October 19, 2023 — This report presents a high-level look at available pan-Canadian data on hospital staffing — including sick time, overtime and agency use — and potential impacts on patient harm to explore trends observed during the COVID-19 pandemic. Further analysis on how to support a resilient health workforce now and in the future, including outside of hospitals, is essential.
The pandemic challenged hospital staff on many fronts:
- Uncertainty surrounding COVID-19
- Challenges with personal protective equipment, including rationing and fatigue related to constant use and changing guidelines
- Working shifts with sub-optimal staffing levels
- Concerns for the health of loved onesReference1
- Health care workers getting sick themselves or having to isolate
- An increased number of lost time claims filed with workers’ compensation boardsReference2
All of these factors made the delivery of care exceedingly difficult for health care teams during this timeReference3 — a period which also saw increases in preventable hospital harms in patients.
To cope with the pandemic, hospital health workers were redeployed to other service areasReference4 and worked many hours of overtime.Reference5 Some provinces and territories called on retired health workers to return to practice to meet demands, as well as relaxed and streamlined entry to practice and licence requirements for new physicians and nurses or health workers from other jurisdictions.Reference4 Many hospitals adjusted care models to support health care workers working to their full scope of practice, incorporated nursing students for bedside supportReference1 or turned to private agencies to fill staffing gaps.Reference6
Hospitals relied heavily on overtime and agency staff during the pandemic
In 2021–2022, nurses and other health care providers working in hospital inpatient units across Canada logged more sick time and overtime hours compared with the previous year.
- There was a 17% increase in reported sick time from the previous year, with the total sick time hours translating to a shortfall of about 6,500 calculated full-time equivalents (FTEs)Footnote i that year.
- More than 14 million overtime hours were logged for those units in 2021–2022, which was a 50% increase from the previous year and equates to about 7,300 calculated FTEs.
Throughout the COVID-19 pandemic, nurses working in the hospital sector increasingly reported experiences of burnout, moral distressReference1 and a desire to leave the profession.Reference7 In 2022, the number of registered nurses (RNs) working in hospitals and providing direct care to patients declined slightly, by 1% (828 fewer RNs).Reference8 In the same year, Statistics Canada reported 95,800 vacant nursing, personal support worker and health care worker jobs, a record high for the industry.Reference7
While hours purchased and worked by nurses and other health care providers from outside agencies made up only a small portion of the total volume of hours worked in hospital inpatient units (about 1%), there was an 80% increase in the volume of purchased hours, from 850,000 in 2020–2021 to over 1.5 million in 2021–2022. Note that these values are likely higher due to jurisdictional differences in reporting and some jurisdictions not reporting at all. In 2022, the number of RNs that were self-employed or working for private nursing agencies increased by 6% (867 more RNs).Reference6 Contracts with private agencies offer higher rates of pay and more flexibility in scheduling, which was commonly noted as desirable among nurses during the pandemic.Reference1
Patient care in hospitals is increasingly complex as the population ages, rates of chronic diseases increase and medical technology advances. Elements that help hospitals retain staff and deliver quality careReference1 are
- A team-based approach
- Familiarity with hospital protocols, staff and equipment
- Time with patients to deliver care and plan for continuity of care
Hospital harm also trended upward during the pandemic years
Rates of harm to patients increased along with rates of staff absenteeism, overtime and use of agency staff.
- Across Canada, the rate of hospital harm increased to 5.9% in 2020–2021 and 6% in 2021–2022 and 2022–2023 after remaining stable between 5.3% and 5.4% since 2014.
- In 2022–2023, 1 in 17 patients admitted to hospital was unintentionally harmed during their stay.
The Hospital Harm measure reports the rate of hospitalizations with at least one unintended occurrence of harm that could be potentially prevented by implementing known evidence-informed practices. Harm as a result of hospital care, treatment, medical procedures or in-hospital accidents is generally captured within the measure.Reference9
Harm prevention in hospitals requires awareness and action from personnel of all levels because harm is most often the result of a chain reaction, a failure of the system at multiple stages that makes it difficult to provide proper care.Reference10 COVID-19 added new challenges for health care providers due to the changing care needs of more complex patients, as well as uncertainty and evolving guidance around the clinical management of patients. Frequent staffing changes that disrupted care continuity or reduced time with patients may also have contributed to these observed trends.
