The nursing crisis in B.C.: How we got into this mess

By Patricia Bailey, Vancouver Sun, 19 July 2001

OUTSTANDING ISSUES: What each side wants

When B.C. nurses refused to work overtime for eight weeks this spring, 6,000 surgeries had to be cancelled. The reason is a critical shortage of nurses in the province—but it's not the first time that has happened. A similar situation occurred in the summer of 1989, when it was estimated nearly 600 more nurses were needed. Twelve years later, the province needs 1,000 more nurses. Can we find ways to solve the problem? Reporter Patricia Bailey examines the complex circumstances that led to the current crisis and turns to the experts for some solutions.

The shortage of nurses currently plaguing B.C.'s health-care system wasn't supposed to happen.

From 1993 to 1997, the province closed hospital beds and eliminated nearly 1,600 full-time nursing positions. More than 1,000 of the province's nurses took early retirement.

At the time, it was believed that medical advances and the move from hospital to community-based care would reduce the length of hospital stays and the need for acute-care nurses.

Instead, technological and medical breakthroughs have made health care more complex and expensive to deliver. At the same time, demands on the system are increasing.

B.C.'s population has grown to more than four million from 3.2 million a decade ago.

While fewer people are staying in hospitals overnight, the number of people needing surgery has increased.

Between 1992 and 1998, the number of surgical day patients increased by 19 per cent, according to Hans Krueger, a consultant and researcher studying the impact of health reform on patients.

They thought people wouldn't need to stay in hospitals as long and so they wouldn't need as much staff.

But the level of sickness wasn't reduced. There are just fewer beds. And the competition for those beds has increased, said Mary Ellen Purkis, head of the university of Victoria School of Nursing.

While the number of day surgeries has increased, hospitals have become places where the very sick stay for extended periods, putting increased demands on nursing staff. New drugs and technological advances have added to the strain, because patients who might have died 20 years ago now survive and require extensive care.

Health care reform didn't eliminate just nursing jobs. About 3,200 full-time jobs for such health care workers as lab technicians, unit clerks, porters and licensed practical nurses also disappeared.


Consequently, today's registered nurses are multi-taskers. Their administrative load has increased, as has the amount of time they spend on functions for which they are overqualified, such as carrying food trays and cleaning rooms, according to an ongoing international study of nurses, including those in B.C., that is being carried out at the University of Pennsylvania.

You're talking about a situation where a highly paid professional is sitting making phone calls to find someone to work, or passing a food tray, said Michael Villeneuve, senior policy adviser at the office of nursing policy with Health Canada.

Gary Moser, president of the Health Employers Association, which represents B.C. hospitals, agrees the definition of nursing duties needs to change. Some responsibilities can be delegated to other health-care workers, such as care-aides, he said.

The union representing health-care workers agrees.

We're going to look at non-direct patient care duties that RNs are performing and see what other members of the health care team could be performing them, said Mike Old, a spokesman for the Hospital Employees' Union, which represents licensed practical nurses, care-aides, cleaners and housekeepers.

The employers' association also wants to hire more LPNs, who can provide care to more stable patients and assist the RNs. The LPNs' professional association, the Canadian Practical Nurses Association, is also lobbying for an expanded nursing role for its members. The Hospital Employees' Union also believes LPNs are under-utilized, and should be used to help with such tasks as administering medication and assessing patients.

But there is no consensus. The University of Pennsylvania's research demonstrates that patients tend to fare better in facilities where nursing duties are performed mainly by RNs, Lorraine Gillespie, president of the Registered Nurses Association of B.C. said.

An RN can respond faster because she has a larger scope of practice, she said.

Demographics may play a part in nurses feeling that they are overtaxed. The average age of a Canadian nurse is 43. Nursing researchers state repeatedly that if extra help for lifting, running to the lab, fetching supplies, stocking linen closets or other non-nursing work was available, it would allow nurses to concentrate on nursing and ease their fatigue.

Extra support is also necessary because patients who stay in hospitals are increasingly complicated to treat, according to Health Canada's Villeneuve.


While full-time nursing positions were being eliminated in the mid-90s, part-time positions were being added. Part-timers were cheaper for the employers and gave nurses—a predominantly female workforce—more flexibility to balance work and family life.

Just how significant the shift to part-time work has been is a matter of dispute between the nurses and the employers. Whatever the increase, roughly half of B.C.'s nurses are not full-time—a situation mirrored in the rest of Canada.

Part-time and casual workers can be beneficial to the system, Moser says.

You get lots more flexibility in the way in which you use nurses ... particularly when you have less money to operate with.

But Lorraine Gillespie, president of the Registered Nurses Association of B.C., says part-time and casual nurses are less likely to bond with their patients.

This can have a negative effect on patient care, she says.

The employers' budgetary concerns aren't the only reason for the number of part-timers, Moser says.

Because of child rearing and childbearing there has been an appetite on the part of nurses to take more control about when they work.

In 1998, the NDP government allocated $50 million to create 1,000 full-time equivalent nursing positions.

