Nursing shortage in Canada

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There has been a nursing shortage in Canada for decades. This became more acute in the period between 1943 and 1952 as Canada's health services were expanding, the number of hospital beds increased along with the number of hospitalizations.[1] By the mid-1940s across Canada the shortage, estimated at 8,700, led to a re-organization and re-conceptualization of nursing in Canada, according to a 2020 journal article in BC Studies. The nature of nursing was changing with new and time-consuming responsibilities, such as the administration of penicillin.[2] During that period, there was no unemployment for nurses, especially if they were willing to be mobile. However, working conditions for nurses were very poor, with low wages combined with long hours; nursing force retention was challenging.[3] As well, since almost all nurses were women, they had responsibilities at home they had to manage.[2] In response to the shortage of nurses, women trained as registered nurses (RNs) but had left the workforce when they married, were encouraged to return to work, volunteers were engaged, nursing courses were accelerated, and new categories of regulated nursing were added to registered nursing—"practical nurses" and "nursing assistants."[4] At that time, a "utopia of nursing" referred to teams of nursing staff which included registered nurses and other regulated nursing and hospital worker support personnel.[5] Some of these auxiliary positions were also open to First Nations women and other racialized groups.[6]

Since at least 1998, the Canadian Federation of Nurses Unions (CFNU) have been calling for solutions to the nursing shortage in Canada.[7] In 2005, registered nurses worked an estimated 18 million hours of overtime—both paid and unpaid, representing the "equivalent of 10,054 full-time positions".[7] The nursing force had among the highest rates of "burnout, injury and illness."[7]

Along with a nursing shortage, there has also been a shortage of nursing educators, particularly nursing faculty in academia.[7]

The COVID-19 pandemic in Canada has led to a nursing crisis as the nursing shortage is one of the main factors behind unplanned forced closures of emergency rooms, lengthy offloading times for ambulances, critical care bed alerts where intensive care units have been forced to refuse any additional patients, and hospitals working over capacity. During the seventh wave of the Covid-19 pandemic, the lack of nurses, along with the health system's backlog and a resurgence of hospitalized COVID-19 patients,[8] has contributed to the health crisis.

Reports of those in the nursing profession who have the highest rates of "burnout, injury and illness" date back to at least 2008.[7] There were 304,558 registered nurses who were licensed to practice in Canada as of 2020.[9] Most had a single employer (84%) at the time of registration.. During the pandemic, health job vacancies had increased by 56.9% since 2019 in Canada to a "record high of 100,300. The highest vacancy rate was experienced by hospitals.[10] Some of factors leading to the exodus of the nursing labour force included "workload, burnout, lack of structural value, the need for leadership and mentorship, and lack of flexibility, autonomy and voice laced with overt racism, discrimination, and gendered inequities," according to a Royal Society of Canada-funded study.[10] During the seventh wave of the Covid-19 pandemic, the lack of health care personnel, particularly nurses, along with the health system's backlog and a resurgence of hospitalized COVID-19 patients were some of the factors contributing to the overloading of emergency departments and lengthening of ambulance off-loading times.[8]

Overview

There has been a nursing shortage in Canada for decades. Across North America during the post-World War II years, there was a serious shortage of registered nurses.[1] By the mid-1940s in Canada, the nursing shortage was approximately 8,700 and it was increasing along with health services in Canada and the number of hospital beds and hospitalizations.[11] It was so severe that Vancouver General Hospital's newly built pavilion remained out-of-service because there were not enough registered nurses to staff it.[4] The number of hospital beds across Canada increased from 1943 to 1952 by 26% and the number of admissions to hospitals increased by 74%. The nature of nursing was also changing with new and time-consuming responsibilities, such as the administration of penicillin.[2] During that period, there was no unemployment for nurses, especially if they were willing to be mobile. However, working conditions for nurses were very poor, with low wages combined with long hours and nurse retention was challenging.[4] As well, since almost all nurses were women, they had responsibilities at home they had to manage.[2] By January 1943, 50% of Vancouver General Hospital's registered nurses were married women who had returned to work as nurses when encouraged by the hospital's administrators.[4] In response to the shortage of nurses, volunteers were used and nursing courses were accelerated, and new categories of regulated nursing were added to registered nursing—"practical nurses" and "nursing assistants."[4]

