Nurses rally to fight staff shortages, deteriorating morale

Barbara Sibbald

CMAJ 1999;161:67-8

The physician supply is expected to decline everywhere. Ontario alone anticipates a drop from about 20 000 practising physicians in 1997 to 18 000 in 2021.¹ But the outlook for the nursing profession looks even bleaker. Statisticians have predicted a nationwide shortfall of up to 113 000 registered nurses by 2011.

Harbingers of the shortage are already evident. In April, Newfoundland's largest hospital took the unprecedented step of closing 15 surgical beds due to a "critical shortage of nurses." The Newfoundland and Labrador Medical Association says the shortage is "having a significant impact on patient care." A hospital in Northern Ontario had to shut down most operations because of a shortage of doctors and nurses.² A Saskatchewan district health board is closing beds and threatening to cancel staff holidays. And there are ongoing shortages in northern, rural and specialty areas, particularly in the long-term-care field.

For physicians, the nursing shortage could have far-reaching implications. It may become more difficult — and expensive — to hire nurses for private-practice offices. Patient care may be compromised, and waiting lists may grow longer. Reports from Newfoundland indicate that the shortage is already delaying elective surgery.

"In 1997 we were talking about the pending shortage, but for the most part the shortages are starting to happen now," says Lynda Kushnir Pekrul, president of the Canadian Nurses Association. The Canadian Institute for Health Information (CIHI) reports that Canada has seen a 3.4% drop in the number of registered nurses between 1993 and 1998 (see Pulse, page 15).
CNA President Lynda Kushnir Pekrul: lots of challenges ahead Photo: Canadian Nurses Association

And the problem is being compounded by a new demand for more nurses in Canada, the US and the UK. Ontario has promised to hire an additional 7700 of them, while BC and Alberta each want 1000, and Saskatchewan is looking for 200. "Ontario's going to have to go pretty far afield," warns Kathleen Connors, president of the 70 000-member National Federation of Nurses Unions (NFNU). "They're going to have to lure them from the US."

All this leaves professional nursing associations biting their tongue in an effort not to say "I told you so" — they began predicting the crisis more than a decade ago. The CNA, NFNU and the Canadian Association of University Schools of Nursing (CAUSN) have been meeting since last year to plot a 3-prong strategy to boost recruitment, retention and recovery of the large number of RNs who have left the profession. The CNA has also launched its first-ever online recruitment system to link nurses and employers (www.nursesatwork.com).

But all nursing organizations acknowledge that what's really needed is a united national approach. They're impatiently waiting for the federal government to make good on its promise to set up a nursing advisory committee. Ottawa also announced a $25-million nursing research fund for studies on roles, recruitment, efficacy of nursing practice and nurses' impact on decision-making. Little has actually happened, save for the early-May appointment — after a delay of nearly 6 months — of Judith Shamian to the new position of executive director of nursing policy at Health Canada. "It's really frustrating to watch this unfold," says the CNA's Kushnir Pekrul, "because we've been trying to talk about these issues for years."

Nursing leaders first began warning about the pending shortage in the 1980s. Initially there were enough nurses, but they began leaving the profession in droves because of difficult working conditions. A 1990 study by the CNA and the Canadian Hospital Association concluded that the problems included inadequate staffing, a lack of education opportunities, an increase in the number of unskilled staff performing nursing duties, lack of decision-making power and a lack of job satisfaction and respect from other health professionals. The study discovered growing dissatisfaction among nurses over the previous decade and a problem with availability.

Deficit hysteria

There was a brief flurry of activity. Ontario created a body to research issues, and many workplaces adopted self-scheduling to increase job satisfaction. Then, says Connors, "deficit hysteria" hit, the federal government cut cash transfers to the provinces and the provinces responded by laying off nurses. Meanwhile, other nurses who had left were forced to return to the workplace to support their family.

Overnight, the shortage changed into an apparent surplus, but it was a David Copperfield illusion. The shortage of nurses at the bedside and in clinical settings continued, and poor working conditions worsened as support staff were cut back. At the same time, wages were frozen or rolled back. Dissatisfaction escalated. Not surprisingly, enrolment in nursing schools began to decline.

