The pandemic has made visible long-standing and systemic problems in the Canadian healthcare system. It is a publicly funded system, valued and paid for by taxpayers, and part of the Canadian cultural identity. It is also a system that seeks to contain costs and this has been a feature of health policy ever since healthcare budgets threatened to dwarf funding for other vital social and government departments that also contribute to the health of the population. Of less interest, perhaps, has been the need for substantial reform of the healthcare system to achieve better return on investment for Canadians.
The result for policy makers has been to focus on cost containment rather than real reform – although there have been isolated and uncoordinated efforts to shift the healthcare system from one which focuses on illness to one that addresses primary care, health promotion and illness prevention. The first (cost containment) is much easier to achieve than reform in the short term and governments always think in the short term. There is little public support for real reform and many stake holders and the system are resistant to change.
It is in this context that the nursing profession has found itself on the receiving end of the cost containment agenda. Nurses comprise the largest national healthcare workforce – 439, 975 regulated nurses in 2019 (RNs, LPNs and registered psychiatric nurses in western Canada)[1] plus a large number of technical, unregulated assistive personnel for whom we have inadequate statistics. Nursing personnel work continuously around the clock, all week, where most other healthcare providers deliver episodic care – mostly on a regular work week schedule. Outside of regular business hours, it is nurses who implement and monitor the plan of care for themselves and for other team members. Nursing care is therefore a core business line and costly, but most decision makers have no idea what nursing care actually consists of or what value proposition it holds for the system. Generally, human beings protect their self-concept by failing to imagine themselves as ever needing nursing care – they reject being that dependent.[2] In media representations, nurses may be either absent or static, with machines apparently providing the essential monitoring. Most nursing care is designed to detect potential problems and prevent them, so success means that the work is largely invisible. In our payment system, nurses who work in institutional care settings are included in the cost of a “bed” along with the housekeeping and other overhead costs. If these costs go up, there is more pressure on nursing costs. Further, the public may think that all that is needed is the “bed” and a ventilator; they do not always recognize that nursing care is the essential ingredient in achieving positive outcomes.
For the last two decades, nurses have been bearing a disproportionate burden for cost containment. Lower reimbursements and higher acuity of patients and residents (and increased competition in for-profit sectors like long term care and home care) have led many employers to reduce nurse staffing; maintain historical workloads; and alter staff mix as a means to balance budgets.[3] This is because nurse staffing costs (wages and benefits) make up a substantial proportion of organizational costs. This is not surprising since the reason people are admitted to any institution for care is because they need nursing care. Otherwise, they would be somewhere else recovering from their illness, injury or surgical procedure. Nursing cost containment has had negative impacts on the work environment. Nurses are typically not replaced for absences such as illness, leaving colleagues to pick up the slack and work short. Nurses can be required to care for too many patients and work overtime when staffing is not adequate. They may be threatened with being reported to their professional regulator if they refuse. This can mean working 4, 8 or even 12 hours more after a 12-hour shift. For a human service that demands intense emotional, physical and intellectual work, the risk of error due to fatigue, and serious consequences, is so great.
Patients are in acute care settings are often more seriously ill and less stable with shorter hospitalizations; care is more technologically complex; and patient assignments (ratio of patients per nurse) have not changed to reflect this reality. Electronic medical records have added data entry clerk work to the expectations and up to 25% of a nurses’ time may now be spent entering data – much of which is a benefit for administration and other providers and offers little support for designing and monitoring nursing care. The situation for long term care is comparable but with more unregulated care providers and fewer professional staff. Professional staff in long term care spend most of their time in administrative work and have less direct resident contact. Turnover everywhere is high as staff seek better work environments, resulting in less stability and team cohesion. The human resource situation was challenging already and then the pandemic made all of these well documented issues visible and more acute. Providing nursing care when isolation and protective measures are implemented takes more time and, when family members cannot be present, this adds to the overall burden of care. There was no surge capacity in the system and no plan despite warnings from nurse leaders that the situation was deteriorating and abundant evidence about what was needed to address nursing human resource issues prior to the emergency.
The system has never viewed nurses as core to the delivery system unless they are in short supply or engaging in job action. Nurses only have the attention of decision makers in times of crisis. Designated “essential workers,” in most provinces they are not legally able to engage in a strike. They also care about the people they serve. It has been said that nurses love nursing but they hate their jobs. The pandemic emergency has created extreme psychological, moral and ethical distress for nurses as they know that they are not able to provide the safe and competent care that people need in order to recover or to die peacefully and comfortably. They worry about making errors due to fatigue and unrealistic workloads. They are willing to work extremely hard at great personal sacrifice and this makes them vulnerable to exploitation.[4] They are, however, tired of being lauded for their compassion and dedication (but never for their knowledge and skill) while they struggle to find meaning in work that has become servitude in place of service.
Nurses are becoming a major contributor to the “she-session” that has emerged during the pandemic. Nursing is still a pink-collar ghetto – about 90% of nurses are women who have had to cope with their added work demands on top of the additional burden the pandemic placed on them as mothers, wives, and daughters. Many nurses have chosen to under-participate in the workforce as a means of preserving personal health and sanity, contributing to the shortage. Some scholars believe that the human resource shortage is more one of under-participation than of overall numbers. This indicates that the nation may not be short overall of qualified nurses as much as individual employers, who cannot, or will not, provide humane work environments.
