The Agenda with Steve Paikin (Audio) - What's the Cost of Ontario's Nursing Shortage?

Episode Date: October 18, 2024

Reports have shown that there's a nursing shortage in Ontario. Why are nurses leaving the profession and what are we going to do about it?See omnystudio.com/listener for privacy information.

Nursing is a critical part of our healthcare system, but retaining and attracting nurses to the profession is becoming a huge burden. Joining us now on what this nursing shortage is costing the province and potential solutions, we welcome on the line from Montreal, Charlene Stewart, International Canadian Vice President at SEIU Healthcare. And with us in studio, Sandra Carroll, Vice Dean of the Faculty of Health Sciences and Executive Director of the School of Nursing at McMaster University.

Lamo Dholkar, President of the Registered Nurses Association of Ontario or RNAO, and a Primary Care Nurse Practitioner. And Rosalie Wanch, Senior Policy Analyst with the C.D. Howe Institute. Welcome everyone in studio and of course on the line. I'm going to set up the table first. As we know, not all nurses are employed in hospitals. Some are employed by staffing agencies.

And in recent years, those wages look different. So I'm going to direct your eyes to the screens over there. According to the Government of Canada Job Bank in 2023, the median wage for a registered nurse in Ontario was $38.05 per hour. In December 2023, the Auditor General released a report on emergency departments that found agency nurses in hospitals were paid more than $75 per hour with some higher rates in Northern Ontario.

And in July of last year, the Ontario Nurses Association asked hospitals to submit data from 2022 and it shared it with the Globe and Mail to show that there were more than 1 million total reported hours worked by agencies and hospitals. And they charged on average, not median, wage of $140 per hour, the total bill of more than 168 million in the reported time. All right, on one hand, nurses and staffing agencies are getting paid more. That's a good thing. People are getting paid for the work they do. On the other hand, it seems to be costing hospitals much more.

So I'm going to start, Lomo. What are we supposed to do here? So I think the problem is much deeper than just a cost reimbursement for agency nurses in work settings because we have to look at the agencies have always been there for decades. Having said that the price the steep price hike that we see has been because of the nursing shortage crisis that has been more highlighted more so since COVID. On top of that Bill 124 was another damper where it did have a significant negative impact on the nursing morale and of course the work plus the workload and the high burnout rates was enough for nurses to think

about exiting the profession in total, which led us to a huge nursing shortage crisis. That also gave rise to a lot of agency nurses being utilized and hence the steep costs. So if you are going to look at agency nurses were charging $75 an hour and now you have $142 to $250 if you can see some of the reports up north, $250 an hour, which is in general a huge health care cost because this is our taxpayer money that we are paying to these private agencies to deliver care and these nurses are one of our own. So it's a bigger problem. The cost is just the tip of the iceberg.

All right, Rosalie, I'm going to get you to respond as well. Yeah. Well, I've got maybe a bit of a different perspective, because it certainly is true that we do have a shortage of nurses, particularly in some care settings. However, when you actually look at the overall labor stats, employment in healthcare has actually grown more

than the rest of the economy, even when wages in Ontario particularly weren't growing at the same rate and keeping up with inflation. So it's actually a bit more complex than just not having enough because we're actually adding more nurses than we are in other, more people to work in healthcare than we are in other areas of the economy. And though the prices for agency nurses might be high, fully 63.3% of hospital spending is already directed towards compensation.

So one of my concerns is about how filling staffing gaps might be crowding out other areas of care or limiting hospitals in how much they might be able to invest in things that could make work better or improve outcomes for patients. So overall, I think it does put hospitals in a bit of a budget crunch, but I don't see it as strictly a shortage issue. I see it as a much more complex change in what we actually consider to be the health sector.

Okay. Charlene, I'm curious. It's not just the province of Ontario. A report last month projected that $1.5 billion will be spent nationwide on agencies, a six-fold increase from pandemic levels. Will this trend, is this a trend that's going to be moving forward?

