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May 10, 2022

Half of our nurses are thinking of quitting: how can we keep them healthy, happy and helping patients?

National Nursing Week

By Jane Coutts for the Canadian Federation of Nurses Unions.

What are professionalism, compassion, dedication and personal sacrifice worth?

If you’re a registered nurse in Ontario, $5,000. That’s the amount the province’s government has promised nurses if they don’t quit their jobs between March 31 and September 1, 2022.

Certainly suggests a lot of nurses are at risk of bailing from their jobs before summer’s over, doesn’t it? There’s a reason for that: Statistics Canada data show job vacancies for registered nurses and registered psychiatric nurses soared during the first 21 months of the COVID-19 pandemic, from 10,575 in the fourth quarter of 2019 to 22,955 at December 31, 2021 – an increase of 117 per cent.

Job vacancies for licensed practical nurses also soared over those two years, growing by 190 per cent from 3,710 to 10,765, and nurse co-ordinator/supervisor vacancies increased from 420 to 595. Overall, there was a 133-per-cent increase in nursing vacancies.

At those kinds of numbers, you know it’s not just a problem for Ontario. In 2021, Quebec also announced a program to keep people on the job but went further, offering nurses who had already quit or retired cash to come back. The size of the bonuses depends on which part of Quebec you work in – nurses in central or populous regions are entitled to $5,000 when the program starts and another $10,000 if they work full time for 12 months; their colleagues in more remote areas get $8,000 up front and then $10,000 for that year of full-time work.

In January 2022, when Omicron was surging, New Brunswick’s offer for luring retired critical care nurses back to work included a one-time payment of $1,000, an additional $1,000 premium per 37.5 hours worked, pro-rated plus expenses and even child care expenses, if the nurse relocated. Similarly, this year Manitoba offered bonuses for switching to intensive care work, along with the $6-an-hour increase to nurses already working in intensive care.

Trouble is, none of those schemes or the others across the country are going to solve nursing’s problems, according to Linda Silas, president of the Canadian Federation of Nurses Unions (CFNU).

“Nobody is against getting money,” Silas said in an interview, “but if it’s just money to shut me up, it’s not offering a solution. What nurses are asking for is high-quality worklife and respect for their job. They want to feel good at the end of their shift, and it’s not a bonus of $5,000 that’s going to make them feel better.”

The failure of what some are calling bribes to keep nurses on the job won’t go unnoticed by patients, Silas says.

“[Patients] realize, when they’re in distress, when they’re ringing a bell and nobody comes. When they’re in a hallway at their most vulnerable with a little thin curtain protecting them from the general public, and still no one comes. You know, they have a little school bell by their side to ring, and still nobody comes.”

Nurses don’t want things this way: the theme of this year’s National Nursing Week (May 9‑15) is “We answer the call.” But it’s increasingly hard for them to do so with job vacancies surging and the failure of governments across Canada to accept that short-term solutions like bonuses cannot solve staffing problems that have been building for years.

What’s brought us to this point? Nursing researchers say it’s only partly due to the pandemic – that COVID‑19 exposed and exacerbated problems that have been around for decades.

A CFNU study done before the COVID‑19 pandemic began, Mental Disorder Symptoms Among Nurses in Canada, used the same methods as a 2016 study looking at the extent of post-traumatic stress disorder (PTSD) among public safety personnel in Canada (including border services agents, correctional workers, firefighters, paramedics and police). Prepared by Andrea Stelnicki, Nicholas Carleton and Carol Reichert, the CFNU study shows that the high-stress situations nurses regularly work in can be traumatic.

“These types of stressors can have a cumulative effect, wearing down nurses’ abilities to cope,” the authors wrote. “Exposure to trauma can result in mental disorder symptoms consistent with PTSD, depression, generalized anxiety, panic disorder, and alcohol use disorder. Exposure to trauma may also contribute to the risk of suicide.” Information was collected through an online survey, which 7,358 regulated nurses filled out.

The three most frequent trauma exposures nurses reported were being physically assaulted (93 per cent), a death after extraordinary efforts were made to save the patient’s life (89 per cent), and the death of someone who reminded the nurse of a friend or family member (86 per cent). Twenty-three per cent of nurses screened positive for PTSD, 36 per cent for major depressive disorder, 26 per cent for generalized anxiety disorder, and 20 per cent for panic disorder. These rates of mental disorder symptoms were similar to those for public safety personnel, and much higher than for the general public.

