Programs That Prepare RNs ........................................................................................ 42 5.2. Student Admission and Enrolment, RNs .................................................................................... 43

5.2.1. Admissions, 2002, 2003 ................................................................................................ 43 5.2.2. Gender Profile of Admitted Students ............................................................................ 44 5.2.3. Admission Targets......................................................................................................... 44 Table 6. Admission Targets and Success in Meeting Them, 2001–2003, RNs .......................................44

Building the Future: An integrated strategy for nursing human resources Page i


5.2.4. Enrolment Targets ......................................................................................................... 44 Table 7. Total Full-time Students Enrolments Across all Program Years, RNs ....................................45 Table 8. Total Part-time Student Enrolments Across All Years, RNs ....................................................45 5.2.5. Aboriginal Students ....................................................................................................... 45 5.2.6. Retention Rates.............................................................................................................. 46 Table 9. Retention Rates for Classes Entering in 1998 and 1999, RNs .................................................46

5.3. Resources to Maintain or Increase Enrolment, RNs................................................................... 46 Table 10. Capacity of Schools to Maintain Current Enrolment, RNs......................................................47 Table 11. Capacity of Schools to Increase Enrolment by 10%, RNs .......................................................49 Table 12. Capacity of Schools to Increase Enrolment by 25%, RNs .......................................................50 Table 13. Capacity of Schools to Increase Enrolment by 50%, RNs .......................................................51 Table 14. Capacity of Schools to Increase Enrolment by 100%, RNs .....................................................52 5.3.1. Summary of Capacity to Increase Enrolments .............................................................. 53 Table 15. Summary of Capacity of Schools to Expand by 10%–100%....................................................53 5.3.2. Preferred Number of Students ....................................................................................... 53

5.4. Faculty Recruitment, RNs .......................................................................................................... 54 Table 16. Number and Type of Faculty Positions Available in 2003.......................................................54 5.4.1. Full-time Tenure Stream/Permanent Positions.............................................................. 54 5.4.2. Full-time Contract Positions.......................................................................................... 55 5.4.3. Part-time Contractual Positions ..................................................................................... 55

5.5. Clinical Training Capacity of RN Schools ................................................................................. 57 Table 17. Competition for Clinical Placements Faced by RN Schools....................................................57 Table 18. Models of Clinical Practice in Each Year of RN Programs.....................................................58 Table 19. Reasons for Choice of Model of Clinical Practice...................................................................59 Table 20. Timeframes Used for Clinical Practice, RNs...........................................................................59 5.5.1. Dependency on Preceptors, and Availability, RNs ....................................................... 59 Table 21. Dependency on Preceptors in Community Agencies................................................................60 Table 22. Availability of Preceptors in Community Agencies..................................................................60 Table 23. Dependency on Preceptors in Acute Care Settings, RNs .........................................................60 Table 24. Availability of Preceptors in Acute Care Settings....................................................................61 Table 25. Incentives Offered to Preceptors..............................................................................................61

6. RN Education and Capacity — Discussion ...................................................................................... 62 6.1. Educational Sector Capacity, RNs.............................................................................................. 62

6.1.1. Admissions and Trends in Admissions.......................................................................... 62 Table 26. Admissions to Diploma and Baccalaureate Programs 1997–2001 .........................................62 Table 27. Enrolment in Diploma and Baccalaureate Schools of Nursing 1997–2001 ............................63 6.1.2. Retention Rate ............................................................................................................... 63 6.1.3. Resources to Support Capacity...................................................................................... 65

6.1.3.a. Availability of Teachers.................................................................................... 65 6.1.4. Capacity to Increase Enrolment..................................................................................... 67 6.1.5. Enrolment of Aboriginal Students ................................................................................. 67

6.2. Clinical Training Capacity and Models ...................................................................................... 68 6.2.1. Models of Clinical Practice ........................................................................................... 69 6.2.2. Dependence on and Availability of Preceptors ............................................................. 69

7. LPN Education and Capacity — Survey Findings .......................................................................... 71 Table 28. Regional Response Rates to Survey Questionnaire, LPNs.......................................................71

7.1. Types of Programs That Prepare LPNs ...................................................................................... 71 Table 29. Number of Sites per Program, LPNs .......................................................................................72 Table 30. Capacity at Permanent & Temporary Sites .............................................................................72 Table 31. Hours of Theory and Practice in LPN Programs ....................................................................73 7.1.1. Number of Classes Admitted per Year .......................................................................... 73 7.1.2. Maintenance of Waiting Lists........................................................................................ 73

7.2. Student Admission and Enrolment, LPNs .................................................................................. 74

Building the Future: An integrated strategy for nursing human resources Page ii


7.2.1. Admissions, 2002, 2003 ................................................................................................ 74 7.2.2. Gender Profile of Admitted Students ............................................................................ 74 7.2.3. Admission Targets......................................................................................................... 74 Table 32. Admission Targets and Success in Meeting Them, 2001–2003, LPNs.....................................75 7.2.4. Enrolment Targets ......................................................................................................... 75 Table 33. Total Enrolment in October 2003 ............................................................................................75 7.2.5. Aboriginal Students ....................................................................................................... 76 7.2.6. Retention Rates.............................................................................................................. 76 Table 34. Retention Rates for Classes Entering 1999–2002, LPNs.........................................................76

7.3. Resources to Maintain or Increase Enrolment, LPNs................................................................. 77 Table 35. Capacity of Schools to Maintain Current Enrolment, LPNs....................................................77 Table 36. Capacity of Schools to Increase Enrolment by 10%, LPNs .....................................................78 Table 37. Capacity of Schools to Increase Enrolment by 25%, LPNs .....................................................79 Table 38. Capacity of Schools to Increase Enrolment by 50%, LPNs .....................................................80 Table 39. Capacity of Schools to Increase Enrolment by 100%, LPNs ...................................................81 7.3.1. Summary of Capacity to Increase Enrolments .............................................................. 81 7.3.2. Preferred Number of Students ....................................................................................... 82

7.4. Faculty Recruitment, LPNs ........................................................................................................ 82 Table 40. Number and Types of Positions Available in Schools, 2003....................................................83 7.4.1. Full-time Tenure Stream/Permanent Positions.............................................................. 83 7.4.2. Full-time Contract Positions.......................................................................................... 83 7.4.3. Part-time Contractual Positions ..................................................................................... 84

7.5. Clinical Training Capacity of LPN Schools ............................................................................... 85 Table 41. Competition for Clinical Placements Faced by LPN Schools..................................................85 Table 42. Models of Clinical Practice in Each Year of LPN Programs ..................................................86 Table 43. Reasons for Choice of Model of Clinical Practice...................................................................86 Table 44. Timeframes Used for Clinical Practice ...................................................................................86 7.5.1. Dependency on Preceptors, and Availability, LPNs ..................................................... 86 Table 45. Dependency on Preceptors in Community Agencies................................................................87 Table 46. Availability of Preceptors in Community Agencies..................................................................87 Table 47. Dependency on Preceptors in Acute Care Settings, LPNs.......................................................87 Table 48. Availability of Preceptors in Acute Care Settings, LPNs.........................................................87 Table 49. Incentives Offered to Preceptors..............................................................................................88

8. LPN Education and Capacity — Discussion.................................................................................... 89 8.1. Organization of Practical Nurse Education in Canada ............................................................... 89 8.2. Education Sector Capacity, LPNs............................................................................................... 89

8.2.1. Admissions and Trends in Admissions.......................................................................... 89 8.2.2. Retention Rate ............................................................................................................... 90 8.2.3. Resources to Support Capacity...................................................................................... 91

8.2.3.a. Availability of Teachers.................................................................................... 92 8.2.4. Expanding Admissions Given Available Resources ..................................................... 92 8.2.5. Enrolment of Aboriginal Students ................................................................................. 93

8.3. Clinical Training Capacity and Models ...................................................................................... 93 8.3.1. Models of Clinical Practice ........................................................................................... 93 8.3.2. Dependence on and Availability of Preceptors ............................................................. 94

9. Under-represented Populations in Nursing ..................................................................................... 95 9.1. Previous Relevant Canadian Research ....................................................................................... 95 9.2. Current Focus Group Findings ...................................................................................................96

9.2.1. Key Sources of Information and Influence.................................................................... 97 9.2.1.a. Nurses Participants Know................................................................................. 97 9.2.1.b. Social Context — Racism, Cultural Issues, Stereotypes .................................. 97 9.2.1.c. Outreach............................................................................................................ 98

Building the Future: An integrated strategy for nursing human resources Page iii


9.2.1.d. Personal Experience, Media reports ................................................................. 99 9.2.2. Perceptions of Nursing as a Career.............................................................................. 100

9.2.2.a. Diversity of Nursing Profession and Practice Settings ................................... 100 9.2.2.b. Work Conditions — Effects on Personal Lifestyle ........................................ 101 9.2.2.c. Professional Status, Treatment and Recognition ............................................ 102 9.2.2.d. Salary, Job Security, and Upward Mobility.................................................... 103 9.2.2.e. Independence, Freedom to Take Initiative...................................................... 104

9.2.3. Educational Factors ..................................................................................................... 104 9.2.3.a. Educational Requirements .............................................................................. 104 9.2.3.b. Costs, Funding, Scholarships.......................................................................... 104 9.2.3.c. Location of Schools ........................................................................................ 105 9.2.3.d. Cultural Sensitivity and Relevance — Language, Type of Medicine ............ 106 9.2.3.e. Role Models, Mentoring ................................................................................. 107

10. Conclusions ....................................................................................................................................... 108 10.1. LPN, RN and RPN Education in Canada ................................................................................. 108 10.2. Educational and Clinical Capacity of Schools to Prepare RNs ................................................ 108 10.3. Educational and Clinical Capacity of Schools to LPNs ........................................................... 109 10.4. Under-represented Groups in Nursing...................................................................................... 110

11. Recommendations ............................................................................................................................ 112 REFERENCES........................................................................................................................................ 115 Appendix A. Acronyms ........................................................................................................................... 120 Appendix B. Nursing Associations ......................................................................................................... 121 Appendix C. Glossary of Key Terms ...................................................................................................... 122 Appendix D. Key to Geographical Names and Acronyms ...................................................................... 124

Building the Future: An integrated strategy for nursing human resources Page iv


Preface

This report is part of an overall project, Building the Future: An integrated strategy for nursing human resources in Canada. The goal of the project is to create an informed, long-term strategy to ensure that there is an adequate supply of skilled and knowledgeable nurses to meet the evolving health care needs of all Canadians. Through surveys, interviews, literature reviews, and other research, Building the Future will provide the first comprehensive report on the state of nursing human resources in Canada. The project comprises the following two phases.

Phase I: Research about the nursing labour market in Canada is being conducted in stages. Reports will be released as the research work is completed to share interim findings and recommendations with the nursing sector. A final report will be produced at the conclusion of this phase that will include all of the recommendations accepted by the Nursing Sector Study Corporation.

Phase II: A national strategy will be developed in consultation with government and non-government stakeholders that builds on the findings and recommendations presented at the completion of Phase I.

To oversee such a complex project, the Nursing Sector Study Corporation (NSSC) was created in 2001. The Management Committee of NSSC comprises representatives of the signatories to the contribution agreement with the Government of Canada and other government groups.

The multi-stakeholder Steering Committee for the project comprises approximately 30 representatives from the three regulated nursing occupations (licensed practical nurse, registered psychiatric nurse, and registered nurse), private and public employers, unions, educators, health researchers, and federal, provincial and territorial governments. The Steering Committee guides the study components and approves study deliverables including all reports and recommendations.

Members of the Management Committee and the Steering Committee represent the following organizations and sectors. Aboriginal Nurses Association of Canada Association of Canadian Community Colleges Canadian Alliance of Community Health Centre

Associations Canadian Association for Community Care Canadian Association of Schools of Nursing Canadian Federation of Nurses Unions Canadian Healthcare Association Canadian Home Care Association Canadian Institute for Health Information Canadian Nurses Association Canadian Practical Nurses Association Canadian Union of Public Employees Health Canada

Human Resources and Skills Development Canada National Union of Public and General Employees Nurse educators from various institutions Ordre des infirmières et infirmiers auxiliaires du

Québec Ordre des infirmières et infirmiers du Québec Professional Institute of the Public Service of Canada Registered Psychiatric Nurses of Canada Representatives of provincial and territorial

governments Service Employees International Union Task Force Two: A human resource strategy for

physicians in Canada Victorian Order of Nurses Canada

Together, we are committed to building a better future for all nurses in Canada and a better health system for all Canadians

Building the Future: An integrated strategy for nursing human resources Page v


Executive Summary

This report describes the historical context of nursing education in Canada. This provides a background to the descriptions of current educational programs — their current enrolments, future enrolment plans, resources available, constraints on resources, and access to clinical placements and teachers. It also includes qualitative findings from focus groups that shed light on why Aboriginals, Black Canadians, and men are so under-represented in nursing.

Research Design & Methods

Several research methods were used to generate the information required to answer the research questions. A descriptive survey design was used to collect information from schools of nursing in Canada that prepare RNs, LPNs, and RPNs about their current and future plans for capacity. Ethical approval for the study was received from the University of Toronto. Questionnaires in French or English were sent to all schools of nursing that participate in the education of nurses. Reminder postcards, e-mail messages, and direct appeals by professional organizations that relate to the schools of nursing were used to encourage schools to respond. Response rates of 40% for LPN schools and 57% for RN schools were achieved. Only one of three RPN schools responded. As a result, there is no report for RPN education. Data were entered on SPSS (Statistical Package for the Social Sciences) files and analyzed.

In addition, searches were made of published literature, of unpublished documents, and of Web sites to assemble the information required to describe the historical context of the nursing education programs that are in place today. Interviews were conducted with key informants who had direct experience of critical events and activities that shaped contemporary nursing education. To answer questions about why certain groups were under-represented in nursing education programs — specifically Aboriginal people, men and Black Canadians — following ethical approval from the University of Toronto, focus groups were held with members of these three groups in Toronto, Prince Albert (Saskatchewan. Individuals who were college and university students but not studying nursing were recruited to participate; the tapes of the focus groups were transcribed and analyzed for themes that explain why members of these groups do not pursue nursing as a career.

Findings: Schools That Prepare Registered Nurses (RNs)

Responses were received from 57% of schools that participate in the education of registered nurses (RNs). The lowest provincial/territorial response rate was from schools in Quebec. The majority of schools indicated that they had increased their enrolment from 2002 to 2003, and 70% either met or exceeded their enrolment targets. However, 70% do not plan to expand their admissions in 2004, 17% do plan to expand and 13% plan to decrease the number of students they admit. A total of 20,634 full-time students were enrolled in the participating schools. Men comprise 9% of the enrolled students. Only 20% of schools have designated seats for Aboriginal students or specific strategies to try to recruit these students. Despite this, 39% of schools reported having a total of 433 self-identified Aboriginal students enrolled in 2003. Retention rates vary widely (from 33 to 100%) but the average retention rate across all schools was 67% of students admitted in 1998, and 61% of those admitted in 1999. Half the schools had retention rates of 74% or higher for both years of interest. Baccalaureate programs have had a higher retention rate than diploma programs.

Five resource areas were examined: faculty, students, clinical placements, space, and administrative support. Currently 60% of schools report having insufficient faculty and clinical

Building the Future: An integrated strategy for nursing human resources Page 1


placements, 70% have inadequate financial support for students, and 40–50% have inadequate space. Up to 20% of schools cannot increase their enrolments by even 10% because they have no ability to access the resources they require, particularly clinical teachers. However, up to 80% could increase by 10% if provided with additional financial resources; 50–65% could increase by 25%, about a third could expand by 50%, and 20% could double the number of students they admit, if they had the financial resources available to them. The resources in shortest supply, and which constrain the ability to expand, are clinical placements in the community and acute care hospitals, full-time faculty members, and clinical teachers.

Schools sought to recruit 176 faculty members prepared at either the master’s or doctoral level to fill tenure stream/permanent positions. They were able to fill 125 of these positions, frequently with individuals in the process of acquiring graduate degrees but not completed, or with the intention to begin studies. Schools were able to fill their 264 full-time contract positions with individuals who were master’s prepared, or who were working towards one, and almost all of the 1,294 part-time contract positions with baccalaureate and master’s prepared individuals. Sixty-one percent had some difficulty and 21% had a great deal of difficulty accomplishing this. All specialty areas were in short supply.

Only 10% of schools do not compete with other health science programs for clinical placements, and the rest compete with between 1 and 8 other programs. Most of the schools find the majority of placements to be student-friendly. Schools used a distributed model of clinical placements (a combination of classes and clinical experiences) each week in years one and two, with a mix of distributed and block placements becoming more frequent in the upper years, particularly year four. Eight-five percent of schools are dependent on clinical preceptors for community and acute care in their senior years, and one third find there are insufficient numbers available to them. Schools generally offer non-monetary incentives to preceptors to recognize their contributions.

Findings: Schools That Prepare Licensed Practical Nurses (LPNs)

Forty percent of schools of nursing that prepare LPNs responded to the survey; the lowest response rates were from Quebec and the Atlantic Provinces. All 37 participating schools are publicly funded, with 59% having permanent funding, 13% contract and 7% funding from brokered programs. The majority of schools (57%) offered their programs on one site only, but the rest offered them on 2–12 sites. There was a wide range of hours of theory and clinical practice across the programs, but most schools provided between 700 and 1,000 hours of theory and laboratory practice and between 800 and 1,100 hours of clinical practice. About 70% of schools maintain waiting lists of students who apply but are not admitted to the class they apply to. These waiting lists range from a few weeks to several years. Enrolments ranged from 12 to 734 students, but the majority of schools had fewer than 100 students enrolled. Total enrolments for the most recent year were 3,947 full-time students and 1,003 part-time students. During the period 1999–2003, 50% of schools increased their admissions, 6% decreased them, and 12% remained the same. Over these same years, between 47% and 63% of schools met or exceeded their admission targets, and about one third of schools were below their targets each year, but only by a few students. The majority of schools do not plan to increase their admissions in 2004. Twelve percent of enrolled students were men. Twenty-two percent of schools reserved seats for Aboriginal students, and 14 schools reported a total enrolment of 149 self-identified Aboriginal students. The average retention rate for 1999–2002 was highly consistent at around 70%, with the median rates being 70–77%.

Schools were asked about the adequacy of their resources in five areas: faculty, students, clinical placements, space, and administrative support. The areas of greatest shortage are clinical placements in acute care, clinical teachers, and laboratory and classroom space. Half the schools reported that their



current resources are adequate for the number of students they enroll; 50% have inadequate clinical placements and clinical teachers available, although they are adequately resourced in other areas. Half the schools could increase their enrolments by 10% with their current resources; with additional financial resources, 50% of schools could increase by 25%, 40% could increase by 50%, and 33% could double their enrolments.

The participating schools were able to fill their faculty vacancies in 2003. These consisted of 39 permanent positions, 102 full-time contract positions, and 185 part-time contract positions. Sixty-five percent of schools were able to fill these positions with little difficulty. The preferred credential for most of these positions was a baccalaureate degree in nursing.

Only 8% of schools did not compete with other health science programs for clinical space: 76% competed with programs that prepare RNs and 38% competed with other LPN programs. Half the schools reported that the majority of places that provided clinical experience for their students were student-friendly.

Half the schools use block placement for students in the first year of the program, and 29% used a mix of block and distributed placements. Block involves having the students spend blocks of time in practice and then blocks of time in classes. Distributed means having students combine classes and clinical practice periods each week. The reasons these models are used is because the schools believe such models are academically superior (50%) and that they maximize the use of clinical resources (65%). Only half the schools use preceptors, and half of these schools are not able to find the number of preceptors they require. They reward preceptors with plaques and receptions.

Findings: Under-represented Groups in Nursing

Six focus groups were held with university and college students who were Aboriginal, Black Canadians, or men pursuing non-nursing careers. They reported that, for them, nursing consisted of dealing with blood, needles, dying people, and mess. Nurses were invisible on the health care team, endured poor working conditions, were abused by patients, took orders from doctors, were subservient, and lacked job security. The Aboriginal students gained most of their impressions from nurses who worked on reserves where they grew up, and they did not believe that nurses were respectful of their people. Black students had family members who were nurses, or family members of friends who were nurses, and they saw these “women” as overworked and trapped in exhausting jobs. These students had little to no sense that there were three different professions within nursing or what the career opportunities were within nursing. Both Black Canadian and Aboriginal students reported that their families would not find nursing as an acceptable career for them because there are not enough opportunities to justify the investments they would have to make in their children’s future.

Aboriginal students recommended that nursing provide opportunities for members of their communities to blend traditional healing and medicines with western medicine in nursing programs. They believed that members of their communities needed opportunities to change nursing, and, in the course of doing that, could give something back to their community. This desire to give something back was also strongly felt by Black students who saw nursing as a career that would allow them to do that. Both Black and Aboriginal students identified racism as a problem in nursing, which was manifest by a lack of members of their communities in senior management positions. Role models are important for all three groups as a way of attracting members of their communities to nursing. These role models should visit students in elementary schools and high schools and in the first year of college and university programs in



order to recruit them into nursing. For young men, the words nursing and nurse are problematic because they convey such overwhelmingly female images.

Recommendations

1. One of the major constraints on the expansion of programs to prepare RNs is the availability of faculty members with master’s and doctoral preparation. Therefore, it is recommended that enrolments in graduate programs be expanded immediately. Special initiatives to make it financially possible for students to study full-time are needed. As a model for achieving this goal, nursing traineeships awarded to students by the U.S. federal government should be explored; this was started in the 1960s to address a shortage of master’s prepared nurses. The expansion of doctoral programs requires the availability of more doctoral and post-doctoral fellowships funded at levels that make full-time study realistic for nurses.

2. Clinical education of students is a critical component of nursing education and yet it is difficult to identify “best practices” in clinical nursing education. Expansion of both LPN and RN programs is constrained by perceived limits in the capacity of acute care and community practice environments to absorb more students. Therefore, it is recommended that an immediate study be undertaken of how to maximize current clinical resources. Secondly, it is unlikely that all of the clinical practice needs for the current level of enrolment, let alone an expanded one, can be met within the available practice environments. Therefore, it is recommended that funds be made available to all schools of nursing to introduce or expand the simulation opportunities available to their students; this would help to conserve the clinical practice opportunities for those activities and processes that cannot be learned through simulation alone. As well, consideration should be given to establishing some central simulation laboratories that could be used by several schools of nursing, and potentially by other health science disciplines, for their training needs.

3. Half the schools of nursing that prepare LPNs, and 60% of those that prepare RNs, describe themselves as highly stressed and having difficulty managing the numbers of students they have with the resources available to them. Nursing education has never been adequately costed. It is recommended that a study to cost nursing education be undertaken immediately in preparation for an expansion of enrolments so these expansions are adequately funded and current levels of funding adjusted.

4. More than 80% of schools of nursing can manage some degree of expansion in enrolment, and a few of them can expand considerably if they have adequate financial resources to support the increased numbers involved. It is recommended that a national strategy be developed for expanding enrolments in schools of nursing. In collaboration with the provinces, the strategy should address the additional numbers of graduates needed per province to meet the nursing workforce needs, the enrolment increases required to meet these graduation targets, the identification of schools with the potential to expand, and the financial costs of doing so (including the costs of developing simulation laboratories).

5. Retention rates are too low in many LPN and RN schools of nursing. This comes with a high cost to students, and it is an enormous waste of students’ potential and of faculty resources. Importantly, some schools of nursing have excellent retention rates. It is recommended that target retention



rates of 90% be established for schools of nursing, while acknowledging there are year-to-year fluctuations. A great deal is known about how to increase retention: admit students with appropriate academic backgrounds; portray nursing realistically in recruitment activities; once students are admitted, assist them to develop strategies to cope with the current upheavals in nursing and more generally in the health care system; aggressively support students, particularly those entering with grades lower than the class average; and make it clear to students how and where they can seek assistance. This information should be incorporated into retention strategies established within every school.

6. There are too few Aboriginal people and men in nursing schools. Additionally, although not supported by statistics, there is a perception that nursing is recruiting too few Black Canadians into its ranks. Several studies have been undertaken that provide direction for increased recruitment and retention of members of these under-represented groups. It is recommended that specific recruitment initiatives be developed by schools of nursing to attract Aboriginal students based on recommendations identified in Against the Odds (National Task Force on Recruitment and Retention Strategies [NTFRRS], 2002) and by replicating the activities undertaken by several schools in Western Canada that have been successful in both recruiting and retaining Aboriginal students. Similarly, recommendations in the report Men in Nursing (Hanvey, 2004) should be followed to attract and retain men.

i) The participants in the focus group study conducted as part of this project added new perspectives and ideas about how to recruit students from the three populations of interest. There is a need to make the view of nursing and nurses held by university and college students, their families, and perhaps the public at large more positive. This means a public relations campaign that is beyond the scope of any one school of nursing. Health Canada, professional nursing associations and provincial/territorial health ministries should combine efforts to position nursing in a positive light. This includes correcting the view that nursing is only about blood, needles, death, and mess, that nurse are invisible members of the health care team, that nursing is not a prestigious career, and that nurses’ working conditions are uniformly negative. The opportunities to give back to Aboriginal and Black communities through nursing are important messages for potential students from those communities. Emphasizing the career opportunities in nursing is needed, including the opportunities in management and teaching and the salaries available for these positions. The issue of racism in nursing cannot be ignored because of its impact on recruitment. The quote from a young person in a focus group involving Black students, “It gets more diverse as you go lower” is an indictment of nursing’s openness to people of all races, particularly among the registered nurse and registered psychiatric nurse professions.

ii) It is important that practising nurses be made aware of the impact of their behaviour and attitudes on Aboriginal and Black communities (and, frankly, on all communities). Every nurse is potentially a role model and the impression that each nurse makes on the people she/he cares for can be profound. This is particularly true in Aboriginal communities where the need to portray nursing as a desirable career to young Aboriginal people is crucial. Individual nurses may be the most important and influential tool in this recruitment strategy.

iii) The recommendation from men that the nursing consider changing the name of practitioners cannot be dismissed. Nurse and nursing are intrinsically female names and it is difficult for



most men to embrace them and identify with them. Perhaps it is time to take this recommendation seriously.

iv) Finally, carefully designed recruitment initiatives are needed to present career opportunities (not job opportunities) in nursing to students from these three under-represented groups — at the elementary level, in Grade 9, and to students in first year of university and college; these are critical years in which career decisions are made. Sending nurses from these three groups to recruit in schools is crucial to the success of these recruitment efforts.

7. There is a need for greater communication, and potentially collaboration, across the educational sectors of the three nursing professions. At this time, there are no ongoing mechanisms in place to allow this communication to occur. Therefore, it is recommended that a mechanism, such as a council, be established, with representatives from all three nursing professions, with the objectives of enhancing communication among the three professions, planning for intra-disciplinary collaboration, and presenting a coherent, collaborative and mutually respectful face of nursing education in Canada.



1. Introduction

This report focuses on the education of members of the three regulated nursing professions: registered nurses, licensed/registered practical nurses, and registered psychiatric nurses. It does not include information on the capacity of educational programs to prepare registered psychiatric nurses because only one school responded to the survey. This report is intended to complement the Canadian Nursing Labour Market Synthesis to be presented as part of the overall research for Building the Future.

It begins with a description of the methodology used to gather data for the report. To offer a context for the current findings, the next chapter presents an historical overview of nursing education for each of the three nursing professions. This is followed by a brief overview of nursing education in Canada and key source countries.

The report then moves into a presentation of the findings from the surveys mailed to all nursing schools involved in the preparation of RNs and LPNs (separate chapters), with each chapter followed by a discussion of these findings. The literature review is integrated into these discussions. Chapter 9 presents the findings of focus groups that were held with Aboriginal Canadians, men, and Black Canadians to better understand why members of these three groups are under-represented in nursing.

Finally, the conclusions to be drawn overall from this research are presented. The final chapter then presents the recommendations for action.

For a list of other acronyms used in the report, please see Appendix A. The following acronyms for nurses are used in this report.

RNs registered nurses LPNs licensed/registered practical nurses RPNs registered psychiatric nurses

(Note that although the acronym RPN refers to registered practical nurses in Ontario, Canada, it is not so used in this report. Also, in Canada, RPNs are educated and regulated as a separate profession only in Manitoba, Saskatchewan, Alberta, and British Columbia)



2. Methods

Overall Research Questions. Research questions were formulated to address the objectives of this study.

1. What is the history of the education of LPNs, RNs and RPNs in Canada, including the following?

• provincial/territorial variations across the three nursing groups

• significant decisions in the evolution of education of each group

• factors influencing the educational patterns and decisions

• current patterns and locations of nursing education programs and Canada-wide trends in nursing education

2. What are the international trends in nursing education, including educational preparation to enter the RN, LPN and RPN professions in relevant countries and the location of schools?

3. What is the current capacity of the education sector, the limits of that capacity, factors limiting the capacity, and admission and retention rates?

4. What is the clinical training capacity, models of clinical nursing education, use of preceptors, and limitations in the capacity of preceptors?

5. Why are Aboriginal people, men and Black Canadians not choosing nursing as a career?

2.1. Consultations with Stakeholders — History of Nursing RNs. Dr. Jan Storch provided the background information on the development of collaborative

programs in British Columbia. Dr. Storch was Director of the School of Nursing at the University of Victoria from 1996 to 2001 and continues as a professor. Professor Penny Ericson provided background information on the process used in New Brunswick. Professor Ericson was Dean of Nursing at the University of New Brunswick from 1988 to 1998. She is now professor emeritus and dean emeritus and continues to teach and supervise graduate students. Professor Rivie Seaberg provided the background information on the process in Ontario. Professor Seaberg chaired the Umbrella Working Group for the College of Nurses. She is now Director of the Centre for Nursing at George Brown College in Toronto. Dr. Susan French provided information on the current situation in Quebec. Dr. French is Director of the School of Nursing at McGill University.

LPNs. Professor Rivie Seaberg provided background information on the Ontario process. Professor Seaberg is the Director of the Centre for Nursing at George Brown College in Toronto and chaired the Umbrella Working Group for the College of Nurses of Ontario that oversaw the consultation process for LPN education. Verna Holgate, Executive Director of the College of Licensed Practical Nurses of Manitoba, provided background information on LPNs in Manitoba. This information was taken from the following documents from the Manitoba Association of Licensed Practical Nurses: An Historical Perspective 1946 – 1986 and Educational Enhancement Criteria & Supply/Demand Requirements (August 1995). Patricia Fredrickson, Executive Director/Registrar of the College of Registered Licensed Practical Nurses of Alberta provided information on the development of LPN education in Alberta.



RPNs. The following people provided background information for the historical overview: Annette Osted, Executive Director of the College of Registered Psychiatric Nurses of Manitoba and member of the Board of Directors of Registered Psychiatric Nurses Association of Canada; Dr. Marlene Smadu, Associate Dean of Education (Regina Campus) of the University of Saskatchewan. From 1992 to1994, Dr. Smadu was Assistant Program Head — Curriculum of the SIAST (Saskatchewan Institute of Applied Science and Technology) Wascana Institute nursing program; Professor Diana Davidson Dick, Dean of Nursing at the Saskatchewan Institute of Applied Arts and Technology.

2.2. Surveys of Schools of Nursing — Capacity of Schools Survey methodology using a mailed questionnaire was employed in this study. Ethical approval

was received from the Office of Research Services of the University of Toronto, including approval of an information letter informing the schools of nursing of the context of the study and the protection they had in participating. The participants were not required to sign a consent form, but rather their decision to complete and return a questionnaire conveyed their consent to participate. Anonymity of the participants was one of the conditions of participation.

The purpose of this study was to gain information about the capacity of schools of nursing in Canada that prepare RNs, LPNs, and RPNs, in terms of their current enrolment of students, their plans for future enrolments. and their judgment about the extent of their capacity. As well, information was sought about the resources available to them and the resources they would need to maintain and expand their enrolments. For this type of information, a descriptive survey is an appropriate approach because through it, information about prevalence, distribution and interrelationships of variables can be ascertained (Polit, Beck & Hungler, 2001).

Three different but complementary versions of the questionnaire were developed for each nursing profession based on the objectives of the study. There were many common questions across the three versions of the questionnaire as well as questions specific for each profession, particularly regarding the structure and capacity of the programs. Structuring the questionnaire for RN schools was a particular challenge for two reasons. The education of RNs is in transition in Ontario and the majority of English-language RN programs are members of university/college collaborative programs; thus, the questionnaire had to accommodate these factors.

Pilot Versions. Drafts of these questionnaires were distributed to members of the Steering Committee of the project for their input regarding the clarity, relevance, and comprehensiveness of the questions, given the objectives. They were invited to make revisions and suggest areas that required further questions. In addition, selected school administrators from all three professions were asked to review the questionnaire, complete the questions, and provide feedback as to the clarity of the questions and their format, and to suggest areas and specific questions to fill gaps. The following people provided feedback.

• two administrators of university programs that prepare RNs, from different provinces

• two administrators of community college programs that prepare RNs, from different provinces

• two administrators of college programs that prepare LPNs, from different provinces



• members of the Steering Committee, including an administrator of a college program that prepares LPNs and a teacher in a program for RPNs

Revised versions. The questionnaires were revised on the basis of this feedback; refinement of specific questions continued in collaboration with members of the Steering Committee until acceptable versions were developed. The original intent for RN schools involved in collaborative programs was to send a two-part questionnaire to the credential-granting partner (in all cases, the university partner) and to ask that partner to distribute the first part (which sought information about enrolments, admission rates, retention rates, etc.,) to each college partner and to complete the second part themselves (which sought information about resources on behalf of all partners in the consortium). As a result of feedback from the pilot study, we sent each partner sections one and two and had them respond separately.

Participants. All schools of nursing in Canada were asked to participate. Lists of all schools in Canada that participate in the preparation of RNs, LPNs, and RPNs were compiled from information provided by members of the Steering Committee, the Canadian Nurses Association, and the Ordre d’ Infirmiers/Infirmières Auxiliaire du Québec. Each school received a package containing a cover letter from the co-chairs of the Steering Committee of the project, the information letter approved by the Research Ethics Board, a copy of the version of the questionnaire appropriate for the school, and a stamped and addressed envelope in which to return the completed questionnaire. The questionnaire and covering letters were translated into French, and French-language LPN and RN schools received these versions.

Packages were sent to English-language RN schools in early February 2004 and to French-language RN schools in late February, to English-language LPN and RPN schools in early March, and to French-language LPN schools in late March.

One month after the questionnaires were sent to English-language schools, a reminder postcard to return the questionnaires was sent to all schools that had not responded. Approximately one month after the French-language schools received their questionnaires, a postcard in French and English was sent to all French-language schools that had not responded and also to the non-responders in the English-language schools. Therefore, the English-language schools received two reminder postcards and the French-language schools received one. Since the response rates from the French-language schools were low, e-mails were sent to the directors of all the French-language schools (LPN and RN) repeating the French-language message from the postcard and attaching copies of the questionnaires and the information letter. The Canadian Association of Schools of Nursing (CASN) sent an e-mail message to all of its members encouraging them to respond to the questionnaire; all members of the Steering Committee received an e-mail message asking them to contact schools of nursing in sectors that they represented to encourage them to participate. Finally, individualized e-mail messages (in English) asking that the schools participate were sent to many English- and French-language RN school directors with attached questionnaires and information letters, and to faculty members in the RPN programs that had not responded.

Three data files were constructed, one for each nursing profession (RN, LPN, and RPN). Responses from the completed questionnaires were entered into these data files and analyzed using the SPSS statistical package. Written responses to questions and comments that accompanied answers were recorded in a Word file and analyzed using a qualitative descriptive approach.



Data Quality and Limitations. The following response rates were achieved across the three different types of programs.

