Simply put, Canadian hospitals are having a very hard time attracting and retaining new nurses because those already in the profession feel they are being treated very badly.
Nurses feel they bore the brunt of years of layoffs and reduced funding, where corners were cut at every turn. Workloads went up at the same time workforces went down.
A pronounced disconnect has developed between the level of care nurses are trained and want to give and the much lower level they can provide due to the shortage of resources. That alone is enough to demoralize nurses. But that is combined with the casualization of many positions, as well as a feeling nurses aren’t listened to when they voice concerns about the impact changes have on them and patients.
The problems became so ubiquitous, affecting so many people and for so long, that a sort of institutionalized disparity has set in. Many nurses already in the system are thinking about leaving the profession, and as word got out about the terrible work conditions, people who may at one time have considered going into nursing have been discouraged from doing so.
The Canadian Federation of Nurses Unions (CFNU) conservatively pegs the shortage at about 20,000 across the country and expects that number to reach as high as 113,000 by 2011.
Even in New Brunswick, where the per capita representation of nurses is among the highest in the country there is still a large shortage, said Debbie McGraw, president of the New Brunswick Nurses Union (NBNU).
There’s a lot of burnout and a very high rate of long-term disability. McGraw blames bad working conditions for the 300 nurses on LTD in the province out of total workforce of 5,700 which is one in every 19.
A study by the NBNU in the fall of 1999 found that 30 per cent of nurses under the age of 30 are thinking about leaving the profession and three-quarters of nurses over 50 would take advantage of an early retirement package.
While the health-care system shows some signs of revival with funding being at least partially restored — some of which presumably will be used to hire more nurses — the shortage is unlikely to get better any time soon. While there are signs of a slow trickle of expat nurses returning to Canada, unions and professional associations believe nurses will not return in any significant number until they are certain they will return to stable, full-time jobs with good work environments, reasonable workloads and appropriate remuneration. And there’s the rub. The health-care system is locked in a vicious cycle that will present a nearly Herculean challenge for hospital HR departments. Ultimately the work environment won’t get better until more nurses are hired but more nurses won’t enter the profession until the work environment gets better and work loads are reduced.
For hospitals it means that after years of downsizing, a new focus on recruitment and retention is taking hold.
Sign-on and referral bonuses are being offered to attract new hires, efforts to market the profession are underway, lobbying efforts have been launched to get the powers that be to increase the number of nursing graduates and recruiters are scouring the world.
In February, the Registered Nurses Association of Ontario will be part of a job fair in Texas designed to lure home nurses who left Canada at a time when jobs were still being eliminated.
But now that the context has changed and hospitals are desperate to hold onto nurses it’s still going to take a lot of extra effort and determination to overcome the skepticism of nurses who are wary of initiatives launched by management.
“Yes we are understaffed, there is no question about that but we are doing the best we can,” said Joan White, manager of recruitment and retention for the North York General Hospital in Toronto. She readily admits the workloads have gone through the roof in recent years as nurses were let go at the same time the number of patients in need of acute care went up.
Late last summer, a renewed effort to find nurses was launched. While some hospitals in Ontario have been offering sign-on bonuses to attract new nurses, North York General opted instead to offer referral bonuses. “It hasn’t been a huge success because there is a lack of registered nurses out there who can be referred.”
And while nurses complain about the casualization of labour in recent years, White said that in the Toronto area casual nurses can basically work as many hours as they want. And many must be choosing to do so because anytime a full-time position is posted at the hospital it often goes unfilled.
Hospitals like North York General are giving nurses more responsibility (another common demand of nurses) and a pilot project has been launched in New Brunswick to develop a more collaborative relationship between nurses and doctors. North York General is also looking at providing nurses with more educational support, and in the next round of collective bargaining, White would like to see more shift and weekend premiums introduced. Base salaries aren’t that different between Canada and the United States, but the premiums paid in the U.S. make moving there more attractive, said White.
While funding is going back into the health-care system to hire more nurses, provinces will likely have to do more than that to make nursing an attractive profession again. Aside from graduating more nurses, White also believes Ontario salaries capped at $58,000 aren’t enough to attract people who will have to go through four years of school in order to go into the profession.
“I’m not aware of any other profession that requires a four-year degree and has a limit on potential income,” said White.
