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https://www.infirmiere-canadienne.com/blogs/ic-contenu/2025/03/31/integration-novateur-hopital-francophone

Project aims to help overcome nursing shortage by training and retaining more nurses and being innovative in how care is delivered

By Judith Makana, Natalie Ladouceur, & Josette Roussel
March 31, 2025

The COVID-19 pandemic crisis that has gripped the world since 2020 has revealed and amplified the issues that various health systems have been facing for decades (WHO, 2023). One of these issues — perhaps the most pressing — is the lack of nursing resources. Whether nurses have left the profession for early retirement or extended leave due to difficult working conditions, the foundation on which health systems rely on has weakened. This shortage of nursing staff not only has detrimental effects on health systems, but also directly impacts the populations (patients, clients, relatives and loved ones), which is the core of the nursing profession, as well as the entire community of health professionals (CIHI, 2024).

Proposed solutions

Although the nursing shortage is a multifactorial problem, the following two solutions are key: (1) train more nurses and (2) be innovative in how care is delivered — through strategies such as improving working conditions and enhancing internal career opportunities — to ensure the retention of nursing staff. Training is probably the solution where health-care institutions have the least control, as it remains the prerogative of colleges and universities.

Retaining nursing staff is not a simple endeavour. Today, more than ever, the nursing profession offers a wide range of professional opportunities, making the job market extremely competitive. For example, offering bonuses to new hires is no longer sufficient because employers will find themselves competing in a crowded job market, where nurses can pick and choose from many available offers. However, it is possible to improve working conditions to benefit both staff and patients.

What makes Hôpital Montfort unique

As the only francophone academic hospital offering bilingual services in Ontario, Hôpital Montfort is in a unique situation due to its proximity to Quebec, among other factors. Some differences, including better working conditions and salary competition between the two provinces, make the migration of nursing staff (registered nurses [RNs] and registered practical nurses [RPNs]) to Ottawa understandable. However, since regulations are not the same, there are disparities in professional practices within the same category of nursing staff from the two provinces. The nursing staff trained in Ontario is ahead in terms of autonomous and collaborative interprofessional practice, especially regarding physical assessments of patients using a holistic approach (CNO, 2023).

One of the most significant disparities is that Hôpital Montfort recruits a significant number of RPNs from Quebec that have not been exposed to the reality of acute care settings, potentially combined with a lack of autonomous practice in the comprehensive physical assessment of patients. This disparity carried significant negative consequences: (1) the enormous mobilization of resources, both human (orientation, mentoring, improvement learning plan) and financial (integration period length and staff turnover rate); (2) lack of optimization of employee experience, which can result in low retention; and (3) the risk of moral distress among staff related to a perception that work was not well done or could not be accomplished at all.

Hôpital Montfort set out to improve RPNs’ theoretical knowledge regarding adult physical assessments. Because it is an academic hospital, it worked in collaboration with the Institut du Savoir Montfort to create continuing professional development for its staff. The professional development initiative includes physical assessment modules (theoretical and practical) to help integrate RPNs trained outside the province of Ontario. Over time, this training has been developed to support different categories of nursing staff.

Training project phases

The project was carried out in three major phases:

1. Data collection through the following:
• Discussions with the College of Nurses of Ontario to understand the evaluation process for transferring a licence obtained in another province to make it valid in Ontario
• Meetings with colleges within the Outaouais region
• Collecting feedback from RPNs trained outside Ontario already working at Hôpital Montfort
• A literature review on effective support strategies for potential participants
2. Trial phase: project implementation
3. Maturation phase: program evolution and formulation of version 2.0 of the program

The ultimate goal of the trial phase was to answer the following questions: (1) During a nursing shift, what are the care needs of in-patients admitted to acute settings at Hôpital Montfort ? (2) What knowledge and skills will a nurse need to meet these needs in a holistic vision of care?

The trial phase took place from March 2023 to February 2024 and included physical assessment workshops for staff. The workshops included training modules on physical assessments including theoretical components and high-definition simulations in line with the practices and processes specific to Hôpital Montfort (i.e., policies, procedures and medical directives).

In light of the principles of andragogy (adult learning) and to avoid cognitive overload of participants while ensuring that they are well equipped before starting their practice, a pathway has been developed to ensure alignment of these physical assessment workshops with the already existing integration process for new staff members:

1. General orientation (same for all staff members)
2. Nurses to fill out the self-assessment learning needs tool
3. General orientation for nurses (same for all nurses)
4. Data collection from self-assessment learning needs tool
5. Physical assessment workshops, which enabled Hôpital Montfort to better understand the needs of each newly hired nurse
6. Specific orientation, which was dependant on needs identified by nurses in their learning needs self-assessments and in the assessment workshop
7. Follow-up support as needed

As indicated above, Hôpital Montfort developed different tools, including a learning needs self-assessment tool, a tool for evaluating nurses’ practical skills, and a tool that gave them the opportunity to give their feedback on the workshops.