Table 1. Response Rates for RNs, LPNs, and RPNs Type of program No. sent No. returned Response rate

RN programs 128 73 57%

LPN programs 93 37 40%

RPN programs 3 1 33%

The response rates were low in all sections. The response rate from RN schools was particularly low in Quebec, at only 37.5%. Outside of Quebec, the overall response rate was 65%. Therefore, caution must be exercised in generalizing about all RN programs but particularly about programs in Quebec. The response rate for LPN programs was also low and again particularly so for Quebec and the Atlantic Provinces, where it was only 26% and 31% respectively. Again, caution must be exercised in generalizing about all LPN programs.

Note: Only one response was received from RPN programs so no report is included in order to protect the anonymity of the one respondent.

2.3. Literature Review — Educational Capacity and Trends Note: There is no literature section in the report per se; rather, the literature is integrated into the

discussions in Chapters 6 and 8.

Search Strategies and Identification of Relevant Literature. Both broad and narrow key words and phrases were used to search all sources. A broad term such as nurse(s) was used in an effort to capture information relating to all three regulated nursing professions. More focused words and phrases such as registered nurse(s), licensed practical nurse(s), and registered psychiatric nurse(s) were used in an effort to access data for each of the regulated nursing professions.

Published Literature and Bibliographic Databases. Information on published literature was searched through bibliographic databases such as MEDLINE, CINAHL, Healthstar and Ovid. Popular publications and academic literature were also scanned.

Grey Literature. The Internet provided access to grey literature such as reports, news releases, statistical data, and databases, as well as to documents from university-based academic research units, governmental publications, and nursing regulatory bodies. Documents and data were also obtained through direct correspondence with government officials, research units, nursing associations, and regulatory bodies.

Data from Regulatory Bodies. Direct contact was made with regulatory bodies for the regulated nursing professions in some provinces and territories. RNs and LPNs are regulated in all provinces and territories, whereas RPNs are regulated only in the four provinces of Western Canada. A review of the literature was conducted to examine perspectives of a chief executive officer (CEO) about a number of key issues influencing nursing practice. Areas relating to the CEO role, cost containment, evidenced-



based decision-making, means of coping with tight labour markets, employee utilization patterns, and patient safety programs and concerns were examined.

2.4. Focus Groups — Under-represented Groups A qualitative methodology was used in this investigation. Focus groups were created comprising

university and college students in groups under-represented in university and college nursing programs. They were asked about the reasons nursing is not appealing as a career choice within their group and what can be done by nursing to address this problem. Ethics approval was received from the Health Sciences 1 Research Ethics Board at the University of Toronto.

2.4.1. Target Group

The target populations for the focus groups were students who are members of the particular communities of Canadians that are under-represented in most nursing education programs and in the workforce. These groups are Aboriginals/Native (includes First Nations and Métis), Black Canadians of African or Caribbean descent, and men. The criteria for participation were that students be pursuing post-secondary education and neither be currently enrolled in a nursing program nor have chosen nursing as a career. These samples purposely differed from those in previous studies; earlier work had involved male and Aboriginal students in either high school or nursing programs. No previous research — on these groups of interest and about the appeal of nursing as a career — had targeted students who had demonstrated the capacity to gain entrance to post-secondary education and to explore a range of career options but had not pursued nursing as one of those options. Their voices and their opinions were viewed as another important source of information about the appeal of nursing as a career.

2.4.2. Data Collection

The focus group guide used in the Canadian Nurses Association (CNA) study (Hanvey, 2004) was expanded and revised. A number of questions were added to those used in the CNA study of men in nursing. For example, students were asked if they knew about the three different nursing professions and if this made any difference to the appeal of nursing. Students were also asked whether the costs of study, the location of nursing schools, the types of clinical study required, and mentors/role models make a difference to the attractiveness of nursing as a career choice. Participants had the opportunity to ask questions about the study.

There were no notable differences in process among the focus groups. In every group, participants appeared very eager to contribute. Differences of opinion were voiced, lively discussion among the participants was generated, a group problem-solving approach emerged at times, and requests for information and questions were voiced by participants, signalling their interest in the directions of this research inquiry.

2.4.3. Recruitment

Educational institutions were selected as recruitment sites based on the types of nursing education programs they offered and the availability of students whose views were of interest in this research. The three groups of interest were recruited as follows.

First Nations students were recruited through the University of Toronto, using e-mail announcements and flyers posted at First Nations House, which houses the Office of Aboriginal Student



Services and Programs, and at the Native Students’ Association of the University of Toronto. The focus group was held at First Nations House. Flyers were posted in buildings at First Nations University, SIAST, and the University of Saskatchewan. These schools offer a collaborative program to prepare registered nurses and a program to prepare licensed practical nurses. The focus group was held at First Nations University.

Black Canadian students of African or Caribbean descent were recruited at two sites in Toronto. At George Brown College (LPN and RN programs), flyers were posted on student bulletin boards (George Brown also offers a broad range of technical and human service programs). This focus group was held in the Centre for Nursing at George Brown College. At the University of Toronto (RN program), flyers were posted in buildings that house programs with a high enrolment of Black Canadian students. An e-mail announcement was also sent to electronic lists for faculty and teaching assistants in these programs. This focus group was held at the Faculty of Nursing of the University of Toronto.

Male students were recruited at two institutions. At George Brown College, where the focus group was held, flyers were placed on student bulletin boards and in the career centre. At the University of Toronto, were the second focus group was held in the Faculty of Nursing, flyers were the only method used and were placed in high-traffic buildings that house the major libraries, the bookstore, and the career centre. They were also placed in a college of the university that houses a number of diversity studies programs, in an effort to encourage participation by ethnoculturally diverse male students. The University of Toronto offers programs to prepare registered nurses as well as graduate level nurses.

No RPN Site. The original proposal included the plan for a third focus group with Aboriginal students at a college site that offered an RPN program. Many attempts were made to reach people at this college to secure permission to recruit students and conduct a focus group on campus, and to recruit an individual who could lead a focus group. After several weeks, with no success in making contact with individuals who could facilitate the process and with time running out, the idea was abandoned.

2.4.4. Participants

Mixed purposeful sampling methods were used, including criteria-based sampling, cascading snowball sampling, and maximum variation sampling methods. Maximum variation sampling was used to achieve ethnocultural variation within focus groups for male students.

A total of 52 students participated in the following six focus groups: 18 First Nations students, 18 Black Canadians, and 25 males.

• Two focus groups (16 students) were held with Aboriginal/Native students (includes First Nations and Métis), (2 of whom were men).

• Two focus groups (16 students) were held with Black Canadian students of African or Caribbean descent (3 of whom were men).

• Two focus groups (20 students) were held with male students of ethnoculturally diverse backgrounds (2 of whom were First Nations, and 2 Black Canadian).

The groups ranged in size from 7 to 10 students. Within each focus group, participating students

represented a wide variety of areas of study. The recruitment was successful therefore in sampling a broad range of students on all three campuses. At the same time, many of the students who contacted the researcher reported that they had learned about the study from another student. The focus groups for male



students included a cross-section of students from diverse ethnocultural, racial, and indigenous backgrounds. Snowball sampling was therefore also effective, as was maximum variation sampling.

2.4.5. Data Analysis

The audiotapes from the focus group interviews were transcribed, and information that might identify the participants was either eliminated or falsified. The interview data were summarized and a descriptive report was prepared of the themes generated from content analysis. Themes were generated from the whole sample, from each of the three groups of students, and from comparisons among the groups.



3. History of Nursing Education in Canada

Note: The provinces and territories of Canada joined Confederation at varying times since its conception in 1867. See Appendix D at the end of this report for further details.

3.1. History of RN Education in Canada Like the very history of Canada, education to prepare registered nurses has two roots, one

originating in French-speaking Canada and a quite different one in the English-speaking areas.

3.1.1. Origins in English and French Canada

French Canada. In 1639, three French nuns of the nursing order of Augustine de la Miséricorde de Jésus arrived in what is now Quebec City to provide care to the settlers; they subsequently established Canada’s first hospital, Hotel-Dieu, in 1644 (The Canadian Encyclopedia, 2004a). Jeanne Mance, a laywoman, moved from France to Canada with a group of settlers in 1641 and established what would become Hotel Dieu Hospital in Montreal. Mance provided care to the citizens, ran the hospital, and, importantly, was instrumental in recruiting sisters from the Hospital Sisters of St. Joseph de la Fleche in France to assist her in the hospital. These developments set the pattern for health care and hospital management in Quebec until the 1960s. Religious orders were the backbone of the system, and they established schools of nursing attached to the hospitals to train nurses for their hospitals (Catholic Encyclopedia, 2004; Dick & Cragg, 2003).

English Canada. In the 1850s, Florence Nightingale had identified a series of principles for schools of nursing, including the critical ones that schools should be financially independent of hospitals and students should not be under the control of hospitals (Dick & Cragg, 2003). In English Canada, the early schools of nursing were nominally established on the basis of Nightingale’s principles; however, the need for service students provided to the hospital dominated the agenda of these schools and the hospital boards of directors dominated the schools of nursing, including having financial control over them. Dr. Theophilis Mack established the first school of nursing at the General and Marine Hospital in St. Catharines, Ontario, in 1874 — a school subsequently named the Mack Training School. Hospitals were being established in almost every community in the Atlantic Provinces and in the larger towns of Western Canada. Regardless of their size, hospitals started schools of nursing. By 1909, Canada had 70 schools of nursing (Mussallem, 1965). Nursing education did not emerge from the control of hospitals until the latter half of the 20th century, but the struggles of the early days about what should have priority — education or service — continued throughout this period.

3.1.2. University-based nursing education

University-based nursing education had a different beginning. As early as 1905, the Graduate Nurses Association of Ontario approached the University of Toronto asking it to establish a nursing education program, an invitation that was not taken up. A similar request to Queen’s University reached the same fate (King, 1970). In 1918, the Canadian National Association for Trained Nurses conducted a survey of university presidents to determine their views on developing schools of nursing in their institutions. Only the president of the University of British Columbia (UBC) responded positively; in 1919, with strong support from the superintendent of the Vancouver General Hospital, UBC established the first degree program in Canada in 1919. It may not be a coincidence that the President, prior to



coming to UBC, had been at the University of Minnesota, where the first university nursing program in the United States was developed in 1909 and the first baccalaureate degree established in 1919 (Baumgart & Kirkwood, 1990; King; University of Minnesota, 2004).

The Canadian Red Cross Society recognized the need to improve the quality of health services available, particularly in the new area of public health, and in 1920 provided funds for six universities to start certificate programs to prepare graduate nurses for public health. Along with UBC, all started one-year courses, including McGill University, Dalhousie University, the University of Alberta, the University of Western Ontario (actually funded by the local Red Cross chapter), and the University of Toronto. All the programs, except the one at Dalhousie, survived after the funding came to an end in 1923 (Baumgart & Kirkwood, 1990). The University of Toronto (U of T) went on to develop a three-year diploma program, and, in 1942, a four-year degree program funded by the Rockefeller Foundation. The degree program at U of T was entirely under the control of the university with students taught by university nursing faculty; as such, it was referred to as an integrated program. Other universities developed what was known as non-integrated or “sandwich” programs in which students spent a first year at a university, three years in a hospital school of nursing, and then a final year back at the university for which they were granted a degree. These programs meant that the universities did not have to invest in either the clinical and theoretical education of students in the practice of nursing or the faculty required to teach them. King (1970) believes the non-integrated programs were a deterrent to the development of both nursing education and practice because they created confusion about what contribution university education could make to nursing practice. Within universities, nursing faculties were challenged by the double jeopardy of being women and being in a “vocation” at a time when technical education was highly suspect as a legitimate endeavour at the university level (Baumgart & Kirkwood, 1990).

3.1.3. From Hospitals to Education Sector

Over the first half of the 20th century, two struggles occurred: in the diploma sector, wresting control of nursing education from hospitals; and within the university sector, determining the structure of a nursing baccalaureate degree program.

Three studies, conducted 30–35 years apart, were influential in the following two events: 1) redirecting nursing education out of the hospital sectors and under the control of the education sectors in the provinces, and 2) influencing the shape of university programs.

Study # 1. In 1929, the Canadian Nurses Association, with financial assistance from the Canadian Medical Association, commissioned George Weir, a professor of Education at UBC , to study the state of nursing education. He challenged the prevailing view in many arenas that nurses did not need to be educated, and was scathing in his review of practices in many schools at the time, including the practice of admitting students with little if any high school education to schools with no teachers and subsuming any education to the service requirements of the hospitals (Weir, 1932). Among his recommendations were to increase the qualifications of students entering schools of nursing and to give nurses a liberal education as well as a technical education. He proposed that “university training schools for nurses should … award degrees in Nursing as in Arts, Law, Engineering, Pharmacy, Agriculture, Medicine, or any other field of learning” (Weir, p. 393). This report led to the closure of many of the smallest schools and to the upgrading of educational programs in general, but it did not lead to an educational revolution in nursing. That had to wait another 60 years.

Study # 2. The second study was undertaken by Dr. Helen Mussallem and focused on whether Canadian diploma nursing schools were ready for accreditation (Mussallem, 1960). Her conclusions were



that only 16% of schools could meet accreditation standards and what was needed was a complete re-examination of nursing education prior to any accreditation process.

Study # 3. Dr. Mussallem followed this report with one for the Royal Commission on Health Services in 1965, noting that, at the time, there were 188 schools to prepare registered nurses in Canada — 170 controlled by hospital boards, one by a lay board, and 17 in universities (Mussallem, 1965). Mussallem recommended that all nursing education come under the control of educational institutions and that they prepare two categories of practitioners: the technical nurse and the professional nurse. The professional nurse was to be educated in a university and the technical nurse in a two-year program, under the auspices of universities until a junior college system could be developed in Canada. Furthermore, she recommended that universities adopt the four-year integrated type of university program and abandon the more prevalent “sandwich” approach. She marvelled at the willingness of universities to grant degrees for such programs when they had no control over the major component of the program (Mussallem, 1965).

This report did have an impact. Community college systems developed across Canada in the 1960s and nursing schools began to be moved to them. Ontario, Quebec, and Saskatchewan moved all nursing programs out of hospitals into colleges while Alberta, British Columbia, Nova Scotia, Newfoundland, and Manitoba retained some or all hospital-based programs until the 1990s (Dick & Cragg, 2003). There is some debate about whether this was a wise move. If nursing could have managed a move to degree education by locating all its programs in universities first, there is a belief that this would have strengthened the education overall and produced a more autonomous practitioner and critical thinker. In reality, however, there were too few faculty members available in the early 1970s to meet university standards for appointment.

The debate about whether registered nurses require a degree raged through much of the 20th century. Every provincial/territorial professional nursing association had a committee studying the issues and recommending policies. In 1979, Alberta was the first province to endorse the position that, by 2000, a degree in nursing would be required in order to receive an initial license as a registered nurse. This was known as the “entry to practice” position. Ontario followed in 1980, and by 1989, all provinces had taken similar positions. The Canadian Nurses Association endorsed the position in 1982 (Bajnok, 1992). The question was how to get there.

3.1.4. The Development of the Entry to Practice Initiative

The 1990s saw a remarkable movement in the education of registered nurses in Canada — perhaps the most remarkable in its history — as entry to practice became a reality. Bajnok (1992) pointed out the “enormity of the task” of reaching the goal by 2000 in light of the fact that, in 1990, fewer than 20% of new nurses graduated with degrees in nursing. The provinces began moving toward a degree as an initial licensure requirement in the late 1980s, using very different strategies. The following are three case studies, involving British Columbia, New Brunswick, and Ontario. Each used a different strategy. British Columbia had a bottom-up, grass roots approach to collaboration between colleges and universities that ultimately spread across the province. New Brunswick placed RN nursing education completely in the hands of its universities. Ontario took a top-down approach, with the College of Nurses mandating collaboration between colleges and universities.

3.1.4.a. British Columbia

The Collaborative Nursing Program of BC (CNPBC) was one of the first collaborative efforts in Canada and provided a model for subsequent efforts in other provinces. It consisted of the University of



Victoria as the university partner and up to nine college and university college partners all working together to offer baccalaureate education. This collaboration grew from a mutual desire on the part of both faculty members and the nursing administrative leaders in the partner organizations to realize the objectives of entry to practice. In this way, this collaborative effort was a more “grassroots” effort than some others that were either imposed by government or driven by administrators.

Timing is an important feature in successful systems changes and it played a role in BC’s collaborative development. The BC government was anxious to see more cooperation between universities and colleges, and this collaborative initiative was an excellent example of the kind of cooperation they were looking for. The government also believed that the provincial universities should coach the university colleges so they could move to degree-granting status, and, again, this initiative was successful. To assist in the development of this collaboration, the Ministry of Advanced Education provided an initial grant and a subsequent series of grants for curriculum development.

The original collaboration that had begun to take shape in the late 1980s consisted of the University of Victoria and four colleges: Camosun College, Malaspina College, Okanagan College, and Cariboo College. Malaspina, Okanagan, and Cariboo colleges were all slated by the provincial government to become university colleges within a specified period of time, and so the collaborative effort at those sites was designed to foster a transition from educational efforts aimed at preparing students for transfer to a degree-granting institution or program completion at the diploma level over to independent degree-granting offerings. Because of its proximity to the University of Victoria, and its own interest in remaining a community college, Camosun College remained the primary transfer partner, with the university offering years 3 and 4 of the four-year program. Together, they developed a set of principles to guide their relationship and the development of a common curriculum. Students enrolled at Camosun College received the first two years of their degree program at the college and then moved to the University of Victoria for their last two years. Students at the other three colleges (Malaspina, Cariboo, and Okanagan) in transition to university colleges undertook their entire program at the college and, for a time, received a University of Victoria degree until legislation enabled those institutions to offer their own degree.

The original five partners were joined by another four colleges and one university college: Langara and North Island colleges in 1992; Selkirk College in 1993; and Douglas College and Kwantlen University College in 1994. Students at these four colleges also transferred to the University of Victoria after two years for degree completion. Because several of these colleges were a significant distance from Victoria, the university established a campus on the Lower Mainland to accommodate students from Langara and Douglas colleges closer to their homes. To gain recognition for the excellence of their program, the existing partners applied in 1992 to the Canadian Association of University Schools of Nursing for “candidacy status,” which is the first phase of the process of accreditation for new programs. They were successful in this application, as well as in subsequent school approval reviews by the Registered Nurses Association of British Columbia — this approval is required if graduates of schools of nursing are to write the national registration exams. In addition to these external evaluative processes, the collaborative program has conducted an ongoing formative evaluation of the program as it has evolved.

The collaborative partner, in addition to attending to the students, undertook to develop scholarships across the faculties. Based on the assumption that the baccalaureate preparation of students requires an academic environment regardless of whether that environment is housed by a university or a college, faculty members from each the sites worked together to develop research studies and other forms



of scholarship at all the sites. Using Boyer’s model, they developed a template of scholarly activities achievable within the collaboration (Storch & Gamroth, 2002).

The collaboration proved to be remarkably resilient through the 1990s, but certain decisions made by the provincial government, along with the evolution of some of the partner institutions, have recently complicated and disrupted the original partnerships. Originally, the BC government worked closely with the 10 partners to determine student flow patterns to calculate the funding needed by each institution. Thus, students, faculty, and administrators had some way to estimate the numbers of students entering the 3rd and 4th years of their program each year. In the late 1990s, the government changed the funding for student flow by requiring that one college’s nursing students would be divided in half, with one part of the class moving on to the university and the other part moving on to a university college for their final two years of the program. Using their principles of collaboration, the partners managed this external change quite well.

In 2002, the BC government announced that by 2005, entry to practice would require a degree in nursing. Therefore, all the college programs in BC developed plans to terminate their diploma programs and entered into partnerships with a university or university college. Then, in 2003, the BC government made a decision to permit colleges to award “applied degrees”; two of the college partners in the CNPBC decided to take this opportunity. This has made it difficult for all 10 partners to work together, since 7 of the 10 partners could not agree that one collaborative program could offer two types of degrees — a regular baccalaureate degree and an applied baccalaureate degree. With regret, the collaborative program partners have thus gone their separate ways, with at least seven continuing to work together as before (but under a new name). The outcome of the lengthy governmental approval process for these degrees has not, at this time, been completed. This philosophic rift among the partners is all about the equivalency of the BScN degree and an applied degree in nursing. Furthermore, the introduction of this applied degree challenges the national uniformity of the BScN/BN nursing degree credential. One additional and recent development has been that Okanagan University College has been designated as a campus of the University of British Columbia. At the time of writing, it is still envisioned that this university college will continue in partnership with the six other collaborative nursing program partners offering the regular baccalaureate degree program.

The Collaborative Nursing Program of BC is reconstituting itself and is searching for a new name. The partners now involve the University of Victoria, Camosun, Selkirk and North Island colleges, Malaspina University College, the University College of the Cariboo, and Okanagan University College. Some of the university colleges have become involved in the mentoring role of colleges similar to the University of Victoria, since their upper-level program years are well developed and they have been granting the degree for some time. But it is important to note that this program and the baccalaureate degree are still uniform across all seven partners. The Lower Mainland campus of the University of Victoria School of Nursing is scheduled to close in 2007, since it is anticipated that by that time both Douglas College and Langara College will be offering the final years of an applied degree program.

Principles of Success of Collaborative Programs. The Collaborative Nursing Program of BC was, and continues to be, a creative and inspirational example of how nursing education can provide access to a nursing degree so provinces can achieve the goal of entry to practice. It required a remarkable degree of vision and cooperation among the partners, a willingness to trust the intentions of all partners, flexibility in developing operating rules, the absence of defensiveness on the part of the university and the colleges regarding their capacity to deliver programs, and an ability to keep their eye on the overall goal rather than being derailed by short-term issues and conflicts. Clearly, the government served to both



facilitate and disrupt the program. Decisions that served the ambitions of some senior administrators in some of the college partners were not necessarily constructive with regard to the best interests of the original 10-partner collaborative program.

3.1.4.b. New Brunswick

Prior to 1995, New Brunswick had two university nursing programs. The University of New Brunswick provided BScN education in English and the University of Moncton provided a similar program in French. There were also five community college programs that offered both English- and French-language diploma programs to prepare RNs.

The Nurses Association of New Brunswick (NANB) is the licensing body for nurses and has the authority to approve schools of nursing and set standards for these programs. In response to the 1982 CNA Entry to Practice resolution, the NANB established a committee to develop a plan for phasing out diploma education and moving to degree-only programs. Their initial effort was to propose a 20-year transition phase to degree education. When that was rejected for being too long, the revised proposal called for phasing out all diploma programs over an eight-year period and concentrating degree education in the two universities, which would then offer programs in some of the previous diploma locations. It is interesting to note that, in New Brunswick, the choice from the start was not to adopt collaboration between colleges and universities as the strategy to attain degree education for nursing but to locate RN nursing education in the universities. This proposal was taken to a vote at the annual NANB meeting in 1987.

The NANB committee consisted of nurse educators and administrators, but there were no staff nurses represented on the committee (Rheaume, 2003). This meant there were no nurses who were union members on the committee, so when the proposal came forward for approval, the unionized nurses did not support it. They objected because the plan did not protect registered nurses, whom they saw as vulnerable in terms of career progression if the RN nursing workforce became dominated by new degree-prepared RNs. The union was not against a degree as entry to practice but wanted their membership protected in terms of their careers. Also, college faculty members who did not have graduate education in nursing had no way to upgrade and meet the requirements for faculty positions at the universities because there were no graduate programs in New Brunswick at that time. They faced loss of their jobs if the college programs closed. Because of these issues, and after an effective lobby of its members by the nurses’ union (Rheaume, 2003), the proposal was turned down at the meeting. However, the NANB disallowed the vote after having identified a number of voting irregularities. Nonetheless, the committee that had prepared the policy heard the concerns expressed by staff nurses and diploma school teachers and developed a new proposal.

The proposal that went forward to a vote at the 1989 NANB meeting included the following: protection of the right of diploma-prepared nurses to continue to practise; inclusion of experience as a criterion for career advancement; increased access to degree education for nurses through expansion of the programs; and the development of a master’s degree in nursing program to provide opportunities for diploma school teachers to qualify for university positions. The latter was delivered as a promise by the university programs to use every effort to develop a master’s program, and not as a guarantee of a master’s program. Despite this “soft promise,” the proposal was unanimously approved.

While the NANB could set standards for programs and had the right to determine the entry to practice criteria, the government had to approve of these because it provided the funds. NANB and the heads of the university programs negotiated with the government, including the premier, over several



years to support this proposal. The government was persuaded of the value of moving to degree education, but that approval was driven, to a large measure, by the fact that the cost of the diploma schools was high, and they calculated that by closing these schools, they would save money (Rheaume, 2003). In 1991, the government approved the proposal, and when the memorandum of agreement was signed, 100 seats/places in nursing programs were cut and funding from the diploma programs was transferred to the universities. An additional response by government to the NANB proposal to increase RN qualifications was to cut the ratio of RNs to LPNs in the health care system as a further cost-saving manoeuvre (Rheaume, 2003).

A large task force that consisted of representatives from the diploma programs, universities, and government was established and it developed an implementation plan. A memorandum of agreement was developed that included the closure of diploma programs, the transfer of responsibility for all nursing education to the universities, and a commitment on the part of the universities to hire college teachers who were interested and who had a master’s degree; if their master’s was not in nursing, these teachers had to agree to pursue one. The University of New Brunswick developed a master’s in nursing program that gave teachers who were interested access to graduate education. Most diploma teachers opted not to transfer to the universities because the salary scales were lower and these teachers could transfer into other government positions through their union contract and protect their salaries and benefits.

The University of New Brunswick received funding for 150 students and the University of Moncton for 100. The new programs began in 1995 and graduated their first classes in 1999. They continue to function successfully.

3.1.4.c. Prince Edward Island

One of the reasons that New Brunswick succeeded in the transition to degree-based education for RNs was the pattern established in their neighbouring province of Prince Edward Island. In 1988, PEI became the first province in Canada to have a baccalaureate degree legislated as the requirement to become a registered nurse. There was support for this from the provincial Department of Health, the Association of Nurses of Prince Edward Island, and the University of Prince Edward Island, and from nurses across the island. The one diploma program on the Island closed and a new program was established at the University of Prince Edward Island. This move by PEI served notice to other Atlantic provinces of things to come.

The creation of university-controlled nursing education may result from a different set of circumstances within the province than those that lead to university-college collaborations elsewhere. In the cases of New Brunswick and Prince Edward Island, there was strong support from the professional organizations for locating the programs in universities and the nursing unions also supported this. There were also limited players in terms of the number of universities and colleges and, in the case of New Brunswick, long distances between the universities and some of the college sites where the universities maintained programs. These are somewhat surprising circumstances because few players and long geographic distance might just as easily have led to a decision to adopt a college–university collaboration model. Access to graduate education in nursing is a factor but it is unclear how powerful an influence it is, one way or the other. In New Brunswick, it drove the development of a graduate program rather than being a product of access to such education.



3.1.4.d. Ontario

Ontario took a different route to achieving a nursing degree as entry to practice. The Registered Nursing Association of Ontario (RNAO) had been one of the first professional organizations to support the entry to practice policy, but it did not have the authority to set standards for nursing education or to approve nursing programs. That authority resided with the College of Nurses of Ontario (CNO), the registering body. Ontario has a large nursing education enterprise. In the 1990s, there were 10 university programs and 22 college programs. Some of these players had developed collaborative arrangements; for example, York University had developed a collaborative program with Georgian College and with Seneca College through which students started in the colleges and then after two years moved to York to complete the program. The Council of Ontario University Programs in Nursing (COUPN) — which is a policy forum for the deans and directors — and the heads of the programs in the Colleges of Applied Arts and Technology (CAATS) met to explore potential ways of working together; however, the challenges seemed overwhelming.

Two simultaneous and complementary processes occurred that resulted in adoption of the entry to practice policy. The College of Nurses of Ontario (CNO) had not officially taken a position that a degree should be the entry to practice requirement. Ontario had been a partner in the National Nursing Competencies Project, an initiative led by the Canadian Nurses Association. This project, which started in the early 1990s, identified the competencies required by registered nurses (and licensed practice nurses and registered psychiatric nurses) in order to be licensed. The CNO established an Umbrella Working Group that included representatives from all nursing organizations and front-line staff to determine the acceptability of the 331 competencies identified for RNs. This Working Group conducted a survey of 2,500 nurses and held focus groups across the province. The vast majority of competencies were endorsed and, importantly, buy-in by all sectors (i.e., hospitals, public health) of nurses across the province was achieved. The decision was taken that the competencies represented baccalaureate education in nursing. The CNO Council comprised lay and elected members. Prior to the Council meeting, at which the recommendations would be presented, extensive education and interpretative sessions were held with Council members. In December 1998, the recommendations of the Umbrella Working Group were unanimously passed by the College of Nursing Council. Included were the following recommendations.

a) The education of nurses to meet the competencies should be through a program that confers a baccalaureate degree in nursing.

b) The degree as entry to practice should be achieved by January 1, 2005.

c) The college and university systems should collaborate to achieve the educational reforms needed.

Additionally, the Minister of Health was asked to support the recommendations and the ministers of Health, and Education and Training were asked to implement a funding mechanism and a work plan that would result in partnerships between colleges and universities (College of Nurses of Ontario, 1998).

During the 1990s, a massive hospital restructuring exercise was undertaken in Ontario. As a result there were many mergers between hospitals and reductions in beds. As a further consequence, many nurses lost their jobs. This disruption was magnified when a new government was elected in 1994. This government made significant cuts to hospital budgets, resulting in more nursing job losses and the elimination of full-time positions in favour of part-time ones that did not require the employer to pay benefits. The media were filled with stories of discontented and disenchanted nurses who were leaving the province to go to the United States or leaving the profession altogether. Application numbers to schools of nursing plunged. In 1998, a new Minister of Health was appointed who was committed to repairing the



damage done to nursing. She appointed a Nursing Task Force with the mandate to examine nursing services in Ontario and to recommend needed changes. This Task Force reported in January 1999 (Ontario Ministry of Health, 1999) and, among other things, recommended that the entry to practice for registered nurses be a baccalaureate in nursing and that the baccalaureate programs be achieved through collaborations between college and university schools of nursing. The Minister accepted these and all the other recommendations of the Task Force on the day the report was released. Ontario had achieved “entry to practice.”

Several new university schools opened in response to the entry to practice developments. The college and university schools arranged themselves into partnerships and negotiated a variety of curriculum patterns for the degree. Some could be described as 2x2 in which students started their program in a college and transferred to the university partner for the upper two years. Other schools designed curricula that could be taken completely at either a college or university partner site. Still others have students moving between sites throughout the program. Some partnerships have worked well and others have been fraught with difficulties. However, the legislation is in place, and the last graduates of diploma programs must have completed these programs by December 31, 2004; to sit registration examinations as of January 1, 2005, a baccalaureate will be required.

Ontario achieved entry to practice in a top-down process initiated by the College of Nurses and reinforced by government. Outstanding leadership and skilled politics were demonstrated by many players, including the Executive Director of the CNO and the Chief Nursing Officer in the Ontario Government. In this province, the educators were not significant players.

Degree-based Programs as Compared with Collaborative Programs. So, what are the differences between province-wide degree-based education that is controlled and managed by the universities as compared to programs delivered by collaboration between colleges and universities? The former removes the issues related to budget control, conflicting hiring practices and the merging of different cultures. The latter reduces the sense of winners and losers and creates opportunities for teamwork that may be seen as models for students and practice environments. It also creates opportunities for conflict, particularly in circumstances when the collaborations are forced on the partners. In all cases, strong and inspirational leadership is required from people positioned to make it happen. When it is university controlled, the leaders must create the perception of fairness and openness to communities that previously enjoyed having their own nursing programs, and the baccalaureate programs that serve the communities must be perceived as high quality, accessible, and worthy successors to the “lost” programs. When collaboration is the model, the directors must respect each other and demonstrate the abilities to mutually problem-solve and negotiate issues so there are not winners and losers. Neither is easy.

3.1.4.e. Quebec

Quebec remains the only province not to have committed to entry to practice by January 1, 2005; however, they are in the early phases of developing collaborative programs between colleges and universities, which students will enter this fall while maintaining the diploma programs. To date, this process has been dominated by the Ministry of Education and not by the schools of nursing or their professional bodies.

3.1.4.f. Other Provinces/territories

Entry to practice was not achieved in all provinces by 2000, but the precedent had been set by PEI, New Brunswick, Nova Scotia, Saskatchewan, and Newfoundland. The next decade of RN nursing



education will require consolidation of the programs developed over the past decade and the establishment of new objectives to guide the education of registered nurses in the future. Furthermore, Canada has lessons to share with other countries as the worldwide trend toward a nursing degree as entry to practice is achieved.

3.2. History of LPN Education in Canada The education of licensed practical nurses had a different start in Canada than the education of

registered nurses and registered psychiatric nurses. In the case of the latter two professions, the need for nurses to staff specific hospitals was the driving force behind the development of schools of nursing in those hospitals. Once these schools were established, the next 50 years were spent trying to gain control of the students’ education and to impose standards that the schools would have to meet. However, in the case of practical nurses, in both Canada (Mussallem, 1965; Russell, 1970) and the United States (McGuane & Bullough, 1995), it was a shortage of registered nurses exacerbated by World War II that led to the recognition that “nursing assistants” needed education beyond on-the-job training. Of note here is a comment by Kathleen Russell (the first director of the school of nursing at the University of Toronto): “It is the official approval of the [nurse] auxiliary that is new, not the worker” (Russell, 1956, p. 26).

Individuals who provide care to patients and contribute to the management of patients’ environments in their homes and in hospitals have always been part of the nursing scene (Russell, 1970). They have carried a variety of titles: nursing aides, nursing assistants, nursing auxiliaries, and attendants. Although not used widely across Canada until recently, the title “practical nurse” was used in both Manitoba and British Columbia when the educational programs were established in these provinces. The evolution of the name in Canada reflects the evolution and the acquisition of a distinct identity by the profession of practical nursing.

The education of practical nurses got a later start than the other nursing professions (65 years later than RN education and 20–25 years later than RPN education) and for most of its history was subject to top-down control from RN professional organizations or provincial/territorial ministries of health. Moreover, the history of practical nursing and of the education of its practitioners cannot be separated from that of registered nurses because developments in the latter profoundly influenced, both positively and negatively, the education of the former.

The education of practical nurses can be traced through three phases: the establishment of educational programs (1939–1960), the evolution of educational programs (1960–1990), and the expansion of practical nurses’ scope of practice (1990 onward).

3.2.1. Phase 1: The Establishment of Educational Programs

In 1939, the Canadian Nurses Association recognized that in order to better address the shortage of nurses that pre-dated — but was exacerbated by — the outbreak of World War II, nursing assistants (the most common title at the time) needed to be educated (Mussallem, 1965; Russell, 1970). The CNA recommended that each provincial/territorial nursing association establish schools to prepare nursing assistants, and it provided a syllabus for a proposed one-year educational program. The CNA also recommended that legislation be passed to license these workers (Russell).

The end of the war and the return of soldiers who needed to be reintegrated into civilian life stimulated the Department of Veterans Affairs (DVA) and the provincial/territorial nursing associations to establish programs to train practical nurses (Russell, 1970).



Ontario was the first province to pass legislation to establish nursing assistants and was the first to establish a school of nursing to educate them (Russell, 1970). The Registered Nurses Association of Ontario developed a curriculum and financed a “demonstration” program in London, Ontario, in 1941. The program deviated from that proposed by the CNA in that it was only six months in length, with the first three months spent in classes followed by three months of supervised practice in hospitals and, for home-based practice, with the Victorian Order of Nurses (VON). Only eight classes had graduated before the demonstration was declared a success and terminated in 1945. The RNAO recommended to the government that schools for nursing assistants be established throughout the province, independent of hospitals (Russell).