One of the biggest concerns of nurses in the past few years is the sense that they have been essentially ignored. Although they are the people on the front line providing the service hospitals exist to provide, their contributions and suggestions were being largely ignored.
The nurses feel like they have been dismissed as subservient assistants to doctors and their insights and suggestions for how to handle the system ignored.
During the move to reduce employee head counts many of the positions that were eliminated were at the middle-management level. Nurses say that has meant they were and still are often being managed by people who aren’t nurses and therefore don’t appreciate what they are saying.
Most recently, and most tragically, the issue was brought to light in the report from an inquest into the deaths of 12 young children at the Winnipeg Health Sciences Centre in 1994 (see box page 15).
It’s a problem that North York General has already moved to address. “They’re very much listened to here,” said White. The chief nursing officer doesn’t wait for nurses to knock on her door with complaints, but goes from unit to unit checking on working conditions and holds open forums for nurses to air their complaints but, she added it’s not unusual for as few as 10 nurses to show up at forums.
Stress workshops are also offered to help nurses cope but attendance is similarly low. “Those issues that are brought forward we do try to work on,” she said. Last spring they began to hear about a lack of staff on night shifts. When everything was stable it was fine but when extra staff was needed during an emergency it wasn’t available. So the hospital created a new position of administrative co-ordinator who is onsite after-hours and who can respond to shortages by reassigning people from other places in the hospital.
“There are definitely some workplaces that have made substantial efforts to make the work environment better,” said Kathleen Connors, president of the CFNU. But she also feels that hospitals will not be able to break that vicious cycle and attract new nurses until they get the work environment right.
It has to start with the little things, she said, by treating nurses with the respect and recognition they deserve as invaluable contributors of knowledge and skills to the health system. “It can be something as simple as saying ‘thank-you,’” she said. Acknowledge what they put up with and tell them they did a great job after a difficult shift, or order pizza on those busy days when nurses might not get to take their meal break — small things like that go a long way to recognize what nurses are doing, she said.
With fewer young nurses entering the profession in recent years, the average age has naturally gone up. In New Brunswick, 60 per cent of nurses are 46 years or older. And, as the New Brunswick research has shown, a large number of those are looking to retire early.
As a way to hold onto those workers, the NBNU is proposing a phased retirement program where nurses 55 or older can work two or three days a week and begin to draw on their pensions while maintaining contributions. They essentially receive 92 or 93 per cent of their full-time salaries while still working less and not hurting their pensions at the other end.
In the end, it may come down to circumstances beyond the control of hospitals and nurses alike, said Kelly Lamrock, director of research and communication for the New Brunswick Health Care Association. The demand on the system is going up at the same time funding has become scarcer and things can’t possibly be expected to continue like that, he said. The only way to attract more nurses is to improve their work environments by a fundamental reorganization of the health-care system.
Not until more resources are directed toward pharmacare, more primary care and home care will workloads and remuneration improve, he said.
“Nurse shortages and overworking nurses is the price you pay for a status quo system that tries to be all things to all people.”
SIDEBAR
Inquest shows systemic problems in nurse-management relations
The work conditions that nurses have been complaining about were highlighted in a report that was released late last year from an inquest into the deaths of 12 young children in 1994 at Winnipeg Health Sciences Centre.
The report concluded that the pediatric cardiac surgery program at the Health Sciences Centre provided an inadequate level of service and while some of the problems were related to the abilities and conduct of specific individuals, there were other problems that were largely systemic in nature. “These systemic problems related to the structure of the HSC, in particular to hospital policies and procedures governing staffing, leadership, teamwork, communication, decision-making and quality assurance,” the report stated.
Throughout 1994 concerns were being expressed by nurses to people in authority at the hospital but were largely ignored. The inquest concluded that because nurses were considered to occupy a subservient position concerns they raised were not always treated appropriately, in fact they were often dismissed as stemming from their “inability to deal emotionally with the deaths of some of the patients.”
With that problem brought to light, associate chief judge Murray Sinclair made the following recommendation: “Also of particular importance is that nurses not be treated by doctors and hospital administrators as undertrained subordinates, whose concerns can be readily dismissed as emotional responses to tragic outcomes.”
The most significant recommendation was for introducing whistleblower legislation to protect nurses, said Kathleen Connor president of the Canadian Federation of Nurses Unions. Nurses should feel free to express concerns about how the system is being run but right now nurses feel intimidated by administrators and doctors, she said.