The study also found that over their lifetimes, one third of nurses had thought of suicide, with 17 per cent planning for it and eight per cent attempting it.

With that level of trauma even before COVID‑19, many nurses were in too precarious a position to withstand the tidal wave of catastrophe it would bring to the world, their workplaces and even their homes. Another national study done for the CFNU surveyed 4,467 practicing nurses over four weeks starting in late November 2021. In it, two thirds of nurses reported they had worked at least three of their last five shifts without full health care staff, and seven out of 10 reported their workplaces or units were regularly over capacity. Two thirds felt the quality of health care had deteriorated in the previous year, and a quarter of nurses surveyed gave patient safety in their workplaces a failing grade.

Those circumstances add up to stress that has clearly taken a toll: two out of three nurses surveyed said their mental health is worse than it was one year ago, and 94 per cent were experiencing symptoms of burnout, with 45 per cent reporting severe burnout, up from 29% just prior to the pandemic.

For many participants in the survey, leaving their jobs had become the only option: more than half – 53 per cent – were considering leaving their position within the next year. The total comprised 27 per cent who would look for a different nursing position, 19 per cent who wanted to leave the profession, and seven per cent thinking of retiring.

Thoughts of leaving were more common in early-career nurses (59 per cent vs. 56 per cent among mid‑career nurses and just 20 per cent of late-term nurses). Licensed practical nurses in the survey were more likely, at 52 per cent, to be considering quitting than registered nurses and registered practical nurses.

The top reasons nurses gave for considering leaving their workplaces were:

  • Burned out or tired, 57 per cent;
  • Capacity issues and not being able to provide adequate care, 45 per cent;
  • Insufficient staffing levels, 43 per cent;
  • Lack of administrative support or poor management, 36 per cent wanted to escape;
  • Unpredictable staffing and scheduling/redeployment, 21 per cent; and
  • Inadequate communication/recognition, 21 per cent.

COVID‑19 brought particular pressure to health care workplaces, said Linda McGillis Hall, a professor of nursing and researcher at the University of Toronto. Health care has always been subject to surges that place huge demands on nurses and the system overall, but surges have always ended.

“This time there’s been no relief, there’s always been a new variant, each one maybe not worse in terms of being more deadly, but more challenging in terms of what it did to nurses’ work and the work environment.”

“The biggest issue to me was nurses had no relief…they lost the ability to take vacation time as planned, where they used to have to sometimes do an overtime shift or stay late, now it became incessant.”

Maura MacPhee, a professor at the University of British Columbia, whose nursing research includes leadership, teamwork and workload, believes nurses are leaving the profession because they must rush to care for too many people at once and feel they are not able to give patients the care and help they entered nursing to provide. Over time, she said, nurses become emotionally exhausted and burned out. In turn, patients have also become distressed, and anger builds – sometimes to the point of violence. Nurses, unable or unwilling to take the stress, leave.

Sheri Price, a researcher and a professor of nursing at Dalhousie School of Nursing, agrees – she thinks nurses feel they have to choose between their patients’ health and well-being and their own.

“Every nurse I’ve ever interviewed has told me they entered the profession because they wanted to use their knowledge and skills to provide care and make a difference in patients’ lives,” she said in an interview.

“When that doesn’t happen, you’re leaving the workplace not feeling good about the quality of care. That really matters to nurses. Nurses want there to be quality of care, but not – and this is what I’m really concerned about – not to the detriment of themselves.”

There has been a lot of talk of the importance of building resilience in health care workers so they can handle the many difficult situations they work in, but expecting nurses to get tougher is the wrong approach, Price says.

“We’re talking years of chronic staffing shortages, years of unmanageable workloads, we’re talking years of demand and expectation that have rendered nurses exhausted – all of this pre-pandemic – and then you’re forced into presenteeism, you’re not taking care of yourself, you’re forced to go to work, and it leads to a breaking point.”

Like many people, nurses often struggle to find mental health support, and burnout – and their depression and anxiety – can be worsened by the guilt of being the one who couldn’t keep going. The stigma attached to mental illness is as much of a problem in health care as in any other part of society, Price adds. “Nurses tell us that if they had a physical injury and were off sick, their colleagues would check in on them,” she said. “But when they have a mental health leave of absence…no one asks them how they’re doing.”

It’s not just nurses who suffer in these scenarios, of course. Nurses who are stressed, overworked and burned out cannot provide the best patient care. UBC’s Maura MacPhee described a list that’s used to measure what essential care has been missed because of heavy workloads, developed by a British nursing researcher Jane Ball.