Evaluation of the project

What started as a specific need to bridge the gap between theory and practice for RPNs trained outside Ontario quickly became a relevant component for different categories of nursing staff, both newly hired and already employed. During the trial phase, 28 RPNs and RNs participated in the eight scheduled sessions. Although this phase undoubtedly contributed to improving the quality of patient care, we recognize the limitation of establishing a direct correlation between the outcomes of these training sessions and organizational indicators, such as the number and nature of documented incidents (e.g., falls, delirium, medication errors).

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Hôpital Montfort already has a system for evaluating all formal training related to the integration of new staff and, more particularly, for nursing staff who, to date, benefit from one of the longest orientation and training periods. In the perspective of continuous improvement — both in terms of the content of the training and the process of these workshops as an integral part of the orientation “curriculum” for new nursing personnel trained outside the province — the same evaluation tool was therefore used to maintain the established process and collect consistent data that would help show improvement in real time.

This evaluation was possible because we focused on certain questions of the tool, in particular: (1) the learning methodology (adaptation of the theory to the concrete realities of the hospital, for example, by including the internal policies, procedures and guidelines); (2) interactivity (combining theory with practice through simulations); (3) time allocated for training (training modules spread over two days); and (4) free comment box (collection of suggestions, points for improvement and future needs).

The results show that 78% of staff members who participated in these workshops responded to the questionnaire and indicated a complete satisfaction rate. These results corroborate the approach to learning according to the adult-learning principles of andragogy, which stipulate, among other things, the fact that “[a]dult learners have an inherent need for immediacy of application” (CNA, 2021, p. 13). The workshops were offered in a sequential format that offered theoretical courses (combining scientific rigour and the reality of the hospital) and practice-focused learning (using simulations combined with information and debriefing sessions).

Qualitatively, the project had the following relevant emerging themes: (1) “individualized” orientation as a driver of better preparation of nursing staff; and (2) the combination of scientific data and technology to support practical training modalities. Here are some excerpts from the comments section of the questionnaire:

• “Very good exercise, excellent.”
• “It was very interesting and it would help in practice (care unit).”
• “Good interaction, very good atmosphere, very useful training.”

Finally, the classification of nursing skills according to Benner (1984) shows that a change of environment can move a nurse from the competent or expert level category to that of a beginner. It goes without saying that a good orientation and integration process for new staff should take this reality into account. This is what Hôpital Montfort has accomplished brilliantly thanks to this innovation.

Conclusion

Differences in nursing practice between provinces can contribute to the perpetuation and exacerbation of the shortage of health professionals across Canada. Provincial constraints and requirements can limit nursing practice and hinder the delivery of holistic care.

In light of the recommendations issued in the federal government’s Nursing Retention Toolkit: Improving the Working Lives of Nurses in Canada (2024), it would be wise for governments to enter into agreements with educational institutions and provincial regulators to better prepare and equip nursing staff, regardless of where they work, to provide care that meets the complex needs of Canadians.

Thanks to the resources available at Hôpital Montfort (clinical practice, research, training, technologies, and high-fidelity simulations), their innovative program enabled it to survive the nursing shortage during a crucial pandemic crisis while ensuring a high standard of care for patients. The lessons learned from the trial phase have served as a basis for developing other specific workshop formats for different care sectors.

The next phase will be to evaluate the impact of this program on organizational indicators that influence patient care.

Acknowledgments: We thank the Institut du savoir Montfort, continuing professional development division, for its collaboration in developing this program.

References

Benner, P. (1984). From novice to expert: excellence and power in clinical nursing practice. Addison-Wesley Publishing Company.

Canadian Institute for Health Information (CIHI). (2024). The state of the health workforce in Canada, 2022. https://www.cihi.ca/en/the-state-of-the-health-workforce-in-canada-2022

Canadian Nurses Association. (2021). Certification mentorship toolkit.
https://hl-prod-ca-oc-download.s3-ca-central-1.amazonaws.com/CNA/2f975e7e-4a40-45ca-863c-5ebf0a138d5e/UploadedImages/documents/17_0874_Certification_Mentorship_Toolkit_2021_EN_Copy.pdf

College of Nurses of Ontario. (2023). Practice standard: scope of practice. https://cno.org/Assets/CNO/Documents/Standard-and-Learning/Practice-Standards/49041-scope-of-practice.pdf

Government of Canada. (2024). Nursing retention toolkit: improving the working lives of nurses in Canada. https://www.canada.ca/en/health-canada/services/health-care-system/health-human-resources/nursing-retention-toolkit-improving-working-lives-nurses.html

World Health Organization (WHO). (2023). Health workforce [web page]. https://www.who.int/health-topics/health-workforce#tab=tab_1

The authors are all employed by Hôpital Montfort in Ottawa.

Judith Makana, RN, BScN, MScN, CSIC(C), is a nursing professional practice advisor.

Natalie Ladouceur, RN, BScN, MScN, is the director of professional practice.

Josette Roussel, RN, M.Ed., M.Sc, FCAN, is associate vice-president, patient care, and chief nursing executive.

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