Because of the mid-twentieth century nursing shortage, nursing labour was reorganized and re-conceptualized.[11] To expedite entry into nursing, debates were held across Canada about auxiliary nursing roles for assistants and practical nurses. At that time, a "utopia of nursing" referred to teams of nursing staff which included registered nurses and other regulated nursing and hospital worker support personnel.[5] Some of these auxiliary positions were also open to First Nations women and other racialized groups.[6]

Since at least 1998, the Canadian Federation of Nurses Unions (CFNU) have been calling for solutions to the nursing shortage in Canada.[7] In 2005, registered nurses worked an estimated 18 million hours of overtime—both paid and unpaid, representing the "equivalent of 10,054 full-time positions".[7] The nursing force had among the highest rates of "burnout, injury and illness."[7] Citing a 2002 Canadian Nurses Association (CNA) study, they said that without new policies and direction, the projected shortage of registered nurses in 2011 would be 78,000 RNs and up to 113,000 by 2016.[7] The report also noted there there was a "shortage of nursing faculty".[7]

Measuring nursing shortage

Based on various models used by Employment and Social Development Canada (ESDC)'s Occupational Projection System (COPS) team, some provincial governments, Canadian Nurses Association (CNA), and Statistics Canada on vacancies, the 2019 International journal of health planning and management article said that there was a shortage of nurses in Canada. In 2012, it was 2.6% and the projection for nursing professional shortages across Canada in 2022, was between 50,000 and 60,000.[12] The article said that nursing shortages can be measured based on professional standards, projections, or supply and demand economics.[12] Professional standards set the nurse to patient ratio. According to the Canadian Federation of Nurses Unions (CFNU) in 2014 an average nurse to patient ratio for Canada is 1:4.[13][12] According to projection‐based shortage, a 2009 Canadian Nurses Association (CNA) report, the shortage of RNs in Canada would be approximately reach 60,000 full‐time equivalent (FTE) by 2022.[12] The economic concept of nursing shortages considers supply and demand—how many nurses are available and what is the actual demand.[12] As of 2019, there were limited statistics on the nursing labour market, particularly as related to vacancies.[12] The 2019 paper said that these concepts—professional standards, projections, or supply and demand economics— were not being sufficiently used to measure nursing shortages; instead, most often, the indicator was "essentially the number of nurses per 1000 inhabitants".[12]

One of the reasons given for Canadian nurses leaving Canada for the United States was unsafe patient ratios. In Ontario, one nurse said she was responsible for caring for six patients at a time.[14]

Shortage of nurse educators

A 2014 study in Canada and another in 2019 confirmed that along with the shortage of nurses in Canada, there was also a national shortage in nursing educator in higher learning,[15][16][17] which reflects the global shortage identified in 2011 by the Institute of Medicine and in 2020 by The World Health Organization (WHO).[17]

A 1967 journal article in Canadian Nurse predicted a severe future shortage of nurses in Canada unless the shortage of nursing faculty in undergraduate and graduate programs was remedied.[18] In the mid-1960s some of the factors that contributed to a lack of retention and growth in nursing faculty included the rate at which professors reaching retirement age being matched by new and younger hires. There were much higher salaries for these individuals in non-academic professions. The workload for nursing faculty was excessive.[18]

Pandemic-related nursing shortages

A 2022 review of how the pandemic impacted the 400,000 nurses in Canada, sponsored by the Royal Society of Canada and published in the FACETS journal said that by 2021, health job vacancies had increased by 56.9% since 2019 in Canada to a "record high of 100,300. The highest vacancy rate was experienced by hospitals.[10] The report found that for decades, the "nursing labour market" was "under stress" but "widespread systemic change" did not occur.[10] The pandemic-related workload increase combined with chronic stress represented a "tipping point of systemic burnout".[10] Some of factors leading to the exodus of the nursing labour force included "workload, burnout, lack of structural value, the need for leadership and mentorship, and lack of flexibility, autonomy and voice laced with overt racism, discrimination, and gendered inequities," according to Annette Elliott Rose, one of the study's authors.[10]