Ball’s research shows when nurses are overworked, they regularly leave essential work undone. That causes them emotional and moral distress. “Nurses go home distressed because they’ve not provided proper care for their patients,” MacPhee said. “The number one thing left undone on the list is providing comfort and therapeutic care. Another essential thing left undone is surveillance, where nurses are monitoring patients’ physical and emotional status. When nurses are rushed, they don’t often catch slow or subtle changes in patients – and patients can deteriorate and even die without proper nurse surveillance.”

When missed care chronically accumulates, nurses can’t take it anymore, and they leave, MacPhee says – resulting in other nurses facing heavier workloads and more patients at risk.

Those risks and the consequences of inadequate nursing have been well documented. A CFNU paper “Nurse Staffing: More for Less, Myth vs. Reality” notes that in acute care, lower levels of nurse staffing (and higher proportions of less-skilled care providers on staff) lead to increased mortality rates, more falls and infections, and longer hospital stays for patients. The numbers are remarkable: one U.S. study of more than 18 million hospital discharges found hospitals that increased the number of registered nurses and licensed practical nurses on staff had fewer incidents of patient harm and shorter stays by patients but did not increase costs.

So increasing nursing care is good for nurses’ mental and emotional health and patients’ comfort and health. It reduces distress in both groups.

How do we get there?

Price says it’s time to stop searching for the perfect solution and bring in a combination of responses to deal with a multifaceted problem.

“There’s not going to be one band-aid. We’re going to have to address staffing, workload, [nurse-to-patient] ratios, we’re going to have to address the work environment, how we work together to support one another, we’re going to have to address mental health supports and ensure those are present.”

Mélanie Lavoie-Tremblay, an associate professor of nursing at Université de Montréal, researches ways to keep nurses from leaving the profession. She too sees a range of actions, big and small, that will help end the nursing shortage. Nurse’s mental health needs to be supported, but that could start with simply ensuring nurses have a chance to talk about what they went through after a difficult day.

Beyond that, every nurse should be given more opportunities to show leadership on the job, which could start with letting them organize how they do their work on any given shift. That should proceed to having nurses bring their knowledge and experience to the table when decisions are made that will shape care. “Nurses know best what they need to do,” she said in an interview. “The solutions we have are not new,” she added. “They have been around for the last 20 years. It’s the basics we’re asking for, the basics.”

McGillis Hall thinks that should start with planning to avoid another disaster such as COVID brought to the health care system. She and several colleagues (including Sheri Price) have received Canadian Institutes of Health Research funding for a national study to look for ways to keep nurses on the job and reduce burnout, addressing the psycho-socio factors that have caused so much burnout among nurses. Their approach will be to ask nurses themselves what would help.

“We’re going to be asking nurses: what do we need to do to keep you?” McGillis Hall said. “What’s going on in your work environment as we come out of COVID, what do we need to do differently, and what will it take to get you to want to stay in the profession? For you, and for the next wave of students who emerge, what is needed? It’s really time that we heard nurses and listened to them.”

Improving health care teams, so nurses don’t feel they have to do everything themselves was a common theme in interviews. “Working together and recognizing opportunities to support one another is critically important,” said Price.

MacPhee said more effort needs to go into training different types of health professionals to work as teams, starting early with interprofessional undergraduate education. “This would be a benefit for all disciplines – to learn more about who does what and how a team can best support each other and patients and their families.”

Price believes there is a wealth of evidence available to overcome the crisis in Canadian nursing. Canada’s steady progress to a crisis-level shortage of nurses (even without the pandemic) was predicted more than 20 years ago and has been faithfully tracked and studied since. What’s needed now, she said, is to get health care policy makers and governments to act on the research evidence available.

Silas thinks the heart of the problem lies with governments that are well aware of the need for more nurses and for profound changes for all health care workers – but choose not to act on it. They know there’s evidence available showing how health care education should be reimagined, so teamwork is established from the beginning as the key to delivering high-quality care. They know work should be structured so everyone can use their knowledge and expertise most effectively; they certainly have no excuse not to see how imperative it is to support nurses in practical ways on the job, and with mental health programs to keep them well when they’re away from it.

“We will never fix this human resources crisis without them first admitting we have a problem,” Silas said. “Governments have been told over and over, and shown the research and asked for funding to put best practices in place. National Nursing Week is always about great work nurses do; this year let’s focus on a vision of the great work they could be doing.”

“We need to paint a picture of the future, because if we paint a picture of today, it would be a bleak one,” Silas said.