R-E-S-P-E-C-T: A Key to Nurse Retention.

In Canada, nurses have known about the chronic shortage of nurses for years; the pandemic has just opened the floodgates. For the authors, the current nursing crisis and the accompanying response have led to flashbacks of the early 2000s, when extensive advocacy work took place to prevent a looming nursing crisis. In the key reports reviewed in this paper, the statement "lack of respect for nursing" has echoed over and over and over again and continues to be heard today throughout social media. Based on nurses' voices, meaningful respect starts with nurse leaders and administrators recognizing nurses' education, knowledge, values and experience; seeking and listening to nurses' voices and input on decisions affecting nursing; and striving for quality practice environments with reasonable workloads, adequate supplies and resources. While long-term planning must take place to correct this, there is no easy fix and no single strategy to turn the situation around quickly. Short-term strategies to relieve nurses' feelings of disrespect are a good place to start to retain nurses and stop the bleeding. It is time to work with all the nurses to find ground-level strategies to assure a sustainable and healthy nursing workforce for today and tomorrow. In this paper, the authors provide an overview of the meaning of respect both generally and from the nurses' perspective using the literature from the past 20 years. The authors then outline several implications for nurse leaders and administrators that are relevant today.

Community Care and COVID-19: A Case Study.

Community Care City of Kawartha Lakes provides primary care through its Community Health Centre, a range of hospice services and numerous community support services. Along with other essential service providers, our organization has continued to operate throughout the pandemic. As a community-based health services provider, we recognized the imperative and the privilege for our organization and the larger home and community care sector to support individuals, especially those most vulnerable due to health status, socio-economic circumstances or isolation, to safely remain at home during the pandemic, in compliance with public health directives. This article describes the strategies and approaches we implemented along with reflections on the leadership practices and principles that emerged. It does not purport to be an exemplar for crisis management of the COVID-19 pandemic. Rather, it seeks to draw attention to the contributions made by community-based organizations and potentially serve as a case study for debate.

Voices Raised: The NCLEX-RN Experience in Canada.

The journey to this issue on the National Council Licensure Examination (NCLEX) began when the CJNL editorial director received two unsolicited NCLEX-focused manuscripts for consideration to publish. Adding to the growing body of articles and news stories published about the NCLEX since its 2015 implementation in Canada, the two papers revealed that the NCLEX-RN remains a controversial and unresolved issue for our profession. CJNL has long published special issues to focus attention on specific topics. Such focused publication creates a convenient repository of knowledge and information about a given subject, facilitating deeper exploration of the issue and serving as a historical reference point for the topic going forward. This issue continues that tradition by presenting 10 papers that discuss the NCLEX from the perspectives of researchers, policy makers, educators, students and a coalition of nurses that is vigorously advocating for remedies to address the disproportionately adverse impact of the NCLEX on students and especially on francophone writers. As CJNL's editor for policy and innovation, I was asked to serve as guest editor for this issue, and it has been my privilege to do so.

Commentary: Regulation and the Nursing Profession: A Personal Reflection.

Against the backdrop of Ontario's "Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System," this commentary offers personal reflections about nursing regulation and the profession. The evolution of the three pillars of nursing is briefly described, and emerging changes in regulatory structures and professional associations are identified. The nature of the relationship between the regulator and the registrant is commented on, and the lived experiences of regulation from the perspective of an employer and a chief nursing executive are discussed. In the context of the examples shared in the commentary and the proceedings of the Inquiry, the author calls upon each pillar of the profession to work together more effectively to protect the public and optimize the contributions of our profession as a whole.

Multidimensional approach to restraint minimization: The journey of a specialized mental health organization.

The executive-level witnessing and review of restraint events has been identified as a key strategy for restraint minimization. In the present study, we examined the changes in restraint practices at a tertiary-level mental health-care facility with implementation of an initiative, in which representatives from senior management, professional practice, peer support, and clinical ethics witnessed seclusion and restraint events, and rounded with clinical teams to discuss timely release and brainstorm prevention strategies. Interrupted time series analysis compared the change from pre-implementation (14 months prior) to postimplementation (35 months' following) in the number of incidents/month, total hours/month, and average hours/incident/month for each of seclusion and mechanical restraint. With implementation, there was a step decrease in average hours/seclusion (-28.3 hours/seclusion, P < 0.001) and total seclusion hours (-1264.5 hours, P = 0.002). The postimplementation rate of decrease of -0.9 hours/incident/month was different than the pre-implementation rate of increase of 0.7 hours/incident/month for mechanical restraint (P = 0.03). Pre-implementation, there was a rate of decrease of 6.1 incidents/month (P < 0.001) and 4.5 incidents/month (P = 0.001) for seclusion and mechanical restraint, respectively. Postimplementation, there was a rate of increase of 0.3 incidents/month and a rate of decrease of 0.05 incidents/month for seclusion and mechanical restraint, respectively, both of which were different than pre-implementation (seclusion: P < 0.001, mechanical restraint: P = 0.002). In conclusion, the total hours of seclusion and average hours per seclusion and per restraint incident were reduced, demonstrating the value of leadership witnessing and daily rounds in promoting restraint minimization in tertiary-level mental health care.

