Canada’s Health Workforce Crisis — Dr. Leigh Chapman and Dr. Doug Sinclair

Avis Favaro

Hello and welcome to the Canadian Health Information Podcast. We call it the CHIP for short.

I’m Avis Favaro, and I’m hosting this conversation for the Canadian Institute for Health Information, known as CIHI. Our goal, an in-depth look at the Canadian health system, behind the data, and looking at problems and solutions.

A note. The opinions expressed here don’t necessarily reflect those of CIHI, but this is a free and open discussion. And this episode is about one of the most pressing issues in Canadian health care.

There is a cross-country critical shortage of doctors and nurses, along with many other health professionals. Frontline teams are exhausted after almost three years of battling COVID and the effects of delayed care for everyone else. Nurses are quitting hospital work or moving to other areas of practice. They just can’t take the long hours, forced overtime, abusive patients, and some are speaking out.

Female Speaker

The physical exhaustion, like, a lot of times, I can’t even get up from the bed the next day.

Female Speaker

I work 28 shifts in a row doing overtime, just trying to get us through. And a lot of our staff are doing that.

Female Speaker

When is this going to end? When is this going to stop?

Avis Favaro

Dozens of emergency units and hospital wards across parts of the country have had to temporarily close because of lack of staff. And those that are open, there have been eye-popping waits.

Joining us today are two people who are seeing the health crisis up close, people who have ideas and may have some influence in shoring up what some call a health system on the edge of collapse.

Dr. Doug Sinclair is a longtime emergency physician in Toronto and Halifax, a member of the Canadian Association of Emergency Physicians, and he’s now Vice President of Medicine, Quality and Safety at the IWK in Halifax. Welcome, Doug.

Doug Sinclair

Thanks, Avis. Thanks for having me.

Avis Favaro

And we’re joined by Canada’s newly named Chief Nursing Officer, Leigh Chapman, a registered nurse and PhD in Toronto with a very big job to get nurses back onto the frontlines. Welcome, Leigh.

Leigh Chapman

Thank you very much for having me.

Avis Favaro

So when you got the call that you were being tapped for this job, Canada’s top nurse, the first one in over a decade, what was your reaction?

Leigh Chapman

I was very honoured. I still am very honoured. Somewhat daunted by the task of representing over 400,000 nurses in this country. But I think overall, I’m very thrilled for the position and really look forward to the opportunities to meet with nurses from across the country and certainly do my best in terms of bringing their voice to the federal government in decision-making.

Avis Favaro

Can you explain what your mandate is?

Leigh Chapman

My immediate priorities are very focused on health workforce issues, which is sort of not surprising. So looking at efficient integration of internationally educated nurses; looking at multi-jurisdictional registration, so having nurses registered in two or more provinces and territories.

Avis Favaro

Right. And do you have any targets you have to hit?

Leigh Chapman

Part of the issue of targets is that we don’t have a clear picture of sort of workforce data for nursing across the country. So that’s, perhaps, a third priority is to look at having unique identifiers for nurses nationally so that we aren’t double counting and that we’re able to actually make some projections in terms of supply and demand with some accuracy.

Avis Favaro

Before we move on to the bigger issue of HHR, I do want to say, you have a very personal story behind your reason for moving into frontline nursing, especially in harm reduction and overdoses. And this has to do with something that happened to your brother. Do you want to share that?

Leigh Chapman

Sort of midway through my PhD, my older brother, Brad, died of an overdose and had experienced homelessness for most of his adult life, and with cycles of incarceration. And it really sort of lit an equity fire, I guess, in me, and I really was troubled with, how does this happen in a resource-rich country like Canada, that people fall through, not just cracks, but really gaping holes in the system.

And so, I think I got very involved in harm reduction work and homeless health care specifically. And really, at the core of that is around equity-deserving groups and ensuring that our Canadian health care system meets the needs of all Canadians, not just those who are resourced and housed, but those who are also sleeping rough on our streets and sometimes also using drugs to survive, like my brother, so.

And that’s always been that push for advocacy, for evidence-based health care that is really centred around the individual receiving care has been really something guiding my work in the last seven years, for sure.