Stresses on the system are leading to incivility and violence as people, who are angry about the pandemic and about the restrictions and limitations of the health care system, are aggressive and violent toward health care providers. Inadequate personal protective equipment placed nurses and their families at personal risk and treated them as a disposable asset. Why work in inhumane conditions that offer so little in the way of meaning or reward? This is what nurses mean when they say they are not valued.
Historically, perhaps the only time nurses are valued is during war. The origins of professional nursing date from Nightingale and the positive impact of nursing care during the Crimean War (1853-1856). Large numbers of professionally educated and experienced nurses volunteered for service during the Boer War/South African War (1899-1902) and during both World Wars. They contributed to saving lives and restoring soldiers to health so they could be re-deployed or re-join the workforce when demobilized. They were recognized as professionals and given commissioned officer ranks that reflected their leadership roles. They were a recognized return on investment for the country and there is a monument to the WWI Nursing Sisters in the Hall of Honour in the Parliament Buildings (supported by Prime Minister Mackenzie King, but paid for by nurses through subscription).
Once war was over, nurses were de-mobilized to a system that did not want their experience and leadership skills. Many military nursing veterans went back to university and sought roles in other sectors where they could exercise their competencies. The Canadian Medical Corps was reduced to a handful of nurses after each world war.[5] The government and the military viewed nurses as a temporary workforce, that could be augmented if required. That stance has not changed. Any demand for surge capacity in nursing services has always depended on existing nurses volunteering to do more, and often with less. There is no surge capacity that does not depend on overtime; unrealistic workloads; retired nurses coming back to work; or replacing nurses with less qualified personnel. In the 1918-19 influenza pandemic, that struck as World War I was winding down, a shortage of healthcare personnel contributed to mortality. Medicine had little to offer to treat those afflicted. “[…] good nursing care was the best predictor of outcome. Nurses came to the rescue by working long, hard and tirelessly. One important outcome of the epidemic was a general recognition of the visiting nurse service and all nursing as a valuable and essential community service.”[6] Once the emergency was over, however, this recognition faded.
It may be that the pandemic is the last nail in the coffin of nurse exploitation. A global event such as a pandemic can have a major social and economic impact. Following World War I, for example, there was an acute shortage of domestic workers (mostly women) in the western world. During the war, domestic servants realized that there were other jobs that paid more and offered independence and quality of life. A shortage of labour post war and the influenza pandemic offered work that had more social value and prestige and nursing was one of those appealing jobs. In place of dawn to dusk servitude, there was real opportunity to pursue leisure activities and to have a family life. Initially, the wealthy class that depended on domestic servitude tried vainly to restore the previous social order. In England, the government passed laws that made domestic servants ineligible for unemployment payments because they had the option of working in service but would not. The measures failed and “the servant problem” became a permanent one.
Nursing education and experience actually offers many opportunities for success in alternate careers. The knowledge and skills gained are a real asset to many fields of endeavour. Based on recent surveys, we know that many nurses plan to leave their practice settings once the pandemic is over and that some plan to leave nursing altogether. They will be part of the great exodus of women from traditional models of work.
There is still an opportunity to change this if the will is there to apply what we know, from 40 years of research, are measures that attract and keep nurses in their profession and their practices. It will require decision and policy makers to realize that things are not going back to “normal” once the pandemic ends. Nurses have been forever changed by this experience. It will take a recognition of the value of nurses and the value proposition that they offer to an efficient and effective healthcare system. It will take better utilization of their intellectual capital to address unmet needs for care that are wasted because of historic and outdated notions of women’s work and nursing work. It will take more than recruiting additional new nurses to a dysfunctional system that has reduced capacity to integrate and support them.
The health of the nation as we recover from this challenging time may depend on how we decide to support professional nursing services. Our ability to meet a similar challenge in the future will be significantly compromised if we fail.
In a recent podcast, David Frum, Canadian-American journalist and commentator, remarked that surge capacity is like an insurance policy. If you never use it, it is not wasted.[7] Canada is not prepared for any disaster. Experience ought to teach us that and support us to exercise good judgment for health human resource planning post pandemic.
[1] Canadian Nurses Association. Nursing Statistics. https://www.cna-aiic.ca/en/nursing/regulated-nursing-in-canada/nursing-statistics. Accessed Feb 28, 2022.
[2] ZR Wolf, “Nurses’ work: the sacred and the profane,” Holistic Nursing Practice 1, 1 (November 1986):29-35. doi: 10.1097/00004650-198601010-00007. PMID: 3641845.
[3] D Everhart, D Neff, M Al-Amin, J Nogle, R Weech-Maldonado, “The effects of nurse staffing on hospital financial performance: competitive versus less competitive markets,” Health Care Management 38, 2 (2013): 146-155. doi: 10.1097/HMR.0b013e318257292b
[4] SM Reverby, Ordered to Care: The Dilemma of American Nursing, 1850-1945 (New York: Cambridge University Press, 1987).
[5] Veterans Affairs Canada, “The Nursing Sisters of Canada.” https://www.veterans.gc.ca/eng/remembrance/those-who-served/women-veterans/nursing-sisters. Accessed Feb 28, 2022.
[6] KR Robinson, “The role of nursing in the influenza epidemic of 1918-1919,” Nursing Forum 25,2 (1990): 19-26. doi: 10.1111/j.1744-6198.1990.tb00845.x. PMID: 2235652. p. 19.
[7] David Frum, “The Hub” podcast. Host Sean Spear, March 4, 2022.