Regulated Nurses, 2015

Methodology GuideMay 2016

Production of this document is made possible by financial contributions from Health Canada and provincial and territorial governments. The views expressed herein do not necessarily represent the views of Health Canada or any provincial or territorial government.

Unless otherwise indicated, this product uses data provided by Canada’s provinces and territories.

All rights reserved.

The contents of this publication may be reproduced unaltered, in whole or in part and by any means, solely for non-commercial purposes, provided that the Canadian Institute for Health Information is properly and fully acknowledged as the copyright owner. Any reproduction or use of this publication or its contents for any commercial purpose requires the prior written authorization of the Canadian Institute for Health Information. Reproduction or use that suggests endorsement by, or affiliation with, the Canadian Institute for Health Information is prohibited.

For permission or information, please contact CIHI:

Canadian Institute for Health Information495 Richmond Road, Suite 600Ottawa, Ontario K2A 4H6

Phone: 613-241-7860Fax: 613-241-8120www.cihi.cacopyright@cihi.ca

ISBN 978-1-77109-456-6 (PDF)

© 2016 Canadian Institute for Health Information

How to cite this document:Canadian Institute for Health Information. Regulated Nurses, 2015: Methodology Guide. Ottawa, ON: CIHI; 2016.

Cette publication est aussi disponible en français sous le titre Le personnel infirmier réglementé 2015 — guide méthodologique.ISBN 978-1-77109-457-3 (PDF)

Table of contents About CIHI’s nursing data ........................................................................................................... 4

More information ................................................................................................................... 4

Regulated professions ................................................................................................................ 5

Terminology ................................................................................................................................ 6

Data sources and collection ........................................................................................................ 8

Data quality ........................................................................................................................... 8

Population estimates ........................................................................................................... 14

Methodology ............................................................................................................................. 14

Inflow and outflow ............................................................................................................... 14

Graduate outmigration ......................................................................................................... 14

Retention and entry ............................................................................................................. 15

Average age ........................................................................................................................ 15

Urban and rural ................................................................................................................... 16

Health region ....................................................................................................................... 16

Health region peer groups ................................................................................................... 17

2015 population by health region......................................................................................... 17

Comparability of data ................................................................................................................ 18

Methodological and historical changes ................................................................................ 18

RN data, 2006 to 2015 ........................................................................................................ 19

LPN data, 2006 to 2015 ...................................................................................................... 23

RPN data, 2006 to 2015 ...................................................................................................... 25

Appendix: Population estimates, by jurisdiction, urban/rural areas, 2006 to 2015 ..................... 26

References ............................................................................................................................... 28

Regulated Nurses, 2015: Methodology Guide

4

About CIHI’s nursing data Collecting and reporting health human resources (HHR) data assists decision-makers in the planning and distribution of health care providers. Since 2002, the Canadian Institute for Health Information (CIHI) has collected data on the supply, distribution and practice characteristics of the 3 groups of regulated nursing professionals in Canada: registered nurses (including nurse practitioners), licensed practical nurses and registered psychiatric nurses.

More information The following companion products are available from CIHI’s website at www.cihi.ca/hhr:

• Regulated Nurses, 2015: Summary Report (.pdf)

• Regulated Nurses, 2015: Canada and Jurisdictional Highlights (.pdf)

• Regulated Nurses, 2015: Chartbook (.pptx)

• Regulated Nurses, 2015: RN/NP Data Tables (.xlsx)

• Regulated Nurses, 2015: LPN Data Tables (.xlsx)

• Regulated Nurses, 2015: RPN Data Tables (.xlsx)

• Regulated Nurses, 2015: Health Regions (.xlsx)

Information and analyses on 30 other health professions in Canada are available at www.cihi.ca/hhr.

Feedback and questions are welcome at hhr@cihi.ca.

For more information, please contact

Program Lead, Health Workforce Information Canadian Institute for Health Information 495 Richmond Road, Suite 600 Ottawa, Ontario K2A 4H6

Phone: 613-241-7860 Fax: 613-241-8120 Email: hhr@cihi.ca Website: www.cihi.ca

Regulated Nurses, 2015: Methodology Guide

5

Regulated professions There are 3 regulated nursing professions in Canada. Each province and territory has its own legislation governing nursing practice, as well as its own body that regulates and licenses its members.

Below is a brief description of each type of regulated nursing provider.

Registered nurses (RNs, including NPs) are self-regulated health care professionals who work both autonomously and in collaboration with others to enable individuals, families, groups, communities and populations to achieve their optimal levels of health. At all stages of life, in situations of health, illness, injury and disability, RNs deliver direct health care services, coordinate care and support clients in managing their own health. RNs contribute to the health care system through their leadership across a wide range of settings in practice, education, administration, research and policy. RNs are currently regulated in all 13 provinces and territories.

Nurse practitioners (NPs) are RNs with additional educational preparation and experience who possess and demonstrate the competencies to autonomously diagnose, order and interpret diagnostic tests, prescribe pharmaceuticals and perform specific procedures within their legislated scope of practice. NPs are currently regulated in all 13 provinces and territories.

Licensed practical nurses (LPNs) work independently or in collaboration with other members of a health care team. LPNs assess clients and work in health promotion and illness prevention. They assess, plan, implement and evaluate care for clients. In the province of Ontario, licensed practical nurses are referred to as registered practical nurses. LPNs are currently regulated in all 13 provinces and territories.