Avis Favaro

And it must have been all the worse during the pandemic for nurses doing what you were doing.

Leigh Chapman

Yeah. I think there’s certainly been a lot of trauma that nurses have experienced from witnessing the number of deaths that nurses have witnessed. I think also nurses have been faced with unprecedented things that they’ve had to do in their work life. For example, being the sole care provider for somebody in an intensive care unit and having family members say goodbye to their loved one via iPad on FaceTime. And that’s really completely unprecedented.

I think the critical staffing shortages that nurses have faced have been exceptionally difficult. Sometimes nurses are unable to leave at the end of their shift. There’s certainly a lot of collective trauma within the profession due to that frontline work.

Avis Favaro

Along with the shortage of nurses, there’s also a shortage of family doctors and emergency physicians. And that is no surprise to you, Dr. Sinclair. Is that right?

Doug Sinclair

That’s correct, Avis. I was the Chair of what we call the Collaborative Working Group. We produced a report back in 2016 — it seems like a long time ago — and we stated at the time, based on our research, that we, in 2016, had a deficit of 478 full-time emergency physicians at that time. And we predicted that that number would go to 1,070 by 2020, 2 years ago, and 1,500 in 2025 based on who said they were probably going to retire and based on our residency training numbers.

And after that report, we met with all the post-grad deans in Canada, multiple governments [indiscernible] and basically, nothing happened. And of course, then the pandemic came along, so these numbers that we stated then that showed an extreme deficit of emergency physicians are only worsened by COVID.

Avis Favaro

How frustrating is that?

Doug Sinclair

Well, it’s very frustrating because, so often, as Leigh said, when we talk to government, they say, we need data. So we provided data, and here we are. And we know it’s a lot worse. We don’t have the data to say how much, but that’s a big deficit.

And we had practical solutions then for increasing training position for emergency physicians and reallocation of positions, and those take time. And basically, nothing happened. So here we are now in a crisis that, as Leigh has intimated, was totally predictable even without COVID. And now people are scrambling for solutions, and many of them will take some time to implement.

Avis Favaro

Right. Actually, I should note that CIHI is going to be coming out with updated health workforce data in a couple of months. So that will be the data, more data, and hopefully, we’ll get an even clearer picture.

So just tell me what you’re hearing from emergency physicians on the frontline about what they’re seeing, what they’re facing.

Doug Sinclair

Well, emergency medicine is very much a team sport. And where it’s really been hit is the frontline nurse, absolutely, as well as emergency physicians. And also, our clerical and registration staff that work in emergency. And what we’ve learned, of course, our environmental service workers who are absolutely critical to an emergency medicine operation. So the whole team has been hit extremely hard.

And what’s happened is, people are leaving emergency departments, and either they’re looking for somewhere else or they’re simply leaving the profession, which is very sad. I think a number of emergency physicians, nurses, I mean, they are in moral distress, as Leigh has said, trying to provide remote care and when you can’t have loved ones around, as well as the massive waiting times for emergency when you know that people in the waiting room or on ambulances, are suffering. This is really a cause of moral distress and has, unfortunately, caused many physicians and our nursing colleagues to leave the profession.

I’ve been in this business for 40 years in practice, and I’ve seen many dips and many crises in the past when there weren’t any nursing jobs or when physicians left for the United States. And there’s no question that this is much more extreme than we’ve seen before.

Avis Favaro

Okay. Well, let me open this up to both of you. First off, let’s talk about the effect on patient care. Is this impacting how patients are being treated? Leigh?

Leigh Chapman

I would say without a doubt it’s impacting patient care. I think that we’re actually seeing patients either not access necessary services when they need to, which is resulting in certainly a delay, sometimes a delay in diagnosis or in treatment or in interventions, and certainly, lengthy waits for care. The health workforce issues are certainly compromising our publicly funded system, our Canadian health care system as we know it.

Avis Favaro

And, Doug, where in the system are these shortages of these frontline teams felt the most?

Doug Sinclair

Well, no question, our primary care system, which has struggled for many years, is really in significant trouble. So, access to primary care is in such a desperate state that patients are having to go to emergency departments for the only place that’s open.