Only half that many were created; the rest of the money went to pay for overtime and relief nurses, Moser said.

Family and lifestyle requirements and the increasing difficulty in attracting foreign nurses were to blame, he said.

The nurses' union argues that while health care is becoming increasingly complicated to deliver, nurses' wages have risen only marginally in the last decade, compared to the pay of their less skilled colleagues in the Hospital Employees' Union.

A decade ago, the starting wage for an RN was $18 an hour; today it's $21.40—an increase of 17 per cent. By contrast, the starting wages for care-aides and porters rose from $12 in 1990 to $19 in 2000—an increase of 54 per cent.

What happened?

During the period of health care restructuring, all health care professionals were told they had to scale back their wage demands. For a three-year contract beginning in 1993, the nurses' union accepted a one per cent pay equity increase and a general pay increase of 1.5 per cent per year for two years.

The Health Employees Union got a 3.7 per cent general pay increase in 1994. In 1996, the nurses—like the health sciences professionals and HEU—accepted a one per cent wage increase over two years. In 1998, all three unions voted in favor of a settlement that gave them no wage increases in each of the first two years and two per cent in the third year.

But HEU wages have still gone up more than 50 per cent because of pay equity and comparability, deals the union made with the former NDP government so they would reach wage parity with the B.C. Government Employees Union. Now, the nurses say, it's catch-up time.


Before health-care reform, a head nurse or unit manager was responsible for overseeing one particular unit in a hospital, such as surgery, and was specially trained in that discipline.

But between 1993 and 1998, employers in B.C. got rid of almost 50 per cent of head nurses and unit managers, according to Heather Clarke, a researcher with the provincial health ministry.

The result, nurses claim, is that their clout in the system has been reduced.

Today, one person—often not a nurse—has to manage more than one nursing unit and keep track of a whole team of health professionals, including physiotherapists and pharmacists, said Health Canada's Villeneuve, who was himself a head nurse from 1994 to 1999. Can you imagine the number of bodies that person has to deal with?

Nursing researchers say the removal of this management layer has created a number of problems. First, there isn't anyone to train new nurses except the floor RNs.

As a result, nursing schools are having a hard time placing their students for the preceptorships, or six- to eight-week internships, that are part of all degree programs, according to the RNABC.

New nurses need mentoring and role models, said Villeneuve.

A head nurse was very visible in the hospital. When I was new, that person kept an eye on me and made me a good nurse.

In addition, having a manager who is trained as a nurse simply makes it easier to practise, said the University of Victoria's Purkis. If you're working with a nurse manager who understands the context of your practice, you can just tell her that there is a problem and she'll make sure you have the resources.

The HEA's Moser agrees that hospital managers are now spread too thin because of cuts to nursing managerial jobs. But Moser said bringing back more nurse managers would require more money, which is just as rare as it was before.


B.C. has fewer nurses per capita than any other province or territory except Nunavut, according to the Canadian Institute for Health Information.

The number of nurses in the province has declined steadily since 1994 from a high of 74 for every 10,000 people to 68 today. In Manitoba the figure is 87, in Alberta it's 73 and Ontario there are 70 for every 10,000 people.

In the past, B.C.—which has historically trained only about 50 per cent of its nursing workforce—simply hired from elsewhere.

The nursing shortage has always been on a 10-year cycle ... it's always been able to right itself, said the health ministry's Clarke, who is a co-investigator in the University of Pennsylvania's international study of nurses' working conditions.

What is significant about the current shortage is that we really do have ourselves in a mess because it's international.

Global demand for nurses is increasing because health-care is a booming industry, particularly in North America, where a large part of the population—the baby boomers—is aging. Hospitals in particular are scrambling to fill vacancies because nurses have so many job opportunities in home care and the more lucrative private sector.

It's difficult to get a handle on the extent of the current Canadian shortage, but Ginette Lemire-Rodger, president of the Canadian Nurses' Association, says Canada should be graduating about 10,000 nurses annually to replenish the workforce in the next 10 years. In 1999, only about 4,000 nurses graduated.

Lemire-Rodger anticipates the shortage will get worse as more nurses retire. A demographic analysis conducted for the CNA in 1997 projected the country could be short between 59,000 and 113,000 nurses by 2011.


The B.C. Nurses' Union argues that giving B.C.'s nurses the highest wages in the country will facilitate recruitment. But nurses in B.C. are already among the highest paid in Canada, and yet the province has fewer registered nurses per capita than either Manitoba and Saskatchewan, where wages are lower.

The HEA's Moser insists that while competitive wage packages are important for recruitment, paying nurses great gobs of money, won't lure them here or keep them once they arrive.

The health employer and the RNABC believe incentives are the answer, and are proposing that the government forgive a portion of new graduates' student loans to entice them to stay in the province.

Overseas recruitment is getting harder to do because the nursing shortage is international, said Moser. Those same nurses we want are also being actively sought by the U.S. and other countries in Europe as well.