According to CIHI, the nurse-to-population ratio went from 1:122 in 1992 to 1:131 in 1997. Ontario offers a perfect case study. The province lost nearly 10% of its nursing workforce — 8346 nurses — between 1992 and 1997. It was the sharpest decline in Canada, and resulted in a nurse-to-population ratio of 1:145 people in 1997, compared with 1:123 in 1992. Many nurses were forced to work casually; half of Canada's 227 000 registered nurses still work on a part-time or casual basis.

To make matters worse, demographics became an issue. The CNA's 1997 workforce analysis, completed by statistician Eva Ryten, indicated that the current nursing shortfall is predominantly due to aging baby-boom nurses and an aging population. The CNA disseminated Ryten's report and its dire predictions widely — it predicted a shortfall of 113 000 nurses by 2011 — but the results were disappointing. "There was lovely rhetoric 2 years ago, but [politicians] have done nothing," says Kushnir Pekrul.

Today, the average RN is 47 years old; most nurses retire at age 55. By 2011, more than 100 000 of Canada's 227 000 RNs will have retired or left the profession. Most of those remaining will be older than 37; in fact the modal age will be 48.

Few new graduates

On top of everything else, there are record-low numbers of new graduates — only 10% of practicing nurses are now under age 29. The CNA anticipates only 5200 new nurses will graduate from Canada's 70 university and college schools of nursing in 2000 — about half of what is needed to meet demand. In the 1970s, about 10 000 nurses graduated annually.

However, a decade of media coverage documenting poor working conditions and nursing surpluses has persuaded many potential nurses to pursue new careers. Wendy McBride, executive director of CAUSN, says the image of nurses striking because of poor working conditions is only making things worse.³ Many high school students continue to think there is a surplus of nurses and they think nursing is predominately a female profession that involves bathing people and emptying bed pans.

CAUSN wants to change those perceptions. Last year, deans and directors of nursing schools met to discuss and share successful recruitment strategies aimed at both secondary and elementary school students. Minority groups, aboriginals, men and "second entry students" — those who have completed a university degree — are also prime targets. Nursing hasn't managed to make the profession gender neutral, since males still account for only 4.4% of nurses. This means that almost 50% of potential applicants — males — are eliminated immediately. CAUSN is making nursing school information more accessible through its Web site (www.causn.org), and it hopes to produce a multilingual guide.

But McBride says the important thing will be a "national strategy to improve the image of nursing . . . and the quality of working life." For instance, she says many new graduates are forced to take on-call positions. "[This is] a lousy way to start your career. If they're investing 4 years, they deserve a long-term career and decent salary."

The CNA and NFNU share these concerns. Connors is also worried about the brain drain. Between 1994 and 1998, 6000 newly graduated Canadian nurses went to the US to work. "We have to be competitive. RNs will go where they get respect and recognition, remuneration and input into decision-making. We've had 2 contracts settled by back-to-work legislation imposing wages and conditions. It doesn't bode well for RNs." She says the solution lies at the bargaining table and in political will. "If the federal government has pride in the health system, they have to make the investment," she says.

Provincial and territorial governments are certainly putting some money back into hiring nurses, but "RNs aren't sitting around waiting for the phone to ring," says the CNA's Kushnir Pekrul. And simply hiring more nurses won't solve all the workplace problems. "There are lots of other challenges," says Kushnir Pekrul.

The most important thing, says Connors, is that frontline nurses be given a place at the decision-making table. "We want that true partnership, not the rhetoric. I've never seen RNs more determined to get what they want."

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1. Kralj B. Physician human resources in Ontario: a looming crisis. Ont Med Rev 1999;66(4):16-20.
2. OReilly M. Hunger strikers protest First Nations health care. CMAJ 1999;160(11):1547.
3. Sibbald B. RN = Really Neglected, angry nurses say. CMAJ 1999;160(10):1490-1.

© 1999 Canadian Medical Association