In Manitoba, the Licensed Practical Nurses Act, designed to provide for the training, examination, licensing, and regulation of practical nurses, received royal assent on March 23, 1945. It was the first such legislation enacted to govern practical nurses in North America. The Licensed Practical Nurses Act was administered by an Advisory Committee appointed by the Manitoba Government.

• The Saint Boniface School for Practical Nurses had its early start in September 1943. The Manitoba Association of Registered Nurses (MARN) approved a course for nurses aides.

• Sister Yvonne Prevost was responsible for training the auxiliary workers in St. Rose du Lac, Mantioba. In 1945, Sister Prevost applied to MARN to have her training accepted as a course for licensed practical nurses. She adopted the curriculum endorsed by MARN and her graduates became the first licensed practical nurses in Manitoba

• In January 1946, the Grey Nuns opened a school for practical nurses at the St. Boniface Sanitorium. The first courses were 18 months’ duration. Upon graduation, the graduate received a license as a practical nurse with a special diploma in T.B. nursing. In 1948, the program became known as the St. Boniface School for Practical Nursing.

• In 1946, The Central School for Practical Nursing (now known as Red River Community College) was established.

While Manitoba was the first province to establish a program, it was quickly followed by Alberta. In 1945, the DVA and Canadian Vocational Training sponsored the School for Nursing Aides, and enrolment was limited to those who had been in the Armed Forces (Glover, 2001). This program was 40 weeks long, and was divided equally between classes and clinical practice. By 1947, the program had been opened to civilians, and the Alberta Nursing Aide Act was passed, which provided for the licensing of certified nursing aides (Glover).

Ontario established a DVA-sponsored program in 1946 but terminated it by the end of the year when the intended population was served (Russell). However, the Department of Health in Ontario was sufficiently concerned about the training needs of nursing assistants that it opened educational centres in Toronto and Kingston, which were jointly sponsored by the departments of Education and Health. These programs were closely modelled on the original CNA proposal. The Ontario Nurses’ Act was amended that same year and included regulations for the programs and the provision to license graduates (Russell).

In New Brunswick, the Department of Veterans Affairs established a program in 1945 through the NB Department of Education (not the Department of Health). The Department developed a 39-week curriculum, recruited an instructor, and found hospitals that would provide clinical practice opportunities (Smith, I., 1990). The provincial/territorial registered nursing associations were supportive of it and



helped to design the curriculum. This program lasted until 1947, when a new program was established. Initially this program was a school for practical nurses at the New Brunswick Institute of Technology.

• Then four other schools were started, including one at a vocational school, one at a trade school, and two in hospitals. The New Brunswick Association of Registered Nurses (RNANB) Committee for Nursing Assistants took the lead in determining the nature of the program, its length (9 months, later lengthened to 12 months in 1958), and approved the establishment of schools. Grade 9 was the admission requirement; however, if students were undertaking the program as part of a Canada Manpower scheme, they needed to have Grade 10.

• New Brunswick did not have legislation to license nursing assistants until 1958, and this licensure was initiated in 1960 under the control of the RNANB (Smith). They kept a tight rein on the number of classes that were admitted in order to control the number of nursing assistants available in the province. This was interpreted by the government as trying to control the ratio of nursing assistants to RNs, which the government preferred to see increased (Smith).

• In 1977, the Association of New Brunswick Nursing Assistants (now known as the Association of New Brunswick Licensed Practical Nurses) became the first provincial LPN association to obtain self-governing legislation. (Subsequently, in 1980, Prince Edward Island Licensed Nursing Assistants and the Manitoba Association of Licensed Practical Nurses of Manitoba received similar status.) (CAPNA, 1984).

Once the war ended and returning servicemen were accommodated, the maintenance of the educational programs for nursing assistants was a response to the reality of a continuing nursing shortage. Registered nurses did return from their wartime service, but their return coincided with an expansion of health services and other factors. Little hospital building had occurred during the war years and the hospital infrastructures were in disrepair and proved inadequate for the post-war demands. A massive hospital building program was undertaken that saw an 88% increase in hospital beds by 1960 and an increase in the number of hospitals from 536 to 844 (The Canadian Encyclopedia, 2004b). Hospitals also began to hire registered nurses to staff the units rather than relying almost solely on student nurses, and the demand outstripped the supply. Finally, the Canadian population was increasing rapidly. Mussallem reported that, in 1959, 14,912 certified nursing assistants were employed in hospitals as compared to 68,502 registered nurses practising in all sectors of nursing (i.e., hospitals, public health, all aspects of community nursing).

The discussions that accompanied these early programs emphasized the fact that they were to prepare graduates who would be assistants to registered nurses, and who would supplement, not replace, RNs (Russell, 1970). Mussallem (1965) noted that, in 1960, the International Labor Organization identified that many countries were struggling with the problem of determining what constituted nursing functions in order to be able to determine which of them could be performed effectively by auxiliary nursing staff. This was viewed as important in order to ensure the best utilization of registered nurses. Concern was expressed that the public would be very confused about the roles of the nursing assistant and the registered nurse and there was potential for conflict between the two groups (Mussallem). Inherent in these concerns was the fear that the nursing assistant could end up largely replacing the RN. These concerns led the Special Committee on Nursing Assistants, which had been established by the CNA in 1962, to recommend that the two programs be merged and the role of the nursing assistant eliminated (Mussallem). The CNA presented this recommendation to the Royal Commission on Health Services,



which clearly rejected it in their 1965 report (Russell). By then, hospitals had become dependent on the availability of nursing assistants and the care they provided. Nursing assistants were here to stay, as were the programs to educate them.

3.2.2. Phase 2: The Evolution of Educational Programs

The earliest programs were less than a year in length and most required students to have completed only elementary school. The programs in most provinces were run by the government, for example, the departments of Public Health in Alberta and Ontario, and the Department of Education in New Brunswick. During the 1950s, these programs were transferred to the vocational training sectors of the provinces. Over the next 30 years, most programs were relocated to colleges and, in some provinces, to high schools and hospitals. As well, the entering credentials and course requirements were increased. Furthermore, provincial/territorial professional practical nursing associations (or their equivalents) were granted authority to approve program curricula, and provincial/territorial licensure became mandatory for graduates of the programs.

The program in Alberta serves as a good example of these changes. Starting in 1945, it prepared certified nursing aides, which was for women only; males were trained on the job and were not regulated. The formal education process for males began in 1967. A new education program was developed to combine the education of males and females in 1978, at which time the co-ed students graduated as nursing assistants. In 1964, the admission requirement was raised to Grade 10 and, in 1986, to Grade 12. A new curriculum was initiated in 1978 based on an assessment of the competencies required. In 1982, the Alberta Association of Registered Nursing Assistants applied for designation under the Health Occupations Act to register and discipline graduates. As the Association was also a trade union, a new organization was established, and in 1987, authority was transferred from government to the Professional Council of Registered Nursing Assistants. This body set the requirement that graduates of the nursing assistant programs would write the national examination set by the Canadian Nurses Association Testing Service, which had been available since 1970. In 1990, the title for this nursing role was changed to licensed practical nurse (Glover, 2001).

Three interesting but contradictory features of these early years were as follows.

• Provincial/territorial registered nurses’ associations offered support and sponsorship for the practical nurse programs.

• These same organizations exercised control over the programs, including maintaining standards and controlling enrolment numbers.

• It was decided to locate the practical training in hospitals that did not have schools that prepared RNs. As a result, registered nurses did not have an opportunity through their training to work with students in the practical nurse programs, and neither group was introduced to the boundaries of the other or got experience working with the other in the course of day-to-day practice.

In Ontario, training schools for nursing assistants were established in vocational schools, hospitals, and high schools. As mentioned above, the latter was undertaken as a “demonstration” program in 1957 in London, Ontario. Students in vocational programs took the nursing assistant program during their third and fourth years of high school (at the time, Grade 10 was the entry requirement). This experiment had a twofold purpose: it allowed the program to enter the main stream of the educational system and it was a means to keep young women in school and provide them with an occupation upon



graduation (Russell, 1970). The experiment was a success and programs remained in high schools until the end of the century. Evening programs were introduced in several provinces to increase accessibility. By 1960, there were 43 schools enrolling 2,200 students across Canada and, by 1968, Ontario alone had 55 training centres that prepared 2,253 students (Russell).

By 1970, all the provinces except Quebec and Newfoundland and Labrador had enacted legislation that provided for registration of nursing assistants. In most provinces, the registered nurses’ associations or departments of health were mandated to set standards and approve schools. The exceptions were Nova Scotia and Ontario: Nova Scotia was ahead of the others by having established the Board of Registration of Nursing Assistants; and Ontario had created the College of Nurses in 1963, with the authority to both license RNs and nursing assistants and to approve their programs (Russell, 1970). In 1980, the Manitoba Government enacted a new Licensed Practical Nurses Act, which gave responsibility to the Manitoba Association of Licensed Practical Nurses (MALPN) for regulating the practice and education of Manitoban LPNs. (With legislation changes in 2001, the MALPN became known as the College of Licensed Practical Nurses of Manitoba.) Over the next 20 years, professional associations of registered nursing assistants in all provinces — and in some provinces, councils of nursing assistants — developed and gained control of the programs by setting standards and licensing graduates of the programs. Thus, the programs were emancipated from government control and from the control of registered nurses’ associations.

During the 1980s, most educational programs migrated to community colleges, which had been established in the provinces in the 1970s and 1980s. For example, to address rural and northern needs for practical nurses in Manitoba, programs were established at Assiniboine Community College in 1975 and at Keewatin Community College in 1973. In 1996, the Manitoba Government established Assiniboine Community College as the educational authority for practical nursing in Manitoba. Certificate programs of 10–18 months were established, and admission criteria required Grade 11 or 12. The exception to this trend was Quebec, which continued to house its 18- to 24-month programs in vocational schools under the authority of local boards of education. The program in all these boards followed the curriculum designed by the Ministry of Education of Quebec. All provinces except Quebec required the graduates of the programs to pass the national examination set by the testing service of the CNA. Graduates in Quebec wrote a provincially set examination as part of their educational program.

3.2.3. Phase 3: Expansion of Practical Nurses’ Scope of Practice (1990 and onward)

Since 1990, a number of significant changes have occurred in the education of practical nurses. These changes are not uniform across the provinces but are expected to be adopted nationally over time. As early as 1984, the LPN profession was addressing the diversity in LPN practice and education across Canada. It recommended that the Canadian Practical Nurses Association education committee assist provincial associations in promoting or instituting future program revisions, and thereby decrease or eliminate the diversity in education (CPNA, 1984). Because the national examination was based on competencies common to all jurisdictions, some provinces felt that the national exam did not sufficiently test their graduates; therefore, they entered in discussions with the National Council of State Boards of Nursing in the United States to contract to use the NCLEX LPN exam. Arising from these discussions, all jurisdictions agreed to work towards educational changes that would decrease the diversity in educational preparation. Two other inter-related activities were influential in changing the education and practice of LPNs: the National Nursing Competencies Project (NNCP) and the baccalaureate entry to practice changes for RNs in most provinces.



National Nursing Competencies Project (NNCP). Starting in the early 1990s, the Canadian Nurses Association spearheaded the National Nursing Competencies Project (NNCP). It involved the national and provincial/territorial professional and regulatory bodies of LPNs, RNs, and RPNs, with the goal of mapping the shared and unique competencies expected of entry-level practitioners in all three professions at two points in time, 1996 and 2001. These competencies were to become the foundation for new national RN and LPN examinations and were expected to provide the participating partners with information for decisions and communication about the following.

• registration of new graduates

• consideration of equivalencies for out-of-province applicants

• requirements for entrance examinations

• basic requirements for nursing school curricula

• reasonableness of job requirements

• need for orientation in employment setting

• development of tools for prior learning assessment

However, the effect went much beyond the new examinations. A new set of skills was identified for LPNs that previously was only within the RNs’ scope of practice. LPNs were expected to acquire them through continuing education programs. Examples of LPNs being denied positions unless they had these additional skills surfaced across the country. These expanded competencies also had an effect on educational programs. For example, in Alberta, the Professional Council of Licensed Practical Nurses (PCLPN) required all registrants to upgrade their skills and demonstrate that they had completed courses in physical assessment, medication administration, and infusion therapy. In 1997, this was followed by two further additions to the scope of practice: subcutaneous injections and the administration of narcotics (Glover, 2001). The educational programs, in turn, had to include these items in the curriculum.

NorQuest College in Edmonton, the largest program in the country to prepare practical nurses, currently has a course to teach students to administer medications by percutaneous, subcutaneous and intramuscular routes, among many others courses (NorQuest, n.d.). In Manitoba, the CLPNM evaluates programs on a regular basis (every four years). In 1996, major curriculum changes and lengthening of the program occurred; in 1998, the program saw further additions, including initiating IVs. In 1996, based on the new entry-level competencies, the CLPNM adopted a policy that required all LPNs to complete a program in health assessment, intramuscular injections, and urinary catheterization in order to maintain eligibility for registration in 2001. This was subsequently extended to the end of 2002. The Saskatchewan Association of Licensed Practical Nurses gained authority to review and approve the program to prepare LPNs at the Saskatchewan Institute of Applied Science and Technology (SIAST) in 2000. It conducted its first review of the program in 2002 and recommended a five-year approval. Among their recommendations was that the program begin to teach IV administration of medications and the initiation of IVs, and to increase content in several specialty areas (SALPN Report 2003).

Entry to Practice Changes. By 2005, most new RN nursing graduates outside of Quebec (with a few exceptions in Alberta and Manitoba) will have completed a degree in nursing. This “space” left by RN diploma programs offers the opportunity for LPN programs to adjust their educational requirements to include diploma programs and to expand their scope of practice.



For example, in Ontario, the competency assessment project and resultant changes in entry to practice criteria have influenced LPN education. Ontario had not moved as quickly as many other provinces to require a nursing degree for initial licensure of RNs, but there was pressure within the province to adopt this requirement. The question was how, particularly given the size of the educational enterprise. The College of Nurses of Ontario used the NNCP to tackle the issue of entry to practice of both LPNs and RNs by examining what type of education each required to meet their respective competencies. (Note that in Ontario, LPNs are called registered practical nurses or RPNs.) In both cases, the College established an Umbrella Working Group; the group looking at LPN competencies comprised practicing LPNs, union representatives, representatives of the professional organization, educators, and employers. The purpose of this LPN group was to undertake a broad consultation with practising LPNs, practical nurse educators, and administrators (College of Nurses of Ontario, 1999).

Two of the many findings that surfaced during the consultations were that 1) LPNs encounter many barriers in trying to use their full scope of knowledge and skills in practice, and 2) there are wide inconsistencies in expectations for LPNs across practice settings. As a result of the consultations, it was recommended that an expanded set of competencies be expected of beginning LPN practitioners by 2005 and that programs incorporate these expanded expectations by September 2002 at the latest. A subsequent consultation led to several decisions: that programs to prepare LPNs be housed only in community colleges (thus eliminating the three programs that continued to exist in high schools); that programs be at least four terms long (two academic years); and that students graduate with a diploma in practical nursing, a higher qualification than the certificate previously awarded on successful completion of a practical nurse program (College of Nurses of Ontario, 2002).

In many ways, practical nurse education in Canada is at a turning point. The decisions made in Ontario reflect a substantial increase in educational requirements and recognition. In Saskatchewan, while not directly recommending a lengthening of the SIAST program, the SALPN is recommending an expansion of content that would likely require an expanded program. Furthermore, they recommend that the graduates receive a diploma on completion (SALPN, 2003). These changes raise the question of whether the LPN is, in fact, moving to fill the space left vacant by the demise of diploma-prepared RNs. While diploma-prepared RNs will continue to practise in Canada for up to the mid-21st century, increasingly, registered nurses will be degree prepared. Whether degree-prepared RNs will replace those with a diploma or whether LPNs will figure largely in their replacement is unclear, as are the factors that will influence these decisions over the next half century.

The next decade is likely to be a significant one for LPN education as the now differing educational requirements across the provinces are rationalized. Quebec continues to be something of an outlier as it maintains its programs outside the college system (CEGEPS in Quebec), while the other provinces concentrate their programs within their college systems. A new player on the scene in British Columbia and Quebec is the private college, but it is too early to determine how much or what type an impact, if any, these colleges will have.

As noted earlier, the education of RNs and LPNs is inter-related, with LPN education heavily influenced by movement in RN education. There is little evidence, however, of collaboration among the educational programs to introduce the students to the scope of practice of the other or to plan educational experiences that provide opportunities for all types of nurses to learn to work together. In fact, there is far more discussion and concern about interdisciplinary education (i.e., among nurses and other health professionals) than about intradisciplinary education among the three nursing professions. This is a challenge to nursing education for all three professions.



3.3. History of RPN Education in Canada The education of registered psychiatric nurses has a long but largely undocumented history.

Furthermore, it is a history confined to Western Canada. In this aspect, it is unique among educational programs for nurses in Canada. Almost 85 years ago the first program was established in Manitoba, at the then Brandon Asylum. This historical overview does not attempt to discuss all the openings and closings of schools over the years. Rather, it lays out the evolution of the education of RPNs and identifies significant issues that confronted the profession as it developed — and that confront it now — about how and where RPNs should be educated.

The historical overview is divided into four phases: the pre-nursing phase (1886–1920), the developmental phase (1920–1960), the transition phase (1960–2000), and the educational options phase (2000–2004). The challenges confronting the education of psychiatric nurses in each phase will be discussed briefly, with examples, and an attempt made to analyze the issues. The final phase discusses the challenges facing psychiatric nursing education in the future.

3.3.1. The Pre-nursing Phase, 1886–1920

Prisons were opened before mental hospitals in the early days of Western Canada. The federal government built a temporary penitentiary at Lower Fort Garry, Manitoba, in 1871, and the new provincial government was successful in its application to house the violently mentally ill there because there were no other facilities. They remained there until a permanent penitentiary was built at Stony Mountain to which they were transferred in 1877 (Refvik, 1991). The Selkirk Asylum in Selkirk, Manitoba, was the first mental hospital in the West when it opened in 1886. Several others followed in Manitoba, Saskatchewan, Alberta, and British Columbia, in that order.

There were no nurses in these facilities. They did have a medical superintendent and, in the very early days, untrained attendants who “managed” the patients. The first matron and first chief attendant at the Brandon Asylum when it opened had previously been staff members at the prison (Refvik, 1991). While the concept of treating patients in a benevolent and caring manner had been introduced by Tuke in England in the late 1700s (Nolan, 1993), there is little evidence that this approach or any of the more humane methods were manifest in the early Canadian mental hospitals. Even if there had been a desire to adopt this approach, these hospitals were located in rural areas, where staff were not easily found, and they quickly became overcrowded, with patients sharing beds, beds lined wall to wall in large dormitories and patients treated as objects as they were herded from bed to dining room back to dorm and to bed (Refvik). None of these circumstances are conducive to a humane and caring approach.

In 1882, in the United States, Linda Richards opened the Boston City Hospital Training School for Nurses, the first school in the United States specifically to train psychiatric nurses (Psychiatric Nursing, 2004). There was no replication of this in Canada at the time. While schools of nursing were being established in hospitals, starting with the Mack Training School of Nursing at the General and Marine Hospital in St. Catharines, Ontario, (now the St. Catharines General Hospital) in 1874, they were designed to train nurses to care for patients who had physical illnesses.

A Canadian woman, Effie Jane Taylor, who trained as a nurse at Johns Hopkins Training School of Nursing and went on to be the Dean of Nursing at Yale University, introduced the first psychiatric nursing course into a general nursing program in the United States (at Johns Hopkins) in 1913. That started a trend in the United States and Canada of locating psychiatric nursing in all nursing school curricula. While this trend led to the demise of psychiatric nursing training schools in the United States



and Eastern Canada, psychiatric nursing took a different route in Western Canada. Mussallem (1965) notes the influence that early American nurses had on Canadian nursing because of the fact that they wrote so much while Canadian nurses wrote very little.

In 1889, Britain established a two-year training program for attendants working in asylums that included lectures and demonstrations by physicians, and service in the asylum. Following successful completion of an examination that was rigorous for the times, a Certificate in Nursing the Insane was awarded. Most of the public asylums in Britain (approximately 100) participated in the training program and, by 1899, 1,234 male attendants and 1,418 female attendants had successfully completed the program and had been awarded a certificate. The program did not last beyond 1920, however, because having achieved the credential, the attendants did not benefit in any way in terms of their compensation, working conditions, or career opportunities (Nolan, 1993). Despite the limited years that this program existed, it may have influenced the subsequent programs that developed in Western Canada, where a number of the psychiatrists who served as medical directors of the asylums (as they were developed) were recruited from Britain and would have been aware of the training program for asylum nurses and probably had experience with it.

3.3.2. The Developmental Phase, 1920–1960

In 1917, things began to change in Manitoba mental hospital facilities in response to a report by C. Hincks and C.K. Clarke, which was commissioned by the Public Welfare Commission of Manitoba (Refvik, 1991). Hincks had established the Canadian National Committee for Mental Hygiene, which reflected the more enlightened views of psychiatric treatment of the day. Clarke was a professor of psychiatry at the University of Toronto. They described the conditions in the Manitoba facilities as appalling and recommended a number of changes, including the recruitment of more staff (Refvik).

The concept of having a program to prepare nurses had been suggested in Manitoba in 1913, but it was not until 1920 that it came to fruition. In 1914, there were 1,500 patients at Brandon and the only nurse was the matron. The British-trained medical superintendent at the time was married to a nurse and, although this was not documented, she may have been a mental nurse. As such, she may have influenced the hospital to establish a program to prepare “mental nurses” rather than one to prepare the generalist, registered nurse, which was the approach in Eastern Canada’s mental hospitals and the approach adopted in the United States beginning around 1920. Mental nurses came under an established branch of nursing in Britain, where the nursing registry had been created in 1919, and nurses were prepared in a specialty area, such as children’s nurse, general nurse, mental handicap nurse, and mental nurse.

The program at Brandon, Manitoba, was the first in Canada to prepare psychiatric nurses and essentially became a model for programs that were developed a decade later in the other provinces. While the first classes were offered in 1920, it was not until 1921 that a true program was designed and delivered. The Brandon program, under the auspices of the Minister of Public Works, was two years in length and consisted of subjects related to psychiatry and to general nursing and obstetrics (Refvik, 1991). On completion, students received a diploma in Mental Nursing. Seven students graduated in the first class at Brandon. Classes were taught by the medical staff and the matron. Only nursing supervisors were required to take the course, while other nurses took the course prepared for male attendants.

The psychiatric nursing programs in the other three western provinces were all established in 1930 or 1931. The programs were largely delivered to staff members who were already working at the institution. A diploma in psychiatric nursing from the provincial governments was received on



graduation; however, these graduates had no professional standing because there was no process for registering psychiatric nurses.

It is interesting to note that the medical superintendent who was responsible for developing the first program at Brandon (Manitoba), Dr. B.A. Barager, moved on to become superintendent at Ponoka, Alberta, and was instrumental in establishing the psychiatric nursing program there (Registered Psychiatric Nurses Association of Alberta, n.d.).

These early programs were developed by psychiatrists and largely taught by them, with a little input from the matron who by then was a nurse (Refvik, 1991). This is in contrast to the psychiatric nursing programs in the United States, which were developed and taught by nurses — nurses who were some of the best-educated nurses of the time. In Western Canada, and indeed, anywhere in Canada in the first quarter of the century, it was rare to find well-educated nurses and nurses with qualifications to teach. The issues of who should control the programs, what qualifications faculty should have to teach in the psychiatric nursing programs, and the preparation of sufficient faculty have all been challenges over the decades.

The war years were difficult for these programs as many of the male attendants left to serve in the war and the nursing staff were stretched to manage the facilities. Following World War II, the programs were reduced from up to 500 hours of class time to100 hours and were no longer viewed as adequate to address the newer approaches to care of psychiatric patients. Meanwhile, the problems associated with grossly inadequate staffing continued.

In Saskatchewan, the psychiatrist who was the Director of Psychiatric Services for the province explored what the future should be of the psychiatric nursing programs, including whether they should be replaced by programs to prepare registered general nurses. He consulted widely and visited psychiatric centres in Canada and the United States. He was advised to maintain schools to prepare psychiatric nurses because in the experience of medical superintendents of the many psychiatric hospitals he visited, nurses trained in registered nurse programs — regardless of the amount of time spent in psychiatric hospitals as students — were overwhelmingly attracted to general nursing and not to psychiatric nursing. Thus, the decision was made to enhance the programs at the mental hospitals, to increase them to three years in length, and to include 500 hours of classes. The influence of psychiatrists is clearly evident in shaping the design and future of the psychiatric nursing programs, whereas any influence that psychiatric nurses or registered nurses might have had is invisible. This time the decision was based on explicitly modelling the programs on the British system of training psychiatric nurses in and for the mental hospitals (Kahan, 1973). The curriculum was largely developed by psychiatrists, but, unlike the process for previous initiatives, an educator was hired for each institution to run the program, and teaching was done by physicians, psychiatrists, and nursing staff of the institutions. This program remained in effect in Saskatchewan until the early 1970s (Kahan).

In Manitoba, from 1943 to 1957, a four-year combined program between the Brandon Mental Health Centre and the Winnipeg General Hospital prepared nurses as both general (registered) nurses and as psychiatric nurses (RPNAM, 1977).

3.3.3. The Transition Phase, 1960–2000

Beginning in 1948 in Saskatchewan — and later in the other provinces — legislation was initiated to recognize psychiatric nursing as a distinct profession and to transfer the control of the educational programs to psychiatric nursing councils. While the original psychiatric nursing programs



were under the authority of the provincial governments, the medical superintendents of the hospitals were directly responsible for them. In 1960, in Manitoba, the government simultaneously passed an act establishing “psychiatric nursing as a separate professional entity” and created the Psychiatric Nurse Education Advisory Committee, which had responsibility for establishing admission criteria, the curriculum, and the examinations (RPNAM, 1977, p. 4). However, this committee was chaired by a psychiatrist and was dominated by psychiatrists and the medical directors of the provincial hospitals. It was not until 1980 that further legislation in Manitoba gave the College of Registered Psychiatric Nurses the mandate to approve the educational programs. Similar developments occurred in the other provinces with the passing of psychiatric nursing acts that gave control of the programs to councils that were controlled by psychiatric nurses.

Beginning in the early 1970s, a major shift occurred in every province when programs were transferred from the psychiatric hospitals to colleges and universities. Unlike previous educational developments in psychiatric nursing, this one was led by British Columbia, and Manitoba was the last to make a move. The first program to transfer was in British Columbia in 1971, when the program was moved to the British Columbia Institute of Technology (BCIT) from the Riverview Hospital, concurrent with a transfer of the authority for the program from the Ministry of Health to the Ministry of Education. BCIT launched the program in 1972 and structured it so that it was approximately two years in length, and the first year was common with the first year of the program to prepare registered (generalist) nurses. This program was restructured in 1978 when the two programs were separated, and it continued to graduate students until 1988. In 1984, the Ministry of Education transferred the existing program from BCIT to Douglas College, where it remains. The initial two-year program replicated the previous one, with the first year common with students in the RN program. However, this program was revised and separated from the RN program in 1987.

In Saskatchewan, the transfer of programs from the psychiatric hospitals to the Wascana Institute of Applied Arts and Sciences in Regina occurred in 1972. The Saskatchewan Institute of Applied Science and Technology (SIAST) was created and continued to house an RPN program until 1996, when it was integrated into the four-year Nursing Education Program of Saskatchewan (NEPS), a partnership program of SIAST and the University of Saskatchewan. Students from this program graduated with a Bachelor of Science in Nursing degree, but they could exit after three years, undertake an additional eight weeks of clinical practice in a psychiatric setting (thereby obtaining a Diploma in Psychiatric Nursing from SIAST), and take the examinations to qualify and register as a registered psychiatric nurse.

Both Alberta and Manitoba were much later than the other two provinces in moving programs out of the mental hospitals. In Alberta, control of the program at Ponoka was transferred in 1996 to Grant MacEwan College in Edmonton, which continued to situate a two-year diploma program at Ponoka. The Registered Psychiatric Nurses Association of Manitoba was highly skeptical of the value of moving from hospital-based programs to community colleges (RPNAM, 1977). It effectively gained control of the programs in 1980 when it received the authority to self-govern, including the authority to approve educational programs.

The Manitoba program moved to Brandon University rather than to a community college. In 1986, Brandon University established a post-diploma degree program for registered psychiatric nurses, and graduates received the degree Bachelor of Science in Mental Health. The two diploma programs at Portage La Prairie and Selkirk closed and the diploma program was consolidated at the Centre for Psychiatric Nursing Education at the Brandon Mental Health Centre. However, in 1995, the Manitoba government accepted the position that nurses should have a degree to practise, and so reorganized nursing



education in the province. General nursing education was placed under the control of the University of Manitoba, and psychiatric nursing education was located at Brandon University, which developed a four-year program resulting in the degree Bachelor of Science in Psychiatric Nursing. Students also had the option to exit at the end of three years with a diploma in psychiatric nursing, but this was limited to six students annually. Since 2000, Brandon University has offered all four years of the degree program in Winnipeg as well as in Brandon.

By the end of the 1990s, the shape of psychiatric nursing education was very different than it had been 30 years earlier. No programs were based in mental hospitals, and all had to meet standards set by provincial psychiatric nursing councils. The era of psychiatrist control and apprenticeship-based programs was over. Many of the faculty members who taught students in the various programs had training as registered psychiatric nurses. However, the structure of the programs across the four provinces differed considerably, the preferred qualifications of faculty were far from clear given that the programs were in colleges and universities, and no progress had been made toward establishing graduate programs.

At the start of the 21st century, there were two-year diploma programs in community colleges in British Columbia and Alberta. A third program was integrated into a four-year degree program with a diploma exit after three years in Manitoba. The fourth program, which included preparation to be a registered nurse, was integrated into a four-year degree program with a diploma exit after three years in Saskatchewan. One diploma program had started with a common year with the RN program in two different institutions, but both attempts had been abandoned and the program to prepare RPNs was separated from the one for RN preparation.

There is degree access in British Columbia through an arrangement between Douglas College and The Open Learning University of British Columbia; graduates with Douglas College’s advanced diploma in psychiatric nursing may pursue a Bachelor of Health Sciences in Psychiatric Nursing degree. In Alberta, graduates of Grant MacEwan College may pursue a Bachelor of Nursing Degree at the University of Alberta but, in the process, must meet the qualifications as an RN. They may also do Brandon University’s post-diploma degree in mental health. Saskatchewan students, until 2001, could exit from the NEPS program after three years, qualify as an RPN, and then re-enter the program for a year and receive a BScN degree. Brandon University offers the only dedicated four-year degree program to qualify as an RPN. This is a lot of variety in degree education for a small profession. Except for Manitoba, the degree programs available to students are not exclusively under the control of RPN Councils.

3.3.4. The Educational Options Phase, 2000 One of the major objectives of the professional psychiatric nursing organizations is to achieve

degree education as entry to practice. They are part way there, but the routes vary and the immediate future looks even more complicated than the past.

Manitoba has a four-year degree program but maintains a diploma exit, which few students take. In Alberta, the two-year diploma program at Grant MacEwan College is stable. The normal enrolment of 25 students per year was augmented in 2003–04 through funding for an additional 35 students. This was announced as a one-time-only increase, but efforts are underway to make it ongoing. There is no generic degree program in sight.

A challenging initiative is coming from Douglas College in BC, which has recently been authorized to grant applied degrees. There are tentative plans to offer a four-year applied degree in psychiatric nursing. If approved, this plan will introduce another degree option into the stable of options,



albeit one that differs from all of the others. Also in BC, Kwantlen University College has recently designed and internally approved a baccalaureate degree program in psychiatric nursing and is awaiting funding approval.

Since 2001, Saskatchewan has not had a program to prepare RPNs. In the early 1990s, diploma programs to prepare RNs were available in Regina and Saskatoon through SIAST, but the only degree program was at the University of Saskatchewan in Saskatoon. The RPN program at the time was offered through SIAST, and while it was a separate program, it had a common first year with the RN diploma program; they both shared about six months of common study with the program to prepare LPNs. The government invited the RN programs in Saskatchewan to develop a nursing program that could be offered in both cities. A planning committee was struck with representatives of SIAST, the University of Saskatchewan College of Nursing, and SRNA, and together they planned for a degree program that would be jointly offered by SIAST and the University of Saskatchewan, in both cities. Originally, RPNAS was not part of the plan but they were invited to join; in 1993, after extensive consultation and debate, they did become part of the planning process. In making this decision, RPNAS recognized that it was risking losing students to the registered nursing profession.

Representatives of diploma and degree RN education and RPN education developed the program. The Nursing Education Program of Saskatchewan (NEPS) was launched in 1996, and students had two options: graduate with a degree from the University of Saskatchewan and write licensure examinations to become an RN; or, exit after three years, complete an additional eight weeks of psychiatric nursing practice, receive a diploma in psychiatric nursing from SIAST, and then write the licensure examinations to become an RPN. Students could also do both options: take the diploma, exit, and write RPN registration exams, register as an RPN, return and complete the degree program, write RN registration exams, and register as an RN. Since both RPNAS and SRNA have the legislative authority to approve educational programs for their disciplines so the graduates can write licensure examinations, each gave conditional approval to the NEPS program at its start, consistent with the standard for new program approval.

The worst fears of the RPNAS were realized, and relatively few students chose to exit after three years (RPNAS, n.d.). The Registered Psychiatric Nurses Association of Manitoba refused to recognize the NEPS graduates and to allow them to register in Manitoba on the basis that there was too little psychiatric nursing content in NEPS (RPNAS, n.d.). In 2001, the RPNAS withdrew its approval of the program. Since 2001, there has not been a program to prepare psychiatric nurses in Saskatchewan.

To try to resolve the situation, the provincial government has developed a committee that includes representatives of the RPNAS, SIAST, the University of Saskatchewan, and government, as well as an employer and a consultant. The RPNAS has proposed a number of solutions that include the following.

a) Broker the Brandon University program to the Saskatchewan Indian Federated College (now the First Nations University).

b) Create a separate stream in the NEPS program that would lead to the degree BScPN.

c) Develop a new ladder program that would lead to preparation as a licensed practical nurse in the first two years and then split to prepare RNs and RPNs in separate two upper years, with both programs leading to degrees (BScN and BScPN, respectively).



d) Develop a series of diploma programs in the college system across the province through a brokering arrangement with Brandon University.

With all of these options, the request is for funding to support an annual intake of 60 students (RPNAS, n.d.). While the process is not completely at a stalemate, after three years of discussion, there is still no educational program to prepare RPNs in Saskatchewan at either a diploma or degree level. NEPS is moving forward with plans to develop an accelerated two-year program for students with a previous university degree, adding 100 seats/places to the RN degree program in the process.

The evolution and demise of this initiative in Saskatchewan has been described in some detail because, in the history of RPN and RN education, it represents the most extensive trial of integrating nursing education for two nursing professions while attempting to retain opportunities and separate identities for both.

Currently in Canada, there are only three programs to prepare RPNs: a two-year diploma, another two-year diploma with tentative plans to replace it with a four-year applied degree, and a four-year degree program with a diploma exit.

The future of psychiatric nursing is dependent on the educational programs that produce RPNs. Since psychiatric nursing is to some extent a stepchild of the British nursing structure, it is useful to note the direction that education is taking there. Britain is moving toward degree preparation for all nurses, but currently there are still three-year diploma and four-year degree nursing programs. The four specialist areas in nursing (children’s, general, mental handicap and mental health nursing) are maintained and programs are structured so all students in a nursing program spend the first half of the program in the study of common subjects and the latter half in their specialty area. They then register in the specialty nursing registry that reflects their education. It is interesting to note that several Canadian programs have tried then abandoned having RPN and RN students start their programs in a common first year.