Registered psychiatric nurses (RPNs) work both autonomously and in collaboration with clients and other health care team members to coordinate health care and provide client-centred services to individuals, families, groups and communities. RPNs focus on mental and developmental health, mental illness and addictions, while integrating physical health and utilizing bio-psycho-social and spiritual models for a holistic approach to care. RPNs are currently regulated in the 4 Western provinces (Manitoba, Saskatchewan, Alberta, British Columbia) and Yukon.

Regulated Nurses, 2015: Methodology Guide

6

Terminology Throughout this guide,

• The term regulated nurses is used to describe the 3 groups of regulated nursing professionals as a whole: RNs (including NPs), LPNs and RPNs.

• The term nursing refers collectively to Canada’s 3 regulated nursing professions, unless otherwise specified.

• The term supply refers to all regulated nurses who are eligible to practise in the given year (including those employed and those not employed at the time of registration). Note that secondary registrants (also known as interprovincial duplicates) are excluded from the supply.

• The workforce is a subset of the supply. The term workforce refers to only those regulated nurses who were employed at the time of annual registration.

• The term inflow refers to the number of registrants entering the nursing profession. Inflow occurs when a regulated nurse registers to practise in a jurisdiction in which she or he did not register the previous year. Inflow is calculated by dividing the number of new registrants — regulated nurses who were not registered to practise nursing in the same province or territory the year before — by the total number of registrants in the same year.

• The term outflow refers to the number of registrants leaving the profession. Outflow occurs when a regulated nurse fails to renew her or his registration in a jurisdiction the following year. Outflow is calculated by dividing the number of registrants who did not renew their licence to practise nursing in the same province or territory by the total number of registrants in the same year.

• The term renewal refers to the number of registrants who renewed their registration in a jurisdiction where they were registered the year before.

• Unless otherwise noted and/or referenced, data and information are from the nursing component of CIHI’s Health Workforce Database. At present, the data excludes RPNs in Yukon and LPNs in Nunavut.

Regulated Nurses, 2015: Methodology Guide

7

The figure below illustrates the key concepts of nursing supply, workforce, inflow, outflow and renewal.

Figure 1 Illustration of key concepts

Regulated Nurses, 2015: Methodology Guide

8

Data sources and collection This document summarizes the strengths and limitations of the nursing data contained in our analytical products and the ways in which it can be effectively used and analyzed. This information is particularly important when making comparisons with other data sources and when drawing conclusions regarding changes over time.

Data quality CIHI is founded upon the principles of data quality, privacy and confidentiality. Data collection, processing, analysis and dissemination are guided by CIHI’s commitment to publishing high-quality data in a privacy-sensitive manner. The data quality methodologies are used to maximize the accuracy, comparability, timeliness, usability and relevance of the nursing data in the Health Workforce Database.

Privacy and confidentiality To safeguard the privacy and confidentiality of data received by CIHI, guidelines have been developed to govern the publication and release of health information in accordance with provincial privacy legislation. CIHI is a prescribed entity in Ontario, which means that health information custodians in Ontario can provide personal health data to us without the consent of individuals.

Data collection To practise as a regulated nurse in Canada, annual registration with the appropriate provincial or territorial regulatory authority is mandatory, requiring the completion of a registration form. The completed registration form is the property of the provincial/territorial regulatory authority. Through an agreement with CIHI, each regulatory authority submits a set of standardized data to CIHI, collected using the registration forms. These questions pertain to demographic, education/training and employment characteristics.

CIHI and the regulatory authorities jointly review and scrutinize the submitted data. Once the regulatory authority and CIHI approve the final data, it is added to CIHI’s Health Workforce Database for analysis and reporting.

Note that the statistics reported by CIHI may differ from those reported by the regulatory authorities, even though the source of the data (annual registration forms) is the same. Differences are due to the population of reference, the collection period, exclusions from CIHI’s data and CIHI’s editing and processing methodologies.

Regulated Nurses, 2015: Methodology Guide

9

Population of interest The population of interest includes all regulated nurses who submit an active practising registration in a Canadian province or territory. The population of interest is also further refined to include only regulated nurses who fit the definition formulated by CIHI in consultation with regulated nursing stakeholders to best serve health human resource planning and research needs on a national level. As a result, there are some regulated nurses whose data is not collected by CIHI. These include regulated nurses who submit a non-practising registration (where available from the provincial/territorial regulatory authority) and regulated nurses living or working outside Canada who have not maintained a Canadian licence.

Population of reference and collection period CIHI takes steps to adjust the population of reference of the nursing data to represent more closely the population of interest. To better ensure timeliness, CIHI collects data prior to the end of the 12-month registration period in each jurisdiction. Therefore, the population of reference for the nursing data is all regulated nurses who submit an active practising registration in a Canadian province or territory in the first 6 months of the registration year. The 12-month registration period varies among the provinces and territories, as each jurisdiction is responsible for setting the start and end dates of its own registration period.

This manner of collection enables CIHI to produce more timely data. Analyses completed annually by CIHI indicate that less than 5% of regulated nurses register after the 6-month mark, thus ensuring that CIHI’s trends are consistent with provincial/territorial trends that include those registering after the 6-month mark.

The following definitions apply to the population of reference.

Non-practising registrations

The target population includes regulated nurses who submit an active practising registration; those who submit a non-practising registration are excluded.

First-time registrants

First-time registrants include new graduates as well as regulated nurses who are registering in a jurisdiction for the first time. Information on first-time registrants has varied across jurisdictions and over time, which has resulted in cases of under-coverage.