Nursing Leadership: Making a Difference in Mental Health and Addictions.

Five nurse leaders in mental health offer their perspectives on key issues facing the sector and reflect on how nurses can make a difference in the following critical areas: nursing practice, transitions of care, innovative technologies, challenging stigma and creating patient partnerships.

Positive and negative behaviours in workplace relationships: a scoping review protocol.

INTRODUCTION: Engaging in teamwork requires a clear understanding of positive and negative behaviours that act as facilitators and barriers to collegial workplace relationships. Identifying and correcting underlying barriers, while promoting facilitators, is fundamental to improving care delivery and, ultimately, clinical outcomes. Despite a considerable amount of literature in this area, there is a lack of clarity of the different behaviours as several parallel literatures address similar questions about antecedents, processes and outcomes. The purpose of this study is to synthesise the current state of literature reporting on behaviours in workplace relationships. Using a scoping review methodology, the following research question will be addressed: "What is known about positive and negative behaviours in workplace relationships?" METHODS AND ANALYSIS: We will employ the methodological frameworks used by Arksey and O'Malley and Levac et al. The search strategy will include numerous electronic databases, grey literature sources and hand-searching of reference lists from 1990 to present with a limit to English language. Search strategies will be developed using controlled vocabulary and keyword terms related to various components of workplace relationships. Two reviewers will independently screen titles and abstracts for inclusion, followed by screening of the full text of potential articles to determine final inclusion. A descriptive numerical analysis will describe characteristics of included studies. A thematic analysis will provide an overview of the literature, including definitions, conceptual frameworks, antecedents, outcomes and interventions. DISSEMINATION: In reviewing a wide range of positive and negative behaviours, then integrating into a manageable, meaningful whole, this study is a critical step in helping policymakers, leaders and healthcare professionals effectively use what is known thus far. Knowledge translation activities will occur throughout the study with dissemination of findings to local, national, and international stakeholders, including a wide range of clinicians, leaders and administrators in all sectors.

Better health, better care, better value: National Expert Commission, part 1.

Since about the midway point of the First Ministers' 10-year plan to strengthen healthcare, its impending expiry in 2014 has prompted the leading health professions to consider "what comes next," how to influence that decision and then, how best to position their messages in the politics of whatever might emerge. The Canadian Nurses Association (CNA), which has a century-long history of engagement in health policy, was no exception.

Towards a national report card in nursing: a knowledge synthesis.

This paper is an abridged version of a knowledge synthesis undertaken to inform the proceedings of a collaborative forum of nurse leaders convened under the auspices of Health Canada, the Academy of Canadian Executive Nurses, the Canadian Nurses Association and Canada Health Infoway for the purpose of discussing the development of a nursing report card for Canada. The synthesis summarized the state of the science in the measurement of nursing-sensitive outcomes and the utilization of nursing report cards - information that informed forum participants' dialogue and planning. This condensed version of the synthesis focuses on initiatives related to outcomes and performance monitoring in nursing, including specific indicators and reporting systems and the development, implementation and utilization of nursing report cards.

The BC Educator Pathway Collaborative Framework: creating the foundation for nursing education capacity.

This paper describes the conceptual structure and organizational framework of the Educator Pathway Project (EPP), which is a unique collaborative capacity-building project creating infrastructure for integrating nursing practice learning and development throughout the service and education sectors in British Columbia. Since 2005, two major health authorities, two universities and the provincial nurses' bargaining association have been engaged in an intensive and dynamic partnership to conceptualize and fundamentally change intersectoral directions and possibilities. This unique initiative has required considerable investment and commitment among all partner organizations, resulting in a clear, shared vision of systemwide support of nursing. With the EPP now in its final year of funding, we are beginning to document its elements and interpret its significant impact on nurses and their workplaces across the regions. In this paper, we describe the overall program design, explain the collaborative partnership mechanisms through which we have been implementing the project and articulate a range of processes through which we are working together to enact significant system-level adjustments aimed at a genuine practice-education continuum. As part of sustaining a strong nursing workforce, we believe that nursing practice and education leaders across Canada are ready to employ this kind of creative approach towards realizing our common goals.

British Columbia's provincial nursing workload project: evidence to empowerment.