I think another big area is, we talk about elective surgery. We need to get rid of that term. We need to call it scheduled surgery because the surgery that patients are waiting for, like hip replacements, like cardiac surgery, and where I work, for pediatric surgery, those are not elective. They are absolutely scheduled. There’s a huge deficit in that work, of course.

And there’s no capacity for the health care system to really catch up. Government said, okay, we’ll put some money into working on weekends while I’m working all night in the ORs. That simply is not going to work because of the limitation of our health workforce.

And then that is causing then patients to come to emergency department late because their surgery has been delayed and delayed, and then they start to suffer complications. And we’re seeing that absolutely on screening for colonoscopy. Our gastroenterologists have told us that there are patients with cancers that are being missed, and they’ll eventually kind of catch up to that. So that’s very significant concerns.

Avis Favaro

We’re dealing with a fall season coming up. There’s some suggestions there may be another wave of COVID. There certainly will be more flus and colds and other respiratory things.

Let me start with you, Leigh. Is there a fast-level fix for this nursing shortage?

Leigh Chapman

Health care is a complex issue, there’s no doubt. So I think there’s no fast fix, unfortunately.

Avis Favaro

But a short-term one, given that we’ve got the fall. Is there anything moving in place now for the fall season?

Leigh Chapman

So there certainly is work being done across the provinces and territories looking at health workforce and nursing issues specifically to try to integrate internationally educated nurses much quicker as a means of increasing supply. And looking at, as I've said, those who have left the profession, if we can recruit them back, and certainly, retaining those who are within the profession by making the workplace conditions better.

Avis Favaro

What would that take? What would it take to keep nurses working?

Leigh Chapman

It really isn’t a one-size-fits-all approach. But certainly, what has worked in some jurisdictions has been significant provincial focus, or provincial and territorial focus on health workforce issues, on nursing recruitment and retention issues specifically.

Avis Favaro

Would that mean more money? Better hours? Better work-life balance?

Leigh Chapman

It can mean all of the above. And sometimes it’s not necessarily about dollars. It’s sometimes about the way resources are distributed. And sometimes, another thing that’s been a real positive thing has been in the way of regulatory reform. So, nurses and most health care providers are governed within the provinces and territories, so really trying to make things smoother or easier for nurses.

Avis Favaro

And then there’s the abusive patients component too. I heard from a number of nurses who are just being [roasted] or sometimes even violence directed towards them because people are so frustrated.

Leigh Chapman

Yeah. Absolutely. I think we’ve seen this sort of where nurses have been hailed as heroes during the pandemic, but they’ve also faced — they’ve really been on the frontline and faced abuse and discrimination.

And so that’s what I am referring to when I say looking at the workplace conditions. We need to ensure that providers who are working in these health care settings are absolutely protected and have a safe work environment, safe and healthy work environment, so that they’re not fearing abuse and discrimination or assault when they’re actually going to deliver care.

Avis Favaro

We noticed that during the pandemic, some nurses were offered bonuses. Does that work?

Leigh Chapman

Ultimately, it comes to how their life is respected, how they’re able to balance their life with work. And sometimes, that means more flexibility than they currently have. And sometimes it may mean remuneration. But ultimately, it is an issue of respect.

Avis Favaro

Right. And so to you, Doug, do you see any solutions that are being enacted now that give you hope?

Doug Sinclair

Yeah. A colleague of mine said, a lot of this is taking the pebbles out of people’s shoes. So there’s all kinds of things that in your work environment are irritating and frustrating. So trying to smooth some of those to make the work day a better place, a happier place, because it is a wonderful environment, certainly in emergency medicine.

So what that means is a whole bunch of little things. So, more flexible shifts, more backup. Traditionally, we’ve always staffed to the kind of average. We need to overstaff for emergency physicians and certainly nursing so they’ve got more redundancy in the system. That makes a huge difference to a shift if there’s an extra pair of hands there. And that can be done fairly quickly.

And to carry on what Leigh was saying, the whole issue of respect of health care providers, this is really important. And we can move quickly on this because that is a change. In the past, especially nurses, also physicians, whatever the patient said or however they spoke, that was kind of we had to kind of accept that. And in fact, that’s just not acceptable for anyone. Everyone’s getting grumpy and frustrated. So patients are frustrated, absolutely. In emergency department, they have long waits. But it’s still no excuse for taking that abuse out on — especially on triage nurses.