Regulated Nurses, 2015: Methodology Guide

10

Nurses on leave

The target population excludes any regulated nurse not practising at the time of registration. This creates some confusion for regulated nurses on leave (such as maternity/paternity leave, education leave or short-term illness or injury), as they may or may not be returning to work during the registration period. Therefore, they may submit an active practising registration (where the option exists) but may not actually be practising at the time of registration.

Therefore, the assumption is made that regulated nurses on temporary leave submit active practising registrations with full employment information (when possible) with the intent of returning to that position when the temporary leave ends. While this is not a source of over-coverage, the fact is that some regulated nurses are not practising for the full year of registration.

Non-response

Statistics on item non-response, or not stated values for each reporting data element, are available in the Regulated Nurses, 2015: RN/NP, LPN and RPN Excel data tables.

Duplicate records It is necessary to identify and remove duplicate records within the database. Duplicates may arise when regulated nurses register in more than 1 jurisdiction. A comparison is done between the jurisdictions of registration and employment for each record; when they do not match, the record is excluded. When the jurisdiction of employment is not stated, a comparison is done between the jurisdiction of registration and the jurisdiction of residence for each record; when they do not match, the record is excluded. In cases where the jurisdiction of residence is not stated, the jurisdiction of employment defaults to the jurisdiction of registration and the record is not excluded.

It is common for regulated nurses to work in the territories on a temporary basis and to return to their home province for part of the year. In these cases, where the jurisdiction of employment is a territory, the duplicates are not excluded so that the nursing workforce in the North will not be underestimated.

Sometimes, double-counting cannot be avoided. For example, a regulated nurse who registers and works in more than 1 province/territory simultaneously would be double-counted in the nursing data, as the jurisdiction of employment would match the jurisdiction of registration in both cases.

For Nunavut and the Northwest Territories, the data for RNs is presented as a combined total throughout the summary report and data tables. The RNs in these territories are governed by the same regulatory authority, and because the specific territory in which the RNs usually worked was not available, combined data was submitted to CIHI. Therefore, any duplicates between the Northwest Territories and Nunavut cannot be resolved.

Regulated Nurses, 2015: Methodology Guide

11

Defining the workforce It is important to note the difference between the terms nursing “supply” and “workforce.” The nursing supply data includes all records in the population of reference. The workforce excludes regulated nurses who are not working in nursing; this exclusion is achieved with the Employment Status data element (see Figure 2).

Recoding the data element Employment Status Regulated nurses who do not indicate their employment status (i.e., full time, part time, casual) on their registration form risk being excluded from the workforce population. However, in cases where employment status is not stated but employment information is provided, CIHI, in consultation with the regulatory authority, will change the Employment Status element to employed — status unknown to ensure that the record is included in the workforce. This methodology has been applied to all nursing types.

Regulated Nurses, 2015: Methodology Guide

12

Figure 2 Tracking regulatory authority data to CIHI: The regulated nursing workforce

Year-end registrations

A

Active practising registrations

B1

Non-practising registrations

B2

Submitted to CIHI at 6 months

C1

Not submitted to CIHI

C2

Secondary registrations

D1

Primary registrationsD2

Employment Status: employed in other

than nursing

E2

Employment Status: employed in nursing

E1

Employment Status: not employed

E3

Full time

F1

Part time

F2

Casual

F3

Status unknown

F4

Regulatory authority

Other

B3

Employment Status: not stated

E4

Source Health Workforce Database, Canadian Institute for Health Information.

Regulated Nurses, 2015: Methodology Guide

13

A: All registrations

Box A is the number of registrations submitted to a regulatory authority for nursing.

B: Types of registrations

Box B1 is the number of active practising registrations received by the regulatory authority.

Box B2 is the number of non-practising registrations received by the regulatory authority.

Box B3 is the number of other registrations received by the regulatory authority.

C: Records submitted to CIHI

Box C1 is the number of active practising registrations submitted during the first 6 months of the registration year.

Box C2 is the number of registrations not submitted to CIHI.

D: Primary and secondary registration

Box D1 is the number of regulated nurses whose jurisdiction of registration differs from the jurisdiction of employment. These records are outside of the population of reference, except where 1 of the jurisdictions (registration or employment) is a territory.

Box D2 is the number of regulated nurses whose jurisdiction of registration is the same as the jurisdiction of employment. These regulated nurses are accounted for in the nursing supply.

E: Employment Status

Box E1 is the number of regulated nurses for whom Employment Status is employed in nursing. These regulated nurses are included in the workforce.

Boxes E2 to E4 are the numbers of regulated nurses who are excluded from the workforce, as they are not reported as employed in nursing.

F: Position Status

Boxes F1 to F4 represent the number of regulated nurses included in the nursing workforce. A regulated nurse may have a Position Status of full time, part time, casual or unknown.

Regulated Nurses, 2015: Methodology Guide

14

Population estimates Using population estimates from Statistics Canada, rates per population can be calculated for RNs, LPNs and RPNs. The appendix includes Statistics Canada’s population estimates by province/territory as well as further breakdowns by urban/rural categories for 2006 to 2015.

Methodology Inflow and outflow Changes in the nursing supply reflect the number of registrants entering (inflows) and the number leaving (outflows). Analyzing inflows and outflows provides better information about how the nursing supply is changing over time.

Inflow occurs when a regulated nurse registers to practise in a jurisdiction in which she or he did not register the previous year. Inflow is calculated by dividing the number of new registrants — regulated nurses who were not registered to practise nursing in the same province or territory the year before — by the total number of registrants in the same year. Inflow can include new graduates, regulated nurses who migrate in from other Canadian jurisdictions or foreign countries and those who return to the workforce after extended leave (such as for family responsibilities or further education).

