St. Joseph's Healthcare is believed to be the first in Ontario to replace some of its specialized nurses caring for sick and premature babies with lower-paid staff who have less schooling.

The hospital is eliminating the jobs of four registered nurses who are certified in neonatal intensive care. They will be replaced in July with four registered practical nurses who aren't certified in the specialty but are considered by the hospital to have "a high level of competence."

"We are testing this," said Winnie Doyle, vice-president of clinical services and chief nursing executive. "We saw it as an opportunity to have infants cared for by RPNs."

Across the hospital, 38 RPNs are being hired while more than 60 RN jobs are eliminated as St. Joseph's cuts costs by $26 million. The nursing union has expressed concern about all the replacements, but the changes in the NICU are the biggest worry.

"It's absolutely ludicrous," said Linda Haslam Stroud, president of the Ontario Nurses' Association and a Hamilton nurse. "Our neonates should not be put at risk. They are already vulnerable and are not stable and predictable."

Under Ontario regulations, RPNs work with stable and predictable patients while RNs care for sicker and more complex patients. RNs have university degrees while RPNs have college diplomas. Hospital RNs in Ontario are paid between $31.02 and $44.84 an hour, while a current RPN posting at St. Joseph's lists the pay as being between $26.83 and $29.15 an hour.

"They are nurses in every sense of the word," said Dianne Martin, executive director of the Registered Practical Nurses Association of Ontario. "From every age group whether it's a new baby or an elderly person, the patients best suited to care by an RPN are those in a lower level of acuity with more predictable outcomes — what we would refer to as a more stable patient. Wherever those patients are is where an RPN could function well."

The NICU at St. Joseph's is a Level 2 nursery, which means it can care for babies who are born up to eight weeks early, need help breathing or require intravenous therapy. It also takes babies who are not ready to go home, but no longer need to be at a Level 3 nursery, which treats the sickest and most premature babies. In addition, it looks after babies apprehended by a children's aid society.

"We have infants who are very stable," said Doyle. "The assignment of nurse to baby depends on the condition of the baby."

Right now there are five RNs on every shift and a nurse practitioner during the day. Starting July 1, it would be four RNs and one RPN plus the nurse practitioner on day shift.

The local union says there is no guarantee what mix of babies will be in the NICU at any one time to ensure enough stable patients for the RPN. In addition, NICU nurses attend some deliveries, so at times the nursery has had as few as two nurses.

"I'm very worried about that," said Donna Bain, president of the Ontario Nurses' Association Local 75. "We're blazing the trail, but we're not given evidence to say, 'This is what is working.'"

Doyle said backup from other floors could be called if there were too few RNs to care for the unstable babies at any one time.

Overall, the change is about making sure the hospital has the right mix of RNs and RPNs to give patients the level of care they require.

"It's an ongoing examination of what workforce do you need to care for patients," she said.

But the union points out similar experiments haven't always gone well.

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Concerns about endoscopy having too many unstable patients have recently resulted in a plan to go back to staffing the unit at St. Joseph's solely with RNs.

"Government funding, or the lack thereof, have put hospitals in the position of having to look at the dollars and not what is best for patient care," said Bain.