On the internationally educated front, that’s an interesting one. I think there’s probably more potential in scope on the nursing side. On the physician side, it’s a bit limited. Many of the physicians that have been internationally educated, unfortunately, many of them haven’t been practicing, certainly in acute care, for a long time. So it takes time to get them back to speed.

Different for the Ukrainian. Ukrainian physicians are different. Right?

Avis Favaro

I was going to say that the CIHI data is showing that 9% of nurses are foreign-trained and 26% of physicians are foreign-trained. So it seems like there’s more room to move on the foreign nurses. Is that right, Leigh?

Leigh Chapman

Yeah. We know that there’s a number of internationally educated nurses who are facing long delays on the path to licensure and that sometimes things expire along the route towards settlement in Canada. So their language requirements or their evidence of safe practice may expire.

I think part of the issue with that figure, 9%, is that we know that there are many internationally educated nurses who are coming to a large country like Canada without sort of perhaps knowing where they’re going to settle, so they might be registering in multiple jurisdictions. So we may be double counting them. And I think that’s why we certainly need to look across the country into unique identifiers so that we do have a clear picture of how many IENs we have in this country and how many we need in terms of workforce planning.

Avis Favaro

I know that in Ontario and Manitoba, I believe they’re actually moving quickly to get the nurses doing part of their practicum that they would’ve had to have done before or couldn’t do during the pandemic right at the hospital level to move them in more quickly. Is that an example of a solution that could be looked at?

Leigh Chapman

Yeah. It’s a great solution. It really is an exemplar because it does provide the practice readiness and it also provides language fluency, and really does — it requires, obviously, close collaboration with the employer. But it is a way to really effectively integrate internationally educated nurses into the workforce in a more streamlined fashion.

Avis Favaro

So, Doug, one of the things we talked about in advance of the podcast was the importance of retention; that while it’s good to look to groups abroad, that there’s more to be done, like you said, the pebble in the shoe.

Is there something that we could do to keep doctors from retiring? Tax incentives, anything like that that would keep them in the field longer while we train more domestically, perhaps?

Doug Sinclair

Yeah. Certainly, from a physician point of view, my colleagues might disagree, but I don’t think this is a financial issue. This is very much a respect, a workplace issue. So I think there are many physicians who are either retired or on the verge of retirement, if you said, okay — part of it is hope, right? Here’s the plan. If you can see what the plan is then you can say, okay, I can step up and commit to some part-time work for another year or so. That would make a huge difference, if there was a sense of what the plan was and then support. There’s all kinds of wellness initiatives now that are in small areas. The Canadian Association of Emergency Physicians has some excellent wellness initiatives. So many of the societies have that work, and it’s, again, government to kind of collaborate with them and push them out.

The portability of licensure is also important. Unfortunately, we have, depending on how you account, 11 or 12 jurisdictions, and each of them requires slightly different licensing in Canada. And the portability is a big problem; you can’t move around. Now provinces are a little loathe to do this because they see other provinces as poaching doctors, but we’ve got to get beyond that.

To Leigh’s point about the training capacity, that’s also really important. I think if you said to hospitals, okay, here’s some internationally educated physicians, can you take them on for a period, very defined period of a few months? That’s extra work, if you will, but you can kind of see the benefit. So I think there’d be appetite for that. It would require some leadership and work, but I think [could go].

Avis Favaro

Okay. Are there ways of improving things that don’t involve more doctors and nurses? Or using what we have better?

Doug Sinclair

I think one of the positive benefits of COVID, of course, has been virtual care. Virtual care was minimal, really, except in the North, before COVID, and now it’s taken off. Virtual care is a bit of the Wild West out there with various companies jumping into this. So we have to be careful about virtual care — what actually needs an in-person visit, and how does a virtual care visit connect into the larger system.

Our patients really in general appreciate virtual care. And one of the things we’ve learned is it provides access to patients and families who normally wouldn’t have access to care in rural areas and some of our disadvantaged populations. So there’s some real hope there for virtual care. But lots of work to be done in that regard on the kind of details of how it actually works.