Outflow occurs when a regulated nurse fails to renew her or his registration in a jurisdiction the following year. Outflow is calculated by dividing the number of registrants who did not renew their licence to practise nursing in the same province or territory by the total number of registrants in the same year. Outflow is influenced by a number of factors,1 and these factors will change over time. For those regulated nurses age 60 and older, failing to renew their registration may be a signal that they have retired. For younger regulated nurses, particularly those early in their career, reasons for failing to renew registration could include a better or different job opportunity outside of their province or territory, leaving the profession, parental leave and family responsibilities, or a return to school for additional education.

Graduate outmigration Nurses seeking licensure to practise in Canada are required to register with a provincial or territorial regulatory body. By comparing the number of entry-to-practice (ETP) nursing graduates from Canadian nursing programs with the number obtaining a nursing licence over time, nursing graduate outmigration can be better understood. Graduate outmigration2 is defined as the proportion of new graduates from Canadian nursing ETP programs who do not apply for registration with a Canadian nursing regulatory body.

Regulated Nurses, 2015: Methodology Guide

15

When considering graduate outmigration, it is important to keep in mind that not all Canadian nursing graduates will choose to obtain a Canadian licence to practise nursing. Canadian nursing graduates may choose to pursue further education, leave Canada to practise nursing in another country or leave the profession altogether. Factors influencing a nurse’s decision on where to live and work are diverse and may include social, political, economic, environmental and/or familial issues.1

Retention and entry The nursing supply data in the HWDB allows for analysis of the retention and entry of nurses. One can compare the employment setting of a nurse from one year to the next and consider the movement of each nurse between employment settings. For example, if a nurse was employed in a hospital setting in 2013 and reported working in that setting again in 2014, the nurse would be considered retained. By contrast, if the nurse reported working in a community setting in 2014, the nurse would then be counted as an exit from the hospital as well as an entry to the community setting.

Several factors can affect the retention of a nurse from one setting to another over time. Examples include contraction/expansion of particular settings, age (e.g., retirement), the preference for a setting (e.g., work–life balance, scheduling)3 and reclassification (e.g., outpatient clinic from “hospital” to “community”).

Average age The average age of the regulated nurses for a given province/territory and/or Canada, either by nursing type or as a group, is calculated based on the age of the individual regulated nurses, which is derived from the data elements Birth Year and the current Data Year for each record. Records with missing age are excluded from the calculation.

Average age = 1𝑛𝑛�𝐴𝐴𝐴𝐴𝐴𝐴i

𝑛𝑛

𝑖𝑖=1

Where

i = Individual regulated nurse

n = Total number of regulated nurses in a jurisdiction or Canada

Regulated Nurses, 2015: Methodology Guide

16

Urban and rurali A postal code analysis was performed to determine whether a nurse was practising in a rural or urban setting. In most cases, the postal code used was that of the workplace; however, when the data element Postal Code (Primary Worksite) was not submitted to CIHI, Postal Code of Residence was used. If the postal code was unknown or invalid, it was defaulted as not stated.

Using Statistics Canada’s Postal Code Conversion File (PCCF), postal codes were assigned to statistical area classifications (SACs) — urban, rural, remote and territories. Urban areas are defined (in part) by Statistics Canada as communities with populations greater than 10,000 people; rural/remote is equated with communities outside the urban boundaries and is referred to as rural and small town (RST) by Statistics Canada.

RST communities are further subdivided by identifying the degree to which they are influenced in terms of social and economic integration with larger urban centres. Metropolitan influenced zone (MIZ) categories disaggregate the RST population into 4 subgroups: strong MIZ, moderate MIZ, weak MIZ and no MIZ.

All categories may be interpreted in the following simple manner:

• Urban: Greater than 10,000 people (SAC type = 1, 2, 3)

• Rural: Strong/moderate MIZ and located relatively close to larger urban centres (SAC type = 4, 5)

• Remote: Weak/no MIZ and distant from large urban centres (SAC type = 6, 7, 8)

The urban and rural analysis for the Northwest Territories and Nunavut was completed differently from the analysis for the provinces and Yukon. Urban areas were identified as postal codes within Yellowknife and Iqaluit, and rural areas were identified as postal codes outside of Yellowknife and Iqaluit.

Health region Health regions are legislated administrative areas defined by provincial ministries of health. These administrative areas represent geographic areas of responsibility for hospital boards or regional health authorities. Health regions, being provincial administrative areas, are subject to change.

The health region data presented in this publication includes only regulated nurses who work in direct patient care and whose postal code was within the province or territory of analysis; those employed in administration, education or research are excluded from the health region totals.

i. Details of the RST and MIZ classification schemes can be found in McNiven et al.,4 du Plessis et al.5 and CIHI.6

Regulated Nurses, 2015: Methodology Guide

17

The postal code data and Statistics Canada’s PCCF were used to assign the regulated nursing workforce to health regions. The postal code used was Postal Code (Primary Worksite); when Postal Code (Primary Worksite) was not available, Postal Code of Residence was used instead. If the postal code was outside of the province/territory of analysis, health region was defaulted as outside of jurisdiction.

Health region peer groups In order to facilitate comparisons among health regions, Statistics Canada developed a methodology that groups health regions with similar socio-economic and socio-demographic characteristics; these are referred to as peer groups. The health region peer groups defined by Statistics Canada are presented in the Regulated Nurses, 2015: Health Regions Excel file.

