Kathleen MacMillan is a retired nurse and academic living in Prince Edward Island, and Angela Wignall is a policy nurse working and living in British Columbia.
Beyond the $331-billion spent annually on our publicly funded health care system, Canadians know very little about what value they are getting back from it. And since our provincial and federal governments do not collect enough data to this effect, Canadians know even less about what health outcomes their system of care achieves.
Canada is in dire need of modernizing its fragmented health system. We must improve the ways in which we measure accountability by gathering better data on the outcomes of care, the well-being of care providers, and the return on Canadians’ investment. Unfortunately, accountability is nowhere to be found, and if we do not fix this problem, health care worker recruitment efforts – particularly in the nursing profession – will fail.
During the pandemic, many health authorities and employers demanded more from health staff while implementing poorly co-ordinated, haphazard pandemic responses. This included often inappropriate reassignments of staff members across the health care system; punishing mandatory overtime measures; dramatic increases to workload assignments; restrictions on personal protective equipment; and the active sidelining of professional knowledge and evidence-informed practices (for example, many nurses continue to be over-assigned on their number of patients).
The result of these last three years of human resource mismanagement is that we now have a health care work force that has profoundly lost trust in its leadership, and workers who are living with moral and ethical distress, spiralling mental health care needs, and reasonable fears for personal safety. According to a federal survey in 2021, one in four nurses intended to leave their job, retire, or leave nursing entirely within the next three years. In March, the Canadian Federation of Nurses’ Unions reported that 44 per cent of early-career nurses regret their career choice, with 34 per cent intending to leave the profession entirely.
While COVID-19 has receded from many Canadians’ day-to-day lives, the dysfunctional, inhumane, and unsafe working conditions that existed prepandemic for health care staff (and worsened during COVID) have persisted. The situation has led to unprecedented vacancies and ever-increasing gaps in care for Canadians. Health teams have worked to fill in the gaps while health facilities pay premium costs for travel and agency workers. Governments have continued to forgive budget deficits related to these unsustainable practices, while prioritizing recruiting trips overseas and raiding other countries’ health care workforces. In the meantime, health employers are not held accountable for addressing their own long-standing human resource mismanagement, causing staff to leave or under-participate in the work force. Recruitment alone will not solve these underlying problems.
Both the provincial and federal levels of government insist they are not responsible for how health care programs and services are implemented. They say this is the responsibility of health facilities. Only in extreme circumstances, such as significant financial mismanagement, do provincial and territorial ministries of health intervene. They hold the line that it is not their job to “micromanage” health authorities and employers.
But where no one takes accountability, no one is responsible.
Government-appointed health facility boards rely on senior executives to assess and report on care delivery – but those executives often lack a nuanced understanding of how to lead effective health service implementation. Meanwhile, regulatory bodies are delegating professional practice support programs to already dysfunctional health employers.
Fed up with feeling unsupported and disposable, many nurses are now leaving traditional health employers for working arrangements that respect them. More nurses are choosing travel nursing, whereby they work for private agencies that subcontract them back to the public system at a higher cost. This career path offers higher pay but, more importantly, individual control over working conditions, work settings, assignments, and hours, and can offset spiralling cost-of-living expenses.
Nurses believe in the value of Canada’s publicly funded health care system but are no longer willing to be the silent backbone of it. For the system to survive, we must place accountability with employers to provide safe and appropriate working conditions for nurses and all members of the health care team. Those leading health systems must better understand the work of delivering health care. Employers must invest in their clinical governance infrastructure, led by those with clinical expertise. Governments must measure meaningful outcomes in auditing and reporting, while ensuring that executive leaders of health agencies have the expertise required to lead. Governments must also require safe, evidence-informed, nurse-to-patient ratios with mechanisms for supporting care teams in decision-making when those ratios are exceeded. British Columbia is leading the way by committing to minimum nurse-to-patient ratios, and the whole country is watching.
Canada cannot recruit its way out of accountability. We must provide better support to nurses, to keep them working in our publicly funded system.