The development of psychiatric nursing education at the baccalaureate degree level requires having faculty prepared at the graduate level to teach them. It is unclear what constitutes an appropriate graduate degree for RPNs seeking to teach. A scan of the preparation of faculty members in the three programs reveals a wide range of graduate degrees. This provides an opportunity for the profession to examine all these routes and determine if one is preferable to the others. Universities in the 21st century have raised the bar as to the level of preparation and scholarship required for an academic position. This will pose more of a challenge to psychiatric nursing as it seeks to locate its education at the university level than it did to the establishment of degree programs to prepare registered nurses over the last century (when requirements were not as high).

Psychiatric nursing is an integral part of the British nursing system but only a small part of the Canadian nursing system, which is dominated by registered nurses and their organizations and educational programs. It is unfortunate that the professional organizations that represent RNs and RPNs have neither cooperated over their history nor supported each other’s aspirations. Jeans (2003) called for a unification of nursing organizations so that nursing could speak with one voice. She asked, “Does the discipline of nursing consist of one coherent body of knowledge, or is it indeed three different bodies of knowledge?” (p. 32), referring to LPNs, RNs, and RPNs. Given the dynamic status of psychiatric nursing education, it might be appropriate to ask, “Is this the time to examine how these three types of nursing education might be more coherently organized to reflect nursing as the core discipline?” This does not imply a merger of the three into one generic program; however, the education of registered nurses is on the brink of having achieved a degree as entry to practice and is quite firmly entrenched in universities



across the country, and LPN education is moving to a consistent two-year diploma approach in colleges, leaving RPN education orphaned. Where should it fit in this picture and what is the responsibility of nursing education overall to bring coherence to this picture?



4. Nursing Education in Canada and Key Source Countries

This section offers a comparison of the nursing education systems for RNs, LPNs, and RPNs in Canada with the education systems in countries from which Canada receives the most immigrant nurses. Programs are compared on the basis of availability, graduating credential, length (duration), and location, where such information is available. The information was gathered using Web-based research.

RNs China, Hong Kong, India, Jamaica, the Philippines, the United Kingdom, and the United States

LPNs the United States and the Philippines RPNs the United Kingdom In general, RN, LPN, and RPN programs, and the credentials awarded in Canada and in countries

that produce nurses who migrate to Canada, are similar. Overall, the picture within all three nursing professions (RNs, LPNs, and RPNs) is of a nursing world increasingly uniform in the pattern of nursing education and one likely to move even closer to common patterns of nursing education for each of the nursing professions internationally in the future.

RNs. RN education is increasingly moving to university-based, four-year degree programs.

• India has recently announced that it is striving to replace all its diploma programs with university degree programs by 2005, although there are grave doubts about its ability to achieve this objective because of a shortage of prepared faculty (Healthcare Management, 2003; Nurses Directory – Nursing Colleges in India, n.d.; Sri Ramachandra Medical College & Research Institute, n.d.).

• China is opening new baccalaureate schools of nursing regularly as it drives up the quality of its nursing workforce (Chinese University of Hong Kong, n.d.; Hong, Y. & Yatsushiro, R., 2003; Hong Kong Polytechnic University, n.d.; Nursing Council of Hong Kong, n.d.; Smith, D. R. & Tang, S., 2004; University of Hong Kong., n.d.; Xu, Y., Xu, Z. & Zhang, J., n.d.).

• Jamaica has recently made generic baccalaureate education available (Ministry of Health, n.d.), and the Philippines has moved its entire nursing education system to the degree level (Philippine General Hospital, n.d.).

• The country perhaps farthest from achieving this goal is the United States (Saint Louis University, n.d.; University of Minnesota School of Nursing, n.d.).

LPNs. LPN education varies in length in Canada more so than in other countries. It is more common to find two-year programs here to prepare LPNs rather than the programs of shorter duration found elsewhere, with the exception of the United States where the college-based programs are one year in length.

RPNs. It is not surprising that RPN education is found only in the United Kingdom and Hong Kong (until recently a colony of the U.K.). The rest of the world is increasingly following the North American model of generic nursing education at the undergraduate level with specialization at the



graduate level or through a combination of experience and continuing education programs. In these two countries bucking the trend, they favour degree programs over diploma programs.

It is important to note that all Canadian provincial nursing registering bodies assess each international applicant individually. For example, according to the College of Nurses of Ontario, all international nurses must have completed a nursing program that is equivalent to Ontario nursing programs, provide evidence of recent safe nursing practice, pass the Canadian registration examination, be fluent in written and spoken English or French, and be of good character and suitable for practice (College of Nurses of Ontario, 2004). It is not possible to become an RN, LPN, or RPN in Canada solely on the basis of the type of education program and credentials of the applicant (e.g., LPN diploma, BScN degree, RPN diploma or degree) — they must also meet the above requirements.

Table 2. Overview of RN Programs, in Canada and Source Countries Country RN programs

Type/credential granted Length Location

BScN or equivalent Bachelor of Nursing (BN)a 4 years Canada

RN Diploma 3 years universities community colleges

Baccalaureate 5 years universities China

Secondary Program (diploma) 2–4 years secondary nursing programs health schools

Bachelor of Nursing 4 years Hong Kong

Higher Diploma in Nursing 3 years universities

BSc (Nursing) 4 years India

General Nursing & Midwifery diploma program 3 years universities colleges

Jamaica Diploma programs in hospital schools of nursing Bachelor of Science in Nursing

3 years 4 years

independent schools of nursing

universities

Philippines Bachelor of Science in Nursing (B.S.N) 4 years universities colleges

BA/BSc/BNurs 4 years United Kingdom Diploma of Higher Education in Nursing 3 years

universities colleges of higher education

BScN/BSN 4 years

Associate Degree (diploma) 2 years

United States

Hospital School (diploma) 3 years

universities community colleges hospital schools of nursing

Note. In 2004, there are 128 schools in Canada that participate in preparing students to become registered nurses (RNs).

aThese programs are similar in the countries being compared.



Table 3. Overview of LPN Programs, in Canada and Source Countries Country LPN programs

Type/credential granted Length of program Location

Canada Outside Quebec: LPN diplomaa Quebec: Nursing Assistants

12 months to 2.5 yrs 18–24 months

(Outside Quebec)b

(Quebec)c

China n/a n/a n/a

Hong Kong “Enrolled Nurse” 2 years recognized hospital-based training programs

India “Auxiliary Nurse Midwifery” 2 years schools of nursing

Jamaica Enrolled assistant nurse 18 months 4 community colleges

Philippines “Nursing Attendants” Secondary Course Information not available

secondary courses

United Kingdom

Training no longer exists but many nurses remain in practice

n/a n/a

United States of America

“Practical Nurse” diploma 1 year community colleges

Note. n/a = not applicable. In 2004, there were 93 schools in Canada that prepare students to become licensed/registered practical nurses (LPNs).

aIn Canada, outside Quebec, and Ontario, LPNs graduate with a licensed practical nurse diploma, in Ontario, they graduate with registered practical nurse diploma.

bOutside of Quebec, these schools are located in community colleges except for a recent development that has seen some programs established in private colleges in British Columbia and Quebec.

cIn Quebec, the program provided through 44 Centres de Formation Professionelles are administered through boards of education on behalf of the Ministry of Education.

Table 4. Overview of RPN Programs, in Canada and Source Countries RPN programs

Country Type/credential granted Length Location

Diploma in Psychiatric Nursing 2–3 years Canada

Bachelor of Science in Psychiatric Nursing (BScPN) 4 years universities and colleges

China n/a n/a n/a

Bachelor of Psychiatric Nursing 4 years Hong Kong

Higher Diploma in Psychiatric Nursing 3 years universities

India n/a n/a n/a

Jamaica n/a n/a n/a

Philippines n/a n/a n/a

United Kingdom

BA/BSc/BNurs in Mental Health Diploma in Mental Health Nursing

4 years 3 years universities and colleges

United States of America

n/a n/a n/a

Note. n/a = not applicable.



5. RN Education and Capacity — Survey Findings

Questionnaires were sent to 129 schools and responses were received from 73 schools for an overall response rate of 57%. The regional response rates are reported in Table 5.

Table 5. Regional Response Rates to Survey Questionnaire, RNs West/North Central Atlantic

ON QC

No. schools 35 37 48 9

No. received 21a 22b 18 70

Response rate 60% 59% 37.5% 78% Note. Three schools did not report where they were located. aThree schools reported as one (SK). bTwo schools reported as one (ON).

5.1. Types of Programs That Prepare RNs As of 2004, Canada had 128 institutions that have a role in the preparation of students to become

registered nurses in English- or French-language programs. (This does not include universities that admit only diploma-prepared registered nurses to pursue a nursing degree.) These include 43 universities and university colleges, 1 institute of technology, and 82 community colleges and 2 schools administered by health care organizations. In British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, and Newfoundland, all colleges and universities have formed consortia to offer degree programs. Quebec schools at the college (CEGEP) and university levels have recently formed consortia to offer baccalaureate education, and students were admitted to these programs in the fall of 2004. In Prince Edward Island, New Brunswick, and Nova Scotia, the responsibility for nursing education has been assigned to universities; the universities in NB and NS offer their programs across several sites.

Each school that participates in the preparation of RNs was sent a questionnaire. Two consortia chose to answer as one institution; therefore, while we have information from 73 schools, the results are reported for up to 70 RN schools because in one case, three collaborative partners reported as one and in the other case, two partners reported as one. The phrase “up to” is used because not all participants completed questionnaires, or answered all the questions; therefore, the number of responses to each question is included as part of the results.

The 72 institutions for which we have information (one school did not respond to this question) offered the programs listed below.



No. schools (N=72)

Type of Program

9 2-yr. Nursing Baccalaureate

Programs for students who have previous university degrees or credits.


Programs for students who have previous university degrees or credits.


Programs for students without previous university degrees or credits.


Programs for students without previous university degrees or credits.

5 2-yr. Nursing Diploma

22 3-yr. Nursing Diploma

Only 18 of 70 schools (26%) reported that they offered bridging programs that recognized prior learning and facilitated licensed/registered practical nurses to become registered nurses.

Two-thirds (68%) of 66 reporting schools indicated that they did follow-up surveys to track their graduates, including asking about their location and employment status.

5.2. Student Admission and Enrolment, RNs The first question to be answered was: What is the current capacity of schools that prepare

registered nurses? In order to determine the capacity of RN programs and the stability of this capacity, the schools were asked: for their current level of admissions, for the changes to these admission levels over the last three years, whether the target levels for admission had been met or exceeded, and about plans for expansion and contraction of admission levels for the next year.

5.2.1. Admissions, 2002, 2003

All but two schools reported their admission data for the fall of 2003. Schools were also asked to compare their 2003 admission numbers with those from 2002.

Comparison of 2003 and 2002 Admissions

2003 Admissions (N=68)

68 schools admitted a total of 7,732 full-time and 219 part-time students.

All schools admitted full-time students, ranging from 9 to 362 students per school, with a mean of 114 and a median of 89 students.

Only 16 schools admitted part-time students, ranging from 2 to 83 students per school.

Comparison with 2002 (N=66)

33 schools reported an increase in admissions of a total of 889 students, ranging from 1 to 114 students.

14 schools reported a decrease in admissions of a total of 301 students, ranging from 1 to 80 students.

19 schools reported no change, with 3 schools not reporting.

This represents an overall increase of 590 students admitted to first year in 2003 as compared to 2002.



5.2.2. Gender Profile of Admitted Students

A total of 59 schools reported the breakdown of men and women in their admission numbers. Two schools had admitted no men and the rest had admitted from 1 to 39, for a total of 598. These 59 schools had admitted 6,000 women. Therefore, 9% of these admissions were men.

5.2.3. Admission Targets

Schools were asked if they had met their admission targets for three years, 2001–2003. These years were chosen because 2001 represented the year in nursing education in Ontario when most collaborations were established between colleges and universities, and the majority of students were admitted to baccalaureate programs jointly offered by these new collaborative arrangements.

The number of schools reporting in each year varied, so the numbers are reported as percentages. In 2002, 71% met or exceeded their admission target and in 2003, 69% did. As seen in Table 6, over the three years, the target number of students that schools were seeking to admit went up and the ability of schools to meet those targets improved slightly.

Table 6. Admission Targets and Success in Meeting Them, 2001–2003, RNs

Year Target Exceeding target Below target

Range Total no. % Total no. % Total no.

2001 (N=63)a 16–355 4,477 27 338 34 347

2002 (N=66) 30–480 5,425 29 279 29 454

2003 (N=65) 30–480 7,600 34 217 31 327 aSince admissions in Ontario as of 2002 would be into the collaborative programs only, schools in that province

were asked to report only their 2001 admissions to the collaborative programs and not to the diploma programs, which some maintained.

Admission Plans. Schools were asked to report on the following items regarding admission plans

for 2004. All but 1 of the 70 schools reported. If the following targets are met, the overall number of admissions will increase by a modest 60 students, or .01%.

Results Admission Plans for 2004

70% (48 schools) Plan no change.

17% (12 schools) Plan to increase levels by 6–95 students, for a total of 323 students.

13% (9 schools) Plan to decrease levels by 6–75 students, for a total of 263 students.

5.2.4. Enrolment Targets

Schools were asked to report the enrolment figures for each year of their programs as of October 1, 2003. The Ontario schools were instructed to report only the enrolments in their collaborative programs, not the enrolments in the diploma programs that would end in 2004. Therefore, the numbers for Year 4 of programs captures only the number of students who entered baccalaureate programs in 2000 or earlier, the year before students were admitted to collaborative programs in Ontario. The number of full-time students in total in each year is reported in the following table.



Table 7. Total Full-time Students Enrolments Across all Program Years, RNs Year of program

No. schools reporting

Range of enrolment

Total enrolment

Year 1a 58 9–312 5,986

Year 2 62 7–288 5,728

Year 3 64 1–379 5,673

Year 4b 31 2–361 3,247

Total – – 20,634 Note. Quebec’s 3-year university programs were classified as years 2, 3, and 4. A 2-year degree program was

classified as years 3 and 4. aSome baccalaureate schools do not admit a first-year class. bMost college programs do not have a fourth-year class.

As Table 7 indicates, there are 20,634 full-time students currently enrolled in the 66 schools that reported. For Year 1, 58 schools reported an enrolment of 5,986; however, in an earlier question, 68 schools reported an admission of 7,732. This discrepancy reflects the fact that schools vary, even from report to report, with regard to the actual program year they use when calculating final enrolment numbers. This in turn is influenced by whether it is a two-, three- or four-year program.

As seen in Table 8, fewer part-time students enrolled in each year as compared with full-time students. A total of 649 part-time students are enrolled.

Table 8. Total Part-time Student Enrolments Across All Years, RNs Year of program


Range of enrolment

Total enrolment

Year 1 15 1–83a 159

Year 2 21 1–48 242

Year 3 12 4–24 147

Year 4 7 1–70 101 aOne school had a large part-time enrolment in Year 1, but the other 14 schools had enrolments of 1–24 students.

5.2.5. Aboriginal Students

Schools were asked to report on the following items regarding Aboriginal recruitment and enrolment. All but 1 of the 70 schools reported. The schools were asked to report only the numbers of students who had self-identified as Aboriginal.



Results Aboriginal Recruitment and Enrolment (N=69)

433 students Number of Aboriginal students currently enrolled. These students were enrolled in 27 schools, or 39% of the schools participating in this study. The numbers per school ranged from 1 to 132. The schools with the three largest enrolments (72, 96, and 132) were in Western Canada.

14 schools (20.3%) Specific number of places reserved for Aboriginal students, for a total of 84 places. These reserved places could be filled by non-Aboriginal students if sufficient numbers of Aboriginal students could not be recruited.

Number of schools that employ special recruitment strategies to attract Aboriginal students.

5.2.6. Retention Rates

Schools were asked to report on retention rates for two classes: those entering in 1998 and in 1999. There is much debate as to what should constitute retention. For this study, schools were asked to report on the total number of students who started in 1998 and in 1999, and who had completed the program regardless of the time it required. Clearly some of the students from the classes entering in 1998 and 1999 may not have yet completed but are expected to; nonetheless, they are not included in these numbers. Schools were asked to report on the retention rates for whatever program was in place in those years. Table 9 shows the results.

Table 9. Retention Rates for Classes Entering in 1998 and 1999, RNs

Year admitted


Total students admitted

Total students completed

Retention rate (Range)

1998 45 3,553 2,370 66.7% (33–100%)

1999 42 3,755 2,294 61.1% (22–100%)

For the admission year of 1998, 8 schools reported rates of less than 50%, 5 had rates greater than 90%, and half had rates of 74% and higher.

For the admission year of 1999, 3 schools reported rates of less than 50% (22%, 47% and 48%), 4 had rates greater than 90% (91%, 96%, 98% and 100%), and, again, half had rates greater than 74%.

5.3. Resources to Maintain or Increase Enrolment, RNs The second question to be answered was: What resources are available to schools of nursing to

support their current enrolments and what resources would be required to allow them to expand? A set of questions was asked about current resources and what were constraints on their ability to expand because the additional resources needed to manage the expansion would not be available.



Table 10. Capacity of Schools to Maintain Current Enrolment, RNs


Type of resource Adequate Insufficient Excess

Items on questionnaire %

63 Faculty to teach courses 66 33 1

68 Faculty to supervise clinical practice 40 59 1

69 Number of student applications 56 16 28

65 Number of community placements 38 62

69 Number of acute care placements 41 57 1.5

68 Number of long-term care placements 84 12 4

60 Number of preceptors needed 32 67 1

68 Classroom space 61 37 1

69 Clinical laboratory space 57 41 1

68 Space for student life 57 41 1

69 Faculty office space 52 48 —

69 Meeting rooms for planning 55 45 —

68 Financial support for students 30 70 —

69 Administrative support staff 57 43 —

69 Back-up teachers to cover absences 14 86 —

69 Computers and technical support for students 74 26 —

68 Mentoring of novice teachers 46 53 1

67 Staff to coordinate students' sections 3 16 1

Items added by responding schools / —

A few Counselling for students — —

A few Assistance for students whose first language is neither French nor English

— —

A few Scholarly development of faculty — —

A few Recruitment of faculty — —

A few Enough applications from students to fill the classes

Note. The number of schools responding varied so the responses are reported as percentages. Some schools did not respond to some items; others indicated that they did not require certain resources (e.g., community placements) so they did not assign a rating to the item.

The resources can be grouped into five categories: faculty, students, clinical placements, space,

and administration. The responses indicate that many schools are stretched to manage the number of students they currently have, particularly across faculty and clinical placements, as follows.



% of Schools Summary of Responses by Schools, on Resources

86% have too few back-up teachers to manage the clinical teaching of students (administration/faculty)

70% cannot meet the need for financial support to students (administration)

60% have insufficient clinical placements available in acute care and the community (clinical placements)

60% have insufficient clinical teachers and preceptors, according to faculty (clinical placements)

40–50% indicated shortages of space (space)

Other factors that impact resources. In addition, many schools commented on their particular circumstances and what they also had to consider in determining the number of students they could manage.

• The most frequent comments related to the difficulty of recruiting faculty with preparation at the master’s and doctoral levels. This was identified as a particular issue by small schools and those located in rural and more remote areas, but it certainly was not confined to these schools.

• The second most frequently identified factor was lack of clinical placements, particularly in the community. This issue will surface again in the section on the use of clinical placements.

• Some schools noted that they had several new instructors who were not receiving the support they required because resources were too tight. This creates stress for these instructors and for the whole program.

• Some schools noted that collective agreements at their institutions limit their flexibility in the deployment of faculty members. This lack of faculty for all types of positions is compounded by a lack of degree-prepared nurses in the clinical environments to serve as preceptors.

Resources Needed to Increase Enrolment. Schools were asked to indicate the resources they

would require to increase their enrolments by 10%, 25%, 50%, and 100% (i.e., to double them). These resource requirements are indicated in the following four tables. Schools were asked to indicate if their current resources were sufficient to accommodate the proposed increase, if they would require additional resources but with those additions could manage the increase, or if it was simply not possible to increase their enrolments because the additional resources were not possible to procure.



Table 11. Capacity of Schools to Increase Enrolment by 10%, RNs


Type of resource Have sufficient

Additional required

Not possible

%




62 Number of community placements 40 40 19

66 Number of acute care placements 38 41 21






65 Faculty office space 34 57 9

65 Meeting rooms for planning 42 49 9

65 Financial support for students 28 62 11

66 Administrative support staff 38 53 9

66 Back-up teachers to cover absences 12 73 15

66 Computers and technical support for students 39 48 12

66 Mentoring novice teachers 32 58 11

66 Staff to coordinate students sections 45 44 11

Summary of responses. The responses indicate that more than half the schools would require

additional resources to accommodate even a 10% increase in enrolment. In summary, about 80% of schools could expand enrolments by 10% with current or additional resources that are available to them, if they had the financial resources to acquire them.

Results Key Areas of Resources

Two-thirds Have sufficient — in only two areas: number of applications from potential students, and number of long-term care placements.

Majority Require additional/Have sufficient — for faculty to supervise clinical practice and availability of back-up teachers (where the most severe shortages are).

10–20% Not possible — for any given resource type.

18% / 20% Not possible — (18%) for sufficient preceptors and necessary space for planning is simply not available; (20%) for placements in acute care and the community (the areas of greatest constraint).






Additional required

Not possible

%



















Summary of responses. The responses indicate that 60–70% of schools would require additional

resources to accommodate a 25% increase in enrolment. Obviously, schools that could not manage a 10% increase were not able to support a 25% increase.


40–50% Have sufficient — long-term care placements and student applicants.

50–65% Require Additional — faculty, community and acute care placements, space, and computers.

30% Not possible — in the critical areas of faculty and clinical placements.

15% Not possible — Space is a problem.






Additional required

Not possible

%


60 Faculty to supervise clinical practice 42 58

















Summary of responses. Approximately one-third of the schools either have the resources or

could acquire sufficient resources to allow them to expand their enrolment by 50%.


one-third Have sufficient / Require additional

half Not possible —cannot recruit sufficient students, faculty to teach courses, or faculty to supervise the students clinically; do not have access to sufficient physical space.

half to two-thirds Not possible — in the critical areas of faculty and clinical placements; cannot acquire sufficient clinical practice placements in any setting.






Additional required

Not possible

%


60 Faculty to supervise clinical practice 30 70


56 Number of community placements 21 79

59 Number of acute care placements 20 80










60 Back-up teachers to cover absences – 40 60




Summary of responses. The responses to the ability to accommodate a doubling of enrolment are

not dramatically different than those for a 50% increase. Despite this, the majority of schools now indicate that they cannot manage a 100% increase.


80% Not possible — in the area of community or acute care placements, and the number of preceptors needed.

60%–70% Not possible — in the critical area of faculty. 60% report that they could not recruit sufficient faculty to teach courses. 70% report that they could not recruit sufficient faculty to or supervise students clinically. These are core resources for any school of nursing.

50–60% Space is viewed as a major constraint.



5.3.1. Summary of Capacity to Increase Enrolments

The following table summarizes the potential of the schools to expand their enrolment.

Table 15. Summary of Capacity of Schools to Expand by 10%–100% Potential to expand by given %

10% 25% 50% 100%

%

Have sufficient <25 15 5-10 0

Require additional ~60 55–60 40 20b

Not possible ~20a 30 ~50 80c aNot possible as they are using all the acute care units and patients that are or can be made available. bThey have access to sufficient student applications, teachers, clinical placements, and space to make it possible. cNot possible because essential aspects of running a program (resources such as community and acute care

placements, faculty to teach clinically, and preceptors) are not available for that big an enrolment.

Most Limiting Factors to Enrolment Expansion. Schools were asked to identify the three most limiting factors to enrolment expansion. The frequency with which the most common factors were listed by the schools is listed below.

Reporting frequency of factors Additional list 56 clinical placements 39 full-time faculty 20 clinical faculty 20 sufficient budget 16 space 10 classroom space 9 laboratory space on campus 9 qualified applicants 8 preceptors

In addition to the previous list, one to three schools also identified the following factors. • teacher workload • computers • student housing • government or university policies that limit

enrolments • distances to clinical placements

(e.g., 140 km)

There are four major categories of constraints: clinical placements, with community and acute

care being frequently identified; too few faculty members, including part-time clinical and regular full-time faculty members; space; and budgets. The budget may be a surrogate for too few faculty members. Schools explained that their limited budget did not allow them to hire enough faculty and they could not offer salaries that were competitive with clinical positions such as senior nurses and clinical nurse specialists. Therefore, they could not recruit the number or quality of clinical teachers they needed. A few schools indicated that they did not have enough good applicants.

5.3.2. Preferred Number of Students

They were also asked about the number of additional students they believed they could accommodate if they were asked to increase their enrolments and if the financial resources they required were made available to them. The results are as follows.



Potential number of admissions

Given current resources (n=68)

14–300 students per class (2 schools reported 0) –— schools would prefer to admit. It is interesting to compare this with the current first-year target admission numbers of 30–480 students in a class.

7,491 students in total — schools would prefer to admit, entering in 2004. This is remarkably close to the 7,600 (full time) target for the 2003 entering class.

Given extra financial resources (n=63)

2,101 additional students total — schools could manage to take, with proposed numbers ranging from 0 to 170.

The majority of schools (76%) could manage increases in their enrolments with additional financial resources, and almost half (48%) could manage substantial increases of 30 or more students per class, as follows:

Increase No. of schools that could manage the increase 0 students ..................... 15 schools 5–10 students ............... 7 schools 12–25 students.............. 11 schools 25–90 students ............. 19 schools 70–99 students ............. 7 schools 100–170 students ......... 4 schools

5.4. Faculty Recruitment, RNs The schools were asked to report the number of faculty vacancies they were seeking to fill in

2003, the credentials they were seeking in the candidates, the number of these positions they filled and the difficulty they had in filling them. The vacancies were divided into three categories: full-time tenure stream/permanent positions, full-time contract (time-limited) positions and part-time contract positions. The results are reported in Table 17.

Table 16. Number and Type of Faculty Positions Available in 2003

Type of position No. schools reporting

No. with positions

Range per schoola

Total No. available

No. filled

Tenure stream 66 51 1–13 176 125

Full-time contract 63 46 1–42 264 317b

Part-time contract 64 55 1–285 1,294 1,241 aThe range refers to the number of positions available in any one school. bAdditional contract positions were filled because candidates for all the tenure positions could not be found and

some of these positions were converted to contractual ones.

5.4.1. Full-time Tenure Stream/Permanent Positions

The schools were asked if they were able to recruit people with the kind of credentials and experience they were seeking. Of the 52 schools that had been trying to recruit faculty and that responded to this question, 56% said they were able to find the kind of people they were seeking, 15% were not, and 31% said they were partially successful. The schools were invited to write an explanation for their answers. The reasons they gave included the following. There are good candidates available but many have not completed their doctorates or master’s, therefore compromises are made in the criteria for hiring. Many candidates are hired either with a PhD in progress or with the stipulation that the candidate will commence doctoral studies within a specified period. The same was true for schools that were seeking



candidates with a completed master’s. Many settled for a master’s in progress. Some schools identified that they were not able to hire some of the better-qualified candidates because of budget constraints; they had to hire into part-time or contractually limited appointments instead.

The preparation sought by most schools to fill these positions covered a wide range. Most respondents indicated more than one criterion. In addition to academic credentials, most schools were also seeking candidates with both clinical and teaching experience, and who were registered or eligible for registration in their province. In addition, some wanted a track record of scholarly activity or potential for developing such a track record. The range of preparation sought was as follows.

% of schools Preparation Sought (N=67)

3% post-doctoral experience

16% a completed PhD in nursing

19% a PhD in nursing in progress

24% a completed PhD in an area relevant to nursing

27% a PhD in progress in a relevant area

43–46% a master’s in nursing (46%) or a relevant master’s completed (43%)

5.4.2. Full-time Contract Positions

None of the 67 schools that responded to the question about the credentials they were seeking in full-time contractual appointments sought people with post-doctoral experience or a completed PhD in a relevant area. The additional criterion specified by most schools was current clinical experience.

No. schools (%) Credentials Sought (N=67)

1 school a completed PhD in nursing

2 schools a relevant PhD

3 schools a PhD in nursing in progress

25 schools (37%) a completed master’s in nursing

18 schools (27%) a completed master’s in a relevant area

23 schools (34%) a master’s in nursing

14 schools (21%) a relevant master’s in progress

45 schools (68%) a baccalaureate degree in nursing

14 schools (21%) a diploma in nursing was a criterion. It was not possible to tell if they intended this as the minimum or maximum credential required.

5.4.3. Part-time Contractual Positions

The number of part-time contractual positions schools needed to be filled for the 2003–2004 academic year was enormous and, remarkably, 96% of them were filled. The following list indicates the criteria reported for these positions and the number of schools requiring each criterion. (In addition to these were recent or current clinical experience.)



No. schools (%) Recruitment Criteria (N=70)

28 schools (40%) a baccalaureate in nursing

15 schools (23%) a completed master’s in nursing

14 schools (21%) a completed relevant master’s

11 schools (16%) either a BScN or a diploma

10 schools (14%) a master’s in nursing in progress

8 schools (11%) a relevant master’s in progress

3 schools (4%) a diploma in nursing

Recruitment Difficulty. The schools were asked how much difficulty they had filling their positions.

No. schools (%) Recruitment Difficulty (N=65)

40 schools (61%) Some difficulty

14 schools (21%) A great deal of difficulty

11 schools (17%) No difficulty

Schools were invited to describe or explain the difficulty they had recruiting. Two themes emerged: too few applicants with completed PhDs or master’s degrees; and salaries too low to be attractive. However, others noted that they were successful because they recruited constantly, used personal contacts, and offered to fund candidates’ graduate education. A concern raised was the pressure experienced when there was too little time to recruit faculty between the time advertisements were placed and classes or clinical practice started.

The fields in which schools had most difficulty finding faculty members with expertise are, in order: mental health/psychiatric nursing, obstetrics/maternal–infant/family nursing, pediatric/child nursing, public health/community nursing, and acute care/medical surgical/critical care nursing. Anywhere from 12 to 18 schools reported having had difficulty in finding recruits in these areas. A few schools indicated that it was difficult to find faculty with expertise in geriatrics/gerontological nursing, research, and science.

Adequacy of Current Faculty Resources. The schools were asked about the adequacy of their current faculty resources. Schools were evenly divided in rating their faculty resources: slightly more than half believed their resources were either very inadequate or barely adequate while the other slightly less than half thought they were adequate or more than adequate.

No. schools (%) Adequacy of Current Faculty Resources (N=69)

6 schools (9%) Very inadequate

31 schools (45%) Barely adequate

24 schools (35%) Adequate

8 schools (12%) More than adequate



Some schools explained that several of their faculty were in the process of getting graduate degrees and this increased the pressure on them in terms of workload, as well as on the schools as they tried to protect some of their time. A number of schools noted that their faculty simply had to work too hard: their teaching loads were excessive and clinical section sizes were increased to handle increased enrolments with too few teachers.

5.5. Clinical Training Capacity of RN Schools In this section of the questionnaire, schools were asked about the following items.

• The environment in which they sought clinical practice opportunities for their students, including whether they competed for clinical opportunities with other schools training health science students.

• How “student-friendly” the agencies and institutions were that provided clinical practice opportunities.

• The structure of their clinical practice on a year-by-year basis, including whether practice was assigned in a distributive or block fashion, what hours the students worked clinically, how dependent the students in any given year were on preceptors for clinical supervision, and the availability of preceptors.

Some schools had more than one program; for example, some universities participated in collaborative 4-year programs with colleges, and ran separate 2-year programs for students who already had a university degree. Because the clinical practice plans were structured differently for some of these programs within the same school, the schools were asked to discuss them separately; however, the results are combined for reporting purposes.

Competition. As Table 18 below indicates, the vast majority of schools face competition for clinical experience, with most of it coming from programs that prepare LPNs, followed by other schools of nursing preparing RNs. The number of programs with which programs competed ranged from 1 (17 programs) to 8 (1 program), but most were dealing with 1, 2, or 3.

Table 17. Competition for Clinical Placements Faced by RN Schools

Types of competition No. schools (N=68)

% of schools

Licensed Practical Nurse programs 58 85

Other RN programs 42 63

Programs to prepare physicians 19 28

Private Licensed Practical Nurse programs 15 22

Respiratory Therapist programs 13 19

ER Medical Technician programs 13 19

Rehabilitation Therapist programs 10 15

Registered Psychiatric Nurse programs 9 13

No competition 6 9 Note. In addition to the programs listed in the questionnaire, schools also identified that they competed with

programs to prepare health care aides, social workers, paramedics, and pharmacy students.



Student Friendliness of Practice Environments. Schools were asked how “student-friendly” the clinical environments were for students. This factor was defined as placements that welcome students, treat them well, are concerned that they receive a good experience, and are available to them if they require help. Sixty-seven schools responded; the majority, 72% (48 schools), indicated that most placements for students were “student-friendly,” followed by 19% (13 schools) that said some were, and 10% (7 schools) that said essentially all their placements were good to students.

Models of Clinical Practice. In total, 65 schools reported on their clinical practice models. However, the number of schools reporting on the way they structured clinical practice varied by year, because some schools have 2-year, others 3-year, and still others 4-year programs, and some schools do not have clinical practice in Year 1. The 65 schools reported on a total of 77 programs. Two schools that described their clinical practice model did not identify which program they were describing.

No. of Programs Type of Program

6 2-yr BScN (previous university)

3 3-yr BScN (previous university)

1 3-yr BScN

45 4-yr BScN

3 2-yr Diploma

17 3-yr Diploma

2 Other

Schools were asked whether they used distributed or block placement of students. Distributed placement models intersperse clinical practice with classroom study, usually on a weekly basis. Block placement models have classroom study for a “block” of time followed by clinical practice for another “block.” Some clinical practice models use a mix of distributed and block placements, often at different times of the year.

Since the 65 schools reported on a total of 77 programs, the results for the clinical practice models are reported as percentages of these 77 programs. A distributed model of practice was most common through the first two years, while a mix of block and distributed was used by slightly more than half the schools in the fourth year. Year 3 revealed use of a higher proportion of the mixed model than in the earlier years. Block placements are used by only a small proportion of schools.

Table 18. Models of Clinical Practice in Each Year of RN Programs

Model of clinical practice Year 1 (N=45)

Year 2 (N=68)

Year 3 (N=77)

Year 4 (N=74)

%

Distributed 64 62 45 34

Block 9 13 16 15

Mix of distributed & block 27 25 39 51



Reasons for Choice of Model of Clinical Practice. The schools were asked why they chose the model they had in place. They were given reasons and asked to select as many as applied. The schools reported on 79 programs. The results are reported as the percentage of times the reasons were selected for these 79 programs (Table 19).

Table 19. Reasons for Choice of Model of Clinical Practice

Reason for choice of model % (N=79)

Superiority of the educational model 59

Maximizes clinical resources 57

Class scheduling dictates choice 37

Limited clinical placements dictate choice 28

Availability of faculty dictates choice 14

Timeframes Used for Clinical Practice. The schools were asked to identify the hours of a 24-hour day that students were in clinical practice. They were asked to report in terms of the three usual eight-hour shifts: 0700–1500 hrs, 1500–2300 hrs and 2300–0700 hrs. Schools were also asked if students who were not in a final year consolidation block practised on weekends. The majority of schools indicated that their students did not practise on the weekends outside of their consolidation or final year concentration practice periods. Of 70 schools that reported, 33% included weekend practice times.