Nurses feel they bore the brunt of years of layoffs and reduced funding, where corners were cut at every turn. Workloads went up at the same time workforces went down.
A pronounced disconnect has developed between the level of care nurses are trained and want to give and the much lower level they can provide due to the shortage of resources. That alone is enough to demoralize nurses. But that is combined with the casualization of many positions, as well as a feeling nurses aren’t listened to when they voice concerns about the impact changes have on them and patients.
The problems became so ubiquitous, affecting so many people and for so long, that a sort of institutionalized disparity has set in. Many nurses already in the system are thinking about leaving the profession, and as word got out about the terrible work conditions, people who may at one time have considered going into nursing have been discouraged from doing so.
The Canadian Federation of Nurses Unions (CFNU) conservatively pegs the shortage at about 20,000 across the country and expects that number to reach as high as 113,000 by 2011.
Even in New Brunswick, where the per capita representation of nurses is among the highest in the country there is still a large shortage, said Debbie McGraw, president of the New Brunswick Nurses Union (NBNU).
There’s a lot of burnout and a very high rate of long-term disability. McGraw blames bad working conditions for the 300 nurses on LTD in the province out of total workforce of 5,700 which is one in every 19.
A study by the NBNU in the fall of 1999 found that 30 per cent of nurses under the age of 30 are thinking about leaving the profession and three-quarters of nurses over 50 would take advantage of an early retirement package.
While the health-care system shows some signs of revival with funding being at least partially restored — some of which presumably will be used to hire more nurses — the shortage is unlikely to get better any time soon. While there are signs of a slow trickle of expat nurses returning to Canada, unions and professional associations believe nurses will not return in any significant number until they are certain they will return to stable, full-time jobs with good work environments, reasonable workloads and appropriate remuneration. And there’s the rub. The health-care system is locked in a vicious cycle that will present a nearly Herculean challenge for hospital HR departments. Ultimately the work environment won’t get better until more nurses are hired but more nurses won’t enter the profession until the work environment gets better and work loads are reduced.
For hospitals it means that after years of downsizing, a new focus on recruitment and retention is taking hold.
Sign-on and referral bonuses are being offered to attract new hires, efforts to market the profession are underway, lobbying efforts have been launched to get the powers that be to increase the number of nursing graduates and recruiters are scouring the world.
In February, the Registered Nurses Association of Ontario will be part of a job fair in Texas designed to lure home nurses who left Canada at a time when jobs were still being eliminated.
But now that the context has changed and hospitals are desperate to hold onto nurses it’s still going to take a lot of extra effort and determination to overcome the skepticism of nurses who are wary of initiatives launched by management.
“Yes we are understaffed, there is no question about that but we are doing the best we can,” said Joan White, manager of recruitment and retention for the North York General Hospital in Toronto. She readily admits the workloads have gone through the roof in recent years as nurses were let go at the same time the number of patients in need of acute care went up.
Late last summer, a renewed effort to find nurses was launched. While some hospitals in Ontario have been offering sign-on bonuses to attract new nurses, North York General opted instead to offer referral bonuses. “It hasn’t been a huge success because there is a lack of registered nurses out there who can be referred.”
And while nurses complain about the casualization of labour in recent years, White said that in the Toronto area casual nurses can basically work as many hours as they want. And many must be choosing to do so because anytime a full-time position is posted at the hospital it often goes unfilled.
Hospitals like North York General are giving nurses more responsibility (another common demand of nurses) and a pilot project has been launched in New Brunswick to develop a more collaborative relationship between nurses and doctors. North York General is also looking at providing nurses with more educational support, and in the next round of collective bargaining, White would like to see more shift and weekend premiums introduced. Base salaries aren’t that different between Canada and the United States, but the premiums paid in the U.S. make moving there more attractive, said White.
While funding is going back into the health-care system to hire more nurses, provinces will likely have to do more than that to make nursing an attractive profession again. Aside from graduating more nurses, White also believes Ontario salaries capped at $58,000 aren’t enough to attract people who will have to go through four years of school in order to go into the profession.
“I’m not aware of any other profession that requires a four-year degree and has a limit on potential income,” said White.
One of the biggest concerns of nurses in the past few years is the sense that they have been essentially ignored. Although they are the people on the front line providing the service hospitals exist to provide, their contributions and suggestions were being largely ignored.
