Octavia Bullen had been a clinical intern for only two weeks when something happened that made her question the nursing profession, in which she’s been training for five years.
Her moment came when the Ryerson student overheard a frustrated nurse tell an unvaccinated patient fighting for their life that they didn’t deserve a bed, or care altogether.
Urooj Khatri, another Ryerson nursing student, said she began to fear for her safety every day while doing her clinical placement at a COVID-19 assessment centre.
Her moment came when she realized she was being exposed to the same unvaccinated people time and time again.
It’s not just COVID-19 that has nurses questioning whether they want to stay in the field. According to experts, the nursing profession is facing serious issues that are threatening both the safety of nurses and the quality of patient care. They say unsafe working conditions, overwhelming workloads, staffing shortages, and burnout has pushed existing caregivers into early retirement, while young nurses are considering switching their careers altogether.
“Patient care quality will decline as we lose our experienced and skilled health-care professionals,” said Patrick Neumann, a Ryerson researcher and professor in the department of Mechanical and Industrial Engineering.
He warns that there’s an urgent need to manage health-care staff in a realistic way. If that’s not addressed soon, he says more nurses will be lost, lives will be lost — and public trust will be lost.
“The resulting declines in care quality will mean less healthy populations, untreated diseases and shorter life-spans at the population level,” Neumann said. “These, in turn, will erode trust in the health-care system.”
Neumann, also a design scientist and human factors professional, is leading new research into quantifying nursing workloads and their effects on patient care. To better illustrate the problem nurses are facing, he compared the job design model of the health-care industry to that of the manufacturing sector.
“The manufacturing sector understands that excess workload means errors, staff overturn, reduced product quality and increased costs,” he explained. “Automakers wouldn’t produce a single vehicle if they managed their personnel the way health-care does.”
Susan Bookey-Bassett, a Ryerson nursing expert leading the research with Neumann agrees, comparing the state of the pandemic-struck nursing profession to an out-of-control amusement park ride.
“It’s like a merry-go-round that’s spinning faster and faster and everyone’s falling off,” she said.
The researchers say that there’s going to be a mass exodus of nurses leaving the profession in coming years; this is in part because a large number of working RNs in Ontario are baby boomers who have already worked well into their retirement years— on top of that, Bookey-Bassett says many are being pushed into early retirement even sooner than before.
A study published by the National Centre for Biotechnology Information at the end of 2019 confirmed that, even before the pandemic, Canadian nurses were retiring before the age of 65 because of caregiving demands. The research concluded that better policies — such as more flexible work arrangements, extended paid time off and higher pay — may reduce early retirement. The authors of the study specifically warned administrators to consider the consequences of cutting costs.
“The number of turnover intentions are much higher, and they’re higher in the 25- to 36-year-old age group, which we really rely on,” said Nancy Purdy, another Ryerson researcher and nursing expert leading the quantifying workloads study with Neumann and Bookey-Bassett.
“These are the nurses that we hope are going to stay in the system for a long period of time, and we’re losing them now too,” Purdy said.
Bookey-Bassett says their research indicates that it’s not only front-line staff that are leaving the profession, but nursing managers as well.
“There’s a huge impact, because if we lose experienced nurses that are not only direct-care providers, but also nursing leaders, it’s going to create a health-care system that’s more challenged than it is now,” she said.
While the pandemic has accelerated the impact of the nursing shortages in Ontario, it has been on the radar of those who watch the industry for quite a while.
The Canadian Institute for Health Information predicted in 2012 that Canada will be 60,000 registered nurses short by 2022, if past trends continued.
With about 12,000 nursing graduates across Canada every year, the experts interviewed in this story say that number isn’t enough to replace even the Ontario nurses who will leave the industry — let alone all the other vacancies across the country. And to make matters worse, the number of nursing graduates is also declining. (See chart below)
Cathryn Hoy, president of the Ontario Nurses’ Association, says many nursing professionals predicted the shortage after the Ontario government made the decision to terminate the two-year college diploma program in 2002.
“That was a huge mistake because they really limited the marketplace for graduating RNs,” Hoy said. Many of the students she's spoken to over the years pursue nursing as adults, and typically have the time to commit to a two-year program, but not a four-year undergraduate degree, which also tends to cost much more, she explained.
The problem isn't unique to Ontario or the rest of Canada— a report by the International Council of Nurses released in March 2021 stated that an estimated 13 million nurses will be needed to accommodate staffing shortages around the world in the years following COVID-19.
"My life is at risk, too."
For the nursing students who have watched these long-standing issues come to a head in the midst of a global pandemic, it has them wondering whether the mental and physical risks are worth it, or what it will take to fix such problems and mend their futures.
“If a pandemic were to happen again, at this large of a scale, I would definitely either quit or change my position working in the field,” Khatri said. “I don’t think I would be able to handle the sheer backlash that nurses are facing.”
Khatri says she’s frustrated and scared for her safety, having to work with unvaccinated people every day who consistently come back to get tested but refuse the vaccine when she offers it to them.
“It’s so aggravating to see that people don’t want to follow what's recommended by a public health organization that just wants to improve their community forever,” Khatri said.
“I’m scared for my future because there’s tons of other people I’m taking care of, and my life is at risk, too.”