Urinary tract infections (UTIs), pneumonia, aspiration pneumonia and pressure ulcers are examples of harms that may be linked to nursing staffing levels,Reference11 though team-based models of care in hospitals mean that other health providers also impact rates of harm in these areas. While these types of harms are considered rare events, the rate for each increased during the pandemic (compared with the pre-pandemic period):
- UTIs and pneumonia, by about 20%
- Aspiration pneumonia, by 25%
- Pressure ulcers, by over 50% (this may, in part, be due to better data capture in 2022–2023)Footnote ii
A closer look at highlighted hospital harms and clinical guidelines for care
Patients with impaired mobility or bladder problems may be prescribed a urinary tube (or catheter). These tubes can cause UTIs if left too long or not cared for properly.Reference12
Tactics staff can use to prevent UTIs include
- Toileting patients regularly and avoiding or minimizing catheter use
- Keeping patients hydrated
- Providing regular hygiene careReference12
Patients may be at risk of pneumonia if they are using a breathing tube or are exposed to other patients with respiratory illnesses.Reference13
Tactics staff can use to prevent pneumonia include
- Walking or re-positioning patients regularly, elevating bed height
- Caring for mouth and/or breathing tube regularly
- Following infection prevention guidelines such as those related to isolation, masking and hand hygiene
- Assisting patients with deep breathing exercisesReference14
Patients with swallowing difficulties are at risk for aspiration pneumonia and need extra support to eat and/or clear their mouths to prevent food or fluids travelling to the lungs.Reference15
Tactics staff can use to prevent aspiration pneumonia include
- Thickening fluids or adjusting food fluid textures
- Taking time to position patients correctly and to feed them slowly
- Providing mouth care
- Conducting regular care for nasal and oral feeding tubesReference16
Pressure ulcers and serious skin and tissue injuries may occur if a patient is sitting or lying in a position for too long and/or something beneath them is pressing on their skin. Pressure ulcers may also form if a patient is not re-positioned or transferred properly.Reference17
Tactics staff can use to prevent pressure ulcers include
- Screening high-risk patients, including those with sensory limitations, incontinence and mobility challenges
- Repositioning frequently, with good technique
- Ensuring patient surfaces are smooth and free of tubing or bunched beddingReference18
A hospital stay involves interactions with many different health professionals including nurses, environmental service workers and volunteers. Supportive work environments are key for effective team-based hospital care and patient well-being, now and in the future. The impacts of increases in hospital overtime, sick time and purchased hours by non-physician staff warrant careful monitoring as the demands on the health workforce, and thus the system, continue to grow and evolve in line with Canada’s population.
Further examination of these trends at the provincial/territorial, regional and facility levels will allow for evidence-based decisions by local health system leaders, and will allow for the consideration of factors including workforce capacity, facility size and population needs.
Informed planning and strategies to optimize and support a resilient health workforce are needed across the country. Strategies may include
- Offering greater flexibility for work–life balance
- Providing mental health supports
- Recruiting to maintain full staffing
- Ensuring every team has the right mix of providers and that members are supported to work to their full scope of practice
Data-driven analysis of these strategies will be key to improving the overall quality of employment as well as patient care and safety.
Related resources
- Hospital spending in Canada
- Learn more about selected hospital staffing indicators in Health Workforce in Canada, 2022 — Quick Stats (XLSX)
- Learn more about the Hospital Harm Project
Contact us
We welcome your feedback and questions.
Footnotes
i.
FTEs are calculated by summing the reported earned hours (i.e., worked hours, both regular and overtime) and dividing by 1,950 (1,957.5 in leap years), which is the assumed number of normal earned hours for 1 FTE in a given fiscal year.
ii.
Interpret with caution. Improved data capture may account for some increases seen in rates of pressure ulcers in 2022–2023.
References
1.
Royal Society of Canada. Investing in Canada’s Nursing Workforce Post-Pandemic: A Call to Action (PDF). 2022.
2.
Association of Workers’ Compensation Boards of Canada. National Work Injury, Disease and Fatality Statistics (PDF) . 2022.
3.
Allin S, Campbell S, Jamieson M, Miller F, Roerig M, Sproule J. Sustainability and Resilience in the Canadian Health System (PDF). 2022.
4.
Canadian Institute for Health Information. Canadian Data Set of COVID-19 Interventions. Accessed July 2023.
5.
Canadian Institute for Health Information. Health care provider experiences during the COVID-19 pandemic. Accessed July 2023.
6.
Canadian Institute for Health Information. Health Workforce in Canada, 2021 — Quick Stats (XLSX). 2022.
7.
Statistics Canada. Quality of Employment and Labour Market Dynamics of Health Care Workers During the COVID-19 Pandemic. 2023.
8.
Canadian Institute for Health Information. Nursing in Canada, 2022 — Data Tables (XLSX). 2023.
9.
Canadian Institute for Health Information. Hospital Harm Indicator General Methodology Notes, October 2022 (PDF). 2022.
10.
Baker R, Norton P, Flintoft V, Blais R, Brown A, Cox J, Etchells E, et al. The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada. CMAJ. May 2004.
11.
Oner B, Zengul F, Oner N, Ivankova N, Karadag A, Patrician P. Nursing-sensitive indicators for nursing care: A systematic review (1997–2017). Nursing Open. May 2021.
12.
Canadian Patient Safety Institute. Hospital Harm Improvement Resource: Urinary Tract Infection (PDF). 2021.
13.
Healthcare Excellence Canada. Pneumonia: Introduction. Accessed July 2023.
14.
Canadian Patient Safety Institute. Hospital Harm Improvement Resource: Pneumonia (PDF). 2016.
15.
Healthcare Excellence Canada. Aspiration pneumonia: Introduction. Accessed July 2023.
16.
Canadian Patient Safety Institute. Hospital Harm Improvement Resource: Aspiration Pneumonia (PDF). 2020.
17.
Healthcare Excellence Canada. Pressure ulcer: Introduction. Accessed July 2023.
18.
Canadian Patient Safety Institute. Hospital Harm Resource: Pressure Ulcer (PDF). 2021.