Replacement of Registered Nurses by Less Prepared Providers

Replacement of Registered Nurses by Less Prepared Providers

The Registered Nurses Association of Ontario (RNAO), the professional association representing 13,000 registered nurses throughout the health care spectrum, and Ontario Nurses Association (ONA) have grave concerns about the ongoing replacement of registered nurses by less prepared care providers. The continuation of this type of replacement activity, in the face of mounting evidence that it makes neither financial nor quality of care sense, seriously jeopardizes the quality of health care for people in Ontario.

The recent wave of de-skilling and de-professionalization has been introduced in hospitals and other agencies as they continue their attempts to reduce costs. Registered nurses are being replaced by less knowledgeable health care providers (RPNs and Unregulated Care Providers) at precisely the time when hospital patients/clients are sicker and discharged sooner than ever before. Patients are being discharged to other agencies, or home, with increasingly complex care needs; thus requiring health care providers with more, not less, knowledge and skills . We are dealing with an alarming and growing divergence between the calibre of care that is needed and what is being supplied. In other words, we have a critical and widening gap between care demand and supply.

We believe there are separate, but related, misconceptions feeding the decision-making that has led to this care gap. The first misconception is that registered nurses are too expensive and that utilization of less prepared providers will lead to real cost saving for the institution or agency. A second misconception is that quality of care will not be significantly jeopardized by displacing highly qualified providers with those who have much less preparation.

Research-based evidence is consistent that savings are not accrued when an agency moves to implement a lower skill mix of care providers; in fact the opposite is often the case. For example, hospitals in one study netted a 5% savings after increasing the RN complement in their provider skill mix. Productivity gains were realized because RNs required less supervision than less qualified, providers. Other studies have demonstrated that registered nursing care reduced costs through shorter length of stay and reduced morbidity rates.

Regarding the second misconception, evidence is irrefutable that quality of care is significantly and negatively impacted when registered nurses are replaced by those who lack the knowledge, skill and ability to provide the needed care. The percentage of staff who are RNs is one of 5 major predictors of hospital mortality rates. Specifically, "(h)ospitals with a higher percentage of RNs and higher staffing ratios of nurse to patient had lower mortality rates". Research also demonstrates the influence of RN care in reducing hospitalization, and in achieving earlier discharge for clients; factors that contribute significantly to the well being of people.

RNAO and ONA believe it is essential for hospitals and other health care agencies to be accountable to the citizens of Ontario for the decisions they make during restructuring. Given the consistent evidence that contradicts the direction of restructuring or re-engineering taken by an agency, there must be provisions to ameliorate the problem. Delivering the right care at the right time, in the right place and by the right provider must be a central tenet of all agencies providing health care to the citizens of this province. Furthermore, this must be the government's goal, for the sake of public accountability.

To facilitate agency accountability for the quality of care provided, RNAO and ONA strongly recommend that an Ontario wide system of accountability be established. Only in this way can agencies be discouraged from responding to budgetary constraints by taking actions that directly and negatively impact on the quality of patient care. We need a consistent and finely tuned system of accountability; one that monitors how all agencies achieve expenditure reductions, and takes community differences into account.

Ontarians have a right to know the cost -in human terms- of restructuring initiatives. Communities need to be informed when a decision by their local hospital administrator results in increased mortality, morbidity and/or readmission rates. We need to close the circle of accountability. The Ministry of Health, through the Restructuring Commission, or otherwise, must share the responsibility for the way in which budgetary cutbacks are achieved by individual institutions.

We must move quickly to ensure that health care decision-makers have the same level of accountability as health care providers. The citizens of Ontario deserve no less!