Table 20. Timeframes Used for Clinical Practice, RNs

Times of day Year 1 (N=40)

Year 2 (N=61)

Year 3 (N=76)

Year 4 (N=72)

%

0700–1500 hrs 100 100 100 100

1500–2300 hrs 20 66 91 89

2300–0700 hrs 3 3 13 53

5.5.1. Dependency on Preceptors, and Availability, RNs

Preceptors play an important role in the education of future nurses. A preceptor is a registered nurse who is assigned to an individual student to function as a guide in the care of patients in that nurse=s clinical area of expertise. Schools were asked about their dependency on preceptors, and the availability of preceptors for both community and acute care practice.

Dependency on Preceptors in Community Agencies. Some programs do not include clinical practice in the community. Some schools do not use preceptors until the upper years of a program and a few schools do not use preceptors at all. The number of programs reporting each year is uneven because the tables include 2-, 3- and 4-year programs.

Not all programs are dependent on preceptors to guide their students in community agencies; however, of those that are dependent on preceptors to guide their students in community agencies, the majority become increasingly dependent as students move to the upper years. In years 3 and 4, 60% and 85% of programs are either somewhat or very dependent on preceptors to guide their students.



Table 21. Dependency on Preceptors in Community Agencies

Amount of dependency Year 1 (N=41)

Year 2 (N=58)

Year 3 (N=65)

Year 4 (N= 66)

%

Not at all dependent 83 74 40 15

Somewhat dependent 12 19 37 32

Very dependent 5 7 23 53

Availability of Preceptors in Community Agencies. For programs that are dependent on

preceptors, each year about a third of those programs find there are too few preceptors most of the time. However, at least in years 2–4, half to two thirds of the programs find preceptors are available most of the time and a small proportion in the upper two years find there are always adequate numbers of preceptors. Tables 22 and 23 outline the same information about dependency on preceptors and their availability in acute care settings.

Table 22. Availability of Preceptors in Community Agencies

Availability of preceptors

Year 1 (n= 8)

Year 2 (n=12)

Year 3 (n= 38)

Year 4 (n= 54)

%

Too few most of the time 38 33 32 28

Adequate most of the time 38 67 53 65

Always adequate 25 0 16 7

Dependency on Preceptors in Acute Care Settings. In acute care environments, the dependency on preceptors occurs in the last year of the programs when almost 70% of programs are very dependent on preceptors and another 15% are somewhat dependent. Year 3 demonstrates some dependency but less than half that in Year 2. Few schools have any level of dependency on preceptors in the Year 1 or 2 of the programs.

Table 23. Dependency on Preceptors in Acute Care Settings, RNs Amount of dependency Year 1

(n=42) Year 2 (n= 60)

Year 3 (n= 71)

Year 4 (n=67)

%

Not at all dependent 86 80 54 16

Somewhat dependent 10 12 17 15

Very dependent 5 8 30 69

Availability of Preceptors in Acute Care Settings. Where there is dependency in these years, most schools find preceptors are available most of the time. Two-thirds of the schools that have some level of dependency on preceptors in Year 4 of the program find they are available most or all of the time, while a third deal with an inadequate number most of the time.



Table 24. Availability of Preceptors in Acute Care Settings

Availability of preceptors Year 1 (n=5)

Year 2 (n=9)

Year 3 (n=33)

Year 4 (n=54)

%

Too few most of the time 40 22 24 33

Adequate most of the time 40 78 73 59

Adequate always 20 0 3 7

Incentives to Preceptors. Schools offer a variety of incentives to preceptors (Table 25). A total of 66 schools replied to this question; 8 schools did not provide any incentives to preceptors while 58 provided one or more.

Table 25. Incentives Offered to Preceptors Type of incentive No. schools

(N=66)

Plaques of appreciation 39

Receptions to honour 24

Free continuing education 6

Status faculty appointment 5

Financial honorarium 5

Free/discounted tuition 5

Secondment to school 5

Lower patient loads 1

The most common ways of acknowledging preceptors’ contributions to the education of students are plaques and receptions. Few schools provided the more costly type of incentives, such as honoraria or free tuition, and few offered faculty appointments or arranged for the preceptors to be seconded to the school. In addition to these incentives or rewards, schools offer small gifts, library cards, reduced fees to school-based conferences, and thank you letters.

Alternative types of clinical practice. Schools were asked if they were using alternative types of clinical practice to help offset the constraints in traditional types of agencies and institutions. The list includes: homeless shelters, women’s shelters, primary and secondary schools, parishes, daycares, immigrant centres, societies that serve specific populations (Cancer, Alzheimer, Heart and Stroke, etc.), boys’ and girls’ clubs, fitness clubs, workplaces, malls, church groups, correctional institutions, Cubs/Brownies/Guides, First Nations, international placements, and seniors’ housing.



6. RN Education and Capacity — Discussion

At the end of the questionnaire, schools were invited to make comments. Several noted that no question asked them specifically about their budgets and they wished to have it recorded that the cost of preparing registered nurses was underestimated by governments and by their own institutions. Many described how difficult it was to provide a high-quality program with the financial resources they had.

6.1. Educational Sector Capacity, RNs Two of the major objectives of this survey were, first, to be able to describe the capacity of the

education sector, including its limits and reasons for those limits, its admission targets and trends in those targets, and its retention rates, and second, to describe the clinical training capacity, how that capacity is used, and the role played by preceptors.

6.1.1. Admissions and Trends in Admissions

In order to expand the years over which trends in admissions and enrolments might be identified, data were also examined from the CNA/CASN (2004) report of student enrolments in Canadian schools of nursing that prepared registered nurses from 1997 to 2001. When the 2001 figure is compared with admissions for these four previous years (1997–2000), a steady increase is reflected, with admissions to baccalaureate schools almost doubling (Ontario and British Columbia were responsible for the biggest increases) and admissions to diploma schools increasing by about one-third. There are some omissions to the CNA/CASN data: 1 BC college, 15 CEGEPs (of 40) and 2 Quebec universities did not participate, and 18 schools that did participate did not provide admission data for 2001. There were different response rates for each year of this data collection so the results are not directly comparable, but they provide a reasonably complete picture of admissions over this time period. These numbers are reported in Table 26.

Table 26. Admissions to Diploma and Baccalaureate Programs 1997–2001 Year Diploma

admissions Baccalaureate

admissions Total

admissions

1997 4,390 3,050 7,440

1998 4,566 3,109 7,675

1999 5,470 3,477 8,947

2000 6,382 4,090 10,472

2001 6,470 6,134 12,604 Source: All data are from The National and Faculty Survey of Canadian Schools of Nursing 2001–2002

(CNA/CASN, 2004).

Turning Point and Increased Admissions. 2001 was a significant year in Ontario nursing education history because, that year, while colleges could continue to admit students to a three-year diploma program, most entered into collaborative arrangements with a university and admitted students to four-year baccalaureate degree programs, either in addition to the diploma program or instead of it. This move was made to bring programs into conformity with the requirement of the College of Nurses of Ontario that by January 2005, all graduates of schools of nursing must have a nursing degree to be eligible to write nurse registration examinations. It has an important influence on national statistics because Ontario schools account for 30–40% (depending on the year) of students in RN programs in



Canada. In 2001, admissions to baccalaureate programs in Ontario increased to 1,863 from 825 the year before, but admissions to diploma programs also increased from 2,146 in 2000 to 2,578 in 2001 (CNA/CASN, 2004). While these increases might seem contradictory in light of the Ontario College of Nurses edict, they may not be. The increase in baccalaureate enrolments reflects the start of collaborative programs; students who would previously have entered diploma programs now had access to degree programs. The increase in diploma admissions may be explained by the phenomenon of students taking advantage of the last year to enter a three-year program to become a registered nurse, so those who had been contemplating it could not put it off any longer and so enrolled.

Enrolment Trends. The response rate to the survey conducted for this report (57%) is too low to draw conclusions about enrolment trends beyond 2001. Furthermore, the 2001 data include only admission to degree programs in Ontario (not diploma); however, the 2002 and 2003 data show that for schools that responded — 66 in 2002 and 65 in 2003 — admissions went from 5,425 to 7,600. Slightly more schools were above their enrolment targets than were below. The majority of schools do not plan to increase the number of students they admit in 2004; those that do plan increases are offset almost exactly by schools that plan to decrease enrolments. If these responding schools are even somewhat representative of Canadian schools, then continued increases in admissions have occurred in 2002 and 2003; however, this trend may be starting to plateau, owing to a lack of resources (discussed in detail elsewhere in this report). The CNA/CASN report of enrolment data in Canadian schools of nursing provides information about the trends in total enrolments from 1997–2001. These are reported in Table 27.

Table 27. Enrolment in Diploma and Baccalaureate Schools of Nursing 1997–2001 Year Diploma schools Baccalaureate schools Total

1997 15,730 9,581 25,311

1998 13,171 8,855 22,026

1999 11,609 10,270 21,879

2000 11,248 10,264 21,512

2001 15,788 17,500 33,288 Source: All data are from The National and Faculty Survey of Canadian Schools of Nursing 2001–2002

(CNA/CASN, 2004).

The data reported present some confusion. In Table 27, the 2001 enrolment data seem high for baccalaureate programs since the total of 17,500 is greater than the total of 16,810 admissions from 1998–2001 as reported in Table 26. On the other hand, Table 27 shows reductions in enrolment experienced by RN nursing schools in the later 1990s, which reflect the reductions in applications and admissions through the mid-1990s.

A total of 66 schools provided enrolment data to the current survey, showing that 20,634 students enrolled in 2003. Given that 66 schools represent only 51.5% of all Canadian nursing schools, we can deduct that a trend that started with increasing admissions in 1999 is continuing. However, it is not possible with these low response rates to determine to what extent enrolments have increased since 2001.

6.1.2. Retention Rate

Admissions and total enrolments tell only part of the story of the capacity of Canadian schools. Retention of admitted students until their graduation is critical to ensuring a sufficient supply of nurses



enters the workforce. The retention rates revealed in this study were unsettling. While there are no national standards for retention, it is unlikely that rates as low as 22% or 33% are acceptable; even the median of 74% seems too low. A third of students that started nursing programs in 1998 had not graduated by 2003. The students entering in 1999 fared even more poorly: only 61% of them had finished by 2003. Even given that more students within both of these groups are likely to finish, the completion rates are disturbingly low.

Comparisons were made with the CNA/CASN data. The proportions of students who entered diploma programs in 1997 and 1998 were compared with graduating numbers in 2000 and 2001, respectively. The completion rates were 63% and 47.8%, respectively. A similar numbers comparison of students entering baccalaureate programs in 1997 and students graduating in 2001 revealed a completion rate of 80%. These are only coarse comparisons, meaning that more students from all these entering classes will graduate than is reflected in these numbers. The limitations in the available CNA/CASN data made it necessary to calculate completion rates for classes exactly three years (for diploma) and four years (for baccalaureate) after starting, which does not provide for withdrawals and re-entry of students who subsequently complete. On the other hand, this approach includes students who entered prior to the designated entry year but who did not/will not graduate until the designated completion year.

Reasons for Withdrawal. Students withdraw from nursing programs for a number of reasons, the most common being academic difficulty, family responsibilities, financial difficulty, wrong choice of career, and illness (Bolan & Grainger, 2003; Glossop, 2001; Jalil-Grenier, 1993; Pringle, 2004; Smith, V.A., 1990). Less common reasons include transfer of a spouse to another location (Glossop, 2001), work responsibilities and childcare needs (Aber & Arathusik, 1996), and academic-related attributes such as poor study skills and habits, fewer hours allocated to study per week, lower grade point average, and perceptions of faculty and friends in the program (Jeffreys, 2002; Liegler, 1997; Tinto, 1997). A number of researchers have identified that “non-traditional” students — defined by Jeffreys as those with one or more of the following attributes: 25 years of age or older, with dependent children, English as their second language, a member of an ethnic minority, or male gender — have a higher risk of withdrawal than traditional students (Jeffreys, 2002; Lockie & Burke, 1999; Memmer, 1991).

In a recently completed study on attrition that involved six large university programs from across Canada, students who withdrew identified the top four reasons for leaving as follows: faculty were not supportive; lack of financial resources; the “chaos in nursing”; and the perception that one could not have a good career as a nurse (Pringle, 2004). In this same study, students entering with high-school averages that were lower than the mean entering average had statistically significantly higher attrition rates than those entering with high-school averages at or above the mean (Pringle, 2004). This confirms findings from a study conducted in one Canadian school that found positive correlations between high school and nursing school grades (Bolan & Grainger, 2003).

Improved Current Retention. The good news coming from the current survey data is that many schools have admirable retention rates of 100%, 98%, and 95%, and the mean completion rate of 80% for baccalaureate schools participating in the CNA/CASN study is much better than that for diploma schools. Therefore, the move to baccalaureate education as entry to practice may have an ameliorating effect on attrition but with some caveats. One of the reasons that baccalaureate programs may have lower attrition rates is that students compete for admission based on their academic records. A higher proportion of academically able students may enter baccalaureate programs than diploma programs because of admission criteria. This is not true for many diploma programs, because the mandate of many colleges is



to not discriminate on the basis of previous academic performance but to admit on a first-come basis. This probably puts more students at risk of academic difficulty and, hence, failure or withdrawal because of stress due to academic pressure. If an academically marginal student runs into a stressful family situation, she or he has less capacity to work through it than a student who is more academically able. For example, a student who is doing well but is struck with a family crisis can afford to not study for a couple of weeks and still catch up whereas a less able student may not be able to do that.

Importance of Family Support. One of the strongest findings in the Pringle (2004) study of attrition in Canadian baccalaureate programs was the students’ need for support from faculty members and for program expectations to be perceived as relevant by students. “Support” means faculty members need to closely monitor the performance of students and to seek out and offer support to students who give any indication of stress or academic struggle. This requires resources. A second important finding was the necessity to portray nursing realistically to potential students so they are not caught off-guard when they encounter the following: highly stressed and unsupportive staff nurses; media that challenges the effectiveness of the system; environments that do not have the equipment required by nurses to fulfill their responsibilities; or, staffing that is so short that essential patient care activities are missed.

6.1.3. Resources to Support Capacity

One of the major, if not the major, driving forces behind admission rates, and a significant contributor to retention of students, is the resources available to RN schools of nursing. The responses to the survey (across most resource categories) indicate that at least half the programs are struggling to manage the current number of students, across most resource categories. There are only four areas in which most programs have sufficient resources: numbers of applications for the number of places/seats they can fill; staff to coordinate student sections for clinical placements; clinical placements in long-term care; and, computer and technical support for students. In contrast, most schools have insufficient numbers of clinical teachers, too few community placements and acute care placements, too few preceptors, insufficient financial support for students, and not enough back-up teachers to fill in for teachers who are ill or unable to fulfill her/his responsibilities. These are critical resource areas for any program. In light of these answers, it is not surprising that most schools indicated that they are not planning to expand their admissions in 2004.

Clinical teachers, preceptors, and acute care and community placements are the core of nursing education programs. When schools are short of these resources, they have a difficult time meeting their responsibilities to students. The fact that that more than half of the respondents to this survey indicated that they have insufficient resources in these areas should raise alarms across the nursing community. Complicating the picture is the fact that these types of resources cannot easily be found. Most schools reported competing for placements with more than one other type of program. Most schools also reported that they are using non-traditional agencies and experiences to offset the lack of traditional visiting nursing and acute care hospital opportunities.

6.1.3.a. Availability of Teachers

Other areas that are less visible but are nonetheless critical to the stability of programs are the availability of classroom teachers and the capacity to mentor new teachers. Programs will find teachers for classrooms because they must. However, these teachers may not have expertise in the subject of the course, or they rotated through to cover various topics but with no stability, leaving students with few or no experts to help them if they are having difficulty (Pringle, 2004). Furthermore, programs that are short



of teachers may have to expand class sizes, with the result that students have little opportunity to ask questions or to seek guidance from a teacher who is spread too thin. Mentoring new teachers is a good long-term investment in creating an effective and stable teaching staff.

The schools provided information about their need and ability regarding hiring new teachers. Most schools (77%) had vacancies they were trying to fill in all three categories of positions: full-time tenured/permanent, full-time limited-term contract, and part-time contract. Amazingly, most were able to fill the majority of these positions to their satisfaction in terms of getting people with the qualifications they were seeking. The category that proved to be most difficult to fill was that of full-time tenured or permanent. This was the category with the highest expectations regarding preparation, with over 40% of schools seeking people with a completed PhD in either nursing or a relevant area, or a PhD plus post-doctoral experience (few sought the latter). The need for post-doctoral experience is likely to increase in university schools in order to make new tenure stream faculty members competitive for research grants, which are essential to their ability to be tenured. About 70% of schools were successful in filling these positions, and 86% described themselves as either partially or completely successful in filling the positions. This is reasonably good given the market and the number of positions available. The CNA/CASN report (2004) provides information about the number and preparation of faculty members in Canadian schools.

• The 2001 data (which does not include responses from 1 BC college, 15 Quebec CEGEP schools, and 2 Quebec universities) indicate that there were 4,279 faculty members, of which 445 had a completed PhD and another 39 had post-doctoral experience. Thus about 11% had doctoral preparation. In 2001, there were only 16 graduates from Canadian PhD programs in nursing, and 161 enrolled in these programs.

• By 2002, the number of doctoral students enrolled in nursing PhD programs had increased to 235 (Alcock & Arthur, 2003), although it is not known if the same schools reported in these two different surveys. No information is available for the number of nurses in or graduating from non-nursing PhD programs.

• The fact that 125 tenured/permanent positions were filled in 2003 by the 66 reporting schools reflects the fact that many of these schools hired individuals who were either in doctoral programs or were committed to entering doctoral studies.

That most schools were generally satisfied with the qualifications of the people recruited to fill

the positions indicates a commitment to assisting their new recruits to complete their studies. However, this is expensive because schools have to protect the time of these doctoral candidates if they are going to succeed, which requires more faculty or puts more strain on the faculty members who take on more responsibilities. Nevertheless, the number of students in nursing doctoral programs is too low to meet the need and is a further constraint on expansion.

Hinshaw (2001) reported, with lament, that in the United States in 1995–2000, 50.2% of faculty members in baccalaureate and graduate programs had PhDsa. She also notes that shortages of educationally prepared faculty will continue because of the reduction in the number of nurses and therefore, fewer numbers entering graduate school, the graying of the professorate, and a prepared nurses. Several schools noted in their response to this survey that the salaries and workload of faculty members were significant deterrents for individuals they sought to fill faculty positions.



The results of searches for full-time and part-time faculty members to fill contract positions are positive. The schools filled all 264 available positions and seemed to fill the unfilled tenure/permanent positions with people on contract. Completed master’s degrees in nursing, or in a relevant area, were the preparations of choice for most schools. Next on the list were people with in-progress master’s degrees. CNA/CASN data (2004) reveal that in 2001, there were 281 graduates from master’s programs in nursing and another 1,542 enrolled. Given that the current survey reports results for only about half the RN nursing programs in Canada and does not indicate the demand for master’s prepared nurses in clinical environments, clearly the number of master’s prepared nursing graduates is too few. It is remarkable that as many of these positions were filled as the results indicate.

Fifty-five schools reported that they needed to recruit approximately 1,300 part-time contract teachers in 2003 and they managed to find 1,241 people to fill these positions. While a very few schools identified that a diploma in nursing was sufficient, most required at least a baccalaureate degree, and more than half were seeking if not a completed master’s degree, then a master’s in progress. More of those seeking nurses with master’s preparation want the degree in nursing rather than in a relevant area. This demand for nurses with master’s preparation in nursing combined with that identified in the previous paragraph indicates a huge demand for this level of preparation. Unfortunately, current enrolments in master’s programs are not sufficient to meet this demand.

The areas of faculty expertise that schools reported as being in shortest supply reflect most areas of clinical specialization. The one surprise was the few number of schools that identified gerontological nursing as an area of shortage.

6.1.4. Capacity to Increase Enrolment

In summary, schools have limited capacity to increase their enrolments. About 25% of schools could expand their current enrolments by 10% with their current resources, 20% could not expand even with additional resources, and 60% could expand if more financial resources were made available.

As the proposed increases in enrolment get higher, fewer schools can manage them with their current resources. None of the reporting schools would be able to double its enrolment with current resources, but 20% could double enrolments if financial resources were made available to them.

About 70% could increase enrolment by 25% with either current or additional resources, and 50% could increase their enrolment by 50% with current or additional financial resources. Therefore, there is very limited capacity within the education system to expand with current resources; but that capacity increases if financial resources are made available to schools. The resources in shortest supply are faculty, including back-up faculty and faculty to supervise clinical experience, and clinical placements in community and acute care facilities. Meanwhile, half the schools are stretched and stressed to support the numbers of students they currently enroll. Several question their ability to sustain the effort required for much longer.

6.1.5. Enrolment of Aboriginal Students

A relatively small proportion of schools participating in this survey either set aside places for Aboriginal students or deliberately tried to recruit Aboriginal students. Numbers from this study were compared with those from the recent study Against the Odds, by the National Task Force on Recruitment and Retention Strategies (NTFRRS, 2002). That study surveyed 64 universities/colleges in Canada and, of these, only 9 schools reported having designated seats for a total of 35, and 16 of the participating



universities/colleges reported that they had a total of 237 Aboriginal students enrolled. In contrast, this survey found 14 of 73 RN schools with reserved seats, 27 schools with Aboriginal students, and 433 students enrolled in 2003. It is likely that the 50% of RN programs that did not respond to this survey enroll at least some Aboriginal students, which would only augment the numbers.

It is difficult to explain the difference in the numbers in the two studies, other than the fact that there were different schools involved. The good news is that the picture may be brighter than Against the Odds portrayed; however, given the need for nurses, many more Aboriginal students are required. What this earlier report makes painfully clear is the struggle these students go through to make it into nursing programs and then to succeed in them (NTFRRS, 2002), as captured in the following statement from the report:

The title of the report, “Against the Odds,” was formulated after interviewing the Aboriginal nursing students and learning of their struggles to become registered nurses. Aboriginal nursing students face formidable challenges in completing post-secondary programs. Against these odds, men and women are pursuing their educational goals, drawing on the support of their families and communities, other Aboriginal students, their teachers, and available program infrastructure. They are strong and determined; they will succeed (p. 5).

What is also clear is that students who make it into post-secondary education are already the success stories. The biggest challenge facing Aboriginal young people is getting through high school with the background needed to be successful in whatever career they choose to pursue (NTFRRS, 2002). If schools of nursing in Canada accept the need for more nurses who are Aboriginal in origin, then the barriers and challenges facing these students must be confronted and eliminated. One of the challenges is the lack of role models (e.g., Aboriginal faculty members) in schools of nursing. The NTFRRS report indicates that 13 schools that participated in the study had a total of 28 Aboriginal faculty members, most at an instructor level. The report describes this as a “virtual absence of Aboriginal professorate” (p. 64). They found only 8 Aboriginal students in master’s programs, so the paucity of Aboriginal professors is likely to continue.

6.2. Clinical Training Capacity and Models The second major objective of the survey was to describe the clinical training capacity for nursing

education, how that capacity is used, and the role that preceptors play in the education of student nurses.

Regarding the adequacy of clinical resources, as discussed in the previous section, currently only 35% (of 65 responding schools) indicate that they have adequate community placements, 41% have adequate acute care placements, and 84% have adequate placements in long-term care facilities. Furthermore, there is limited capacity to expand: 19% of 62 responding schools that use community placements in their programs cannot find more clinical placements in the community to allow them to expand by even 10%; similarly, 21% cannot find additional acute care spaces to accommodate a 10% expansion. These numbers increase to about one-third of schools indicating they have no capacity to increase community and acute care placements if a 25% expansion is suggested, to two-thirds of schools at the suggestion of a 50% expansion, and to about 80% of schools if doubling enrolment is suggested. Therefore, limits in the availability of community and acute care placements are two of the most constraining factors in schools’ capacity to expand their enrolments. One-third even have difficulty meeting their current needs for students’ clinical experience in the community and in acute care settings.



Schools are offsetting these limitations by using non-traditional agencies and programs for placements. While creative, the examples provided by the schools are not able to offset the shortages, particularly in acute care.

6.2.1. Models of Clinical Practice

Two-thirds of schools of nursing use a distributive model of clinical placements for the first two years of their programs. In the third and fourth years, a mix of distributed and block is more common. Few schools use block placements as the predominant model in any year. Schools select the approach they believe is academically superior or the one that will maximize the use of their clinical resources. There is no evidence to support these claims. This is an area that has received little attention in nursing research. Cox (2002) notes the predominance of distributed models of clinical education over block and describes the dissatisfaction expressed by the students in one baccalaureate school of nursing with this approach. Students complained about the difficulty preparing for both class and clinical practice in the same week. In response to this, the school developed a 2x2 approach, which they tested on fourth-year students. Students spent two weeks in class and two weeks in clinical practice over one semester. As a result of “overwhelmingly positive” responses from students, faculty, and clinical sites, the school adopted this approach to scheduling clinical practice for both semesters in the junior and senior years.

In the early years of nursing programs, it may not be possible to place students in clinical areas for blocks of time because of the need to have students available to take other foundational courses. However, some schools do use a block versus a distributive approach. This presents an opportunity to compare the two approaches and to determine if there are advantages of one over the other in terms of student learning, student sense of integration into the clinical environment, stress levels, effect on the clinical environment and patients, faculty productivity, etc.

Schools that prepare registered nurses are competing with each other, with schools that prepare other types of nurses, and with schools that prepare other types of health care practitioners. The number of schools competing for clinical experience for their students is staggering. The burden on agencies that have to coordinate all these placement requests is also staggering, and it may be so for patients who are exposed to several different types of learners at one time.

These results demonstrate a preponderance of daytime, Monday–Friday, distributive clinical practice scheduling. In the face of shortages of clinical practice opportunities and intense competition for practice environments, it seems reasonable to test out other models: more block schedules, and more evening and weekend use of clinical sites. The latter two could introduce difficulties in terms of faculty availability or willingness to be available, and competition with students’ employment. Nevertheless, there is a need to experiment to find efficiencies and ways of stretching the clinical resources that are available. As well, the use of simulations and laboratory-based clinical learning will need to increase if schools are to be able to increase enrolments.

6.2.2. Dependence on and Availability of Preceptors

Schools of nursing become increasingly dependent on the availability of preceptors as the students move to their upper years and more individualized experiences are sought for them in highly specialized areas. Most schools do not have faculty with the breadth of expertise required to provide the clinical teaching and supervision that students require. Limiting students’ experience to only those areas in which there is faculty expertise will produce neither qualified nor satisfied students. There is much literature that attests to the value of preceptors and how they enrich programs (Bain, 1996) as well as how



they should be selected, prepared for the role, and nurtured in it (Dibert & Goldenberg, 1995; Piemme, Kramer, Tack & Evans, 1986).

Diploma programs are generally not dependent on preceptors from the community while baccalaureate programs are. Two-thirds of programs that are dependent on preceptors in the community find that there are sufficient numbers of preceptors available all or most of the time. This level of availability is better than some perceptions of it. Acute care is not so different from community care in the dependence on preceptors except there is greater dependence, particularly in the senior year of programs. However, programs find that preceptors in acute care are not as available as they are in community care. Few programs report that they can always depend on the availability of preceptors.

The current nursing shortage, which is unlikely to improve in the short term, has much to do with the lack of availability of preceptors. This is exacerbated by the high proportion of new graduates on some units who may not have sufficient experience or confidence to act as preceptors. The vast majority of nurses indicate that they are willing to serve as preceptors, and the nurse managers support this view. However, there simply may be more students than there are nurses with enough experience to meet the need.

The types of rewards offered to nurses when they serve as preceptors are not likely to encourage those who are unwilling or ambivalent to accept the challenge (Dibert & Goldenberg, 1995). Most rewards are in the form of plaques that recognize service, or receptions. Few schools provide financial rewards, reduced or eliminated tuition, or other tangible forms of recognition like faculty appointments. The latter is a challenge because of the administrative work involved in making appointments and in tracking nurses because of their relatively high turn over rates. Clearly, nurses become preceptors because of the satisfaction they receive from it and because they feel a responsibility to “give back.” However, in the face of increasing clinical demands and limited staff resources, schools will have to find ways to make the role more attractive.



7. LPN Education and Capacity — Survey Findings

The overall response rate (40%) was calculated on the basis of the total number of schools (93) to which questionnaires were sent. Thirty-seven schools responded to the survey. Responses to the questionnaire were received from every region of Canada. Table 28 reports the number of responses received regionally.

Table 28. Regional Response Rates to Survey Questionnaire, LPNs West/North Central Atlantic

ON QC

No. schools 13 21 43 16

No. received 9 11 11 6

Response rate 69% 52% 26% 38% Note. 37 out of 93 schools responded.

7.1. Types of Programs That Prepare LPNs In 2004, Canada had 93 “schools” that prepare students to become licensed/registered practical

nurses. The term school requires explanation in the context of the education of LPNs.

• In the provinces of Quebec, New Brunswick, Nova Scotia, Manitoba, and Saskatchewan, there is essentially only one program in each province, but it is provided differently in each province.

• In Manitoba and Saskatchewan, one college (i.e., one school) in each province administers the program but does so at a variety of sites and through a number of different arrangements. All students are counted as belonging to one school. Only one questionnaire was sent to each of these provinces.

• In Quebec, the program is provided in Centres de Formation Professionnelles (CFP), administered through boards of education or in private colleges on behalf of the Ministry of Education. For this survey, each CFP was treated as a school and was sent a questionnaire, as was the private college.

• In New Brunswick, the program is administered through a number of sites of the New Brunswick Community College. Each site was treated as a school and was sent a questionnaire, as was each site that administers the program in Nova Scotia.

• In the other provinces and territories where the programs are located in community colleges (and in British Columbia, also in private colleges), each college (i.e., school) that provided a program to prepare LPNs was sent a questionnaire and invited to participate.

Schools reported on the source of their funding and whether it was permanent for a fixed number of students or contractual for a varying number of students. All 37 reporting schools are publicly funded, and 1 indicated that it had another source of funding in addition to this. Fifty-nine percent of 32 schools have permanent funding, 13% have contract funding and 28% report other funding. One school listed “slip year” funding, several are funded on a per student basis, one receives it in the form of cost recovery, one has provisional funding, and two reported being funded per student exam.



Several schools offer their programs through “brokered” arrangements. This means that a group — such as a community college that does not have an LPN program but wishes to offer a program, usually for a predetermined period — will contract with an established school with an approved curriculum to offer that curriculum. Seven of the 37 reporting schools indicated that they had brokering arrangements. Three of the seven schools have one brokering arrangement each, two schools have three brokered arrangements each, one school has five, and one has ten.

Table 29 provides information on the number of sites through which schools offer their programs. More than 50% of the schools have only one site.

Table 29. Number of Sites per Program, LPNs No. of sites per program

1 2 3 4 5 6 7 9 12

No. of programs (N=37) 21 6 0 3 2 1 2 1 1

The following summarizes how many temporary and permanent sites the schools have.

Number of Temporary and Permanent Sites

Permanent Sites 4 schools have no permanent sites.

26 schools have only 1 permanent site.

3 schools have 2 permanent sites.

4 schools have 4 permanent sites.

Temporary Sites 21 schools have no temporary sites.

16 have anywhere from 1–10 temporary sites, distributed as follows: 8 schools — 1 site 1 school — 4 sites 1 school — 2 sites 2 schools — 6 sites 3 schools — 3 sites 1 school — 10 sites

Table 30. Capacity at Permanent & Temporary Sites

Student Capacity No. schools with given range of students

No. Range 12–49 50–96 100–199 200–750

Permanent sites (N=32) 3,780 12–734 11 12 5 4

Temporary sites (N=17) 833 6–180 12 2 3 0 Note. Schools were asked to provide information on the number of students they could manage in their programs.

• 43% (16 of 37 schools) reported that they offered bridging programs that facilitated health care aides to become licensed/registered practical nurses.

• 72% (26 of 36 schools that responded to this question) reported that they tracked their graduates after they had completed the program.



Number of Classroom and Clinical Practice Hours. LPN schools report the length of their programs in classroom and clinical hours rather than in months or years. There is a wide range of hours, which vary depending largely on the province in which the programs are located. Thirty-five schools responded to the question; the range and frequency of hours is reported in Table 31.

Table 31. Hours of Theory and Practice in LPN Programs Theory & lab Clinical practice

Hours No. schools, % No. schools, %

400–499 1 3% 1 3%

500–599 0 0% 1 3%

600–699 2 6% 3 9%

700–799 6 17% 4 11%

800–899 15 43% 10 35%

900–999 8 23% 8 23%

1,000–1,208 3 9% 8 23% Note. N=35

The majority of programs have theory and laboratory hours in the range of 700 to 999 hours, with the mode being in the 800 to 899 hour range. The most prevalent number of clinical practicum hours is in the 800 to 1,099 range, with the mode being in the 800 to 899 hour range. The range varies greatly: from schools with fewer than 500 hours of theory and of practice, to another with more than 1,150 hours of theory, and still another one with more than 1,200 hours of practice.

7.1.1. Number of Classes Admitted per Year

Number of Classes Admitted per Year (N=35)

1 class per year 57% admit one class per year.

> 1 class per year 8 schools admit more than one class per year as follows: 7 schools — 2 classes 3 schools — 6–7 classes 4 schools — 3–4 classes 1 school — 12 classes

7.1.2. Maintenance of Waiting Lists

When schools have more applicants than they are able to admit, some maintain waiting lists. Of the 36 schools that responded, 25 (68%) maintain waiting lists. At the time of the survey (early 2004), there were 1,207 students on waiting lists. The lists ranged in number from 10 to 341 students per school.

There is a wide range of practices related to waiting list management. One school has no time limit and another allows students to remain on the waiting list until either they get into the program or cancel their application, and another allows them to remain on the waiting list until the next intake. Four schools maintained waiting lists for a year, and three schools maintained them for 24 weeks. The average length of time students spent on these waiting lists ranged from one month to four years. Only four schools had students waiting more than a year, and in seven programs, the average time spent on their waiting lists was one to six months.



7.2. Student Admission and Enrolment, LPNs The first question to be answered was: What is the current capacity of schools that prepare

licensed practical nurses? In order to determine the capacity of LPN programs and the stability of this capacity, the schools were asked for their current level of admissions, for the changes to these admission levels over the last three years, whether the target levels for admission had been met or exceeded, and about plans for expansion and contraction of admission levels for the next year.

7.2.1. Admissions, 2002, 2003

Schools were asked to compare their most recent admission numbers with those of the previous admission.

Comparison of 2003 and 2002 Admissions

2003 Admissions (N=37)

37 schools admitted a total of 1,957 full-time students and 127 part-time students.

All schools admitted full-time students, ranging from 9–160 per school, with a mean of 54 and a median of 50 students.

9 schools admitted part-time students, ranging from 1–50 per school, with a mean of 14 students. The part-time admission distribution was bi-modal; 5 schools admitted 5 or fewer part-time students and 4 schools admitted 15–50 students.

Comparison with 2002 (N=35)

17 schools (49%) reported an increase in admissions of a total of 251 students, ranging from 2–44 students, with a mean of 16 and a median of 14 students.

2 schools (6%) reported a decrease of a total of 11 students.

15 schools (43%) reported no change.

This represents an overall increase of 240 students admitted to first year in 35 schools in 2003 as compared to 2002.

7.2.2. Gender Profile of Admitted Students

A total of 33 schools reported the breakdown of men and women in their admission numbers. Three schools admitted no men, and the rest admitted between 1 and 44 men in their classes for a total of 193. In contrast, these 33 schools admitted 1,620 women. Therefore, 12% of the admissions were men.