Due to a shortage of nurses, in March 2022, during the COVID-19 pandemic in Canada, the first of many unplanned closures of emergency rooms took place—the first such occurrence since 2006. By September 2022, across Canada there were "dozens of forced closures of emergency rooms took place because of insufficient staff.[19] By May, Ontario Health reported emergency department "record-high wait times and patient volumes."[20] Hospital administrators said that one of the reasons for hospital staff shortages is the retirement since 2018 of many healthcare workers who are over the age of fifty who cited "the pandemic and burnout as top reasons."[20] Other administrators said staffing issues were a concern before the pandemic.[20] While some raised concerns that nurses who left their profession because of the vaccine mandate had contributed to the shortage, one hospital CEO said the number of those who left for that reason was so small, it was a "non-issue".[20] A September 2022, New York Times article said that nurses in Canada left the profession because of "unsafe working conditions, wage dissatisfaction, and burnout from the pandemic".[19] Sixteen emergency departments had to close in September because of nursing shortages in Canada's "most populous province", Ontario.[19] Ontario Council of Hospital Unions president said in August that the work force which had been working through the pandemic in an unsafe work environment, and had their wages cut, was "exhausted" and "demoralized".[19]

Due to shortages in staffing, Intensive Care Units (ICU) reached full capacity in August 2022, forcing the UHN to announce a 'critical care bed alert' at the Toronto General Hospital affecting the Cardiovascular (CVICU), Cardiac (CICU), and Medical Surgical Intensive Care Units (MSICU).[21] On 28 October the UHN announced that the Toronto General Hospital was again under a 'critical care bed alert' with the three intensive care units—CVICU, Cardiac CICU, and MSICU—at total bed capacity.[22]

In August 2022, with the province of Ontario facing the peak of the seventh wave of COVID-19, the University Health Network (UHN) in Toronto, which operates the largest hospital in the city—Toronto General–said that there were so understaffed that they were calling in nursing students.[23] They put out a call for "volunteers" to fill nursing shifts. During the sixth wave they were forced to do this several times.[23] In August, some patients waited 33 hours in ER to get an inpatient bed in Toronto.[8]

Canadian Federation of Nurses Unions (CFNU) said on Twitter on 31 October 2022, that it had become normalized for hospitals to operate understaffed at overcapacity, with nurses regularly working 16 hour shifts—two nurses recently worked 30 hour shifts.[24]

By mid-October 2022, prior to the beginning of the "traditional flu season", across Canada emergency departments were "under intense pressure".[8] Concerns were raised as in Europe an eighth COVID-19 wave was beginning.[8][25]

In the province of Quebec, there were staff shortages of all health care personnel—but mainly nursing personnel—negatively affected all of the province's health-care network."[8] Largely because of the ongoing COVID-19 pandemic, emergency departments were operating at overcapacity, which in Montreal reached up to 200%.[8] On 14 October, there were 4,000 health-care workers on leave because of COVID.[8]

Emergency departments overloaded

During the seventh wave of the Covid-19 pandemic, the lack of health care personnel, particularly nurses, along with the health system's backlog and a resurgence of hospitalized COVID-19 patients were some of the factors contributing to the overloading of emergency departments and lengthening of ambulance off-loading times.[8] By 27 October there were 1,921 COVID-19 hospitalizations in Ontario and 121 more COVID-19 deaths.[26] Prior to that, the last time the numbers were so high was on 9 February with 2,059 hospitalized with Covid-19.[26]