The nurses feel like they have been dismissed as subservient assistants to doctors and their insights and suggestions for how to handle the system ignored.
During the move to reduce employee head counts many of the positions that were eliminated were at the middle-management level. Nurses say that has meant they were and still are often being managed by people who aren’t nurses and therefore don’t appreciate what they are saying.
Most recently, and most tragically, the issue was brought to light in the report from an inquest into the deaths of 12 young children at the Winnipeg Health Sciences Centre in 1994 (see box page 15).
It’s a problem that North York General has already moved to address. “They’re very much listened to here,” said White. The chief nursing officer doesn’t wait for nurses to knock on her door with complaints, but goes from unit to unit checking on working conditions and holds open forums for nurses to air their complaints but, she added it’s not unusual for as few as 10 nurses to show up at forums.
Stress workshops are also offered to help nurses cope but attendance is similarly low. “Those issues that are brought forward we do try to work on,” she said. Last spring they began to hear about a lack of staff on night shifts. When everything was stable it was fine but when extra staff was needed during an emergency it wasn’t available. So the hospital created a new position of administrative co-ordinator who is onsite after-hours and who can respond to shortages by reassigning people from other places in the hospital.
“There are definitely some workplaces that have made substantial efforts to make the work environment better,” said Kathleen Connors, president of the CFNU. But she also feels that hospitals will not be able to break that vicious cycle and attract new nurses until they get the work environment right.
It has to start with the little things, she said, by treating nurses with the respect and recognition they deserve as invaluable contributors of knowledge and skills to the health system. “It can be something as simple as saying ‘thank-you,’” she said. Acknowledge what they put up with and tell them they did a great job after a difficult shift, or order pizza on those busy days when nurses might not get to take their meal break — small things like that go a long way to recognize what nurses are doing, she said.
With fewer young nurses entering the profession in recent years, the average age has naturally gone up. In New Brunswick, 60 per cent of nurses are 46 years or older. And, as the New Brunswick research has shown, a large number of those are looking to retire early.
As a way to hold onto those workers, the NBNU is proposing a phased retirement program where nurses 55 or older can work two or three days a week and begin to draw on their pensions while maintaining contributions. They essentially receive 92 or 93 per cent of their full-time salaries while still working less and not hurting their pensions at the other end.
In the end, it may come down to circumstances beyond the control of hospitals and nurses alike, said Kelly Lamrock, director of research and communication for the New Brunswick Health Care Association. The demand on the system is going up at the same time funding has become scarcer and things can’t possibly be expected to continue like that, he said. The only way to attract more nurses is to improve their work environments by a fundamental reorganization of the health-care system.
Not until more resources are directed toward pharmacare, more primary care and home care will workloads and remuneration improve, he said.
“Nurse shortages and overworking nurses is the price you pay for a status quo system that tries to be all things to all people.”
SIDEBAR
Inquest shows systemic problems in nurse-management relations
The work conditions that nurses have been complaining about were highlighted in a report that was released late last year from an inquest into the deaths of 12 young children in 1994 at Winnipeg Health Sciences Centre.
The report concluded that the pediatric cardiac surgery program at the Health Sciences Centre provided an inadequate level of service and while some of the problems were related to the abilities and conduct of specific individuals, there were other problems that were largely systemic in nature. “These systemic problems related to the structure of the HSC, in particular to hospital policies and procedures governing staffing, leadership, teamwork, communication, decision-making and quality assurance,” the report stated.
Throughout 1994 concerns were being expressed by nurses to people in authority at the hospital but were largely ignored. The inquest concluded that because nurses were considered to occupy a subservient position concerns they raised were not always treated appropriately, in fact they were often dismissed as stemming from their “inability to deal emotionally with the deaths of some of the patients.”
With that problem brought to light, associate chief judge Murray Sinclair made the following recommendation: “Also of particular importance is that nurses not be treated by doctors and hospital administrators as undertrained subordinates, whose concerns can be readily dismissed as emotional responses to tragic outcomes.”
The most significant recommendation was for introducing whistleblower legislation to protect nurses, said Kathleen Connor president of the Canadian Federation of Nurses Unions. Nurses should feel free to express concerns about how the system is being run but right now nurses feel intimidated by administrators and doctors, she said.
