Addressing the Critical Nursing Shortage in Canada: The Need for PhD-Prepared Nurses to Lead Transformative Change

We are facing a critical nursing shortage in Canada following in the post-COVID-19 pandemic crisis (Tomblin Murphy et al., 2022). Nursing shortages are not new (Cohen, 1989; Park, 1983; ‘The Nursing Shortage’, 1963), but the impact of COVID-19 alongside global crises like climate change and war have spotlighted the significance of the problem at this historical moment (Peters, 2023). I recently completed by PhD in Nursing at the University of Alberta. The journey was a long five years in which I had to navigate a pandemic, raising 4 kids, working full-time a nurse leadership and in direct hospital-based care in one of the largest urban centres in Canada, and significant family crises. I love the diverse opportunities that my nursing career has brought me. I feel a strong connection my professional identity as a nurse and appreciate the monumental impact that the discipline and profession have had on shaping the healthcare system and shaping the health of people in Canada. However, in navigating my doctoral journey I began to see the significant barriers to succeed within system that continues to undervalue nurses as formal leaders and contributors to health knowledge. This must change.  

I encountered multiple barriers that many nurses face when making the choice to pursue higher education as part of a career goal in nursing scholarship. The further I got in my research journey the more I could see the incredible sacrifices that I would have to make as a mid-career nurse choosing to delve into academia in a professional context in which clinically practicing nurses are not well integrated as with other healthcare professional, namely physicians. My area of research is nurse historical, particularly the history of registered psychiatric nursing (RPN) education in British Columbia, which is not a well-integrated research area in terms of practical application to healthcare resource planning and clinical care decision-making.

I received may congratulations upon sharing that I finished my research but no invitations or interest to read research other than from fellow nurses. My choices were to remain a nurse leader in the healthcare region, or to sever that connection and pursue academia, but there does not seem to be space for both. With this I continue to ask the question, in a deeply flawed health care system in which we cannot attract of retain nurses why are we not building a strong nursing scholar and researcher base to transform the system from within?

Yes, professional nurses are needed in direct care to ensure that evidence-informed, competent care is delivered in health care settings like hospitals, community-based health care services. However, in the past fifty years nurses have made great strides to become better placed in health care leadership teams, attained the baccalaureate entry to practice level for all provinces and territories except Quebec creating graduate-level nursing programs across the nation (Pijl-Zieber et al., 2014). Many barriers exist for nurses to pursue master's and doctoral level degrees in nursing. That is not to say that nurses cannot and should not pursue graduate degrees in an area outside of nursing, and indeed nurses did strategically build faculty this way when professionalization entailed severing from hospital-based training schools to the post-secondary institutions (College of Registered Nurses of British Columbia, 2012; Duncan et al., 2020). The move from hospital-based education shifted the service-based relationships that nurses had to hospitals in which nurses were employees trained for the specific needs of the institution in which they were hired to educating students who graduated with a strong foundation enabling their mobility across the country and globally (Duncan et al., 2020). Data support the benefit of baccalaureate entry to practice for RNs (Duncan et al., 2020). However, nursing students may continue to conceptualize nursing as a vocational field similar to that of a skilled trade (Gray, 2017) which obscures the value of scholarly nursing work and, more importantly creates a shortage of faculty to teach new nurses.

The recent nursing workforce report published by the Canadian Association of Schools of Nursing (CASN) highlighted the need for full-time nursing faculty positions with a projected 543 full time faculty needed in 2022 (CASN, 2021). The CASN report is the only longitudinal national collection of nursing education in Canada, however, it only captures data on registered nurses (RN) and nurse practitioner (NP) programs. Statistics about RPN education is absent, a significant omission considering that RPNs are a main group of nurses who deliver care to people living with primary mental health issues in Canada (CIHI, 2021b).[1]

The supply of RN faculty is an important factor impacting capacity to education new RNs (CASN, 2021). Factors like retirement of existing faculty, inflow of newly prepared faculty, and ability to attract and retain qualified staff impact this. The system remains siloed, either work in post-secondary institution or work clinically. But with the instability in undergraduate nurse education this does not seem a viable choice in an unstable world. Only a small percentage (26.8%) of RN faculty are employed on a permanent basis, and over half are currently over the age of 50 (CASN, 2021).

What is the future of nursing, an inextricably linked practice-based profession and discipline which connects education to the practical application in the health care setting (Anthony & Landeen, 2009), if nurse leaders cannot infiltrate the top of the system and prioritize PhD preparation? We can interrogate nursing education past, and know it should not only be driven by the role and limitations of nurses today, rather, nurse leaders in the clinical setting and in academia must consider the role of nurses from a broad perspective to at how nurses are best positioned to facilitate transformative change socially, politically, and economically through leading interdisciplinary research teams.  

Almost two decades ago American nursing scholars were cautious about the explosion of Doctorate of Nursing Practice (DNP) degrees being offer in the USA because they anticipated it would come at the risk of nurses not advancing in research (Dracup et al., 2005). While Canada has been much slower to develop DNPs Canadian nurses have been completing DNP programs in the USA as a means of building credentials and obtaining positions within non-research-based schools of nursing. However, this may have come at the sacrifice of nurses not being prepared to lead research teams. The risk of not supporting nurses to pursue PhD-level education is that theory-based science and research in the discipline of nursing will decrease because nurses will not have the research training necessary to be Principal Investigators on interdisciplinary research teams. The hallmark of a doctorly-prepared programs is the expectation of both utilizing and developing knowledge in nursing (Dracup et al., 2005). The divide between clinical practice and research is sometimes difficult to conceptualize because these are not distinct paths.

