Ontario’s RN understaffing crisis: Impact and solution

As part of its Queen’s Park on the Road (QPOR) actions this Fall, RNAO is issuing a political bulletin on the major #NursingCrisis facing Ontarians. Here is a short version of the bulletin. The full version can be found here.

For decades, Ontario has had an RN understaffing problem. The COVID-19 pandemic has ushered in a new, deeper crisis in RN staffing. While nurses have been resilient in the face of inordinate stress throughout the pandemic, and have had to find ways to adapt and reach out for help when necessary, there are limits to what they can endure and for how long. Many RNs have reached or crossed that limit and have left their jobs. Some have left Ontario or the profession altogether. And others plan to depart the profession post-pandemic. The magnitude of these departures is significantly higher than ever before. RNAO insists on urgent action from health-system employers and government. At risk is the effective functioning of Ontario’s health system, the health of Ontarians, and the future of nursing in Ontario. Retention and recruitment must be aggressive.

Voices

Here are voices from survey respondents to the Canadian COVID-19 nursing workforce survey:

• “We have felt dispensable and disrespected in a time when we have given up so much personally and professionally, and risked the health and safety of ourselves and our loved ones.”
• “I have felt real fear for the safety of my family and my patients unlike anything I have ever known.”
• “I wake up thinking about work (workload, adequacy of my work, impressions by team members and management) and feel anxious almost all the time - I am hyperalert at work and energized in a fight-or-flight manner. I go home and feel like a zombie with no energy left - I cry often; generally unprovoked. The stress and heaviness of the workloads and expectations makes me feel paralyzed often.”
• “Staff morale is low, there is a staffing crisis. Many older staff have retired, and many are leaving the department I work in. There is a lack of support/recognition from management. Increased job stress and workload have left me burnt-out and stressed, I no longer enjoy my job and am thinking of changing my profession.”
• “It's exhausting! Working with higher acuity patients, working more hours, short staffed and now fighting Bill 124. It’s demoralizing to have Bill 124. It presents a bleak future in nursing.”

Background

A rich body of evidence indicates that RN care is directly linked to positive outcomes on numerous patient, organizational and financial markers. RNAO’s 2017 scoping review of 70 years of research into RN effectiveness, updated in 2020, confirms positive health outcomes from RN care across a broad range of quality-of-care indicators including, but not limited to, mortality rates and morbidity rates (i.e., pressure injuries and infections). And yet, RN understaffing in Ontario is a long-standing problem driven by misguided government and employer policies designed to lower the proportion of RNs employed in Ontario. For more than three decades, the number of RNs per capita in this province has trailed the rest of Canada. Ontario entered the COVID-19 pandemic nearly 22,000 RNs short of the rest of Canada on a per-capita basis, according to the latest data.

The impact of the pandemic on RN understaffing and wellbeing

Ontario’s long-standing RN understaffing problem has become an RN human resource crisis. Since January 2020, the understaffed RN workforce has waged an unrelenting battle with COVID-19. As of Nov. 7, 2021, 603,711 persons in Ontario have tested positive for the COVID-19 virus, resulting in almost 10,000 lives lost and many thousands more left to grieve. The toll on our colleagues and their families is immeasurable.

RNAO has been involved in three surveys of the nursing profession over the course of the pandemic to gain a greater understanding of the effects of the COVID-19 pandemic on the nursing workforce:

• RNAO's Work and Wellbeing Survey, focused on Ontario’s nursing workforce.
• The Canadian COVID-19 workforce survey, in partnership with Australia’s Rosemary Bryant AO Research Centre at the University of South Australia and Nursing Now International.
• The Healthy Professional Worker (HPW) Partnership, led by Dr. Ivy Bourgeault of the University of Ottawa.