Avis Favaro

And what about the backlog of surgeries, diagnostics, testing? Millions of people across the country are still waiting for tests. Is there an opportunity here?

Doug Sinclair

Oh, absolutely. There’s a huge backlog, but I know you’re going to do some future work on Choosing Wisely. There’s lots of science that would suggest that, frankly, many of the tests that we order are actually not necessary. So, rather than investing in getting all those tests done, let’s really take a serious look on what actually needs to be done and alter the resources.

So for example, we know we have backlogs in testing for colon screening and we need to put resources into that. There’s other tests, perhaps, we’ve ordered in terms of imaging and other lab tests that Choosing Wisely would suggest aren’t necessary, and we can allocate resources in that regard — reallocate.

Avis Favaro

I hope the opportunity is taken.

So, Leigh, do you have a timeline for goals? And what would success for you look like?

Leigh Chapman

Well, it is a two-year appointment, but I certainly do have some immediate priorities. I think my goals are certainly to bring that frontline perspective, that on-the-ground perspective and nurses’ voices to decision-making at the federal level. That really is the ground-up perspective that I hope to bring to the minister and, really, to decision-making within the federal government, because I think that better understanding those conditions will help us with any initiatives that we’re going to implement. And so I certainly am a roll-up-your-sleeves kind of nurse, and really hope to use that in this key role.

Avis Favaro

And at the end of your two-year term, what would be your wish?

Leigh Chapman

So I think, really, some stability in the workforce and pride in the profession would be overarching goals.

Avis Favaro

The nurses have gotten very vocal during the pandemic. I’m sure you’ve seen nurses taking to Twitter and much more open about doing interviews. This is a critical issue for nursing.

Leigh Chapman

Yeah. And I have an advocacy background and I certainly would much prefer to see a very engaged workforce than an apathetic workforce. So we do have that engagement. And I think we can absolutely work with that energy to make things better for the profession as a whole.

Doug Sinclair

To you, Doug, how would you measure success? Let’s talk short term about getting through the winter with staffing shortages.

Doug Sinclair

Well, I would see, certainly, some commitments to increased coverage of emergency departments; decreasing wait times with more innovative models; using paramedics, nurse practitioners wisely. And we have the measurements; let’s see some change in that regard.

And of course, a big plug for vaccination in the fall with the COVID booster coming out, with flu vaccinations coming, then with mask-wearing, hand washing, all that stuff that we learned through COVID. That’s critically important that we continue into the fall.

Avis Favaro

What would failure look like?

Doug Sinclair

I think failure would be increasing numbers of physicians leaving and getting discouraged. And some of that is actually measured on some of the engagement surveys. So it’s not just a feeling, it’s actually measurement.

So if we continue to see erosion of physicians leaving practice, that to me is very sad and would be a failure of the system. So it’s incumbent upon us as leaders to make sure that we can, as I said, get the pebbles out of the shoes of many of our providers; understand what’s going on at the frontline to make every day a better shift for them. So that will make a big difference.

Avis Favaro

Thank you both for joining. I almost want to do this interview in a year from now and see how far we’ve gotten. As I said, the nurses are becoming more vocal. I’ve noticed physicians are more interested in talking about this. This looks like a critical point going forward. So, thank you both for joining.

Doug Sinclair

Thanks very much.

Leigh Chapman

Thank you very much.

Avis Favaro

The demands on Canada’s health system will last long after COVID-19 eases, as we deal with a huge backlog of procedures. And for that, we need a strong health force. CIHI will have new important data coming out on that later this fall.

Thank you for joining our discussion today, and please join us for our next podcast when we look into other important health topics that matter to you.

Our Executive Producer is Jonathan Kuehlein. Special thanks to Aila Goyette and to Alya Niang, host of our French CIHI podcast.

If you want to learn more about the Canadian Institute for Health Information, please go to cihi.ca. That’s C-I-H-I dot c-a, where you can get reliable data on important health measures across the country. And subscribe to the CHIP wherever you get your podcasts.

I’m Avis Favaro. Talk to you next time.