Thank you. Well, it appears that it is. And I would argue that the staffing crisis is real. I mean yes there's been a lot of hiring over the past year, a lot of incentives to attract nurses into the sector and I represent primarily registered practical nurses across the country. So the crisis is the same and the agencies are being relied upon to fill those jobs as well. And there is different levels of dependency. I mean hospitals

is one but also in long-term care they're being utilized as well where you know the funding is different but we don't have the extra resources to be spending on agencies and this is a critical thing that the that the country needs to deal with. We have hired more nurses but when they get into the workforce because of the working conditions they don't stay. So you know you have to follow the data right to the end. Yes, they lots going into colleges, lots of them being hired but they don't last in the workplaces because of the conditions. So then the employers are relying on agency staff. This has become the attraction for workers because they can choose their hours, they can choose where they work, which also causes an issue because they don't know,

they're not familiar with the institutions that they're being placed in, which adds extra pressure to the full-time employees in those facilities. So despite the money that I think we could put back into frontline care to provide better wages so that people stay in the jobs, which would correct the staffing crisis and also the burden of mental health and the care that's provided. So, agencies is an epidemic of itself that we need to address. It's become more attractive to work for an agency because of the wages, but you noted only half the wages go to the front line, the other is going to profit.

So you've got nurses that are starting up agencies so that they can make more money. So this is a true epidemic that we have to deal with. It makes no sense to be wasting resources on agencies. Sandra, Ploma had mentioned, staffing agencies are not new. We may have heard more of them in the pandemic, but they were doing their work for decades beyond.

I'm just curious. We've seen one particular province, Quebec, that has announced that it is going to be sort of shifting away from, from agents. Should we, should staffing agencies be phased out? Well, certainly, you know, I'm in the education business, so I wouldn't be able to speak for the acute care settings, but agencies have always been there. I worked for an agency as a new grad. But so I don't think we can ever phase them out.

I think it would not be sustainable for any organization to continue to use agencies with inflated prices. I would question how much of that actually goes to the nurse working and how much goes to the agency. So I don't think we can ever phase them out. It is not sustainable in acute care settings to keep relying on them. But we had to during the pandemic. But there are major investments going on

to retain nurses in acute care. I'm curious. I just want to know, when you were working at a staff agency, what were you doing? What type of work were you doing? Was it all across Ontario? All across Toronto. Toronto, okay. All across Toronto. So as a new grad, it was really enjoyable. You could test out different types of hospitals, different settings, and you just got to explore differently than when you were placed as a learner. All right. All right. We have heard a lot about nursing shortages in the province.

Let's look at how many nurses there are in Ontario. In 2023, there were nearly 160,000 employed nurses in Ontario. In that same year, there was a gain of more than 12,000 nurses and a loss of more than 7,000 nurses, resulting in more than 5,000 nurses to the field. Lomo, when you see these figures, what are the first thoughts about the state of the profession? So I would agree with Rosalie at certain points when Rosalie mentioned that nursing hiring has been on the rise and I think there's a lot of advocacy work that was put in place right through COVID, before

COVID and even after where we were advocating for increasing nursing seats across institutions, trying to hire, bring in internationally educated nurses and expediting their registration, internationally educated who are already living in Ontario, ready to work. And I think so that led to a lot of increase in hiring of nurses. But I think we also have to compare it to how much are we retaining?

Because just hiring is never enough. Like you have expedited internationally educated nurses, but you're not offering a healthy workplace environment. You're not offering safe workloads. You are not offering a mentorship or supportive program or professional development. Nurses also have to take care of themselves. Like it's a profession which has a high potential for burnout. There have been reports after reports, like even the Kaihai report that came out not too

long ago did mention that there are still a lot of things that we can do. There were 26,000 nursing jobs that had to be filled. And if you look at a Canada-wide, I think Ontario is one of the lowest RNT population ratio. You know, that speaks a lot to, yes, we welcome certain government steps that have been taken to hire more nurses, but are we retaining them? I think we have to also look at the retention strategy and long-term strategies to retain these nursing professionals and not go to agencies or down south.