2015 population by health region Regulated nurses providing direct patient care and rates per 100,000 population by health region are presented in the Regulated Nurses, 2015: Health Regions Excel file.

2015 health region population data was not available from Statistics Canada at the time of calculation. Thus the 2015 rates per population were estimated using 2014 health region population estimates as a proxy. These rates were not adjusted to account for differences in population that may change health status, such as age or sex. While adjusted rates can be quite useful for certain types of analysis, this report presents the actual number of nurses providing direct patient care who worked in each health region.

Regulated Nurses, 2015: Methodology Guide

18

Comparability of data CIHI would like to acknowledge that each regulatory authority has been extremely cooperative and helpful in improving its data collection methods and in helping CIHI develop methodologies to enhance data quality. As part of the data submission process, the regulatory authorities submit to CIHI the changes that have been made to their databases for inclusion in this publication. A review of this information is helpful when looking at trends over time and comparing jurisdictions. Table 1 highlights the data submitted to CIHI in 2015 by jurisdiction for each regulated nurse type.

Table 1 Data submitted to CIHI, by jurisdiction and nurse type, 2015

Nurse type N.L. P.E.I. N.S. N.B. Que. Ont. Man. Sask. Alta. B.C. Y.T. N.W.T. Nun.

RN (excluding NP)

NP

LPN *

RPN

†

Notes * Record-level LPN data from Nunavut is not currently collected in the Health Workforce Database. † RPNs are regulated separately from other regulated nursing professionals in 4 provinces and 1 territory. Record-level RPN data

from Yukon is not currently collected in the Health Workforce Database. Source Health Workforce Database, Canadian Institute for Health Information.

Methodological and historical changes Methodological and historical changes to the data have the potential to make it difficult to compare data across time. CIHI and the regulatory authorities are continually striving to improve data quality; therefore, the following information should be taken into consideration when making historical comparisons and consulting previous CIHI publications. In all cases, comparisons should be made with caution and in consideration of the methodological and historical changes made.

In the past, the regulated nursing data tables focused primarily on workforce counts. Regulated Nurses, 2015 has shifted to a balanced reporting method, where demographic and education data elements are reported for the regulated nursing supply and employment data elements are reported for the workforce.

Regulated Nurses, 2015: Methodology Guide

19

Impact of Ontario’s new registration regulation requirement A new registration regulation requirement, called the Declaration of Practice, was introduced in the 2014 renewal. With this new requirement, a member can renew in the General Class only if she or he has

• Practised nursing in Ontario within the past 3 years; or

• Become registered or reinstated within the past 3 years.

Primarily because of this change to the registration regulation requirement, the Ontario RN supply in 2014 showed a decrease (3.8% from 2013) compared with the trends seen in previous years. Caution should be used when comparing data.

Data elements for the regulated nursing component of the Health Workforce Database For a complete list of data elements, please review the Regulated Nurses Database Data Element List on CIHI’s website at www.cihi.ca.

Please note that there has been variation in the not stated values of certain data elements from 2006 to 2015 among many jurisdictions and across the nursing profession. Caution should therefore be used when comparing data within this time period.

The section below provides information on the data elements that had data quality improvements or changes in data years 2006 to 2015 that may or may not have an effect on comparability. The descriptions are organized by nurse type and by demographic, education and employment data elements.

RN data, 2006 to 2015 Nurse practitioner In the 2008 calendar year, NP data was incorporated into the Health Workforce Database, back to data year 2003. Consistent methodology was applied to the NP records, including the removal of duplicates and the 6-month cut-off for data collection, resulting in a change from NP totals published in previous reports. Refer to Table 2 to see the year of implementation of NP legislation for each jurisdiction.

Regulated Nurses, 2015: Methodology Guide

20

Table 2 Year of implementation of nurse practitioner legislation, by jurisdiction

N.L. P.E.I. N.S. N.B. Que. Ont. Man. Sask. Alta. B.C. Y.T. N.W.T. Nun. First year of regulation

1997 2006 2002 2002 2003 1997 2005 2003 2002 2005 2012 2004 2004

Note From 1996 to 2002, NPs in Alberta were referred to as RNs providing extended services. In June 2002, regulations were changed to refer to these nurses as nurse practitioners. Refer to the College and Association of Registered Nurses of Alberta for additional information. Source Health Workforce Database, Canadian Institute for Health Information.

Alberta — Supply and workforce in 2014 data year The annual growth rates for RNs in Alberta fluctuated between 2013 and 2015. According to the College and Association of Registered Nurses of Alberta (CARNA), the fluctuation is the result of a system upgrade implemented in 2013. CIHI is working with CARNA to further evaluate the data.

Demographic Manitoba — Birth Year, Sex and average age

Starting in 2007, the College of Registered Nurses of Manitoba (CRNM) did not provide record-level values for the data elements Birth Year and Sex in order to conform to provincial privacy legislation. It submitted age groups at the record level in place of Birth Year and aggregate tables on sex and average age each year.

Education Alberta — Location of Graduation

Starting in 2008, CARNA submitted more specific values for Location of Graduation, such as United Kingdom, United States, Hong Kong and other foreign countries. This reduced the number of non-responses.

Northwest Territories and Nunavut — Highest Level of Education

Starting with the 2012 data year, the Registered Nurses Association of the Northwest Territories and Nunavut (RNANT/NU) implemented revisions to the collection of education data for RNs, resulting in an increase in the number of RNs indicating baccalaureate and a decline in those identifying diploma.