One way a qualified foreign nurse can work in this province is through a temporary worker program managed by Human Resources Development Canada. But the B.C. nurses' union must pre-approve such hires, which the HEA says makes it harder for it to recruit temporary nurses whose schooling and qualifications meet Canadian standards. As a pre-requisite to its approval, the union requires proof that the hospital advertised the job countrywide and, if the nurse is to be hired as a specialist, the employer must prove it is committed to providing speciality training for eight nurses already on staff.

In addition to the temporary worker program, there is also a provincial-federal agreement, called the B.C. nominee program, that allows B.C. to circumvent certain immigration rules to allow health workers to move here.

Under the five-year agreement—signed in 1998—the province can submit a list of professionals it wants brought into the country. The government's sponsorship can cut by two-thirds the time it takes for new arrivals to receive landed immigrant status.

Since March of this year, 13 people have been nominated for the program and are currently in the process of obtaining landed status.

We know the employers want to nominate more, but they are so busy with the [nurses'] labour dispute they don't have time to recruit, said Tara McAteer, a search analyst with Health Match, a division of the HEA that recruits health workers.

In addition, there are roughly 250 Filipino RNs working in B.C. as nannies who came here under the provisions of the Live-in Caregiver Program. Many of them say they want to nurse here.

The RNABC has come under fire for allegedly blocking their ability to practise by forcing them to undergo time-consuming tests and upgrading.

But the RNABC counters that it already registers more Filipino nurses than nurses from any other foreign nation. It also says that all nurses, regardless of where they come from, have to meet the association's standards before they can practise in B.C.


The nurses' union claims the shortage of RNs is causing its members to burn out because they are putting in too much overtime.

But the HEA says only 10 per cent of nurses do 50 per cent of the overtime. It estimates the nurses who are doing most of the overtime are working only about 235 extra hours annually—or about five hours overtime per week.

In addition, the association says, the shortage is most acute in specialty areas. And its $60 million overtime bill reflects this—93 per cent of nurses' overtime is done in hospitals and is concentrated in intensive care, emergency and critical care.

B.C. Nurses Union president Debra McPherson said the HEA's data is suspect because it's not based on a comprehensive sample of facilities.

If we're not doing a lot of overtime then why does the system grind to a halt when we stop doing it? she asked.

HEA also maintains that 25 per cent of its overtime bill isn't actually overtime because it's paid to part-time employees who get paid double time when they are called in on designated days off. (During the last round of bargaining, the union offered to suspend designated days off for part-time employees.)


Last fall, blasting B.C.'s pitiful, lack of commitment to nursing education, the University of B.C.'s U.S.-born nursing school director resigned and accepted a job at an American university.

Kathryn May criticized the NDP government of the day for funding only 300 new nursing school seats in 1999 and accused the province of not taking the nursing shortage seriously.

The RNABC began warning about the looming shortage and calling for more seats in universities in 1997. The province graduated 600 nurses in 2000, but that figure would have to increase to 1,600 per year in each of the next 10 years to replace those who will retire, the RNABC's Gillespie estimated.

More than 13,000 registered nurses in B.C. are between the ages of 45 and 65 and the association estimates 4,000 are poised to retire anytime—nurses often retire at 55—and 9,000 will be in a position to retire by 2011.

Interest in nursing as a profession is high. In 1999, the latest year for which province-wide statistics are available, there were 2,600 applicants for 949 available spaces in B.C.'s nursing schools. Kwantlen College's nursing school received hundreds of applications for its 33 spaces last year.

But it costs $12,000 annually to fund one nursing seat, and allocations made by the previous provincial government will add only 493 additional nurses to the system by 2005.

Shirley Bond, the new minister of advanced education, said the new Liberal government plans to increase the nursing workforce by 1,700 nurses over the next five years but has made no specific commitments in terms of funding to nursing schools: We are looking into refresher courses and specialized training. It's part of our new-era commitment to help the health-care system.

Maxine Mott, head of the B.C. Nursing Council—which represents all nursing educators in this province—says any increase in seats must be gradual because nursing schools are short of lab and classroom space. We can't accept more students because we need more space, said Mott, who is also dean of community and health studies at the Kwantlen nursing program.

An influx of new nursing grads will also not immediately alleviate shortages in such specialty areas as cardiology and emergency because only experienced nurses --usually with about two years of on-the-job training—can qualify to specialize, which involves roughly 17 weeks of additional training.

Health employers and the RNABC want the government to provide more funding so mentoring RNs—who are also regular floor nurses—can take time off from their duties to train their less experienced colleagues.

A study released in June by the Canadian Health Services Research Foundation found 8.5 per cent of nurses call in sick every day, one of the highest rates of absenteeism of any profession.

Making health-care facilities places where nurses want to stay doesn't have to cost money, said the health ministry's Clarke, who helped survey more than 17,000 Canadian nurses as part of the University of Pennsylvania's international study.

It's about creating a different culture, valuing nurses, and surveying them about decisions.

The real challenge in the years ahead may lie not in creating incentives or new spots in nursing schools, but in providing nurses with a manageable workload and a greater degree of control, support and respect.