All right. Rosalie, I'm going to get your take on that. It seems like just looking at those numbers, there's enough nurses in this province, some would say, but hospitals specifically are struggling to keep them. Why are nurses leaving hospitals? Well I think maybe instead of thinking about why they're leaving, we can look at why nurses actually choose agencies because really it's their choice. They can choose where they want to work and how

they want to work and for a survey of sort of the top reasons that nurses choose to work with agencies, 80% answered things like better pay, more flexibility, the ability to travel and experience different clinical locations. And to me that kind of goes with maybe earlier career, more likely, and also I don't think that we should just look at wages alone because there's also a difference in terms of the benefits packages. You don't have the same security, you don't necessarily have the

same health coverage or additional benefits when you work for an agency so different nurses will as they take care of themselves and their families will make different choices about the types of employment they want to have. And maybe I'll add a point that some might find controversial. But if nurses are choosing to leave hospitals to go to agencies, then that means that they find it a better way to work. And so that actually puts a competitive pressure

on the hospitals to actually, you know, not pay lip service to retention, but actually do it. Find the pathways that keep the nurses working, prevent burnout, give them the support they need, and there might be other ways to do that, but being an economist first and foremost, competitive pressure is definitely a powerful driver of innovation and improving work standards.

Charlene, I'm coming to you. I'm sure you have a response for that. Yes, I do. We've surveyed a lot of our nurses, our registered practical nurses, on why agencies. And the number one answer is wages. And Rosalie did say that wages. The other thing too is recently by the government's own admission to the nursing shortage in the

province of Ontario through the freedom of information we got data that they are 13,200 short now and predict in the next 10 years that'll be tripled. So there'll be 30,000, 33,000 nurse shortage in the province of Ontario. To me that raises, you know, alarm bells, flags are raising. We need to deal with this now. And when you ask the people doing the work, not making the money, but doing the work, their number one issue is wages and without their and also throughout the sectors. I mean we need a universal nurse wage rate. You'd look at home care they're making $26 an hour and again you know if we're

talking about fiscal responsibilities the system has to be looked at as a whole. People don't want to be in the hospital they'd rather be taken care of at home which saves the province money. But when you're paying registered practical nurses $26 an hour in home care and $36 an hour in hospitals, that causes a shortage in home care and long-term care because they are chasing the money. With the cost of living right now, that's what they're after. The benefits and stuff, they're willing to risk that because of the money. And it is wages and then the working conditions.

It was mentioned, the nurse to patient ratio, that's a cause of why people are leaving too. They're burning out. I recently had a family member in the hospital and I watched patients apologize to nurses for ringing the call bell because they can see physically how burnt out those nurses are. There's been surgeries canceled because there hasn't been enough nurses for the OR or to receive the patients on the ward.

You ask them why, they say it's the working conditions, it's the wages that are not attracting people, which adds to the pressure of the working conditions because nurses are working short. Lama, I'm hoping you can fill in the gaps here. You're on the front lines as well. What are you hearing about why nurses are leaving, similar to what Charlene's story is there?

Is there any stories that you're hearing? So I think compensation is an important aspect of retention and recruitment. But having said that, I think it's not only about compensation. I think it's, as I talked about, safe workloads and healthy workplace environment and that support that you need from organizations. Having myself, I've worked

in both hospital and community, not only as an RN but now as a nurse practitioner. I think I can see bigger, I think bigger stakes here because we are looking at healthcare, you know, down the line. Like I have been at the receiving end of healthcare, my children will be, when I grow older I will be, I work in geriatrics. All these patients that I see are because they have not had access to health in a timely manner or they've not been served well, do not want to go to hospital, or they've been expressing stress and violence

towards nurses, which does put them in precarious conditions. And I think we have to look at it from a policy perspective and organizational perspective. Organizations are moving away, because I know this from ground level, they are moving away from hiring agency nurses, because you also have to look at, yes, agency pay is much more, but then there's no continuity of care, right?

And it's a band-aid, and band-aid solutions are never better. You need to look at it from a policy perspective. And organizations are doing it, but I think we need to hire more. But then the retention is really important, just not hiring. All right. Sandra, big question here. How do you attract nurses into these settings in these environments when clearly what we're hearing

is that it's a bit lopsided when we look at certain aspects? I think culture is a really big part of an attraction. And I can speak from the education perspective, because we place thousands of students into health care environments every year. And that is the introduction that they receive to an opportunity of where they may or may not want to be employed.