Regulated Nurses, 2015: Methodology Guide

21

Employment Quebec — Place of Work

In 2005, the ministère de la Santé et des Services sociaux du Québec (MSSS) merged most of the province’s public-sector hospitals, long-term care facilities and community health centres into 95 health and social services centres (centres de santé et de services sociaux, or CSSSs). Since then, it has become increasingly difficult to accurately determine in which of the 3 institution types nurses are working; in fact, some nurses are working in all 3.

From 2005 to 2014, CIHI did not have a value in its data dictionary that corresponds to this scenario, which has resulted in a large number of nurses reporting other place of work every year and, consequently, low volumes in the categories hospital, community health and nursing home/LTC. In 2015, the Ordre des infirmières et infirmiers du Québec (OIIQ) registration form required RNs to specify their place of work. As a result, the number of RNs decreased in other place of work and increased in hospital, community health and nursing home/LTC.

Quebec — Postal Code

Prior to 2007, Postal Code (Primary Worksite) and Postal Code of Residence were not available from the OIIQ.

For 2007 to 2012, although the OIIQ did not submit full Postal Code (Primary Worksite) and Postal Code of Residence, it did provide CIHI with the required data for the urban/rural and health region analysis.

Starting in 2013, the OIIQ submitted full Postal Code (Primary Worksite). Postal Code of Residence was not submitted due to a privacy regulation in Quebec.

Ontario — Employment Status, Place of Work, Position and Area of Responsibility

Prior to 2011, members of the College of Nurses of Ontario (CNO) provided detailed employment information on only the single employer for whom they worked the most hours. This detailed employment information included the employer’s location, whether the employment was a nursing role, the employer type and the member’s position and area of practice within the employment setting.

As of 2011, members are required to provide detailed employment information about all of their current employers and to designate an employer to appear on the CNO’s register. The CNO does not have a concept of primary employer; however, as CIHI requires a primary employer, the CNO provides CIHI with the employer the member designates as the register address as the primary employer. More information can be found on the CNO’s website.

Regulated Nurses, 2015: Methodology Guide

22

Manitoba — Postal Code

Over the past decade, the CRNM has made efforts to collect Postal Code (Primary Worksite) and/or Postal Code of Residence whenever possible to support CIHI in reporting postal code–related information. Table 3 shows the availability of the postal code data from the CRNM for data years 2006 to 2015.

Table 3 Data availability for Postal Code (Primary Worksite) and Postal Code of Residence

Data year Postal Code (Primary Worksite) Postal Code of Residence 2006 to 2008 Not collected Partial (3 digits)

2009 to 2011 Full (6 digits) Partial (3 digits)

2012 Not collected Partial (3 digits)

2013 to 2015 * Full (6 digits)

Note * More than 300 CRNM members submitted full postal code for employment.

Manitoba — Place of Work

In 2009, a total of 6,573 RNs and NPs failed to indicate their primary Place of Work, which resulted in an extensive increase in non-responses and a low volume of RNs/NPs in each workplace (i.e., hospitals, community health centres, nursing homes and long-term care facilities). Reporting since 2010 has seen improvements in data quality. Caution should be taken when comparing 2009 data with data from other years.

Alberta — Place of Work, Position and Area of Responsibility

According to CARNA, the Place of Work, Area of Responsibility and Position data elements were not mandatory fields from 2011 to 2013 on practice permit application forms, leading to an increase in the number of non-responses in those years.

Alberta — Postal Code

Prior to 2007, CARNA submitted a partial Postal Code (Primary Worksite); starting in 2007, it submitted the 6-digit Postal Code (Primary Worksite).

Regulated Nurses, 2015: Methodology Guide

23

Yukon — Postal Code

Starting in 2009, the Yukon Registered Nurses Association (YRNA) implemented a coding change to the element Postal Code (Primary Worksite). This change affects the number of nurses who were employed in small Yukon communities outside of Whitehorse but who reported under the employer’s Whitehorse office postal code. Caution should be used when reviewing the urban and rural analysis. CIHI is working with the YRNA to further evaluate and increase the accuracy of this field.

Northwest Territories and Nunavut — Employment Status

The RN workforce relies on a core of full-time resident RNs plus a large number of short-term relief staff from across Canada each year. While some RNs return each year, some register in the northern territories only once. This lack of stability in the workforce will result in greater variability in the data.

Data for the Northwest Territories and Nunavut is provided by the RNANT/NU. It is not possible to accurately attribute the number of RNs to the 2 territories; as a result, data for the Northwest Territories and Nunavut is combined under a single set of statistics.

Prior to 2008, Employment Status data was not available from the RNANT/NU; as such, all RNs and NPs employed in the Northwest Territories and Nunavut were coded as employed — status unknown for their Employment Status.

LPN data, 2006 to 2015 Demographic Manitoba — Birth Year, Sex and average age

In 2008, the College of Licensed Practical Nurses of Manitoba (CLPNM) did not provide record-level values for Birth Year and Sex due to provincial privacy legislation. It did submit age groups at the record level in place of Birth Year and aggregate tables on sex and average age.

Quebec — Inflow/renewal/outflow

In 2010, the Ordre des infirmières et infirmiers auxiliaires du Québec (OIIAQ) implemented a change to its member identifiers in the data file submitted to CIHI. Inflow, outflow and renewal trending is not available due to this change.