As a Muslim woman, Khatri says she's also experienced racially motivated abuse in her clinical placements. She's been slapped and punched when trying to care for patients, something she says doesn’t happen to her Caucasian counterparts. She's also had patients ask if her or her family were behind the 9/11 terrorist attack.
“Sometimes it seems like patients in long-term care homes will forget everything except racism,” she chuckled nervously, noting many of the patients she’s cared for had cognitive diseases, such as Alzheimer’s or dementia, and were therefore more likely to act on their impulses than other patients.
“It’s almost like it’s something they remember their whole lives and they feel the need to act on it,” she said.
What Khatri experienced in her clinical placement wasn’t a one-off incident. A study conducted by the Canadian Federation of Nurses Unions found that 61 per cent of nurses had experienced violence on the job while 46 per cent reported exposure to physical abuse more than 11 times. Ninety-three per cent of nurses also reported trauma and mental health issues after being physically assaulted. Another study by the Ontario Council of Hospital Unions stated that, prior to the pandemic, there were more reported cases of violence against nurses in Canada than against police officers and firefighters combined.
Race and age also play a significant role in the abuse nurses in Ontario face. Research published by Science Direct in 2016 found that young nurses of visible minorities were more likely to encounter “demeaning, abusive, derogatory, threatening, and violent interactions,” and “ostracizing exclusions that create emotional injuries and a sense of injustice.”
A 2021 study that specifically focused on two Canadian cities, London and Toronto, found that ethnic minority nurses in particular experienced “excessive physical assaults, verbal aggressive behaviours, racial stereotyping and discrimination, and sexual harassment from patients and patients’ family members.” The study found these assaults to be highly stressful for nurses, and have contributed to staffing shortages.
Hoy said that patients are rarely ever charged and quite often excused for being violent with nurses, making nurses feel guilty for attempting to get someone charged when they lash out.
“If you’re a police officer and someone hits you, they’re automatically charged and taken to jail,” Hoy explained. “But hit a nurse? Well, you know, ‘they were confused, they couldn’t help it, they were scared.’"
While Bullen says she's never experienced this type of abuse from patients during her clinical placements, she says the stress and burnout nurses are facing highlights the critical need for more paid time off between shifts. She says that wouldn't only help keep employees in the profession, but simultaneously allow nurses to “heal,” enabling them to deliver the quality care that patients deserve.
“Nurses are so selfless, but yet, this pandemic has really shown us that they can't be selfless anymore,” Bullen said. “Nurses are caregivers, they’re nurturers, they’re healers — and if we’re not healed as a person, we can't give the proper care to someone else.”
Khatri agrees that nurses deserve more time off to recover from what they’re experiencing, arguing that a nurse needs downtime to properly perform their duties the same way a doctor would before performing surgery.
“Nurses may not be able to perform surgery, but once the surgery is done, who's taking care of the patient?” Khatri said. “We are, which is arguably just as critical as the surgery itself.”
In fact, Neumann, Purdy and Bookey-Bassett say the key factor in their research that will aid the nursing crisis is precisely that — recovery time. They say simply allocating more staff when and where they're needed won't solve the problem, emphasizing that nurses need quality time off between shifts to properly manage the workload demands placed on them. Without that, they say burnout will continue, and patient care will suffer.
“Health-care professionals must have adequate and quality recovering time between bouts of work,” Neumann said. “If recovery is insufficient, or compromised by irregularity or other stressors, then it will not be adequate for the workload demands placed on them, and these problems will continue.”
The Ontario government says it’s responding to the crisis the nursing profession is facing with a variety of measures.
Kylie Richardson, spokesperson for the Ontario Treasury Board Secretariat, says over $1.3 billion has been invested since the beginning of the pandemic to temporarily enhance the wages of personal support workers, which he claims will help stabilize, attract, and attain health-care workers. To further attract and retain future nurses, he says they've recently announced an additional $61 million towards initiatives designed to expand enrolment in nursing education programs. The government is also investing up to $100 million to add an additional 2,000 nurses to the long-term care sector by 2024-2025, he adds.
“As we continue to respond to the evolving COVID-19 situation here in Ontario, the government remains committed to working with public sector partners to support, recruit and retain Ontario’s valued nurses and ensure the health and well-being of Ontarians,” Richardson said.
Government investment is one thing, but Neumann says the industry and nurses’ unions also have to agree to work smarter by adjusting staffing models to include recovery time; this can reduce the amount of money that’s now allocated to recruitment, absenteeism and overtime— savings that could be turned into better pay for nurses, he says.
Although, Bookey-Bassett says whether that will happen is a million-dollar question.
“[It’s] between the organizations and the unions, but organizations are bound by the funding that they have from the government,” Bookey-Bassett said. “So, perhaps, more funding is needed, and it needs to be applied at the direct care level as opposed to potentially other areas within health-care organizations.”
As for Bullen and Khatri, they say it's not quite clear what the future holds for them or their nursing careers.
Bullen says she hopes to see more nurses stay in the ICU where she’s interning, not only for her own educational experience, but for the sake of patients who are suffering.
“I feel bad for them, as a future nurse. I hope it gets better and I wish there was more I could do,” she said. “That’s why nursing is something I hold so close to my heart… Because they deserve a lot better.”