7.2.3. Admission Targets

Schools were asked if they met their admission targets for the past three years (2001–2003). In 2001, 31 schools reported, and of these, 58% met or exceeded their target admissions; in 2002, 63% of 32 schools met or exceeded targets; and in 2003, 47% of 32 schools did so.

The schools were also asked to break down their admission targets and admissions into met, exceeded and below target. Fewer schools responded to this question than to the previous one. Because the number of schools reporting in each year varied, the numbers are reported as percentages. Details are provided in Table 32.



Table 32. Admission Targets and Success in Meeting Them, 2001–2003, LPNs Year Target Exceeding target Below target

Range Total no. % Range Total no. % Range Total no.

2001 (N=21) 12–299 1,320 30% 1–42 65 35% 4–21 77

2002 (N=23) 20–423 1,725 18% 2–62 78 36% 2–18 65

2003 (N=22) 12–642 1,955 43% 1–23 76 33% 1–4 19

Of the LPN schools that responded, all reported a steady increase since 2001 in the target number

of students they are seeking to admit. Furthermore, while about a third of schools did not meet their target each year, the number of students below target is small and has decreased each year. While the number of schools that exceeded their target varied each year, the total number of students by which they exceeded was greater than the number below target, resulting in an overall gain.

Admission Plans. Schools were asked about their admission plans for 2004.

Only 5 (of 36) schools plan to increase their admissions, with increases of 3–40 students planned. If these targets are met, there will be a total increase of 95 students. Two schools plan to decrease admissions, one by 12 and the other by 50 students, for a total of 62 students. The majority of schools, 28, do not plan to change. These numbers indicate that if targets were met, a very modest overall increase of 33 students would have been admitted to these 36 schools in 2004.

Results Admission Plans for 2004 (N=36)

78% (28 schools) Plan no change.

14% (5 schools) Plan to increase levels by 3–40 students, for a total of 95 students.

6% (2 schools) Plan to decrease levels, one by 12 students and the other by 50 students for a total of 62 students.

7.2.4. Enrolment Targets

Schools were asked to report the total number of students enrolled in their programs in the 2003 calendar year. In total, 3,947 full-time students were enrolled by 36 schools, of which 453 students were in brokered programs; 1,003 part-time students were enrolled in total, 23 of them in brokered programs. Therefore, brokered programs are enrolling 12% of full-time and 2% of part-time students.

Table 33. Total Enrolment in October 2003 No. of

students No. in brokered program (%)

Full-time 3,947 453 (12%)

Part-time 1,003 23 (2%)



7.2.5. Aboriginal Students

Schools were asked to report on the following items regarding Aboriginal recruitment and enrolment. All but 1 of the 70 schools reported. Schools were asked to report only the numbers of students who had self-identified as Aboriginal.

Results Aboriginal Recruitment and Enrolment (N=36)

149 students Number of Aboriginal students currently enrolled. These students were enrolled in 14 schools, or 39% of the schools participating in this study. The numbers per school ranged from 1–50. Only 2 schools had relatively large numbers of students, at 48 and 50 per class.

8 schools (22%) Specific number of seats/places reserved for Aboriginal students, for a total of 62 places. The number of reserved seats per school ranged from 2 to 32. These reserved places could be filled by non-Aboriginal students if sufficient numbers of Aboriginal students could not be recruited.

5 schools (%) Number of schools that employ special recruitment strategies to attract Aboriginal students.

7.2.6. Retention Rates

Schools were asked to report on their student retention rates for four years, 1999–2002. The retention rates were calculated using the reported number of students that were admitted and the number from that class that have completed to date. This gives only a rough estimate of retention rates. The details are reported in Table 34.

Table 34. Retention Rates for Classes Entering 1999–2002, LPNs Year

admitted No. schools

reporting Total students

admitted Total students completed (%)

Retention rate range

Median retention rate

1999 25 1,267 853 (67%) 15–96% 70.0%

2000 28 1,519 1,095 (72%) 19–100% 77.5%

2001 28 1,558 1,125 (72%) 15–100% 73.5%

2002 22 1,377 945 (69%) 21–100% 74.0%

Despite the fact that the number of schools reporting ranged from 22–28, the average retention rate per year was remarkably stable, ranging from 67–72%. In each year, there was one extremely low retention rate, and these were all from the same school.

Year Summary of Retention Rates 1999 4 schools below 50%; 5 above 90% 2000 3 schools below 50%; 8 above 90% 2001 3 schools below 50%; 10 above 90% 2002 2 schools below 50%; 6 above 90%.



7.3. Resources to Maintain or Increase Enrolment, LPNs The second question to be answered was: What resources are available to schools of nursing to

support their current enrolments and what resources would be required to allow them to expand? A set of questions was asked about current resources and constraints on their ability to expand because the additional resources needed to manage the expansion have not been available.

Table 35. Capacity of Schools to Maintain Current Enrolment, LPNs Type of resource Adequate Insufficient Excess No. schools

reporting %

36 Faculty to teach courses 64 36 –

36 Faculty to supervise clinical practice 50 50 –


34 Number of community placements 41 59 –

34 Number of acute care placements 44 56 –


30 Number of preceptors needed 47 53 –

35 Classroom space 77 23 –

35 Clinical laboratory space 69 31 –

33 Space for student life 70 30 –

35 Faculty office space 63 37 –

35 Meeting rooms for planning 63 37 –

34 Financial support for students 59 41 –

35 Administrative support staff 54 46 –

35 Back-up teachers to cover absences 31 69 –


35 Mentoring of novice teachers 34 66 –

35 Staff to coordinate students sections 83 17 – Note. The number of schools responding varied so the responses are reported as percentages. Some schools did not

respond to some items, and others indicated that they did not require some of these resources, for example, community placements.

The resources needed by LPN schools can be divided into five categories: faculty, clinical placements, students, space, and administrative support. The three most critical are faculty, clinical placements, and students.

% of Schools Summary of Responses by Schools, on Resources

50% (of ~35) Have adequate faculty resources, except for back-up teachers and mentoring capacity.

< 50% Have adequate clinical placements for their students.

60% or more Are adequately resourced in the areas of students, space, and administrative support.

60% Have too few clinical resources for the students they have now.

50% Have too few clinical teachers and preceptors.



Other factors that impact resources. Schools were invited to write down what they had to consider in determining the number of students they can accept. Overwhelmingly, the responses referred to availability of clinical placements. One French-language school noted the difficulty in recruiting teachers, as did one English-language program located in a remote area, and several schools identified limitations in lab space.

Table 36. Capacity of Schools to Increase Enrolment by 10%, LPNs No. schools reporting

Type of resource Sufficient Additional Not possible



30 Number of student applications 73 27 –










32 Financial support for students 41 59 –




33 Mentoring novice teachers 21 79 –


% of Schools Summary of Responses Regarding Increasing by 10%

~ half Have sufficient space, administrative support and student applications to accommodate a 10% increase.

30% Have sufficient clinical teachers and acute care placements for 10% more students.

most schools Could manage a 10% increase if they were provided with additional funds.







30 Number of student applications 57 43 –
















Adding 25% more students reduces the number of schools able to manage this increase with their current resources but otherwise does not change substantially the scenario involving a 10% increase.

% of Schools Summary of Responses

55% Have sufficient student applicants to be able to manage a 25% increase and with additional funds, could acquire the resources required to teach them.

Most schools Could acquire the resources needed for a 25% increase.

20% Would not be able to secure the needed additional acute care clinical placements to make it possible. Without these placements, it is unlikely that they could manage a 25% increase despite having or having access to the additional resources needed in all the other categories.

If provided with additional budgets so they could purchase or otherwise acquire the resources in the five categories, about 50% of schools could acquire the faculty they need and sufficient clinical placements to increase enrolments by 10%.

Student applicants may be a problem but the answers to the previous question indicated that 73% of schools had enough applicants for a 10% increase. Increasing by 25% is also possible for 50–60% of schools.























Two types of resources — clinical placements and faculty — set the outer limit of the number of schools that could increase by 50%, so it could be concluded that about one-half of participating LPN schools could manage a 50% increase.


One-third Currently have sufficient student applicants to increase their enrolments by 50%.

One-half Could not find enough clinical placements.

One-third Could not recruit sufficient faculty to increase by 50%, even if they had the funds to do so. Only 2 schools reported having sufficient faculty resources or access to enough clinical placements to manage increases of this magnitude with their current resources.








29 Number of community placements - 31 69

30 Number of acute care placements - 30 70


25 Number of preceptors needed - 32 68










28 Mentoring novice teachers 11 54 36

28 Staff to coordinate student sections 14 54 32

When the proposed increase reaches 100%, 70% of schools could not manage it regardless of the provision of additional funds.


70 to 80% Cannot come up with enough clinical placements and teachers to realize a doubling of their enrolments.

One third Could not realize enough resources in most of the other categories, even with more funds to double enrolments.

7.3.1. Summary of Capacity to Increase Enrolments

In summary, most schools can manage enrolment increases of up to 25% either with current resources or having additional funds to hire more teachers and acquire more space; however, once the proposed increases hits 50%, 30–50% of schools would not be able to accommodate these increases because of limited clinical placements or inability to recruit sufficient teachers. With proposed increases of 100%, 70–80% of schools would not be able to manage.

Comments from schools about resources to manage enrolment increases focused on clinical placements and to a lesser extent on space issues within the teaching facilities. Competition with RN schools for acute care placements was mentioned several times. A few schools noted that graduates of their programs could not get full-time positions, so there was no point in increasing enrolment.



The most limiting factors to enrolment increases reported by schools were the following.

No. schools Most Limiting Factors

26 schools availability of clinical placements, with acute care mentioned specifically

19 schools availability of faculty, particularly for clinical teaching

14 schools sufficient laboratory and classroom space

9 schools sufficient numbers of applications from students with appropriate backgrounds

7 schools adequate budget to hire the number of faculty needed

a few schools insufficient preceptors, provincial limitations on numbers, and insufficient administrative support

7.3.2. Preferred Number of Students

Schools were asked how many students they would prefer to admit (i.e., how many students they feel they can comfortably teach, given their current resources). The results are as follows.

Potential Number of Admissions

Given current resources (N=37)

10–730 per class — schools would prefer to admit. 2,986 total number of students preferred — This is considerably more than the

1,957 full-time students that the schools admitted in 2003 and is greater than the number they planned to admit in 2004.

Given extra financial resources (N=33)

1,051 additional students total — schools could manage to take, with proposed numbers ranging from 2 to 150.

The majority of schools (89%) could manage increases in their enrolments with additional financial resources, and more than one- third of them (40% of 33) could manage substantial increases of 28 and more students per class, as follows. Increase ........................No. schools that could manage the increase 0 students .....................5 schools 2–8 students .................5 schools 10–24 students ..............10 schools 28–50 students .............7 schools 60–100 students ...........4 schools 120–150 students .........2 schools

7.4. Faculty Recruitment, LPNs The schools were asked to report the number of faculty vacancies they were seeking to fill in

2003, the credentials they were seeking in the candidates, the number of these positions they filled, and the difficulty they had in filling them. The vacancies were divided into three categories: full-time tenure stream/permanent positions, full-time contract (time-limited) positions, and part-time contract positions. The results are reported in the following table.



Table 40. Number and Types of Positions Available in Schools, 2003 Type of Position No. schools

reporting No. with available positions

Range per schoola

Total No. available

No. filled

Tenure stream 34 18 1-6 39 41

Full-time contract 36 21 1–13 102 100

Part-time contract 35 26 1–27 185 187 aThe range refers to the number of positions available in any one school.

7.4.1. Full-time Tenure Stream/Permanent Positions

The schools were asked if they were able to recruit people with the kind of credentials and experience they were seeking. Of the 23 schools that responded to this question, 65% said they were able to find the kind of people they were seeking, 13% were not, and another 22% said they were partially successful. Therefore, almost 80% were at least partially successful in finding the type of teachers they were seeking. The schools were invited to write an explanation for their answers. The reasons they gave largely referred to a lack of applicants for positions or applications from individuals who did not have the qualifications sought.

In addition to the qualifications listed below, schools sought applicants with clinical experience ranging from two to five years, and two to three years of teaching experience.

(N=23) Preparation Sought

70% BScN

4 schools master’s in nursing completed

4 schools at least master’s in nursing in progress

4 schools a relevant master’s completed

4 schools relevant master’s in progress

1 school completed PhD in nursing

Others completed relevant PhD

7.4.2. Full-time Contract Positions

In addition to the qualifications listed below, teaching experience was the most frequently listed additional criterion sought for these positions.

% of schools Credentials Sought (N=35)

82% diploma in nursing

59% a baccalaureate degree

2 schools The highest credential sought by any school was a completed master’s in nursing or a completed relevant master’s.

1 schools master’s in nursing in progress

2 schools relevant master’s in progress



7.4.3. Part-time Contractual Positions

The credential most frequently sought for part-time contract positions was a diploma in nursing. Additionally schools sought applicants with clinical and teaching experience.

% / No. schools Recruitment Criteria (N=35)

80% a diploma in nursing

49% a baccalaureate degree in nursing. This implies that either this or a diploma in nursing would be considered acceptable.

1–2 schools completed or in-progress master’s in nursing or in a relevant field

Recruitment Difficulty. The schools were asked how much difficulty they had filling their positions. All 37 schools responded.

No. schools Recruitment Difficulty (N=37)

21 schools (57%) Some difficulty

10 schools (27%) A great deal of difficulty

6 schools (16%) No difficulty

Most schools identified that nursing shortages in hospitals made it difficult to second-staff members for part-time positions. One school noted that they could fill part-time positions for only a term, but not full-time positions. The poor pay scale compared to that for clinical positions was noted as a deterrent in recruiting faculty.

Schools reported having most difficulty finding faculty members with expertise in mental health/psychiatry (10 schools), acute care/particularly surgery (8 schools), obstetrics/maternal care (7 schools), and 5 schools reported having difficulty finding faculty in all areas, in pediatrics, and with teaching experience. One school noted the difficulty finding faculty with experience working in the North with an Aboriginal population.

Adequacy of Current Faculty Resources. The schools were asked to categorize the adequacy of their faculty resources.

% of Schools Adequacy of Current Faculty Resources

11% Very inadequate

25% Barely adequate

61% Adequate

0% More than adequate

A couple of schools noted that they had been able to find excellent faculty, and several commented that they had good people but they were new to teaching and needed mentoring, for which there were insufficient resources. Others indicated that they were not happy with the quality of people they were able to recruit.



7.5. Clinical Training Capacity of LPN Schools In this section of the questionnaire, schools were asked about the following items.

• The environment in which they sought clinical practice opportunities for their students, including whether they competed for clinical opportunities with other schools training health science students.

• How “student-friendly” the agencies and institutions were that provided clinical practice opportunities.

• The structure of their clinical practice on a year-by-year basis, including whether practice was assigned in a distributive or block fashion, the hours the students worked clinically, the level of student dependency on preceptors for clinical supervision (in any given year), and the availability of preceptors.

As Table 41 indicates, most schools must compete for clinical experience with other educational programs, the most common being programs to prepare registered nurses, followed by other schools of nursing preparing LPNs.

Table 41. Competition for Clinical Placements Faced by LPN Schools Types of competition No. schools

(N=37) % of schools

No competition 3 8

RN programs 28 76

Other Licensed Practical Nurse programs 14 38

Registered Psychiatric Nurse programs 6 16

MD program 4 11

Rehabilitation Therapist programs 7 19

Respiratory Therapist programs 4 11

ER Medical Technician programs 3 8

Private Licensed Practical Nurse programs 2 5 Note. Schools were asked whether they competed with other types of training programs for clinical placements for

students.

Student-friendliness of Practice Environments. Schools were asked how “student-friendly” the clinical environments were for their students. This was defined as placements that welcome students, treat them well, are concerned that they receive a good experience, and are available to them if they require help. Thirty-six schools responded. About half the programs (53%, or 19 schools) indicated that most placements for students were “student-friendly”, followed by 31% (11 schools) that said essentially all their placements were good to students, and 17% (6 schools) indicated some were student-friendly.

Models of Clinical Practice. Schools were asked whether they used distributed or block placement of students. Distributed placement models intersperse clinical practice with classroom study, usually on a weekly basis. Block placement models have classroom study for a block of time followed by clinical practice for another block. In some clinical practice models, a mix of distributed and block placements are used at different times of the year.



All but one school responded to this question. Some LPN programs extend beyond one year, and since the clinical practice model may differ depending on the year, schools were asked to indicate which model they used in each year where that was relevant (Table 42).

Table 42. Models of Clinical Practice in Each Year of LPN Programs Model of clinical practice Year 1

(N=36) Year 2 (N=28)

Distributed 19% 14%

Block 53% 43%

Mix of distributed & block 28% 43% Note. In the programs that have a second year, they are almost evenly divided on use of the block and mixed models.

Table 43. Reasons for Choice of Model of Clinical Practice Reason for choice of model % (N=36)

Maximizes clinical resources 64

Superiority of the educational model 50

Limited clinical placements dictate choice 33

Class scheduling dictates choice 22

Availability of faculty dictates choice 11 Note. Schools were given reasons and asked to select as many as applied.

Table 44. Timeframes Used for Clinical Practice Year 1 (N=37) Year 2 (N=29)

Days only 10 (27%) 1

Days and evenings 22 (59%) 15 (52%)

All 3 shifts ~25% ~25% Note. Schools were asked to report in terms of the three usual 8-hour shifts:

days = 0700–1500 hrs; evenings = 1500–2300 hrs and nights = 2300–0700 hrs.

7.5.1. Dependency on Preceptors, and Availability, LPNs

Preceptors can play an important role in the education of future practical nurses. A preceptor is a registered nurse or licensed practical nurse who is assigned to an individual student to function as a guide in the care of patients in that nurse’s clinical area of expertise. Schools were asked about their dependency on preceptors and their availability, both for community and acute care practice.

Dependency on Preceptors in Community Agencies. Of the 33 schools who responded for Year 1, 13 reported they do not use preceptors, and 9 use them but do not consider themselves dependent on them. In year 2, 16 schools use preceptors but seven are not dependent on them for their program, and 9 are dependant on them.



Table 45. Dependency on Preceptors in Community Agencies

Year 1 (N=33)

Year 2 (N=33)

Amount of dependency %

Not at all dependent 45 44

Somewhat dependent 30 25

Very dependent 25 31 Note. Only 20 programs use preceptors in Year 1; only 16 programs use them in year 2. Some programs do not

include clinical practice in the community and some schools do not use preceptors at all.

Availability of Preceptors in Community Agencies. For programs that are dependent on preceptors, Table 46 shows that more than half found there are too few most of the time, in both Year 1 and Year 2.

Table 46. Availability of Preceptors in Community Agencies

Year 1 (n=11)

Year 2 (n=9)

Availability of preceptors No.

Too few most of the time 6 7

Adequate most of the time or Always adequate

5 2

Dependency on Preceptors in Acute Care Settings. As seen in Table 47, the majority of programs depend on preceptors, particularly in the second year.

Table 47. Dependency on Preceptors in Acute Care Settings, LPNs Amount of dependency Year 1

(n=22) Year 2 (n=18)

%

Not at all dependent 55 11

Somewhat dependent 5 28

Very dependent 41 61

Availability of Preceptors in Acute Care Settings. Of the 19 programs that reported on the availability of preceptors, 11 found an adequate number most or all of the time in year 1, and of the 21 programs that reported using them in year 2, 14 programs (66%) found they were usually or always adequate numbers.

Table 48. Availability of Preceptors in Acute Care Settings, LPNs Year 1

(n=19) Year 2 (n=21)

Availability of preceptors No.

Too few most of the time 8 7

Adequate most of the time or Always adequate

11 14



Incentives offered to Preceptors. Schools offer a variety of incentives to preceptors. In Table 49 the types of incentives and the number of schools that provide them are reported. A total of 36 schools replied to this question: seven schools did not provide any incentives to preceptors while 29 provided one or more.

Table 49. Incentives Offered to Preceptors Type of incentive No. schools

(N=36)

Plaques of appreciation 18

Receptions to honour 11

Free continuing education 2

Status faculty appointment 2

Financial honorarium 1

Free/discounted tuition 1

Lower patient loads 1

Secondment to school 1

The most common ways of acknowledging preceptors= contribution to the education of students is through plaques and receptions. Few schools provided the more costly type of incentives such as honoraria or free tuition and few offered faculty appointments or arranged for the preceptors to be seconded to the school. A few schools reported that they also provided gifts such as monogrammed watches, gift baskets and gift certificates for books. Two write letters of appreciation for their files. One school noted that it was not allowed to budget for honorariums.

Alternative types of clinical practice. Schools were invited to describe alternative or non-traditional placements they used to help offset limitations in traditional areas. The schools identified Aboriginal reserves, public schools, boys and girls clubs, cast clinics, geriatric facilities, schools for mentally handicapped individuals and street health clinics. One school noted that during SARS a mock hospital unit had been established and students rotated nurse and patient roles which had been effective. A number of schools indicated that they needed to explore new settings but they had not had time to do so.



8. LPN Education and Capacity — Discussion

8.1. Organization of Practical Nurse Education in Canada Practical nursing education in Canada, outside of Quebec, is concentrated in community colleges.

In Quebec, it is concentrated in Centres de Formation Professionnelles (CFP) under the control of local boards of education, which in turn are administered by the Ministry of Education. Outside of Quebec, the credential that the graduates receive is either a diploma or a certificate in practical nursing and the right to write the national registration examination. If successful, the graduates become licensed/registered practical nurses (LPN, RPN in Ontario). In Quebec, the students receive a diploma from the Ministry of Education, and the provincial examination is included in their program. With the diploma, the graduate can become a registered nursing assistant. A new player on the scene is the private, for-profit colleges that are found in Quebec and British Columbia. Unfortunately there is little information about these schools in terms of organization or capacity. As noted earlier, five provinces have only one program. In one of these five, it is offered on only one site, but in the other four provinces, the program is offered at numerous sites.

Western Canadian community colleges have the capacity to offer their practical nursing programs through brokering arrangements with other colleges. This means that a college with an approved program can make it available to a college in a particular location where there is need and demand for it. It may be that this is a temporary demand, and through a brokering arrangement, this approved program can be offered in a short time and for specific periods of time. Only 7 programs reported that they had brokering arrangements, but theses collaborations made the program available to an additional 24 sites. This arrangement seems efficient and sensible. Additionally, some programs offer their program directly but temporarily in some sites. A total of 19 sites were temporary but under the control of 6 colleges.

The curricula across the 37 reporting schools varied widely in terms of the amount of theory and clinical laboratory time, and clinical practice time. The school with the least amount of theory and clinical practice hours had less than half of what was required by the schools with the greatest requirement. There is no question that the early years of this century have seen some major changes in LPN education; nevertheless, this range seems huge given that the same credential is granted to schools at both ends of the spectrum, and that there is reciprocity across the provinces and territories.

8.2. Education Sector Capacity, LPNs One of the major objectives of this survey was to describe the capacity of the education sector

that prepares licensed practical nurses in Canada, including limits to that capacity and reasons for those limits, admission targets and trends in those targets, and retention rates.

8.2.1. Admissions and Trends in Admissions

The vast majority of students in the 37 schools that participated are full-time female students. However, at 12%, the proportion of men in these schools is higher than the proportion of men in the LPN workforce as reported by the Canadian Institute of Health Information (CIHI, 2003). According to CIHI’s report, only 6.8% of the overall Canadian LPN workforce was male, with Quebec having a higher proportion (8.1%) and employing half of the male LPNs in the country. The Quebec Ministry of Education (2003) provided information on the number of students in the CFP schools in 2002–2003,



including the gender breakdown of these students. In that year, 8.3% of the students admitted to CFP schools were men and 8.5% who graduated were men. It appears that Quebec is retaining almost the same proportion of men in their workforce as graduate from their schools; this is in contrast to the rest of the country, where, from the information in this survey, there is a greater loss of male LPNs from the workforce after graduation.

Most of the students enrolled in LPN programs are not studying at brokered sites. Although only 12% of the total number of full-time students were in brokered programs, these students may not have had the opportunity to pursue LPN education in the absence of these programs.

The majority of schools maintain waiting lists. Maintenance of these lists varies enormously in terms of how long students are allowed to remain on them. The fact that there are more than 1,200 students on them indicates at least three things: there is a large applicant pool that must repeatedly compete to be admitted; there is a backlog of students eager to get into programs; and the number of seats/places in LPN schools is not large enough to accommodate the number of students wishing to enter the programs.

The survey results indicate that schools have been increasing their admissions numbers for the last three years, and across this same time period, the number of schools meeting or exceeding their admission targets has grown. It is difficult to know if this finding is representative as only 21 schools provided information for the three years in question. Again, the Quebec data provide an opportunity for comparison at least with Quebec schools. In those three years, admissions in Quebec rose from 1,481 students to 1,706 (Quebec Ministry of Education, 2004). This increase of 15% supports the trend of increasing admissions across the system. When this is paired with the waiting list data, the applicant pool seems robust at this time.

Based on the schools’ plans for the immediate future, this growth trend may be coming to an end. Few schools plan to increase enrolments in 2004 and most plan to maintain the numbers they have. This can be linked to the issue of resources, which will be discussed later. In Quebec, admissions for the period 2002–2004 are projected to be static (1,737, 1,706, and 1,736 respectively); this seems to be reflective of the country as a whole and confirms this survey’s findings. Interestingly, this plateau is projected to end in 2005 with a jump in admissions to 1,804 across the Quebec system and to 1,914 in 2006 (Quebec Ministry of Education, 2004).

8.2.2. Retention Rate

This survey is able to provide only rough estimates of retention rates across the system; however, it is interesting that the rates of retention for four years are so consistent, at around 70%. Again, information provided by the Quebec Ministry of Education (2004) is helpful for the purpose of comparison. In 1998, 662 students were admitted and 472 graduated in 2000 (from a two-year program), for a retention rate of 71%. Rates in earlier years tended to be lower, but projected retention rates for classes entering between 1999 and 2002 ranged from 67% to 76% (Quebec Ministry of Education). It seems that retention rates of around 70% may be the norm. The question is: Is this an appropriate norm? Unfortunately, some schools have very low retention rates (i.e., well below 50%)—a plight that is wasteful for students, the schools, and the profession.

There has been little research on retention or its obverse, attrition from practical nurse schools. Most studies have involved only students in programs to prepare RNs. However, one study was conducted specifically on practical nurse students in one school in the southern United States. The reasons



for attrition mirrored those found in research on withdrawals from RN programs (i.e., academic difficulty, wrong choice of career, personal problems, problems with faculty) (Stickney, 2002). Pringle (2004) examined the reasons students in LPN, RN, and RPN programs withdrew before finishing. Five English-language LPN programs in five different provinces sent questionnaires to students from four different classes who had withdrawn from their programs. Responses were received from 23 former LPN students. Results showed that students leave for multiple reasons. When asked to list the three most significant reasons, they identified difficulties with faculty, academic failure, and financial difficulties most frequently. Fifty-seven percent indicated that they very much regretted leaving the programs. Former LPN students cited more personal counselling and more financial assistance as resources most needed to help them succeed.

Of particular interest in this study was the role that high school admission averages played in attrition. Three LPN schools provided data on the high school admission averages of all students who entered the program and identified those who succeeded, those who left voluntarily, and those who failed the program. There was a small but statistically significant difference in the high school grades and success in the three LPN programs; however, all this difference was accounted for by one program (Pringle, 2004). Therefore, it is not reasonable to state that students with better high school grades have a greater chance of finishing the program. Clearly, this type of analysis needs to be conducted with larger groups before any substantial conclusion can be drawn.

An important finding in the Pringle (2004) study was that leaving programs caused distress. This was particularly true for LPN students. They were much less distressed by the chaos in nursing and the characteristics of a career in nursing than RN students because they wanted to be nurses, regardless of the conditions in the employment areas. They found failing very painful and wanted opportunities to be readmitted and to try again. Even many of those who withdrew voluntarily were stressed by making that decision. Furthermore, LPN students who withdrew either voluntarily or because of failure did not advance their careers. Few went on to other academic programs, either returning to their former jobs or to new positions that were not an advancement over what they had done previously. They were left with no diploma, no professional career, and debt from the costs of the program.

Given the high cost of attrition to students and to programs, every effort should be made to reduce attrition to the lowest possible rate. Retention of 70% may not seem too low, but it speaks to opportunity lost for 30% of students and a 30% loss of employable LPNs. This lost proportion of nurses could go a long way in addressing a shortage. Schools that consistently have retention rates lower than 70% should examine the reasons their students leave and develop corresponding remedies.

8.2.3. Resources to Support Capacity

Schools of nursing enroll the number of students that their resources allow. Administrators in institutions that house schools of nursing will argue that schools should be able to manage their target student numbers on the dollars they have, but many nursing school administrators find they are stretched to do that. Half the schools in this survey reported that they have insufficient clinical teachers, 40% have too few acute and community placements and preceptors, and about 70% have insufficient back-up teachers or the capacity to mentor new teachers. These are core resources to support a nursing program. In contrast, 60–80% had enough classroom teachers, space, administrative support, and long-term care placements. Importantly, a large majority had either adequate or excess numbers of applicants to fill their classes. None of the schools indicated that they had sufficient resources in all areas to offer their programs comfortably.



Schools can get by for a while stretching resources, such as the following: increasing clinical groups and classroom sections; having faculty members work overtime to cover for colleagues who are ill or otherwise unable to work; finding substitute experiences for traditional patient care experiences; and doubling up faculty in offices and having them do their own secretarial work. However, this type of stretching of resources is not sustainable in the long run, and the result is usually a drop in quality of the program and eventually a drop in student applicants when the word gets out that the program is poor.

About half of the schools that participated in this survey are at the point of being stretched. Enrolments have increased over the last three years and maybe for a period of time before that. Forty percent of the schools reported that they have inadequate or barely adequate faculty resources for their current students, and all but a small minority of them are competing for clinical placements for their students. On the other hand, they indicated that they could increase their enrolments by about a third with the resources they currently have. This seems inconsistent and even foolhardy, particularly when they responded with similar figures when asked how many they could take if they had additional financial resources. It does not benefit faculty members, students, or the profession if more students are admitted than can be adequately, if not comfortably, managed. In the long run, it will lead to poor quality, in both programs and graduates.

8.2.3.a. Availability of Teachers

The LPN schools were successful in filling their faculty vacancies in 2003, regardless of the level of position, and they described themselves as at least partially, if not fully, satisfied with the quality of recruits. For part-time and full-time contract positions, none of the schools recruited faculty who had only an LPN diploma, but the majority of schools sought people with an RN diploma. This may explain why they are successful in their recruitment, given the very limited supply of master’s-prepared nurses. Since RN programs are seeking many faculty members with this level of preparation, as are many clinical agencies, the numbers graduating are simply not sufficient to fill these positions available in LPN programs (CNA/CASN, 2004). Even for full-time permanent positions, most schools sought faculty members with an undergraduate nursing degree. No research was found that could guide school directors in determining the level of preparation that best prepared nurses for teaching positions in LPN schools. Experience and availability clearly have to dictate these choices, and given the level of satisfaction expressed by the majority of schools with their recruits, baccalaureate and diploma preparation may be most appropriate.

8.2.4. Expanding Admissions Given Available Resources

While there are inconsistencies in the responses regarding the ability of schools to expand with current resources, there clearly is a view that with additional financial resources, about 60% of schools could expand their enrolments by up to 25%. A constraint on the expansion of some of these schools that could secure enough teachers and clinical placements is insufficient numbers of applicants. This could be overcome with a vigorous recruitment effort. Less than half the schools could expand by 50% because they cannot secure sufficient clinical placements, and 60% do not have sufficient applicants to allow this degree of expansion. Doubling of admission numbers poses more of a challenge to the majority of schools. About 30% indicate that they have access to enough of the key resources to allow them to do it.

These results demonstrate a real capacity to expand enrolments across significant numbers of LPN schools, but the key is that they require the financial resources to do it. They have shown that they can recruit faculty who, for the most part, meet their needs, and despite competition from other schools of



nursing, many feel able to secure sufficient alternative clinical placements to make expanded programs viable.

8.2.5. Enrolment of Aboriginal Students

A relatively small proportion of schools participating in this survey had either reserved seats for Aboriginal students or specific strategies to try and recruit them. Consequently, it is not a surprise that only 3.8% of all the students in LPN schools in this survey are Aboriginal. There is no LPN equivalent to the report Against the Odds (NTFRRS, 2002), which compares data on Aboriginal registered nurses and students in RN programs, so a comparison of the data from this survey was not possible. However, since there was good participation by LPN schools in Western Canada in this survey, and these schools were more likely to have strategies to recruit Aboriginal students than schools in other parts of the country, if anything, the proportion of Aboriginal students in programs across the system may be even lower than found in this sample.

Although LPN regulatory organizations have worked collectively to address these issues —and continue to do so — further attention and action is demanded. The findings of the NTFRRS study are likely to be relevant for LPN programs as well as those preparing RNs, in which case they indicate that schools must develop specific strategies to not only recruit Aboriginal students but take special care of those students once they are in the program in order for them to succeed (NTFRRS, 2002).

8.3. Clinical Training Capacity and Models A second major objective of the survey was to describe the clinical training capacity for LPN

education, how that capacity is used, and the role that preceptors play in the education of practical nursing students. More than half of LPN schools indicated that they had shortages in community and acute care placements but close to half, if they had more financial resources, could find more acute care and community experiences for their students. However, if major expansions in enrolment are considered, limited capacity in these two clinical areas are what poses the greatest constraints on expansion.

8.3.1. Models of Clinical Practice

Block placement and a mix of block and distributed placements dominate the way LPN schools organize their clinical practice in programs that are both one and more than one year in length. They believe this maximizes their use of clinical resources and produces a better clinical experience. No research exists to substantiate these beliefs. One study (Cox, 2002) conducted in a baccalaureate school of nursing tested a 2 x 2 model (i.e., two weeks were spent in class and then two weeks in clinical practice) over one semester, because students complained of the difficulty of having to prepare for class and for clinical practice in the same week. The change to the 2 x 2 was very popular with students and positively received by faculty and clinical agencies. As a result, the school expanded it to the second semester of fourth year as well as to the third year. LPN schools may have already discovered these benefits.

While research is required to determine if one model of clinical practice is superior to another in terms of student learning, from the perspective of managing clinical resources in the face of multiple schools of nursing, block placements seem to hold the edge. Students from one school could come for certain weeks in a term while students from another school could come other weeks. When both schools want a few days each week, it requires a substantial level of coordination and cooperation. It would be useful to identify the anticipated benefits of both models (e.g., stress levels experienced by students, confidence gained over the same period of time, achievement of objectives for the experience, satisfaction



of patients and clinical staff) and to compare the actual achievements of these benefits across LPN schools that have different approaches.

On the whole, LPN schools demonstrate good utilization of available clinical capacity. The schools compete with a large number of other nursing and health science programs for clinical space, and when competing with other LPN programs or RN programs, similar types of experiences are often sought. A study of the demand for clinical placements in centres with multiple schools, the current use of these spaces, and models for managing multiple players with similar and unique demands would be useful.

8.3.2. Dependence on and Availability of Preceptors

One-third of the schools do not include community practice in their programs and half of those who do include it are not dependent on preceptors for assistance. In contrast, all the schools include acute care experiences in their programs, but still not many are dependent on preceptors. Half of those that are dependent on them find that most of the time there are too few. These findings indicate that preceptors do not play a large role in most LPN programs in either the community or acute care clinical areas, and for the majority of schools there is an adequate number when they need them. Only a few schools that do depend on them are not able to find enough of them to support their programs.

The rewards used for preceptors focus on plaques of appreciation and receptions. These are not likely to attract nurses who are not inclined to volunteer, but they reflect the resources available to schools for this endeavour.