So it starts there and the exposure, but we have thousands of students applying to our programs from high school, so it is still a profession that is attracting applicants. But retention is something that begins as they are learners, and students will make decisions about where they want to work early on within their program. But I have to say, you know, there are up to four different generations in a hospital setting and the new graduate is not like the graduate from my generation. What's different?

Well, I think, you know, we have a cohort. Every cohort's different. But now, the new generation, they have only known the internet. They've only known the electronic digital world. So they move, they fast, they have more than one job, they like to move. I don't think things are the same, and they want different things, and they want to be be free and they want to have quality of life but they're also not afraid to move around

so I think we have to really ask our newest registered nurses in the profession why they're moving but I think it's understandable that you could have more than one job, move around at different stages in your life. Oh, sorry, I was just going to say, can I add on to that a bit too? Sure. The newer cohort also has more options. You can, because there are virtual care provision,

after the pandemic, there's been a huge expansion in the private sector wanting their own public health experts, or looking at their own public health experts or looking at their own internal policies or being able to provide some of these services to their employees directly as well as vertical integration with some of the insurance companies becoming mixed up in the provider space. And so really it means that even if we're graduating the same number of nurses, maybe a lower proportion of them will actually work for the public system and may actually be employed in areas

that we wouldn't actually think are traditionally the health sector. And just one... Like what? Sorry. Like what? Well, the explosion in public health in sort of the more government roles, every private sector company had to develop internal policies for infection control and prevention. And so there was essentially jobs almost everywhere that if you were a qualified health professional,

you might be qualified for. So you didn't necessarily need to be a licensed nurse, but if someone went to school for that and they have that expertise, they might have more options than what we would consider traditional nursing care. And I would say I see agencies as still being very much delivering care to patients in the public system. And given how strained our hospital system is, it may not be the most desirable solution.

It's certainly expensive, not the most efficient, but it does provide an avenue to getting people into the hospital to potentially lessen that burden, because if the alternative is no one is there, then that is really the worst outcome. And I think we need to be realistic about the fact that we had over 200 temporary emergency room closures in Ontario last year. And so if agencies are filling that gap, it might be expensive, it might not be ideal, but it's better than the worst outcome of patients not being able to access the emergency

department if they need it. All right. Lama, if you want to chime in. Yeah, I just said, I'm just saying like I want to disagree on that a little bit because I think using agency nurses cannot be justified to be honest because I think we are doing disservice to Ontarians. And I understand when you're saying there's no one to give and therefore agencies are there to fill the gaps but we have to understand that people who run the agencies are business people.

These are not nurses, these are not healthcare professionals, they do not have that the sensitivity lens it's all about a business model. So we use utilizing agency nurses in areas like metropolitan areas or where there's a lot of resource is doing this service to interiors. Having said that, there's some use in Northern Ontario's like my friends have used, have been used as agency nurses to work up north, because there's no one. But then that is why the government has to look at incentives for remote nursing, northern nursing. What are we doing, like students in Laurentian and up north?

Maybe we should give them an incentive loan forgiveness to stay up there. Maybe we should build capacity among the indigenous nurses up there so that they can be utilized to work in their own community, because that's an intrinsic motivation. So using an agency nurses can never be justified because it compromises the continuity of care, the excellence of care and there's no accountability. Having said that, nurses are not to be blamed. It's the beast that we have created because we did not address the nursing crisis.

All right, Charlene, I'm going to get you in on that as well. Yeah, I agree 100%. I mean, agencies, it just doesn't make any sense at all. I mean, the numbers that you quoted at the beginning of the show, you could hire two nurses for what you're paying an agency to provide you with one. And yes, the continuity of care,

I mean that's important. And also the familiarization of the Institute. The nurses who are still working inside the hospital say that it's added pressure to them to orientate an agency nurse into the facility. The patient, I mean it adds stress when a nurse, a full-time nurse in a hospital or registered practical nurse is asked to go from one floor to the other. The orientation is needed for safe care and that's at risk right now. The safe care is at risk because of the staffing shortage, which is caused by not giving them adequate wages. I mean, common sense is why wouldn't you take the agency money that you're paying twice the amount for, hire twice the staff in a full-time facility, and have that continuity of care there for the services and for the patient? It makes no sense. Agencies and the government is the one

that has to deal with this because it is exploding. People are making money off of the agencies, which is what was said, and you've got workers going there because of the fact that there is some flexibility in work. This is not going to, it still hasn't addressed the crisis in the hospitals because you can ask anyone today if you're working side by side with an agency, is it helping the staffing shortage? And it's no.