While we can’t yet report on results of the latter, results of the first two surveys show the profound impact of the pandemic on RN wellbeing:

• RNs and NPs require better supports from government and employers – as they attempt to manage the impact of the pandemic at work and at home.
• About 90 per cent of respondents experienced at least moderate stress, with mid-career RNs/NPs reporting the highest levels of stress.
• Early-career RNs reported the greatest challenges with coping.
• ­­­Burnout is intensifying among the Canadian nursing workforce. Slightly more than two-thirds of the sample (67.9 per cent) indicated they were burnt out, with another 5.8 per cent reporting exhaustion, and 12 per cent reporting disengagement.

Findings from The Ontario Science Advisory Table substantiate RNAO’s survey findings, as they indicate the prevalence of severe burnout in Canadian health-care workers has increased from 30-40 per cent in spring 2020 to more than 60 per cent by spring 2021.

The impact of the pandemic on the RN workforce

RN understaffing combined with an unrelenting and emotionally draining pandemic has caused RNs to leave their jobs or consider leaving the profession. The results are astonishing:

• Ontario risks losing more than 20 per cent of early-career RNs/NPs (26- to 35-years-old).
• We are likely to see a very significant post-pandemic loss of late-career RNs/NPs who opt for early retirement, particularly RNs working in middle and senior management, as well as faculty positions.
• 70 per cent of RNs/NPs working excessive overtime plan to work less hours post-pandemic.
• 68.5 per cent of respondents plan to leave their current position within the next five years, 12.6 per cent of whom plan to leave the profession altogether, while 29.4 per cent plan to retire.

Statistics Canada vacancy data illustrates the extent of the RN human resource crisis:

• Of all occupations measured in Canada, RNs and registered psychiatric nurses have had the largest increase in job vacancies over the past two years (up by 85.8 per cent).
• RN vacancies in Ontario have more than quadrupled since the beginning of 2016, and have more than doubled since the start of the pandemic.
• The number of Ontario RN vacancies that have remained unfilled for 90 days or more has increased by nearly 50 per cent since the start of the pandemic.

Recommendations

RNAO recommends immediate action on RN retention and recruitment by:

1. Repealing Bill 124

Bill 124 caps compensation increases for a broad range of public sector workers, including nurses, at just one per cent. The lack of respect implicit in Bill 124 is triggering many RNs to leave their profession or practice outside of Ontario. Bill 124 must be repealed as an immediate first step for RN retention in Ontario.

2. Increasing RN supply

2. 1. Increase enrolment, and corresponding funding, in four-year baccalaureate (Bachelor of Science in Nursing (BScN)) programs, second entry/compressed programs, and RPN-to-RN bridging programs by at least 10 per cent annually for eight years.
   2. Compress RPN-to-BScN bridging programs to two years.
   3. Fast-track applications and develop funding pathways for internationally educated nurses (IEN) to become RNs in Ontario.
   4. Support faculty retention and recruitment in both CAATs and University programs as a crucial strategy to increase RN supply in Ontario.
3. Immediately developing and funding a Return to Nursing Now Program (RNNP) to attract RNs back into Ontario’s nursing workforce.

Ontario needs to develop and fund a program to bring back into the nursing workforce the 7500 Ontario-licensed RNs who are not currently nursing, including 2500 Ontario-licensed RNs nursing in other jurisdictions. The program would fund those Ontario health-care organizations with vacancies, to offer full-time positions, robust orientation programs, reduced nursing workloads and mental health supports.

4. Supporting nurses through their careers by expanding the Nursing Graduate Guarantee (NGG) program and reinstating the Late Career Nurse Initiative (LCNI).

RNAO’s Work and Wellbeing survey identified early career nurses’ intention to leave is most influenced by the nature of workplace support. Survey respondents 51 years and older are most likely to leave or retire early due to excessive working hours and work intensity. In the past, Ontario successfully retained nurses through NGG and LCNI, which focus on an RN’s career stage.

5. Immediately establishing a nursing task force to make recommendations on matters related to recruitment and retention of RNs.

Ontario will not be able to sustainably retain and recruit an RN workforce in the absence of substantially improved working conditions. RNAO insists that an urgent task force of government officials, nursing associations, unions, health-system employers and employer associations must be struck immediately to ensure necessary improvements. RNAO has repeatedly called for this task force and delays are harmful to Ontarians and their health system.