9. Under-represented Populations in Nursing

This section explores factors that keep members of particular communities of Canadians from pursuing nursing as a career — Aboriginals/Native (includes First Nations and Métis), Black Canadians of African or Caribbean descent, and men. Members of these groups are under-represented in most nursing education programs and in the workforce. Statistics demonstrate that nursing is an overwhelmingly female discipline. Statistics regarding the number of First Nations nurses are less complete than those for gender, given that the former are self-reported and that reporting is not mandatory. Nonetheless, a recent national task force reported that “low numbers of Aboriginal students are enrolled in nursing programs in Canada” (NTFRRS, 2002). Finally, while there are no statistics for other specific cultural groups, there is a perception that particular groups are under-represented in nursing programs, with Black Canadian students being the group most frequently identified.

Objectives of the research were as follows.

• To describe what attracts students to, and what deters students from, pursuing nursing as a career, as perceived by members of groups that are under-represented in the current nursing workforce. In this case, the groups are Aboriginals/Native (includes First Nations and Métis), Black Canadians of African or Caribbean descent, and men.

• To identify the barriers to entering nursing (RN, RPN and LPN) as perceived by students who are members of these under-represented groups.

• To describe what would have to change to increase interest in and access to RN, RPN, and LPN education for students who are members of these under-represented groups.

9.1. Previous Relevant Canadian Research Two recent Canadian research studies that focused on two of the groups of interest influenced this

study. Both addressed the under-representation of particular groups of students in both the nursing workforce and in nursing programs that prepare registered nurses in universities and colleges.

In Men in Nursing, conducted for the Canadian Nurses Association (Hanvey, 2004), 46 male high school students and 45 male nursing students were interviewed in nine focus groups. The study focused intensely on issues related to gender and the stigma that is attached to nursing as a career choice for men. All of these students were asked what attracts them to nursing as a career, what deters them from choosing nursing as a career, and what nursing can do to appeal to more men and attract them to nursing. The directions for the focus groups, and some of the questions used in the focus groups in that study, were used in the current study.

A number of recommendations followed from Men in Nursing, as follows.

• Outreach to high schools, using young men as role models in outreach. • Challenge gender stereotypes, starting with very young children. • Give the public more information about what nurses do. • Depict men in nursing in ways that illustrate exciting employment opportunities, such as

work in an intensive care unit (ICU), emergency room (ER), and nursing management. • Represent the masculine aspects of nursing. • Make male nurses more visible in images of nursing.



In Against the Odds: Aboriginal Nursing (NTFRRS, 2002), from the National Task Force on Recruitment and Retention Strategies, 16 First Nations and Métis nursing students were interviewed. This study drew on earlier work by the Aboriginal Nurses Association of Canada (2000) and a report on nurses in Inuit communities (Health Canada, 2001), both of which included recommendations for recruiting members of these communities into nursing. Against the Odds: Aboriginal Nursing covered a range of recruitment and retention strategies: initiatives to support students in completing high school and enter nursing programs; targeted recruitment of Aboriginal students into nursing; partnerships between government, nursing schools, and communities; transitional or access programs; retention strategies; setup of a database to track efforts at inclusion; and post-graduation recruitment and retention. Participants were asked to discuss their educational experiences in registered nurse programs. Some of the discussions also addressed ways to increase the recruitment of Aboriginal students into nursing programs.

Among the recruitment strategies recommended were the following.

• Hire student recruiters across Canada.

• Reflect the diversity of the student body in all recruitment materials.

• Target schools as well as youth and adult education centres.

• Develop proactive, preventive responses to Aboriginal student attrition.

• Target men for careers in nursing.

• Elevate the inclusion of Inuit students to a critical priority.

Other recommendations related to role models were as follows.

• Engage Aboriginal nursing graduates in recruitment efforts.

• Hire Aboriginal faculty and staff in nursing programs.

• Develop a buddy system for Aboriginal students in nursing programs.

• Encourage Aboriginal graduate study in order to support the development of a Canadian Aboriginal nursing professorate.

9.2. Current Focus Group Findings The following questions were asked of all focus groups conducted for this study.

1) In a word or two, what comes to mind when you think of nursing?

2) If you know any nurses, how do you know them? Do you know any Native/Black Canadian/male nurses? What do you know about their work?

3) Have you ever considered becoming a nurse? Why? Why not?

4) What is appealing, if anything, about becoming a nurse? What is unappealing?

5) Do you know that there are three different ways of pursuing a career in nursing? A bachelor’s degree prepares students to become registered nurses, a two-year college diploma prepares students to become licensed practical nurses, and in Western Canada, a specialized 4-year bachelor’s or 2-year diploma program prepares students to work in psychiatry as registered psychiatric nurses.

a) Does knowing this make any difference to your thoughts about nursing as a career choice?



b) Would you know how to go about getting information about these programs?

6) What should nursing do to be more attractive to Native/Black Canadian/male students?

a) What about the costs of studying nursing? How big a barrier is cost?

b) What about the kinds of clinical experience that are required to qualify as a nurse?

c) Would a strong mentoring program make a difference? How important are role models?

d) Does the location of nursing schools make any difference to the appeal of nursing?

7) How should nursing try to reach more Native/Black Canadian/male students?

A summary of the qualitative findings follows, grouped under the following headings: key sources of information and influence; perceptions of nursing as a career move; and educational factors.

9.2.1. Key Sources of Information and Influence

9.2.1.a. Nurses Participants Know

Many examples were raised in each focus group of nurses students knew who were either family members, the family members of friends, neighbours, or friends.

Aboriginal Students. Aboriginal students knew many nurses, many of them Aboriginal.

Black Students. Black Canadian students also knew many Black Canadian nurses. In the focus groups for Black Canadian college students, many, although not all, said that the messages they get from nurses they know, such as family members who are in nursing, are frequently negative. The consensus was that they had been actively discouraged from entering nursing by family and other Black Canadians they knew.

Male Students. Unlike the male nursing students in the CNA (Hanvey, 2004) study, most of the male students reported that they did not know any male nurses and hence had no role models from which to form opinions.

In the focus group of male university students, students were emphatic that parents do not encourage male students to go into nursing. In fact, parents discourage this choice for male students who are going to university. “If I say I want to be a nurse my parents wouldn’t allow me because of all the money that they’ve invested in me …. it’s not worth it.”

9.2.1.b. Social Context — Racism, Cultural Issues, Stereotypes

Aboriginal and Black Students. Both Aboriginal and Black Canadian students identified concerns of racism when they think about entering nursing. One Native student expressed this in the following way: “Students want to be accepted into the group and it’s hard if someone’s putting you lower. Some people can’t handle racism.” The theme of belonging was also voiced by a Black Canadian student who raised questions about the challenges of work in a profession that is not ethnoculturally diverse. She asked, “Are you going to be happy in that culture of just pure like European, … Caucasian people, or are you going to go to the States or go somewhere else and be like better paid, and work with more people I can identify with? … I can actually identify with them socially and actually feel comfortable there.”

Black Students. Discussion among Black Canadian college students returned many times to the barriers created by systemic and individual racism in nursing, both in nursing education and in the health care system. The very low representation of Black Canadians in nursing management was named as



something that prevents the recruitment of Black Canadian students into nursing programs. One student put it this way: “So when I’m saying that you need people in positions of power, I mean not just light skinned people, you need dark skinned people too so that darker skinned people see this … and it comes down to self-esteem — if they don’t see people that look like them in certain positions, they’re going to think that they can’t do it and they are going to end up, you know, dropping out or not even doing it in the first place.” Another student raised a doubt about whether patients really want to receive nursing care from Black nurses. She said, “There’s a lot of patients what prefer white male doctors … so maybe there’s a like a stigma for nursing as well and you just haven’t looked into it.”

A number of Black students said that nursing is unappealing in light of goals for the social advancement of those in Black Canadian communities. It should be noted in saying this that most of the Black Canadian students who participated in the focus groups identified that they were of Caribbean descent. One student said, “I think a lot of Black people are trying to get over these issues of slavery and have to think to do a job in this day and age that brings you right back — forget about it.” One student explained that “with my family, most of them are nurses, so I wanted to change the legacy of that.”

Black students expressed that while they are under-represented in the ranks of registered nurses, they are very heavily represented in LPN nursing. This reality is encapsulated in the following statement: “it gets more diverse as you go lower.” One student talked about the reasons nursing is less appealing to younger Black Canadian students than it was to the first generation Caribbean Canadians of colour: “I don’t know the different terms like the one Registered Nurse, but like the lower class one, where you’re pretty much just like taking care of people … that wouldn’t appeal to younger people. The older people … who just came like from the Caribbean, they are probably used to taking care of people … they go into kind of like domestic … hands-on work, but for us who are actually born here … it’s not appealing for us. It seems like almost housekeeping or just like taking care of people … and it doesn’t seem as sophisticated.”

Male Students. Male students discussed the gender stereotypes that turn nursing into a stigmatized career choice for men. Many said that this stigma is a powerful barrier that would, on its own, prevent them from considering nursing as a career, although the pay might be good enough to overcome this. This is consistent with the focus and directions of the CNA (Hanvey, 2004) study of high-school and male nursing students. Male students voiced that both men and their employers open themselves up to legal charges based on fears related to men and sexual touch. “I think a lot of it has to do with sex, but like aside from that we all like as a society like value the role of mother and the role of mother tends to be associated with a nurse. You’re sick and in the hospital and you know, some six-foot-tall football player comes in to change your IV, that’s a very different feeling than someone who looks like your mom.” Male nurses expressed that they were not sure that patients really wanted to see men in nursing and suggested research should be done about this.

9.2.1.c. Outreach

All participants. In every focus group some discussion occurred about people who encouraged or discouraged students from pursuing nursing as a career. These influences went well beyond the indirect influence of personal role models. These were active and direct influences. Students in all of the focus groups agreed on the importance of improving outreach to students at the elementary school and high school levels. Aboriginal students, Black Canadian students, and male students all spoke of the importance of sending representatives of their groups to do outreach.



In each group, of the participants who had seen university recruiters come to their high schools to talk about career options, none had ever seen a nursing program representative. This is consistent with the CNA study (Hanvey, 2004) findings. Aboriginal students said they had never had a representative of nursing or nursing education come to their schools on the reserves, although visits by recruiters for the RCMP were commonplace.

Students thought that outreach should start as early as possible, and that included some form of ongoing outreach even at the elementary school level. They said that youth begin to think about career choices as early as Grade 7 and continue thinking about them throughout high school, so intensive outreach and recruitment programs should begin then. According to a male student, another opportune time to do outreach to university students is in their first year or two at university, when some students are changing their minds and deciding on new directions for study.

Many participants felt that there was an urgent need to educate high school students about the prerequisites they need in order to get into nursing programs. A number of Black Canadian university students indicated that they had dropped science courses in high school because they didn’t understand the value and importance of the courses and because they thought that they might do poorly and lower their grade point averages if they stayed in these courses, and thus hurt their chances of going to university. Some students who did this now have regrets, as they are finding their options limited.

Black Students. In one of the focus groups for Black Canadian students, a student who is involved with the Future Teachers Club of the University of Toronto made a case for the start-up of a Future Nurses initiative at the university. There are two other such clubs running on campus, one in engineering and one in law. This is a very sophisticated program that includes multiple outreach strategies involving students, guidance counsellors, teachers, and community members, and the use of videos, posters, career fairs, and professional shadowing, in a process that supports minority students over a number of years as they move from high school to university and on to professional training.

Male Students. Male students suggested that recruiting campaigns should highlight the technological aspects of nursing and provide more information about the courses that men would find interesting. This is consistent with the recommendations of participants in the CNA (Hanvey, 2004) study of men in nursing.

Positive Perceptions

Aboriginal Students. A number of First Nations students reported that Native band councils actively encourage Native students to study and to consider entering a profession, such as nursing. Native students also expressed that family members have tended to encourage them to consider entering nursing. One Native man described a First Nations health team he had worked with in a hospital in Western Canada. The team actively encouraged Native people in that system to enter nursing, and supported them in staying. This approach reportedly had some successes.

9.2.1.d. Personal Experience, Media reports

All participants. Some students knew nurses, not personally but from work in a hospital or in another health care setting. These students could speak firsthand about their experiences working with nurses in hospitals or long-term care facilities. For example, “I worked in a hospital for about 12 years and I know it’s not really wise to make generalizations, but some of the nurses that I ran across there are some of the most miserable, overworked, stressed out people I have ever met. And it’s kind of sad because, of course, you hear about all of the stuff, that they don’t have the right equipment to work with,



they don’t get paid as much as they should be and stuff like that. It’s watching them, you know, it’s kind of depressing sometimes.”

It was possible to observe from what was said how the influence of nurses that students know personally interacted with other factors that affected how students see nursing. For example, a male student who described the stress and overwork of the nurses he knew also recounted his own personal experience with a backlog in a hospital emergency department, and also referred to news reports he’d heard about government cutbacks, nursing shortages, and hospital layoffs. It is important to note that one source of knowledge available to students (such as the nursing students they know personally) operates not as an isolated factor, but very much in conjunction with positive and negative information from other sources.

Frequent references were made in the focus group discussions to the poor treatment of nurses. Speaking about how he had seen patients treat nurses, one student said, “I see that they go and help these old people, which is fine, right, but they’ve got to sponge them down and they get cranky and they yell at you and hit you with their canes. I’ve seen it happen.” Poor treatment referred not only to poor treatment from patients, but poor treatment by the government, and also within the medical system. One student commented, “I’m just thinking of the ways nurses are treated that need to change too. I think the way nurses are perceived needs to be changed … First they fired them, then they shut down beds and stuff, and then they rehire them again, and now who knows what’s going to happen.”

Aboriginal Students. One Native man described a First Nations health team he had worked with in a hospital in Western Canada. The team actively encouraged Native people in that system to enter nursing and supported them in staying. This approach reportedly had some successes.

9.2.2. Perceptions of Nursing as a Career

9.2.2.a. Diversity of Nursing Profession and Practice Settings

Participants in all the focus groups were asked whether they were aware of the three ways it is possible to enter nursing: by earning a bachelor degree to prepare for nursing, by earning a diploma to prepare for practical nursing, and by earning a degree or diploma to prepare to work as a registered psychiatric nurse.

All participants. Although the question of what students know and understand about the various nursing professions did not generate much discussion among students, it was nonetheless an important one. Many students did not have accurate information about what nurses do, or how much they earn, or about the many possibilities for nursing employment. These issues are all related to the question that was asked about nursing professions, and they are critical to how students consider career options, but they emerged in discussions related to other questions.

It is important to note that students, in much of what they reported, did not identify the nurses they knew with nursing professions. When asked, many students were not aware whether the nurses they knew were RNs, LPNs, or RPNs. Students had reached conclusions about the appeal of nursing as a career independent of considerations related to the different nursing professions or the different areas of nursing practice. The following sentiment from a student serves as an example. She linked her disinterest in nursing to what she knew from her mother, who “used to work in an old age home as a nurse, and it’s the stories that she told me that’s kind of drawn me away from it.”



Students in one focus group realized after some discussion that they had erroneously been associating nurses with a single practice setting, such as a long-term care facility or a hospital. Others confused the various options of nursing professions with the different areas in which it is possible to practise nursing. However, some students were also aware that nursing can be a very different experience in different settings.

Participants repeatedly said that the appeal of nursing can vary, depending on the area of nursing or the setting in which nursing is practised. Students stated consistently that nursing can be more appealing in some settings than in others, depending on the preferences of individual nurses. One male student put it this way, “If you tell people these are the various levels or the various streams of nursing [professions], you would have more people interested in the program instead of just seeing nursing as this one track, one dimensional profession. Back in Jamaica, when I was growing up, we had what they call public health nurses … in clinics — clinics that are based in the community, and they were more like social workers who also deal with public health issues. … I think if other people knew about it [the diversity of roles], they would be inclined to [them], especially those who love the social areas but would also like to do something on health issues.”

Aboriginal Students. Aboriginal students did not find that awareness of the three possible ways to enter nursing changed anything about the appeal of nursing as a career. Nonetheless, one student, who is a mother, commented that she would use the information in counselling her sons regarding their career choices in the future.

Black Students. As has been discussed, many Black Canadian students were already aware of the different nursing professions. In fact, these students suggested that emphasis be placed on increasing the enrolment of Black Canadian students in RN programs.

Male Students. Male students thought that the idea of the three nursing professions would be very appealing but only if these professions were similar to the levels in a business hierarchy. The pressures male students experience to maximize their earning power and upward mobility appear to be an overriding factor, to which other considerations are subordinated.


All participants. Some students identified particular areas of nursing that appealed to them. One student said, “You see a lot of street nurses too. They are pretty cool; they do a lot of stuff. They work for maybe agencies or non-profits sometimes. They go around sometimes on the buses delivering hot meals and blankets and condoms.” Others talked about the positive appeal of work in a hospital maternity ward or in public health.

One student said he knew a nurse in an elementary school who “deals with the kids who get injured in what activities they’re in. And she likes the job, so it depends on the environment. Like there’s a big difference between elementary school and an emergency room.”

9.2.2.b. Work Conditions — Effects on Personal Lifestyle

All participants. The aspects of nursing that students found unappealing as a career far outweighed the aspects they found appealing. This was the case in every focus group. Students identified many things they find unappealing, including shift work, giving needles, seeing someone die, the morbid aspects of death and illness, having the responsibility for others’ lives, dealing with blood, dealing with other body fluids, and going home to small children after working around sick people.



Most, although not all, of what students reported about the work of nurses they knew was negative. Often what students knew was the following: nurses work shift work, work long hours, are overworked, work all the time, and have frequent call-ins on top of their regular hours of work. That is, nurses not only have poor work conditions, they lack control over their work conditions. As a male student said about a nurse he knew, “she suffers from ulcers now and she can’t get another job … because of her seniority; she’s stuck at the nightshift.”

These negative aspects of nursing were highlighted repeatedly: nurses work with contagion and may go home to small children, and they may experience emotional trauma from witnessing death or severe injury, and from the stress of an epidemic such as SARS. Many students expressed that the risks involved in assuming responsibility for people’s lives was too great for them to imagine.

Students talked about the negative health effects of the stress of nursing on the energy, personalities, and health of the nurses they knew. One student said about the mother of a friend, “she’s basically stuck in that profession but it just seems stressful from her point of view, …. It makes me think that, OK, I wouldn’t want to go into this profession if I’m going to come home and be stressed out all the time, being tired and complaining about things in my life.” A male student spoke about his neighbour who is a nurse: “By now, because she’s a middle-aged woman, it takes a toll on her doing nightshift. And she said that, well, one of the main factors is the sleep problem because it screws up your sleeping pattern along with, you know, not sleeping at night.”


All participants. Students talked much less about the positive experiences of nurses they knew than the negative experiences. However, a few positive aspects of nursing were highlighted. One student recalled what a friend had told him about nursing: “She enjoyed it because it was so many things always happening at once and it was like such an adrenalin rush that you were always doing something. And it was just like a high almost for her because it’s like you just go from one patient to another to another and things are moving so quickly and you’re not really having time to think about it but you’re doing it and you’re doing your job well.”

A number of students said that nursing and hospitals are appealing because the work experience they offer is very social. Another student put it this way: “You have a group of people that you are kind of connected to once you are on the floor so it’s kind of like you can build relationships and also help one another. If one is tired then you know you can kind of let another person help you. Like there’s room to kind of make bonds and work together as a team — that’s what I think is kind of appealing; but then it can be a negative because you might not get along with the people that you work with.”

Male Students. Male students in the college student focus group engaged in comparisons of professions based on weighing appealing and unappealing factors such as shift work and salary. One student said, “we’re going to have to deal with shift work just the same in [frontline] social work, depending, because there’s obviously agencies that work on the nights… a lot of [frontline] social workers work shift work … I’d rather be a nurse and work for $40 an hour than a social worker earning 18 or 20 bucks.”

9.2.2.c. Professional Status, Treatment and Recognition

All participants. A strong theme was the inadequate recognition nurses receive for the work they do. Participants saw nursing very much as a form of invisible work. “As a nurse, you stay behind the



scenes for your entire life. Okay, you’re earning $60,000, $50,000, but, at the end of the day, you’ve worked a 12-hour shift and nobody knows.”

Male Students. In all of the focus groups, students talked about the treatment of nurses in relation to their place in the medical hierarchy. Male students focused on this particularly, as in this example, “I mean the doctor does sort of [the] brain work, and then the nurse is just standing … the nurse [just] implements the doctor’s orders.” Male students said they had heard that nurses are treated disrespectfully by doctors, “that doctors tend to speak down to nurses and think of themselves as superior.” The only report contradicting this came from a student who knew a male nurse who reported that doctors treated him respectfully.

Students in every group discussed the fact that changing the term nurse to health professional would raise the status of nursing and suggest the inclusion of men. Students all agreed that this would raise the appeal of nursing to male students. Students suggested ways of challenging gender stereotyping in order to break down the stigma of nursing as a career choice for men. Male college students engaged in brainstorming about how the airlines had successfully attracted men to work with airlines by making changes to the title and uniforms of stewardesses. They talked about how calling men chefs instead of cooks increases the status of the work, making it more appealing to men. They recommended that similar adjustments would be necessary if nursing is going to be successful in its appeal to men. These masculinizing strategies are similar to those described by Hanvey (2004), based on interviewing male nursing students and male high school students.

Male students said repeatedly that nurses’ responsibilities don’t reflect their expertise. As they discussed the question of hierarchy, it was clear that many of the men saw a desirable career as one that promised them many work opportunities as well as upward mobility. One student talked about how having a professional degree offered more opportunities, as happens in business and engineering, for example. Another developed the upward mobility aspect further, saying, “I mean, the fact remains, you have to work your way up. But with nurses, they work and work and a lot of them just remain nurses. Even my friend’s mother, she’s got her PhD — she’s a registered nurse and she’s still a nurse.”

Male students also said they think that men value status more so than women, as is reflected in the following: “Men like to be called something more after their name … you know, you’re Michael, the Nurse … you know, you say doctor so and so or you say so and so, master’s in social work. You don’t say that with a nurse. So men need to hear those things, like you have a big ego. We like to feel like whatever we’re doing is important. So, I think a lot of it is about status.”

9.2.2.d. Salary, Job Security, and Upward Mobility

Black Students and Male Students. Job security was a priority voiced by students in focus groups for male and also Black Canadian students. Students expressed differences of opinion and uncertainty about whether nursing will be able to offer job security in the future. One student put it this way: “The thing is, with every change of government, there’s a change of policy so we don’t know what’s going to happen, you know, when the next government comes in. It might be obsessed on tackling the national debt or something. I don’t know.”

Male Students. Independence and having the freedom to take initiative was also linked by male students to upward mobility in work, as described in the following: “Within social work, there’s room for that type of growth, … implementing different programs that could get recognized for you in the field,



and the next job you have could be high up in the administrative position ‘cause they know you to be a self starter who is able to implement programs.”


All participants. The high salaries that some nurses earn hold a definite positive appeal. However, most of the students in the study had very little idea how much nurses earn, or how to find out this information. Those who had some ideas about what nurses earn had very different ideas about those salaries. Most of the participants did not understand that nurses in different nursing professions and in different practice settings can earn sizably different salaries.

One of the things students in every focus group saw as appealing about a nursing career was the freedom to work in other countries, particularly in the United States, where students believed they would earn more money and enjoy more responsibilities as a nurse.

9.2.2.e. Independence, Freedom to Take Initiative

Male university and college students underlined repeatedly that independence was very important to them. One student put it this way: “You’re being told from the chief, like, the head of nursing, this is what you have to do. The head nurse is being told this is what she needs to do to tell her nurses to do…whereas in social work, there’s, yeah, a lot of room to, like, do your own thing and I think that’s important for me.” Male students associated the freedom to take initiative with intangible personal rewards, as well as with greater recognition for their contributions. “It’s self rewarding…. For our youth services, I started off two of my own programs, and there’s something I can just start doing on my own.”

9.2.3. Educational Factors

9.2.3.a. Educational Requirements

All participants. A problem voiced by many students was that they lacked the science and mathematics prerequisites to apply to nursing. This was a barrier that prevented them from considering nursing as a career choice.

Aboriginal Students. First Nations students suggested that a science-based access program such as the Transitional Year Program at the University of Toronto be developed to help students without high school prerequisites to enter nursing programs. This was consistent with the findings of Against the Odds (NTFRRS, 2002) to the question about clinical placement requirements; the only response to this was from Aboriginal students who suggested that it should be possible for students to do placements on their reserves. They claimed that this would make nursing education more appealing.

9.2.3.b. Costs, Funding, Scholarships

All participants. All participants suggested that financial incentives and scholarships would make nursing more appealing, particularly now, with increased educational requirements to qualify as a nurse. Students proposed that incentives such as a cash payment be given to students upon entering nursing programs, or that students receive a free year of tuition in the upper year(s) of the program.

Male students engaged in discussions in both focus groups that exemplified the kind of comparative process students use in evaluating the desirability of career choices. They weighed the pros and cons and compared their career options by considering a number of possibilities together. Weighing the cost of education against the earning potential of a career was a focus of discussion for male



university students. One student said, “Schooling anywhere is expensive, like, so if you want to make up the cost that you incurred for education of being a doctor or a nurse, it’s faster if you become a doctor and then you can pay off the debts and loans.” First Nations students and Black Canadian students voiced similar concerns.

Aboriginal Students. Aboriginal students had unique concerns related to the costs of nursing education. Native students identified funding as a major issue. Although Métis students do not receive band funding, First Nations students can be sponsored to attend various university programs by their bands. However, sponsorship requires yearly renewal and students reported problems with the reliability and continuity of band funding. Some Native students avoid the sponsorship process completely because of long waiting lists (e.g., two years). Concerns such as these are also reflected in the NTFRRS report (2002). One student spoke about the fact that other government funding available to Native students covers the two-year program in nursing but not the four-year RN program. Native students in one focus group agreed that it would be effective if bands put a percentage of their funds aside to support students in nursing studies.

Black Students. The need for special forms of additional financial assistance was unquestioned among Black Canadian university and college students. Black Canadian students agreed that financial support, including scholarships, is a necessity for students in their communities. One student noted, based on his own experience, that scholarships don’t necessarily reach the people who need them. He said, “I agree … scholarships would be such a good idea, but I mean there are so many scholarships that are out there for not just nursing but scholarships in general, and people don’t apply for them at all … That’s what you have to address. You have to address why people don’t use the resources that are available.”

Another student suggested that a scholarship system administered by local community agencies might be helpful, “like Jamaican Canadian Association or Tropicana. It takes the right agency to deliver it too because, I mean, if it’s coming from some place where you can’t really associate with it, like, why would you go and access it? Like, if you’re always hanging around certain places where your own people are, you’re not suspicious of them, like, it’s easier for those agencies to bring things to you.”

Black Canadian students voiced serious concerns about changes in the Ontario Student Assistance Program (OSAP) that are penalizing those who are most in need of financial assistance (e.g., fewer grants and more loans). These students discussed the reluctance of students from immigrant communities to assume educational debt due to a lack of financial backup from family or financial inheritance. Opinions on this subject varied, but clearly it was an issue of serious concern for some students. Black Canadian students described their sense that, while interest is being paid to inclusion, other forms of exclusion, such as the OSAP changes mentioned above, are actually increasing. For this reason, these students suggested that increasing financial aid would make nursing more appealing to Black Canadian students.

9.2.3.c. Location of Schools

Aboriginal Students. The location of schools was a significant issue for Aboriginal students, both in relation to the availability of programming and culture shock. One student said, “My cousin didn’t become a nurse, she became an RCMP instead because it was so far to travel to the [nursing] program.” Another student described the experience of a friend who left the reserve to study nursing, “Her mother took care of her son while she left the reserve, and the school location was three to five hours away. That had hard effects … not only of where the school location was but of how hard and demanding the school was for her to get those qualifications and everything, having to leave her son and travel all the way.”



Other Native students also supported the view that nursing schools must be located closer to northern communities, “to make them more accessible so that [Native students] don’t have to move far away from their families or move with their kids. People quit in our program because they miss their family too much … some are trained to live off the land — they can’t adjust to the city life. They would be able to adjust easier if they made it closer to where they live.” These issues were also discussed in the NTFRRS (2002) report.

9.2.3.d. Cultural Sensitivity and Relevance — Language, Type of Medicine

Aboriginal Students. Aboriginal students agreed on a number of things that would increase the appeal of nursing to Aboriginal students. They were in agreement that nursing education “could be more open to tradition or a holistic way of healing people. There’d be more people in the population interested.” One Native student also suggested that it would help to increase the appeal of nursing if there was a First Nations hospital where Native nurses could know they are needed and accepted. The National Task Force on Recruitment and Retention Strategies (2002) suggested that Native students be able to return to their home reserves to practise. This sentiment was expressed by Native students in this study as well. Another suggestion was that nursing courses be taught in Native languages since, for many Native people, English is their second language. Nurses trained in English cannot communicate with many Native elders, since many elders don’t understand English.

Many First Nations students said that nursing is unattractive to Native students due to the conflict between Western medicine and traditional healing and traditional medicines. “My view on psychiatric nursing is terrible — that they drug people up and it’s just awful. I mean I wouldn’t want to do that. I find it very inhumane and it’s harmful. I know a lot of people who are victims of the psychiatric system who got ECT and their lives are ruined, who got hooked on drugs. I just think that’s an awful thing — psychiatric nursing.” A number of Native students said that nursing education, with all the problems of access encountered by Native students, compounds the culture shock experienced by Native students who leave a rural environment to attend school in the city.

Native students spoke about nurses they were familiar with from health clinics on their reserves. In both Native focus groups, there was agreement that Native people don’t view nursing as a profession that is respectful of Native people. The following participant statement exemplifies this perspective: “Nurses have an image of being not caring, rude, and looking after some people better than others.” This participant stated that it would be very difficult to enter nursing knowing this.

A strong theme reiterated in both Native student focus groups was the need for Aboriginal people who enter nursing to contribute to changes in nursing practice, to adapt the profession to themselves and to the needs of Native people. A report for the First Nations and Inuit Health Branch of Health Canada, Nursing Recruitment and Retention Strategy (Health Canada, 2002), also found that a common goal of Aboriginal nursing students was to contribute to changes in nursing that would benefit Aboriginal people. Aboriginal students who work for changes in nursing face difficult challenges, and this is seen as a drawback of entering nursing for some. One participant described her sister as needing to be “a very determined individual … she wanted to bring some of the traditional aspects into it … she took the bull by the horns and said, ‘look, we need this in this community.’ And you know, there’s a lot of people that feel this way, and she’s very outspoken so she got to them … you have to be focused and determined if you want to make a change out there, but it’s not easy … they had to go through a lot of things, like, to try to change things and not everybody has … an aggressive personality to do that.”



Aboriginal students in both focus groups talked about the value they place on giving back to their communities. Native students said they see a career in nursing as a way of giving back to their communities by helping Aboriginal people who have serious health problems. In the Aboriginal student focus group in Toronto, discussion also centred on the tension between the expectations of bands and students’ own plans for their futures. One student explained that when students return to their reserves to give a number of years of service back to their communities, they do not necessarily have the opportunity to work in the field they studied in school.

Black Students. Black Canadian students also spoke about giving back to their communities and about the importance they place on getting an education so that they can be role models for Black youth in the future.

9.2.3.e. Role Models, Mentoring

Aboriginal Students. Aboriginal students said that role models are very important, and this was also highlighted in Against the Odds (NTFRRS, 2002). They wanted to know how many Natives are there [in nursing education]? Will they get a job? Are they needed? They recommended that the demand for Aboriginal nurses, even on their own reserves, be made clear to Native students. An Aboriginal social work student who had helped encourage other Native people to become nurses said that role models are very significant.

Participants suggested the following to encourage Native students in the field of nursing: “What is it that you’re missing? Do you need tutors or do you need some spiritual guidance or from other grandmothers that have been through nursing? … The late Jean Goodwill did a lot of that, go and speak to students all across Canada on nursing. …She’s been out here lots of … in Ontario because I’ve been to a multicultural conference with her …. And she spoke on Aboriginal nursing, so that has to be ongoing. You can’t just stop, otherwise … that message doesn’t get out.”

Black Students. Black Canadian students saw the mentoring of Black Canadian students as very important to students from immigrant communities who may not have the same family supports as non-immigrant students. Others in the college student focus group said mentoring is essential, since “all people of colour are in special needs, because they do have special needs … Sure, it’s all in front of you but you just need somebody to kind of guide you step by step, to motivate you, and I guess that’s what a mentor is there for.” Again, one student, based on his experience, emphasized that regardless of the programs that are put in place, networks must be created so that those resources find their way to those who need them.



10. Conclusions

10.1. LPN, RN and RPN Education in Canada The following conclusions can be drawn from a review of the histories of nursing education for

all three professions.

a) There is a remarkable lack of collaboration and communication among them.

b) There is little evidence of planning for students to work together to learn the scopes of practice of each and appropriate ways of working together.

c) There may be advantages to all three professions working together in the future: to confront the issues of a nursing shortage, to pressure schools to expand enrolments, and to highlight the limited availability of clinical practice opportunities.

10.2. Educational and Clinical Capacity of Schools to Prepare RNs Regarding the capacity of schools of nursing to prepare RNs, the following conclusions can be

drawn.

a) Admissions to schools of nursing that prepare registered nurses have increased over the period 1997–2001, and there is some evidence that further increases have occurred through 2003. These increases have allowed enrolment to recover to levels not seen since the mid-nineties. There is also some evidence that admission increases may be “plateauing” (as of 2004) as schools struggle with limitations in clinical placements for students in the community and acute care settings, and with limitations in their ability to recruit clinical teachers and preceptors.

b) Schools are recruiting large numbers of faculty for all types of positions and are reasonably successful in securing faculty with the types of preparation they are seeking. Nevertheless, there is evidence that enrolments in graduate programs in nursing are insufficient to meet the demands of the education sector, let alone the health care sector. The areas in which faculty are in shortest supply are mental health, maternal child, pediatrics, public health/community and acute care nursing. In other words, there are shortages in virtually every area of nursing.

c) Clinical placements in acute care and in the community will continue to be major limitations in schools’ capacity to expand their enrolments.

d) 60% of RN schools have insufficient resources for the number of students they currently enrol.

e) 10% of schools could expand their enrolments by 10% with current resources, 70% could expand by 25%, 30% could expand by 50%, and 20% could double their enrolments if provided with sufficient financial resources.

f) Retention rates are poor, particularly in diploma schools, which wastes the resources of these schools, creates significant distress for many students who withdraw, and unnecessarily reduces the numbers of potential nurses available to the health care system. These poor rates may reflect the inadequate level of resources that schools are coping with, which may not be sufficient to provide the faculty and financial support required by students. Baccalaureate schools do better, with retention rates of approximately 80%.



g) Participation rates by Aboriginal Canadians and by men are too low given the need for both in the health care system.

Conclusions that can be drawn in answer to the question about the use of clinical practice

environments and the role that preceptors play include the following.

a) There is enormous competition for access to clinical experience among schools of nursing and with students from other health science disciplines.

b) There is a preponderance of distributive clinical placements from Monday to Friday on days and to a lesser extent, evenings, which may not be the most efficient use of clinical resources.

c) There is essentially no research to guide schools in determining which model (distributive/block) of clinical practice uses practice environments most efficiently and effectively.

d) Schools are dependent on preceptors in the senior years of nursing programs in both community and acute care, and about a third of schools cannot access preceptors in sufficient numbers to meet their needs.

e) Preceptors receive very modest incentives to participate in the role.