And the patient ratios are still at a critical risk for the patients, even with the use of agency workers. So profit in health care shouldn't be allowed, they should be put in the front line so that the working conditions are safer. If you've got enough staff that provides you with safe working conditions because there's enough people doing the work. We haven't even started talking about the mental crisis, mental health crisis that's happening in health care too, because of the workload and their lack of ability to give the patient care that they went to school to provide because they go home at night crying, they're in their cars crying because they weren't able to give

the patient the care that they wanted to provide to them. All right. Let's talk retention. There's a few mentions of retention, what we can do. Sandra, a recent report from the Montreal Economic Institute showed that for every hundred young nurses, 35 are leaving the professional in general, whether it's from hospital to agency, just in general. What can we be doing about this? Well there isn't one solution. Retention is now something our Chief Federal Nursery Chapman has created a retention toolkit

that many of our acute care organizations are utilizing. But it's multifactorial because you know I think we really have to know why people are moving and leaving because I think there are more opportunities now. So not everybody's leaving the profession per se but they are moving around. But I think you have to prepare them for the workforce. And so that's part of what we do at McMaster when we graduate our BScNs. We do prepare them by immersing them

in practical learning with clinical placements so that they are prepared and they do get experience in clinical so that they're aware of what practice looks like as a full-time nurse. Then students can make their choices from there. But I would like to follow those numbers to see if they are sustained. It has been a difficult time for the last four years.

So things have to get better. There will always be vacancies in hospitals. There will always be vacancies in hospitals. There have always been vacancies in hospitals. And the pandemic has really just blown it up. But we don't have one solution. And I do have to say, we have undergone three expansions in our educational program. So all of the schools have enrolled more seats.

And those graduates are now entering the workforce and they're all employed and you know hospitals are trying their best to ensure retention and retention is satisfaction, quality of life, being able to perhaps self-schedule things that have system barriers depending on organizations but you know we really need to ask our new nurses. I'm going to give you the last word on this. In terms of retention, you mentioned some of the stuff, but what needs to be done to keep nurses?

Yeah, I just want to draw your attention to our new work, Registered Nurses Association advocacy work, registered nurses association advocacy work that has been happening for some time on nursing retention and nursing crisis. I think we have addressed various topics on this because we have to look at it upstream. And when I say upstream, I think hospitals are always the end goal.

It's a downstream strategy. Yes, we are focusing on hospitals, but addressing nursing shortage in hospital is very downstream. We need to look at why nurses are burnt out, why nurses are having unsafe workloads. Yes, they have to be compensated, and there has to be fair compensation and wage parity across different sectors.

And as Charlene mentioned, communities are paid less and that's why they don't want to stay in communities. But having said that, if community nurses are not there, these patients who are supposed to be in community are going to flood our EDs and are going to put nurses in precarious work conditions. I think in my geriatric practice, and as Arne has highlighted, I see this day in and day out. I have older patients that come in

that do not have primary care access because they do not have community nurses, they do not have community nurse practitioners or family physicians, and now they're sitting in our clinic because you know they've had no access no blood work for the last two three years and we are almost like sending them into ED multiple ED and now we want to divert ED admission so it's like catch-22 you are not working upstream and and now we want to fix the nursing crisis because now we've put them in that situation where we have. So if I had to say something about

retention I think we need to address the primary care crisis that's happening right now, utilize all the boards, all hands on board including nurse practitioners to fill the gaps in primary care crisis so that these patients do not flood EDs. Also providing a healthy workplace environment and wage parity across all sectors, I think is a good strategy with healthy workplace. All right, we are gonna have to leave it there.

Lammo, Charlene, Sandra, Rosalie, thank you so much, a very important conversation. One that won't be solved today, but one that we will continue to follow. So thank you so much. Thank you for having us.