Quebec — Location of Graduation

Prior to 2007, all Location of Graduation values were coded as not stated. In 2007, the majority of values were defaulted to Quebec (except for the not stated values). From 2008 to 2010, all members were defaulted to Quebec.

Regulated Nurses, 2015: Methodology Guide

24

British Columbia — Year of Graduation

The College of Licensed Practical Nurses of British Columbia (CLPNBC) receives registration requests from students enrolled in Bachelor of Science in Nursing (BSN) programs. If registrants fulfill the academic competencies, they are permitted to work as LPNs. As these registrants have not yet graduated from their BSN program, no data is provided for Year of Graduation.

Employment Quebec — Place of Work

Prior to 2012, the OIIAQ did not collect data for the sub-element mental health centre, because this type of institution, as defined by CIHI, did not exist in the province of Quebec. In 2005, Quebec’s MSSS merged most of the province’s public-sector hospitals, long-term care facilities and community health centres into 95 CSSSs. Since the merger, the OIIAQ has reclassified its definitions for Place of Work starting in the 2013 data year, which resulted in different distribution patterns among the sectors over the years.

Ontario — Employment Status, Place of Work, Position and Area of Responsibility

Prior to 2012, members of the CNO provided detailed employment information on only the single employer for whom they worked the most hours. This detailed employment information included the employer’s location, whether the employment was a nursing role, the employer type and the member’s position and area of practice within the employment setting.

As of 2012, members are required to provide detailed employment information about all of their current employers and to designate an employer to appear on the CNO’s register. The CNO does not have a concept of primary employer; however, as CIHI requires a primary employer, the CNO provides CIHI with the employer the member designates as the register address as the primary employer. More information can be found on the CNO’s website.

Manitoba — Employment Status

For years 2011 and 2012, the CLPNM migrated to a new database. Following the migration, the CLPNM noticed a decrease in the number of members in the category employed — part time and an increase in the number in employed — casual. While this issue was resolved in 2013, these 2 categories are not an accurate reflection of the employment status for the 2011 and 2012 data years.

Regulated Nurses, 2015: Methodology Guide

25

Alberta — Place of Work

According to the College of Licensed Practical Nurses of Alberta (CLPNA), the increase in responses for the value community health centre in 2010 is the result of a reorganization of the health system, which saw many rural hospitals change to community health centres.

British Columbia — Employment Status

As of 2011, the CLPNBC continued to emphasize accuracy and modified its renewal form to include employed — part time and employed — casual. Previously, the 2 categories were combined.

Northwest Territories — Area of Responsibility

From 2006 to 2008, the Northwest Territories Department of Health and Social Services coded practical nurses identifying more than 1 Area of Responsibility as several clinical areas.

RPN data, 2006 to 2015 Education British Columbia — Location of Graduation

As of 2008, there was a substantial increase in the number of RPNs selecting not stated for Location of Graduation. As a result, there was also a decrease in the number of RPNs selecting British Columbia.

Employment Manitoba — Employment Status

In 2009, the College of Registered Psychiatric Nurses of Manitoba (CRPNM) migrated to a new database. Following the migration, the CRPNM noticed that a high volume of the Employment Status employed — status unknown data had been converted incorrectly for that year. Caution should therefore be used when comparing 2008, 2009 and 2010 data.

Manitoba — Place of Work

Starting in 2009, the CRPNM improved the quality of Place of Work data distributed between hospital and community health sectors due to the migration to a new database.

Regulated Nurses, 2015: Methodology Guide

26

Appendix: Population estimates, by jurisdiction, urban/rural areas, 2006 to 2015 Year Canada N.L. P.E.I. N.S. N.B. Que. Ont. Man. Sask. Alta. B.C. Y.T. N.W.T. Nun. Total 2006 32,570,505 510,584 137,865 937,869 745,609 7,631,873 12,661,566 1,183,524 992,302 3,421,361 4,241,691 32,271 43,178 30,812

2007 32,887,928 509,039 137,721 935,071 745,407 7,692,736 12,764,195 1,189,366 1,002,048 3,514,031 4,290,988 32,557 43,374 31,395

2008 33,245,773 511,543 138,764 935,865 746,855 7,761,504 12,882,625 1,197,774 1,017,346 3,595,755 4,349,412 33,088 43,350 31,892

2009 33,628,571 516,729 139,909 938,194 749,954 7,843,475 12,997,687 1,208,589 1,034,782 3,679,092 4,410,679 33,732 43,149 32,600

2010 34,005,274 521,972 141,678 942,073 753,044 7,929,365 13,135,063 1,220,930 1,051,425 3,732,573 4,465,924 34,596 43,278 33,353

2011 34,342,780 525,037 144,038 944,469 755,530 8,007,656 13,263,544 1,233,728 1,066,349 3,790,191 4,499,139 35,402 43,501 34,196

2012 34,751,476 526,895 145,259 944,835 756,836 8,084,768 13,409,558 1,250,406 1,087,223 3,888,552 4,542,578 36,189 43,648 34,729

2013 35,155,499 528,017 145,441 942,991 755,718 8,154,761 13,551,004 1,265,342 1,106,122 4,007,748 4,582,607 36,429 43,884 35,435

2014 35,543,658 529,069 146,162 942,387 754,578 8,214,885 13,677,687 1,280,242 1,122,283 4,120,897 4,638,415 36,990 43,980 36,083

2015 35,851,774 527,756 146,447 943,002 753,871 8,263,600 13,792,052 1,293,378 1,133,637 4,196,457 4,683,139 37,428 44,088 36,919