10.3. Educational and Clinical Capacity of Schools to LPNs Canada is fortunate to have an excellent distribution of programs to prepare LPNs across the

provinces and territories. Programs, particularly in Western Canada, have developed ways of increasing access by establishing temporary sites and brokering their programs to other colleges without programs. However, the wide range of theory and clinical practice time required in the LPN programs across the provinces —that results in the same credential — is unsettling. Attention should be paid to the equitability of these programs, as the requirements are different across the country.

In response to the first question about the capacity of schools to prepare LPNs, the following conclusion can be drawn.

a) The rapid increase in enrolments in LPN schools over the last three years is coming to an end because of a lack of resources, particularly those related to access to clinical placements in acute care hospitals and limited access to faculty for clinical teaching.

b) 50% of the LPN schools in this survey do not have sufficient resources for the number of students they currently enroll; the resources in shortest supply are acute care and community placements, faculty to supervise students clinically, and faculty to provide back-up should any of the teaching staff be absent.

c) With current resources, 30% of schools have the capacity to increase their enrolments by 10%, and 10% of schools could increase enrolments by 25%; however, with increased financial resources, 50% of schools could increase enrolments from 10 to 25%, 40% could manage 50% increases, and 30% could double their enrolments because they have access to the necessary faculty, clinical placements, students, space, and administrative assistance, but they do not have the financial support to acquire them.

d) The majority of schools are able to find sufficient numbers of faculty members with credentials they are seeking to fill the vacant positions; the favoured credential is a baccalaureate degree in nursing.



e) The average retention rates in the LPN schools are around 70%, but the range is very wide, from 20 to 100%; there is an opportunity to reduce the number of students who withdraw either voluntarily or through academic failure.

f) Too few LPN schools make special efforts to recruit Aboriginal students, and, as a result, there are few Aboriginal students in the programs.

g) The proportion of men in these LPN programs is 12% and the number who remain in the workforce, even lower.

The following conclusions can be drawn in answer to the question about the use of clinical

resources.

a) These LPN schools use clinical resources well, including use around the clock.

b) These schools make use of block placements to maximize the effective use of resources.

c) These LPN schools compete for clinical placements with many other nursing (both LPN and RN) and health science students.

d) For the most part, preceptors do not play a big role in the education of LPN students, but where they are used, most schools are able to recruit sufficient numbers of them to meet their needs.

10.4. Under-represented Groups in Nursing The exciting thing about the study of under-represented populations in nursing is that the findings

suggest so very many ways that nursing education can improve outreach and also appeal to the hearts and minds of Aboriginal, Black Canadian and male university and college students.

Black Canadian university students engaged in a very interesting discussion about whether they are getting an education based on what they are interested in and passionate about, or whether they see education as a means to a definite practical goal such as a professional career. Their discussion moved among considerations of personal interests, future possibilities, considerations of community, and practical necessities, with an emphasis mostly on personal interest in, and love of, a chosen area of study. The Future Teachers initiative invites students from minoritized ethnocultural groups to move a further step beyond this by making professional careers the final outcome of their learning and study. This is a successful initiative that provides a highly elaborate model that the field of nursing would do well to adopt in the case of Black Canadian students.

Nursing education outreach may also be able to use information such as that gathered in this study to build the perception that nursing education provides opportunities to increase personal worth, to support personal development (including after graduation from nursing), and to promote the social advancement of Black communities. Nursing education can also appeal to the goal of Black students to become needed role models to youth in their communities.

Aboriginal students spoke about the appeal of responding to the enormous need that exists to provide nursing care to Native people in a way that that population will perceive as respectful and as harmonious with their cultural and traditional ways. This is an ambitious objective but one that Aboriginal students who participated in this study all spoke about and resonated with. The need is there. The question is, How can the formal systems of nursing and nursing education combine their goals of recruiting more Aboriginal students into nursing with the vision and goals of Native students to change nursing? The full answer to this question is somewhat outside the scope of this project, but certainly the



possibilities are very exciting, and the probability is very high of recruiting Native nursing students if their goals are respected and met.

Many of the students who participated in the focus groups lacked information about the different nursing professions, about nurses’ salaries, and about different types of nursing practice. Given that students clearly engage in complex comparisons of tuition and salary and work conditions when they are considering career options, how can they do this effectively without complete and accurate information? It’s not possible. Nursing education can do a much better job of informing students about the practical side of what a nursing career has to offer.

From comparisons of focus groups discussions, it was very clear that male students blend practical necessities with future possibilities. They want to know there will be room for upward mobility in future employment. In order for nursing education to appeal to them, these concerns will need to be addressed directly. Male students stated clearly that salaries are the most effective promotion of nursing possible. For some, this factor outweighed many other concerns. This is supported by the fact that, upon learning more about the salaries of nurses, some male students indicated that they were more interested in nursing as a career option than they had been previously.

Nursing education might consider ways of appealing to the parents of prospective students since parents and families exert influence on students’ career choices. Inclusive images of nursing on posters or in videos could feature students’ parents. The parents of Aboriginal, Black Canadian and male students could be appealed to, based on the concerns voiced by these students.

The tremendous barrier that racism poses is one that nursing can take on in the ways nursing students suggested: by increasing the visibility and the profile of Aboriginal, Black Canadian, and male nurses in nursing practice, in management, and in nursing education. This is how the “image” of nursing can change. It is interesting to note that not a single participant saw nursing as a means to become a nursing educator, even though one of the students said he was considering teaching and saw it as a profession that was somewhat less stigmatizing for men. This is yet another door that nursing education could open to students, particularly those students who are committed to the advancement of their communities.

The need exists for increased financial assistance. This was voiced in connection with Black Canadian students, particularly. Both Aboriginal and Black Canadian students suggested that scholarships would invite more students into nursing education, and male students responded favourably to the idea of financial incentives. One male student suggested that nursing be treated like the military, with fully funded education and mandatory service. Also, it was very poignant and worthy of serious note that one Black Canadian student voiced concern that special forms of financial assistance to Black Canadian students be handled, as much as possible, in a way that avoids backlash (i.e., that Blacks are seen as getting special treatment not available to other students who may be as needy and worthy).

University students have a sense that nursing is in trouble and that the stability of nursing as a career has been undermined by funding cuts and changes in government in recent years. Clearly, this is something that nursing education cannot fix on its own. However, providing information about the things that are being done by government to shore up the job security and work conditions of nurses will be important if future generations of students are going to consider nursing as a career choice.



11. Recommendations

1. One of the major constraints on the expansion of programs to prepare RNs is the availability of faculty members with master’s and doctoral preparation. Therefore, it is recommended that enrolments in graduate programs be expanded immediately. Special initiatives to make it financially possible for students to study full-time are needed. As a model for achieving this goal, nursing traineeships awarded to students by the U.S. federal government should be explored; this was started in the 1960s to address a shortage of master’s prepared nurses. The expansion of doctoral programs requires the availability of more doctoral and post-doctoral fellowships funded at levels that make full-time study realistic for nurses.

2. Clinical education of students is a critical component of nursing education and yet it is difficult to identify “best practices” in clinical nursing education. Expansion of both LPN and RN programs is constrained by perceived limits in the capacity of acute care and community practice environments to absorb more students. Therefore, it is recommended that an immediate study be undertaken of how to maximize current clinical resources. Secondly, it is unlikely that all of the clinical practice needs for the current level of enrolment, let alone an expanded one, can be met within the available practice environments. Therefore, it is recommended that funds be made available to all schools of nursing to introduce or expand the simulation opportunities available to their students; this would help to conserve the clinical practice opportunities for those activities and processes that cannot be learned through simulation alone. As well, consideration should be given to establishing some central simulation laboratories that could be used by several schools of nursing, and potentially by other health science disciplines, for their training needs.

3. Half the schools of nursing that prepare LPNs, and 60% of those that prepare RNs, describe themselves as highly stressed and having difficulty managing the numbers of students they have with the resources available to them. Nursing education has never been adequately costed. It is recommended that a study to cost nursing education be undertaken immediately in preparation for an expansion of enrolments so these expansions are adequately funded and current levels of funding adjusted.

4. More than 80% of schools of nursing can manage some degree of expansion in enrolment, and a few of them can expand considerably if they have adequate financial resources to support the increased numbers involved. It is recommended that a national strategy be developed for expanding enrolments in schools of nursing. In collaboration with the provinces, the strategy should address the additional numbers of graduates needed per province to meet the nursing workforce needs, the enrolment increases required to meet these graduation targets, the identification of schools with the potential to expand, and the financial costs of doing so (including the costs of developing simulation laboratories).

5. Retention rates are too low in many LPN and RN schools of nursing. This comes with a high cost to students, and it is an enormous waste of students’ potential and of faculty resources. Importantly, some schools of nursing have excellent retention rates. It is recommended that target retention rates of 90% be established for schools of nursing, while acknowledging there are year-to-year fluctuations. A great deal is known about how to increase retention: admit students with appropriate



academic backgrounds; portray nursing realistically in recruitment activities; once students are admitted, assist them to develop strategies to cope with the current upheavals in nursing and more generally in the health care system; aggressively support students, particularly those entering with grades lower than the class average; and make it clear to students how and where they can seek assistance. This information should be incorporated into retention strategies established within every school.

6. There are too few Aboriginal people and men in nursing schools. Additionally, although not supported by statistics, there is a perception that nursing is recruiting too few Black Canadians into its ranks. Several studies have been undertaken that provide direction for increased recruitment and retention of members of these under-represented groups. It is recommended that specific recruitment initiatives be developed by schools of nursing to attract Aboriginal students based on recommendations identified in Against the Odds (National Task Force on Recruitment and Retention Strategies [NTFRRS], 2002) and by replicating the activities undertaken by several schools in Western Canada that have been successful in both recruiting and retaining Aboriginal students. Similarly, recommendations in the report Men in Nursing (Hanvey, 2004) should be followed to attract and retain men.

i) The participants in the focus group study conducted as part of this project added new perspectives and ideas about how to recruit students from the three populations of interest. There is a need to make the view of nursing and nurses held by university and college students, their families, and perhaps the public at large more positive. This means a public relations campaign that is beyond the scope of any one school of nursing. Health Canada, professional nursing associations and provincial/territorial health ministries should combine efforts to position nursing in a positive light. This includes correcting the view that nursing is only about blood, needles, death, and mess, that nurse are invisible members of the health care team, that nursing is not a prestigious career, and that nurses’ working conditions are uniformly negative. The opportunities to give back to Aboriginal and Black communities through nursing are important messages for potential students from those communities. Emphasizing the career opportunities in nursing is needed, including the opportunities in management and teaching and the salaries available for these positions. The issue of racism in nursing cannot be ignored because of its impact on recruitment. The quote from a young person in a focus group involving Black students, “It gets more diverse as you go lower” is an indictment of nursing’s openness to people of all races, particularly among the registered nurse and registered psychiatric nurse professions.

ii) It is important that practising nurses be made aware of the impact of their behaviour and attitudes on Aboriginal and Black communities (and, frankly, on all communities). Every nurse is potentially a role model and the impression that each nurse makes on the people she/he cares for can be profound. This is particularly true in Aboriginal communities where the need to portray nursing as a desirable career to young Aboriginal people is crucial. Individual nurses may be the most important and influential tool in this recruitment strategy.

iii) The recommendation from men that the nursing consider changing the name of practitioners cannot be dismissed. Nurse and nursing are intrinsically female names and it is difficult for most men to embrace them and identify with them. Perhaps it is time to take this recommendation seriously.



iv) Finally, carefully designed recruitment initiatives are needed to present career opportunities (not job opportunities) in nursing to students from these three under-represented groups — at the elementary level, in Grade 9, and to students in first year of university and college; these are critical years in which career decisions are made. Sending nurses from these three groups to recruit in schools is crucial to the success of these recruitment efforts.

7. There is a need for greater communication, and potentially collaboration, across the educational sectors of the three nursing professions. At this time, there are no ongoing mechanisms in place to allow this communication to occur. Therefore, it is recommended that a mechanism, such as a council, be established, with representatives from all three nursing professions, with the objectives of enhancing communication among the three professions, planning for intra-disciplinary collaboration, and presenting a coherent, collaborative and mutually respectful face of nursing education in Canada.



REFERENCES Aber, C.S. & Arathuzik, D. (1996). Factors associated with student success in a baccalaureate nursing

program within an urban public university. Journal of Nursing Education, 35(6), 285–288.

Aboriginal Nurses Association of Canada (2000). Recruitment and retention of nurses in isolated Aboriginal communities: A preliminary analysis of strategies. Ottawa, ON: Aboriginal Nurses Association of Canada.

Alcock, D. & Arthur, H.M. (2003). Federally and Provincially Funded Nurses’ Research Activity and Capacity Building in Canada in 2002. Ottawa, ON: Health Canada, Office of Nursing Policy.

Association of New Brunswick Licensed Practical Nurses (2003). Working together: A framework for the registered nurse and licensed practical nurse. Retrieved August 28, 2004, from <http://www.anblpn.com/new.htm>

Bain, L. (1996). Preceptorship: A review of the literature. Journal of Advanced Nursing, 24(1), 104–107.

Bajnok, I. (1992). Entry-level educational preparation for nursing. In A.J. Baumgart & J. Larsen (Eds.), Canadian nursing faces the future (pp.401–419). St. Louis, MO: Mosby.

Baumgart, A.J. & Kirkwood, R. (1990). Social reform versus educational reform: University nursing education in Canada, 1919–1960. Journal of Advanced Nursing, 15, 510–516.

Bolan, C.M. & Grainger, P. (2003). High school to nursing. Canadian Nurse, 99(3), 18–22.

Brush, B.L., Sochalski, J. & Berger, A. M. (2004). Imported care: Recruiting foreign nurses to U.S. health care facilities. Health Affairs, 23(3), 78–87.

Canadian Association of Practical & Nursing Assistants [CAPNA], Special Committee. (1984, February). The present and future role of the practical nurse/nursing assistant in the Canadian health care system: Final report. (Ontario: Author).

Canadian Institute for Health Information. (2003). Workforce trends of licensed practical nurses in Canada, 2002. Ottawa, ON: Author.

Canadian Institute for Health Information. (2003a). Workforce trends of licensed practical nurses in Canada, 2002. LPNDB: Licensed practical nurses database. (ISBN 1-55392-276-1). Ottawa, ON: Canadian Institute for Health Information.

Canadian Nurses Association & Canadian Association of Schools of Nursing [CNA/CASN] (2004). The national student and faculty survey of Canadian schools of nursing 2001–2002. Ottawa, ON: Author.

Catholic Encyclopedia (2004). Jeanne Mance. Retrieved August 3, 2004, from <http://www. newadvent.org/cathen/09584a.htm>

Chinese University of Hong Kong. Retrieved September 12, 2004, from <www.cuhk.edu.hk>

College of Licensed Practical Nurses of Manitoba (2003). Report to CPNA — September 2003. Retrieved August 23, 2004, from <http://www.yourwebperson.com/cpna/MNAnnualReport2003.pdf>

College of Nurses of Ontario (1998, December 10). RN entry to practice decision. Toronto, ON: Author.

College of Nurses of Ontario (1999, September). RPN entry to practice competencies: Project report. Toronto, ON: Author.

College of Nurses of Ontario (2002). Questions and answers about changes in basic education for registered practical nurses in Ontario. Retrieved August 23, 2004, from <http://www.cno.org/ doc/reg/43071_fsRpnEdu.pdf>



College of Nurses of Ontario. Seven requirements to becoming a nurse in Ontario. Retrieved September 20, 2004, from <http://www.cno.org/international_ en/c_RegistryRequirements/regreqs.html>

Cox, L.S. (2002). Focused learning: 2 weeks of class — 2 weeks of clinical. Nursing Education, 27(1), 15–16.

Dibert, C. & Goldenberg, D. (1995). Preceptors’ perceptions of benefits, rewards, supports and commitment to the preceptor role. Journal of Advanced Nursing, 21, 1144–1151.

Dick, D.D. & Cragg, B. (2003). Undergraduate education: Development and politics. In M.McIntyre & E. Thomlinson (Eds.), Realities of Canadian nursing (pp.182–204).Philadelphia: Lippincott Williams & Wilkins.

Glover, K. (2001). Overview of the practical nurse program at NorQuest College, Edmonton, Alberta. In Perspective of LPN history in Alberta. Edmonton, AB: Council of Licensed Practical Nurses of Alberta.

Glossop, C. (2001). Student nurse attrition from pre-registration courses: investigating methodological issues. Nurse Education Today, 21, 170–180.

Hanvey, L. (2004). Men in nursing. Ottawa, ON: Canadian Nurses Association.

Health Canada, First Nations & Inuit Health Branch. (2001, January). Nursing recruitment & retention strategy — HQ progress report. Ottawa, ON: Author.

Healthcare Management (2003, November 16–30). Retrieved September 18, 2004, from <http://expresshealthcaremanagement.com/20031130/coverstory01.shtml>

Hinshaw, A.S. (2001, January 31). A continuing challenge: The shortage of educationally prepared nursing faculty. 2001 Online Journal of Issues in Nursing. Retrieved August 10, 2004, from <http://www.nursingworld.org/ojin/topic14/tpc14_3.htm>

Hong Kong Polytechnic University. (n.d.). Retrieved September 12, 2004, from <www.polyu.edu.hk>

Hong, Y. & Yatsushiro, R. (2003). Nursing education in China in transition. Journal of Oita Nursing and Health Sciences 4(2), 41–47. Retrieved September 15, 2004, from <http://www.oita-nhs.ac.jp/ journal/PDF/4(2)/4_2_1.pdf>

Jalili-Grenier, F. (1993). Recruitment, selection, and attrition in Canadian university schools of nursing. Canadian Journal of Nursing Administration, 6(4), 15–19.

Jeans, M.E. (2003). Designing and managing our infrastructure for success. Canadian Journal of Nursing Leadership, 16, 31–33.

Jeffreys, M.R. (2002). Students’ perceptions of variables influencing retention: A pretest and post-test approach. Nurse Educator, 2(1), 16–19.

Kahan, F.H. (1973). A different drummer. Available from the Registered Psychiatric Nurses Association of Saskatchewan, 2055 Lorne St., Regina, SK, S4P 2M4

King, K. (1970). The development of university nursing education. In M.Q. Innis (Ed.), Nursing education in a changing society (pp. 67–88). Toronto, ON: University of Toronto Press.

Krueger, R.A. & Casey, M.A. (2001). Designing and conducting focus group interviews. In R.A. Krueger, M.A. Casey, J. Donner, S. Kirsch, & J.N. Maack (Eds.), Social analysis: Selected tools & techniques (pp. 4–23). Washington, DC: Social Development Department, The World Bank.

Krueger, R.A. (1994). Focus groups. A practical guide for applied research (2nd ed.). Thousand Oaks, CA: Sage Publications.


http://expresshealthcaremanagement.com/20031130/coverstory01.shtml

http://www.polyu.edu.hk/


Liegler, R.M. (1997). Predicting student satisfaction in baccalaureate nursing programs: Testing a causal model. Journal of Nursing Education, 36(8), 357–364.

Lockie, N.M. & Burke, L.J. (1999). Partnership in learning for utmost success (PLUS): Evaluation of a retention program for at-risk nursing students. Journal of Nursing Education, 38(4), 188–192.

McGuane, E.A. & Bullough, B. (1995). Can practical nursing survive? Journal of Practical Nursing, December, 48–54.

Memmer, M.K. & Worth, C.C. (1991). Retention of English-as-a-second-language (ESL) students: Approaches used by California’s 21 generic baccalaureate nursing programs. Journal of Nursing Education, 30(9), 389–396.

Ministry of Health. (n.d.). Career opportunities. Retrieved September 18, 2004, from <http://www.moh.gov.jm/Careers_in_Health.html>

Mussallem, H. K. (1960). Spotlight on nursing education. Ottawa, ON: Canadian Nurses Association.

Mussallem, H.K. (1965). Nursing education in Canada. (Submission to the Royal Commission on Health Services). Ottawa, ON: Queen’s Printer.

National Task Force on Recruitment and Retention Strategies [NTFRRS] (2002). Against the odds: Aboriginal nursing. Retrieved June 15, 2004, from <http://www.umanitoba.ca/nursing/research/aboriginal_nursing.pdf>

Nolan, P.W. (1993). A history of the training of asylum nurses. Journal of Advanced Nursing, 18, 1193–1201.

NorQuest. (n.d.). Programs. Retrieved August 23, 2004, from <http://norquest.ab.ca/programs/health/pn/ pnftpt.htm>

Nurses Directory – Nursing Colleges in India. (n.d.) Retrieved September 18, 2004, from <http://www. nurses-directory.com/nursingcolleges.htm>

Nursing Council of Hong Kong. Retrieved September 12, 2004, from <www.nchk.org.hk>

Ontario Ministry of Health. (1999). Good nursing, Good health: An investment for the 21st century. Toronto, ON: Queen’s Printer for Ontario.

Philippine General Hospital. Retrieved September 18, 2004, from <http://www.pgh.gov.ph/ main.php?fid=jobs>

Piemme, J.A., Kramer, W., Tack, B.B., & Evans, J. (1986). Developing the nurse preceptor. Journal of Continuing Education in Nursing, 17(6), 186–189.

Polit, D.F., Beck, C.T. & Hungler, B.P. (2001). Essentials of nursing research. Philadelphia: Lippincott.

Pringle, D. (2004). Examining the causes of attrition from schools of nursing in Canada. Ottawa, ON: Office of Nursing Policy.

Psychiatric nursing. (n.d.). Retrieved August 27, 2004, from <http://www.scs.unr.edu/~chaffina/ psychnsg.html>

Quebec Ministry of Education. (2004). Projection du nombre de diplômés disponibles pour l’emploi dans leur domaine pour le programme Santé, assistance et soins infirmiers pour l’ensemble du Québec. Available from OIIAQ, 531 Sherbrooke Ave. E., Montreal, QC H2L 1K2.

Refvik, K.I. (1991). History of the Brandon mental health centre 1891–1991. Brandon, MB: Brandon Mental Health Centre.



Registered Psychiatric Nurses Association of Alberta. (n.d.). Historical overview. Retrieved August 15, 2004, from <http://www.rpnaa.ab.ca/HistoricalOverview.htm>

Registered Psychiatric Nurses Association of Manitoba [RPNAM]. (1977). A brief on psychiatric nursing in Manitoba. Available from the College of Registered Psychiatric Nurses of Manitoba, 1854 Portage Avenue, Winnipeg, MB R3J 0G9.

Registered Psychiatric Nurses Association of Saskatchewan [RPNAS]. (n.d.). Psychiatric nursing education: A program for Saskatchewan. Retrieved August 12, 2004, from <http://www.rpnas.com/public/pdfs/education_brief.pdf>

Rheaume, A. (2003). Establishing consensus about the baccalaureate entry-to-practice policy. Journal of Nursing Education, 42, 546–552.

Russell, K.E. (1956). The report of a study of nursing education in New Brunswick. Fredericton: University of New Brunswick.

Russell, M.G. (1970). The emergence of the nursing assistant. In M.Q. Innis (Ed.) Nursing education in a changing society (pp. 130–147). Toronto, ON: University of Toronto Press.

Saint Louis University. Retrieved September 12, 2004, from <http://www.slu.edu.ph/research/cn.htm>

Saskatchewan Association of Licensed Practical Nurses [SALPN]. (2003). Report to CPNA September 2003. Retrieved August 23, 2004 from <http://www.yourwebperson.com/cpna/ SKAnnualReport2003.pdf>

Smith, D.R. & Tang, S. (2004). Nursing in China: Historical development, current issues and future challenges. Journal of Oita Nursing and Health Sciences 5(2), 16–20. Retrieved September 15, 2004, from <www.oita-nhs.ac.jp/journal/ PDF/5(2)/5_2_1.pdf>

Smith, I. (1990). The RNAs of New Brunswick: Doing for themselves. Fredericton, NB: Association of New Brunswick Licensed Practical Nurses.

Smith,V.A. (1990). Nursing student attrition and implications for pre-admission advisement. Journal of Nursing Education, 29(5), 215–218.

Sri Ramachandra Medical College & Research Institute. (n.d.) Retrieved September 10, 2004, from <http://www.hostindia.com/srmc/index.asp>

Stickney, M.C. (2002). Factors affecting attrition of practical nursing students. Unpublished doctoral dissertation, University of Central Florida, Orlando.

Storch, J. & Gamroth, J. (2002). Scholarship revisited: A collaborative nursing education program’s journey. Journal of Nursing Education, 41, 524–530.

The Canadian Encyclopedia. (2004a). Nursing. Retrieved September 19, 2004, from <http://www. thecanadianencyclopedia.com/index.cfm?PgNm=TCE&P>

The Canadian Encyclopedia. (2004b). Hospital architecture. Retrieved September 19, 2004, from <http://www.thecanadianencyclopedia.com/index.cfm?PgNm=TCE&P>

Tinto,V. (1997). Classrooms as communities: Exploring the educational character of student persistence. Journal of Higher Education, 68, 599–623.

University of Hong Kong. Retrieved September 12, 2004, from <www.hku.edu>

University of Minnesota School of Nursing. (n.d.). About the school. Retrieved August 24, 2004, from <http://www.ahc.umn.edu/ahc_content/colleges/nursing/index2cfm?na>

Weir, G. (1932). Survey of nursing education in Canada. Toronto, ON: University of Toronto Press.


http://www.slu.edu.ph/research/cn.htm


Xu, Y., Xu, Z. & Zhang, J. Nursing education curriculum in the People’s Republic of China and the United States: A comparative perspective. Retrieved September 15, 2004, from <http://www.hiceducation.org/Edu_Proceedings/Yu%20Xu2.pdf>



Appendix A. Acronyms

See Appendix D for acronyms used for provinces and territories. CAATS ............Colleges of Applied Arts and Technology CASN.............Canadian Association of Schools of Nursing CIHI .................Canadian Institute for Health Information CNA .................Canadian Nurses Association CNO .................College of Nurses of Ontario COUPN............Council of Ontario University Programs in Nursing, which is a policy forum for the

deans and directors, and the heads of the programs in CAATS DVA.................Department of Veterans Affairs LPN..................licensed practical nurse NEPS................Nursing Education Program of Saskatchewan NNCP...............National Nursing Competencies Project PCLPN .............Professional Council of Licensed Practical Nurses RN....................registered nurse RPN..................registered psychiatric nurse RPNAM ...........Registered Psychiatric Nurses Association of Manitoba SARS ...............Severe Acute Respiratory Syndrome SIAST ..............Saskatchewan Institute of Applied Science and Technology SPSS.................Statistical Package for the Social Sciences (data software) UBC .................University of British Columbia



Appendix B. Nursing Associations

Web site Association

BC RNABC CLPN CRPNBC

http://www.rnabc.bc.ca http://www.clpn.bc.ca http://www.crpnbc.bc.ca

Registered Nurses Association of British Columbia College of Licensed Practical Nurses of British Columbia College of Registered Psychiatric Nurses of British Columbia

AB AARN CLPNA RPNAA

http://www.nurses.ab.ca http://www.clpna.com http://www.rpnaa.ab.ca

Alberta Association of Registered Nurses College of Licensed Practical Nurses of Alberta Registered Psychiatric Nurses Association of Alberta

SK SRNA SALPN RPNAS

http://www.srna.org http://www.salpn.com http://www.rpnas.com

Saskatchewan Registered Nurses’ Association Saskatchewan Association of Licensed Practical Nurses Registered Psychiatric Nurses Association of Saskatchewan

MB CRNM CLPNM CRPNM

http://www.crnm.mb.ca http://www.clpnm.ca http://www.crpnm.mb.ca

College of Registered Nurses of Manitoba College of Licensed Practical Nurses of Manitoba College of Registered Psychiatric Nurses of Manitoba

ON CNO RPNAO

http://www.cno.org http://www.rpnao.org

College of Nurses of Ontario College of Licensed Practical Nurses of Ontario

QC OIIQ OIIAQ

http://www.oiiq.org http://www.oiiaq.org

Ordre des infirmières et infirmiers du Québec Ordre des infirmières et infirmiers auxiliaires du Québec

NB NANB ANBLPN

http://www.nanb.nb.ca http://www.anblpn.com

Nurses Association of New Brunswick The Association of Licensed Practical Nurses of New Brunswick

NS CRNNS CLPNNS

http://www.crnns.ca http://www.clpnns.ns.ca

College of Registered Nurses of Nova Scotia The College of Licensed Practical Nurses of Nova Scotia

PE ANPEI PEILPN

http://www.anpei.ca http://www.peilpn.com

The Association of Nurses of Prince Edward Island Prince Edward Island Licensed Nursing Assistants

NL ARNNL

http://www.arnnl.nf.ca/ http://www.nlhba.nf.ca

Association of Registered Nurses of Newfoundland and Labrador Licensed Nursing Assistants of Newfoundland and Labrador

NT/ NU

RNANT/NU

http://www.nwtrna.com

No Web site available http://www.hlthss.gov.nt.ca/

The Registered Nurses Association of the Northwest Territories and Nunavut

Licensed Practical Nurses of the Northwest Territories Nunavut, Health and Social Services, Government of NWT

YT YRNA

Email only [email protected] No Web site available

Yukon Registered Nurses Association Licensed Practical Nurses of the Yukon Territory


http://www.cno.org/

http://www.lpnboard.ns.ca/

http://www.nlhba.nf.ca/

http://www.nwtrna.com/

http://www.hlthss.gov.nt.ca/

mailto:[email protected]


Appendix C. Glossary of Key Terms

Note: This glossary is meant to indicate how the following terms are used in this report only. It is not meant to provide comprehensive definitions.

Aboriginal/First Nations/Native. Used synonymously in this document, and all include Métis. 2x2. Program in which students started their program in a college and transferred to the university partner

for the upper two years. admission. The number of students who are admitted to a program at the beginning of the academic year

(see enrolment). collaborative programs. Colleges and universities develop partnerships to offer a nursing education

program that leads to a baccalaureate degree in nursing. college. This term is used differently in the various provinces to denote a post-secondary institution (or

institute) with programs of varying lengths and academic level. In Quebec, the word college refers to CEGEPs (Colleges of General and Vocational Education). These colleges provide general and technical education for students who have graduated from high school. All offer programs to prepare RNs. Professional training is also offered by the Ministry of Education through CFPs (Centre de formation professionnelle).

enrolment. The total number of students who are counted as taking the program after a “count day” in the university or college. A count day occurs after the date on which students who have been admitted may withdraw without penalty; these withdrawn students are then not counted as enrolled in the program (see admission).

ladder program. A nursing education program that allows students to begin studying to be a practical nurse and progress to studying to be a registered nurse, and in some cases to a baccalaureate degree in nursing.

licensed practical nurse (LPN). LPNs are “regulated health care professionals who work in partnership with other members of the health care team to provide nursing services to individuals, families, and groups of all ages. LPNs combine nursing knowledge, skill, and judgement when treating health conditions, promoting health, preventing illness. and assisting clients to achieve an optimal state of health. They assess, plan, implement, and evaluate care for clients throughout the lifecycle as disease progresses, and through palliative stages” (“Building the Future,” 2003b).

non-integrated or “sandwich” programs. Programs in which students spend a first year at a university, three years in a hospital school of nursing, and then a final year back at the university for which they are granted a degree.

Native. Used synonymously with the term Aboriginal in this document, and includes First Nations and Métis.

nurse. For the purposes of the report, a nurse is a graduate of an accredited nursing program who has passed the requisite licensing examinations and is registered with an appropriate regulatory body. A member of any of the three regulated nursing professional groups in Canada: registered nurses (RNs); licensed practical nurses (LPNs), with the title of registered practical nurses in Ontario; and registered psychiatric nurses (RPNs).

nursing assistant. Or “NA,” “registered nursing assistant,” or “RNA” when referenced in the Quebec context. Equivalent to LPN or RPN (Ontario) outside of Quebec.



nursing education program. Refers to the curriculum and to the entity in which students are enrolled. A school of nursing may have one or several programs in which students are enrolled on a full- or part-time basis.

preceptor. A registered nurse, registered psychiatric nurse or licensed practical nurse who is assigned to an individual RN, RPN, or LPN student to function as a guide in the care of patients in that nurse’s clinical area of expertise.

professions. Refers to the three nursing professions (RNs, LPNs, RPNs). program. Same as nursing education program. registered nurse (RN). “Through their legislated scope, RNs are authorized to practice autonomously

regardless of the complexity of the client’s/clients’ condition(s) or the predictability of the outcomes of care. RNs are diversified health care workers, able to provide care to individuals, families, groups, communities, and populations of all ages and levels of health. RNs provide client care across the continuum of health promotion, disease prevention, treatment, support, and rehabilitation and palliative care” (“Building the Future,” 2003a).

registered psychiatric nurse (RPN). RPNs “participate as members of interdisciplinary health care teams in providing holistic care to client groups in the context of mental and developmental health services. Psychiatric Nursing promotes the restoration of client health and wellness through health promotion initiatives that are evidence-based. RPNs practice at all levels of prevention, including primary, secondary, and tertiary health care services across the life span” (“Building the Future,” 2003c).

school of nursing. Refers to the entity that administers the LPN, RN, or RPN nursing education program and employs the staff. In Quebec, LPN education is provided through Centres de Formation Professionelles administered by boards of education. For the purposes of this report, these Centres are equivalent to schools.

school. Same as school of nursing. sector. Hospitals, nursing homes, public health, home care, etc. site. Refers to the location where the program is offered. Schools of nursing may offer their program(s)

on one or several sites. slip year. A term used to denote funding based on the budget from the previous year.



Appendix D. Key to Geographical Names and Acronyms

Note: Dates in parenthesis indicate the year the province/territory joined Confederation.

THE NORTH (the territories) (Referred to in this document as the territories to avoid confusion with the Northwest Territories.) YT Yukon Territory (1898) NT Northwest Territories (1870) NU Nunavut (formerly part of NT, until 1999)

Nursing education programs in the territories:

RNs One in NT. LPNs One in YK and NT,

offered on an occasional basis every two to three years (CIHI, 2003b). It is unknown what percentage the territories contribute to the total LPN workforce.

RPNs None.

WESTERN CANADA West Coast BC British Columbia

(1871)

Prairie Provinces AB Alberta (1905) SK Saskatchewan (1905) MB Manitoba (1870)

CENTRAL CANADA ON Ontario (1867) QC Quebec (1867)

ATLANTIC PROVINCES Maritimes (includes Labrador) NB New Brunswick (1867) PE Prince Edward Island (1873) NS Nova Scotia (1867) ********** NL Newfoundland and Labrador

(1949) — NF until October 2002



AUTHORS’ BIOGRAPHIES Dorothy Pringle, RN BScN MS PhD Dorothy Pringle is a professor in the Faculty of Nursing at the University of Toronto where she was dean from 1988 to 1999. She has been involved in nursing education for nearly 40 years, including appointments at McMaster University and Laurentian University School of Nursing, where she was also director. She has conducted research and published on the care of older people in the community and in long-term care institutions, and currently chairs the Institute Advisory Board of the CIHR Institute of Aging. She is editor-in-chief of the Canadian Journal of Nursing Leadership and co-chairs the F/P/T Planning Committee on Public Health Human Resources. Linda Green, BA MEd EdD (c) Linda Green is pursuing an EdD in counselling psychology for community settings at the Ontario Institute of Education at the University of Toronto. She has worked as a research coordinator for several studies. From 1997 to 2000, she coordinated a study on gender differences in outcomes from the coronary intensive care unit at the Toronto General Hospital, and from 2001 to 2002 was a research analyst at the same hospital on a study of anorexia. Stacey Johnson, RN BScN Stacey Johnson graduated on the Dean’s Honour List with her BScN from McMaster University in 2003. She received the CIHR Burroughs-Wellcome Student Research Scholarship while an undergraduate and worked as a research assistant on several studies. She worked as a staff nurse in the multi-organ transplant unit at the Toronto General Hospital while she carried out research in this study.