This case study describes an ongoing demonstration project that engages nurses and nurse leaders in decision-making with respect to workload management issues at eight practice sites within British Columbia (two per healthcare sector: acute care, long-term care, community health and community mental health). The primary goal of this project is to promote high-quality practice environments by empowering front-line nurses and their leaders: giving them the means to systematically examine and act upon factors that influence their workloads. Examples from practice sites illustrate tangible benefits from the project.

Uncovering blind spots in education and practice leadership: towards a collaborative response to the nurse shortage.

As the nursing shortage becomes an increasingly prominent everyday pressure for practice leaders, the search for quick solutions has intensified. A widespread perception has emerged within the service sector that nursing education is failing to fulfill its responsibility to prepare the next generation of nurses. This perception is escalating tensions between leaders in the education and practice sectors, and creating new barriers towards finding collaborative solutions. Although the "job ready/practice ready" debate between practice and education has been a long-standing undercurrent within nursing, extreme shortages affecting practice sector performance across the country create conditions that fuel heightened distrust and division. In this context, it becomes increasingly important that nursing leaders in education and practice engage in thoughtful and respectful dialogue to ensure that tensions between the two sectors are managed and counterproductive schisms prevented. In this paper, we deconstruct some of the current thinking regarding responsibility for the current problem by describing differences in the distinct cultures and contexts of the practice and education sectors, noting potential "blind spots" that interfere with our mutual understanding and encouraging a better-informed, shared responsibility to promote constructive engagement in preparing tomorrow's nursing workforce.

Leadership for ethical policy and practice (LEPP): participatory action project.

Within Canada's fast-paced, ever-changing healthcare environment, providers are experiencing difficulty practising according to their professional ethical standards, leading many to experience moral or ethical distress. Limited attention has been paid to improvements in the ethical climate in healthcare settings in research focusing on nurses' workplaces. In this three-year study, we focused on how the ethical climate in healthcare delivery can be improved and how the use of participatory action research methods can lead to continued enhancements and lasting changes in services delivery. Together, we developed strategies for taking action, aimed at improving the quality of the work environment. This action involved both nurses in direct care and those in key leadership positions (CNOs or their equivalents). Through the active participation of those for whom the research-based change was intended, these strategies were tested in various sites across British Columbia and can be used as templates or designs for use in other settings. A key component of the success of the projects and action plans that were created was the integral involvement of nurse leaders through all phases.

'Stickiness' and 'inflow' as proxy measures of the relative attractiveness of various sub-sectors of nursing employment.

Workplaces vary in their ability to recruit and retain workers. We introduce two new concepts which can be used as proxy measures of the relative attractiveness of a particular setting, where setting can be defined narrowly (e.g., a particular organization) or broadly (e.g., a sub-sector). "Stickiness" is defined as the transition probability that an employee stays in a given setting; "inflow" as the proportion of new employees. Using a longitudinal dataset of all nurses registered with the College of Nurses of Ontario, Canada 1993-2003, employment site was used to define consistent sectors and sub-sectors. Each nurse was assigned to one sector/sub-sector per year. Stickiness and inflow values were calculated for each sub-sector, and the trends across time were analyzed. Results show that despite shrinkage in the hospital sub-sectors, hospitals remained highly sticky. The expanding sub-sectors, in general, appear relatively unattractive to nurses; they couple medium/low stickiness with high inflow. Considerable variability across sub-sectors was evident. Stickiness and inflow were found to be useful as proxy measures of the relative attractiveness of the various sub-sectors of nursing employment over time. The concepts may be used for other workforces for which linked longitudinal data are available.

Where are nurses working? Employment patterns by sub-sector in Ontario, Canada.

OBJECTIVE: As care shifts to home and community, have nursing jobs followed? We examined changes in the absolute and relative size of the nursing workforce by sector/sub-sectors in Ontario, Canada. METHODS: All nurses registered with the Ontario College of Nurses over the 11 years from 1993 to 2003 were categorized as Active, Eligible or Not Eligible. Active nurses were then categorized by sector (Hospital, Community, Other) and sub-sector. The analysis was repeated by age group and for registered nurses and registered practical nurses. RESULTS: The decline in Active and Eligible nurses was particularly pronounced for younger workers. Both the absolute number and proportion of nurses working in the hospital sub-sector has dropped. In the community sector, growth was evident in the use of nurses as case managers (in the CCAC sub-sector), community agencies and community mental health (representing a shift from hospital-based workers). However, the steady growth in the number and proportion of nurses working in home care agencies was reversed in 1999, with this sub-sector shedding 19% of its nurses by 2003. CONCLUSION: Despite considerable rhetoric to the contrary, nurses still tend to work within institutions (hospitals and long-term-care facilities). However, compared to their numbers in 1993, there were fewer nurses providing direct patient care in Ontario in both the hospital and community sectors, and a higher proportion of older nurses.