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February 8, 2024

To: Canadians concerned about healthcare

From: Tingting Zhang

Date: February 8, 2024

Re: Canada’s Nursing Shortage: It’s Time to Focus on Retention

Canada’s nursing shortage, exposed by the pandemic, remains dire four years later.

It was among the most commonly cited reasons for last summer’s rash of emergency room closures across Canada and longer wait times for both urgent and elective surgeries. The quality of patient care is also eroding: Six in 10 nurses in a 2023 Canadian Federation of Nurses Unions survey said it had deteriorated in the last year.

The nursing workforce is expanding, but not fast enough to meet demand. In 2022, the number of registered nurses licensed to practice increased by 2,273, up 1.1 percent, slower than the 2.5 percent in 2021. Meanwhile, the unemployment rate for nursing occupations is stuck at less than 1 percent, with only about 1,800 unemployed nursing and allied health professionals in December 2023. This as there were more than 30,300 job openings for RNs and registered psychiatric nurses in the third quarter of 2023, according to the latest National Job Vacancy and Wage Survey, with more than half vacant for 120 days or more.

Nursing shortages have serious outcomes: High patient-to-staff ratios, overwhelming workloads, deteriorating standards of care, unsafe practices, and increased burnout.

Burnout describes emotional, mental, and physical exhaustion resulting from chronic workplace stress, and is now a World Health Organization diagnosis. Nurses reported feeling more stress at work during the pandemic, with half saying their post-pandemic mental health is worse. Left unaddressed, burnout can have significant impacts on nurses and the patients they take care of: Reduced job performance, poor quality of life, poor quality of care, poor patient safety, medication errors, intention to leave the field, to name a few.
Besides stress, 89 percent of surveyed nurses reported some form of violence –  verbal, physical, or sexual harassment – at work in 2023. In addition, three-quarters said their workplace is regularly overcapacity. Evidence also shows that high patient-to-nurse ratios increase burnout and job dissatisfaction.

These pressures, in turn, contribute to lower retention of nursing, further contributing to shortages. Four in 10 nurses surveyed intended to retire, leave their jobs, or leave the nursing profession entirely in 2023 and 34 percent of early career nurses intended to leave the profession.

Some are leaving for better compensation and working conditions in the US. Since 2018, the number of Canadian nurses approved to work in the US has more than doubled. According to a recent report, American border states issued 8,909 licences to Canadian nurses in 2023. Many live in Canada and commute to the US for work; for example, 63 percent of Ontario nurses with Michigan licences were commuting. The actual numbers might be higher since the report did not include healthcare workers beyond the border states.

Meanwhile, Ontario will need an additional 33,000 nurses and PSWs by 2028 to meet its program expansion commitments, according to a recent Financial Accountability Office analysis. The much-touted push for faster certification for foreign-trained nurses is unlikely to be sufficient to meet that need. Canada accepted 1,335 registered nurses as economic principal immigrants in 2022, which represented 64 percent of the net increase in RN supply that year.

This means retention is essential, especially for experienced mid and late-career nurses. Early-career nurses rely on mentorship and learn from senior nurses while onboarding. Provincial governments and hospitals should consider flexible return-to-practice programs (ex. shorter shifts and less evening shifts during a week) to attract retired nurses back to the system. They also need to increase funding for evidence-informed and targeted retention strategies such as opportunities for continuing education, promotion of positive collegial relationships, stress-reduction programs, and increased financial compensation.

They should also consider setting minimum nurse-patient ratios. International evidence has shown that setting minimum nurse-patient ratios results in shorter wait time at emergency department and reductions in mortality, readmissions, and length of stay. These avoided costs in turn can fund more nurses. B.C. established  nurse-patient ratios last summer, the first province to do so. As the effects for patient outcomes and the retention rate of nurses become apparent, other provinces can consider similar strategies.

Canada needs a two-pronged approach to deal with the nursing shortage: Both attraction and retention are crucial. It cannot afford to lose nurses to burnout, and opportunities south of the border when the growth in the nursing supply is insufficient to meet current, much less future, demand.

Tingting Zhang is a Junior Policy Analyst at the C.D. Howe Institute.

To send a comment or leave feedback, email us at blog@cdhowe.org.

The views expressed here are those of the author. The C.D. Howe Institute does not take corporate positions on policy matters.