In Canada, we have a challenging context for PhD prepared nurses to navigate between often siloed academic and clinical space. Logically we understand that this work is necessary to develop the discipline of nursing and maintain the connection to clinical practice, but support is not there financially, and the research opportunities are not there. PhD-prepared nurses provide a strong theoretical and philosophical foundation for the nursing profession. This grounding is essential in a healthcare environment where traditional medical models and empirically based disciplines often fall short of embracing the core values of caring, humanistic principles, and relational practice. Nursing leaders in clinical practice must actively foster relationships and create clear pathways for nurses to pursue graduate-level education. Without these efforts, nursing risks being overshadowed by other healthcare professions, leaving nurses feeling undervalued, overlooked, and excluded from important decision-making roles in healthcare.

We are a self-regulating profession. We need PhD prepared nurses to be research leaders and champion answering questions about navigating nursing shortages and developing innovative models of health care to ensure access and equity for all. We need PhD prepared nurses to be leaders of health care research teams to bring a perspective of the most populous health care practitioner in Canada (CIHI, 2021a).

Nurses must demand support for PhD education to ensure nurses are prepared to identify the intersections of politics, gender issues, and social equity with health care to create transformative change. The possibilities and opportunity for nurses as clinically based leaders of health care teams can shape health care in the future. Without this type of future oriented thinking the profession and discipline of nursing will die in a health care context in which physicians remain solidly at the top and the playing field is increasingly saturated with regulated and unregulated health care professionals that do not recognize or understand the integral role that nurses have played and must play in the future of health care to fully embrace and embody holistic health care perspectives and meaningfully integrate broad concepts like indigenous cultural safety, anti-stigma, inclusivity, trauma-responsive care in our perspective as health care leaders at all levels from direct patient and client care to administrative roles, research and scholarly work.

References

Anthony, S. E., & Landeen, J. (2009). Evolution of Canadian Nursing Curricula: A Critical Retrospective Analysis of Power and Caring. International Journal of Nursing Education Scholarship, 6(1). https://doi.org/10.2202/1548-923X.1766

CIHI. (2021a). A lens on the supply of Canada’s health workforce | CIHI. Canadian Institute for Health Information. https://www.cihi.ca/en/health-workforce-in-canada-highlights-of-the-impact-of-covid-19/a-lens-on-the-supply-of-canadas

CIHI. (2021b). Registered psychiatric nurses | CIHI. Registered Psychiatric Nurses. https://www.cihi.ca/en/registered-psychiatric-nurses

Cohen, L. (1989). Why are Canada’s nurses quitting? CMAJ: Canadian Medical Association Journal, 141(12), 1270–1272. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1451537/

College of Registered Nurses of British Columbia. (2012). 100 Years of Nursing Regulation 1912-2012. College of Registered Nurses of British Columbia. https://www.bccnm.ca/Documents/z_centennial/download/CRNBC-Centennial.pdf

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Duncan, S. M., Scaia, M. R., & Boschma, G. (2020). “100 Years of University Nursing Education”: The Significance of a Baccalaureate Nursing Degree and Its Public Health Origins for Nursing Now. Quality Advancement in Nursing Education - Avancées En Formation Infirmière, 6(2). https://doi.org/10.17483/2368-6669.1248

Gray, C. (2017). End free labour from nursing students. Canadian Nurse. https://community.cna-aiic.ca/blogs/cn-content/2017/09/08/end-free-labour-from-nursing-students

Hicks, B. (2008). From barnyards to bedsides to books and beyond: The evolution and professionalization of registered psychiatric nursing in Manitoba, 1955-1980. [Doctoral Dissertation, University of Manitoba]. http://search.ebscohost.com/login.aspx?direct=true&db=cin20&AN=109853021&site=ehost-live

Park, C. L. (1983). Job dissatisfation spurs nursing shortage. Dimensions in Health Services, 60(1), 10–11. https://auspace-athabascau-ca.login.ezproxy.library.ualberta.ca/bitstream/handle/2149/1328/job_dissatisfaction.pdf?sequence=1

Peters, M. (2023). Time to solve persistent, pernicious and widespread nursing workforce shortages. International Nursing Review, 70(2), 247–253. https://doi.org/10.1111/inr.12837

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Sealy, P., & Whitehead, P. C. (2004). Forty Years of Deinstitutionalization of Psychiatric Services in Canada: An Empirical Assessment. The Canadian Journal of Psychiatry, 49(4), 249–257. https://doi.org/10.1177/070674370404900405

The Nursing Shortage. (1963, April 9). The Globe and Mail (1936-), 6. https://www.proquest.com/news/docview/1282753058/abstract/FAE25938BED747D3PQ/3

Tomblin Murphy, G., Sampalli, T., Bourque Bearskin, L., Cashen, N., Cummings, G., Elliott Rose, A., Etowa, J., Grinspun, D., Jones, E. W., Lavoie-Tremblay, M., MacMillan, K., MacQuarrie, C., Martin„-„Misener, R., Oulton, J., Ricciardelli, R., Silas, L., Thorne, S., & Villeneuve, M. (2022). Investing in Canada’s nursing workforce post-pandemic: A call to action. FACETS, 7, 1051–1120. https://doi.org/10.1139/facets-2022-0002

 

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[1] Recognition must be made to the role that RPNs have played in delivery of nursing care in mental health specific services throughout the twentieth century until the 1990s with the deinstitutionalization movement.(Hicks, 2008; Sealy & Whitehead, 2004) The situation of RPN is different because there are no RPN-specific doctoral programs and a single master of psychiatric nursing program situated at Brandon University, the site of the first baccalaureate psychiatric nursing program in Canada.