Nurse shortages in rural communities

Critical nurse shortages were one of the major factors in the unplanned closures of emergency rooms in Ontario rural communities.[27] This raised concerns among the future of rural health systems where emergency health care options are limited.[27] A Canadian Association of Emergency Physicians representative said that an "unprecedented" number of nurses left for "less stressful and better paying jobs".[27] Seventeen of the 160 departments that experienced these closures were rural.[27]

Nursing force retention and exit rates

By 2021, many in the nursing workforce considered taking a leave of absence or leaving the profession for good; others had already left. The factors causing the exit included work environments that were too demanding, understaffing that was chronic not acute, physical and moral injuries, burnout, and concerns for their mental health.[28] In October 2022, following a meeting with collaborative action-oriented government coalition with Canadian Federation of Nurses Unions (CFNU), provincial nurse union leaders, Prime Minister Justin Trudeau, Minister of Health Jean-Yves Duclos, and Minister of Seniors Kamal Khera health care workers, and advocates the Health Canada Coalition was formed with a mandate to respond to the nursing workforce exit rate.[29]

Nurses wages and benefits

Since 2018, the number of nurses leaving Ontario for the United States doubled as wages are higher there and the work environment less stressful—full-time permanent positions are paid $15-$20 more than similar jobs in Canada.[14] They can also earn sign-on bonuses from $10,000 to $20,000, as well as housing and relocation assistance.[14] The U.S.-based Commission on Graduates of Foreign Nursing Schools (CGFNS) said that in 2018, 801 Canadian nurses applied for credential transfers; in 2019 there were 1,300 applications; in 2019 there were 1,300; and by October 2022, the number had increased to 1,700.[14]

Frank Mortimer of CGFNS said the number of Canadian nurses approved to work in the U.S. has doubled over the last five years and could be at an all-time high In 2019, during the pandemic, under the premiership of Doug Ford, Bill 124—Protecting a Sustainable Public Sector for Future Generations Act was enacted placing an annual cap of 1% for three years on most public sector employees, including nurses.[21] This is lower than the inflation rate and according to opposition critics, represented a cut in salary.[21] According to health care workers' unions, this contributed to the staff shortages.[19] According to a 17 July 2022 Financial Accountability Office (FAO) report, in Ontario the government spent "$7.2 billion less than planned across all programs", including health.[30] In 2019, the Ford administration capped the wages of most public sector employees, including nurses, causing staff shortages, according to health care workers' unions.[19] In Ontario, since 2019 with the passage of Bill 124, there has been a "major increase" in nurses relocating to the US.[14]

See also

Citations

  1. ^ a b Twohig 2020, p. 16.
  2. ^ a b c d Twohig 2020, p. 13.
  3. ^ Twohig 2020, p. 19.
  4. ^ a b c d e Twohig 2020, p. 9.
  5. ^ a b Twohig 2020.
  6. ^ a b Twohig 2020, p. 25.
  7. ^ a b c d e f g h i j Maddalena & Crupi 2008.
  8. ^ a b c d e f g h i Shingler 2022.
  9. ^ CIHI 2021.
  10. ^ a b c d e f Tomblin Murphy et al 2022.
  11. ^ a b Twohig 2020, p. 12.
  12. ^ a b c d e f g Ariste, Ali & Dauphin 2019.
  13. ^ Berry & Curry 2012.
  14. ^ a b c d e Woodward 2022.
  15. ^ Allen 2014.
  16. ^ Cash et al. 2009.
  17. ^ a b Boamah 2021.
  18. ^ a b Bartfay & Howse 2007.
  19. ^ a b c d e f Isai 2022.
  20. ^ a b c d Bueckert 2022.
  21. ^ a b c CBC News 2022.
  22. ^ Fisman 2022.
  23. ^ a b Dyer 2022.
  24. ^ CFNU 2022.
  25. ^ Rodriguez 2022.
  26. ^ a b CBC & CP 2022.
  27. ^ a b c d Hassan 2022.
  28. ^ Bourgeault 2021, p. 11.
  29. ^ Canada's Nurses 2022.
  30. ^ CBC News 2022a.

References

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