Urban

2006 26,485,283 235,669 76,703 602,902 445,205 6,110,589 11,164,539 804,305 593,623 2,714,783 3,686,611 24,363 19,480 6,511

2007 26,786,172 237,561 77,063 603,100 447,235 6,163,760 11,268,315 808,233 600,954 2,794,989 3,733,994 24,695 19,646 6,627

2008 27,122,320 241,131 78,138 605,680 450,394 6,225,222 11,385,856 813,521 611,890 2,868,976 3,789,881 25,195 19,736 6,700

2009 27,486,221 245,804 79,381 609,118 454,829 6,298,971 11,501,506 820,908 625,044 2,946,606 3,851,801 25,792 19,642 6,819

2010 27,842,549 250,960 81,101 613,176 458,915 6,374,052 11,635,770 830,050 637,753 2,999,192 3,908,300 26,526 19,793 6,961

2011 28,170,174 255,128 83,470 616,480 462,500 6,445,224 11,762,117 840,829 650,323 3,055,359 3,944,373 27,204 20,042 7,125

2012 28,557,209 257,306 84,853 619,138 464,234 6,517,158 11,903,790 854,765 668,838 3,143,578 3,988,311 27,804 20,187 7,247

2013 28,938,749 259,186 85,214 620,450 464,831 6,583,567 12,041,195 866,204 684,659 3,249,597 4,028,027 27,966 20,422 7,431

2014 29,307,499 261,100 86,101 622,310 465,131 6,642,279 12,164,398 878,947 698,316 3,351,365 4,081,029 28,403 20,537 7,583

2015 29,602,322 261,686 86,628 625,061 465,767 6,686,236 12,275,309 890,226 708,289 3,419,999 4,125,977 28,727 20,658 7,759

Regulated Nurses, 2015: Methodology Guide

27

Year Canada N.L. P.E.I. N.S. N.B. Que. Ont. Man. Sask. Alta. B.C. Y.T. N.W.T. Nun. Rural/remote

2006 6,085,222 274,915 61,162 334,967 300,404 1,521,284 1,497,027 379,219 398,679 706,578 555,080 7,908 23,698 24,301

2007 6,101,756 271,478 60,658 331,971 298,172 1,528,976 1,495,880 381,133 401,094 719,042 556,994 7,862 23,728 24,768

2008 6,123,453 270,412 60,626 330,185 296,461 1,536,282 1,496,769 384,253 405,456 726,779 559,531 7,893 23,614 25,192

2009 6,142,350 270,925 60,528 329,076 295,125 1,544,504 1,496,181 387,681 409,738 732,486 558,878 7,940 23,507 25,781

2010 6,162,725 271,012 60,577 328,897 294,129 1,555,313 1,499,293 390,880 413,672 733,381 557,624 8,070 23,485 26,392

2011 6,172,606 269,909 60,568 327,989 293,030 1,562,432 1,501,427 392,899 416,026 734,832 554,766 8,198 23,459 27,071

2012 6,194,267 269,589 60,406 325,697 292,602 1,567,610 1,505,768 395,641 418,385 744,974 554,267 8,385 23,461 27,482

2013 6,216,750 268,831 60,227 322,541 290,887 1,571,194 1,509,809 399,138 421,463 758,151 554,580 8,463 23,462 28,004

2014 6,236,159 267,969 60,061 320,077 289,447 1,572,606 1,513,289 401,295 423,967 769,532 557,386 8,587 23,443 28,500

2015 6,249,452 266,070 59,819 317,941 288,104 1,577,364 1,516,743 403,152 425,348 776,458 557,162 8,701 23,430 29,160

Source Statistics Canada. Table 051-0001: Estimates of population, by age group and sex for July 1, Canada, provinces and territories, annual (persons unless otherwise noted). CANSIM database. Accessed February 18, 2016.

Regulated Nurses, 2015: Methodology Guide

28

References 1. Clarke D, Plohman J, Cepanec D. Provincial Survey of New Manitoba Nursing Graduates. 2013.

2. Tomblin Murphy G, Birch S, Alder R, et al. Tested Solutions for Eliminating Canada’s Registered Nurse Shortage. 2009.

3. Alameddine M, et al. “Stickiness” and “inflow” as proxy measures of the relative attractiveness of various sub-sectors of nursing employment. Social Science and Medicine. 2006.

4. McNiven C, Puderer H, Janes D. Census Metropolitan Area and Census Agglomeration Influenced Zones (MIZ): A Description of the Methodology. (Geography Working Paper Series.) 2000.

5. du Plessis V, et al.; Statistics Canada; Clemenson H; Agriculture and Agri-Food Canada. Definitions of rural. Rural and Small Town Canada Analysis Bulletin. 2001.

6. Canadian Institute for Health Information. Supply and Distribution of Registered Nurses in Rural and Small Town Canada, 2000. 2002.

12691-0416

Talk to us CIHI Ottawa495 Richmond Road

Suite 600

Ottawa, Ont.

K2A 4H6

613-241-7860

CIHI Toronto 4110 Yonge Street

Suite 300

Toronto, Ont.

M2P 2B7

416-481-2002

CIHI Victoria 880 Douglas Street

Suite 600

Victoria, B.C.

V8W 2B7

250-220-4100

CIHI Montréal 1010 Sherbrooke Street West

Suite 602

Montréal, Que.

H3A 2R7

514-842-2226

CIHI St. John’s 140 Water Street

Suite 701

St. John’s, N.L.

A1C 6H6

709-576-7006

www.cihi.ca help@cihi.ca