Canada’s Health Workforce Crisis — Dr. Judy Morris

Alya Niang

Please bear in mind that the opinions and comments of our guests do not necessarily reflect those of the Canadian Institute for Health Information.

Hello and welcome to the Canadian Health Information Podcast. This is Alya Niang and I'm delighted to be back with you for the third episode from the Canadian Institute for Health Information, also known as CIHI. In today's podcast, we’ll be discussing one of the most urgent problems in Canada’s health care sector, namely the human resources crisis or, to put it in simpler terms, the people crisis we’re currently seeing in the health care domain. We’ll be looking today at these problems and at innovative ways to solve them.

There’s a critical shortage of doctors, nurses, and many other health care professionals nationwide. Front-line teams are exhausted after almost 3 years of the fight against COVID-19 and the effects of delayed treatment for everyone else. Our health care workers are leaving hospital jobs or transitioning to other types of practices. They simply can’t continue with the long hours at work and the mandatory overtime. They are exhausted and demoralized, and some are even speaking out about it. A recent report found that job vacancies in Canada’s health sector have reached a new record of over 100,000 unfilled positions, and the effects of the last few months have been disastrous. Dozens of emergency and hospital service units across the country have had to close temporarily due to staffing shortages, and for those that have remained open, the wait times are enormous. Many people also believe that our current health care system is no longer viable for the future.

To discuss this urgent topic, we’re happy to have as our guest today Dr. Judy Morris, an emergency physician at the Hôpital du Sacré-Cœur in Montréal and associate professor in the department of family and emergency medicine at the Université de Montréal. Dr. Morris has been the Board Chair of the Association des médecins d’urgence du Québec since 2020, and she’s been a member since 2014. Dr. Morris, welcome! We’re very happy to have you with us today.

Dr. Judy Morris

It’s my pleasure. Thank you for having me.

Alya Niang

The pleasure is ours. Dr. Morris, we’re experiencing a severe human resources crisis not only in terms of nurses, but in terms of family doctors, emergency room doctors and more. Would it be fair to say that our current health care system is on the verge of collapse? Do you think this is a new problem?

Dr. Judy Morris

We actually saw this problem coming. At the Canadian Association of Emergency Physicians, we worked on a report that predicted even then that we were going to have a shortage of emergency physicians — in fact, at the time of the report in 2016, there already was a shortage of several hundred doctors — and that things were only going to get worse. The COVID crisis and the pandemic in the past 2 years has only made the situation worse and exacerbated the labour shortage with people leaving the field, and making things even more difficult on the ground.

Alya Niang

Do you know how many emergency physicians left their jobs?

Dr. Judy Morris

I don’t actually have the figure for the number of doctors we’re missing, but just to give you an idea, in 2016, we had already estimated that for Canada as a whole, we were short almost 500 emergency physicians across our network. There were shortages everywhere — in rural settings, in urban settings — and we predicted that 5 years later, so last year in 2021, that we’d be over 1000 doctors short, and over 1500 short at the 10-year mark. And I don’t have the detailed figures, but we know that on top of that, there are also people who have quit because of the tough conditions of the past 2 years.

Alya Niang

Can you give us a bit more insight on those tough conditions, on the reasons that those people quit?

Dr. Judy Morris

We may talk later about the fact that this problem is really even worse for our nurses, attendants, and other health care professionals, but for the people we talked to and who said they were quitting, it’s actually that the system itself has become really cumbersome. That enjoyment you get from working or from having a mission, if you will, to come in and care for patients — when that work is suddenly full of obstacles, causes too much stress, and doesn’t give you the resources you need to do the work, that causes what we call a “moral injury”, that hit to your morale when you realize, “Look, I come to work, I want to care for patients, but I’m short on staff, I’m short on resources, and I don’t have the technological support I need to do this work.” In emergency rooms, it’s even worse. The patients maybe have less access at the front line, less access to surgeries, and we find ourselves in this environment where we’re kind of just short on everything. That really weighs on people, and some of them find themselves forced to quit just to protect themselves, in a way.

Alya Niang

Can you tell us a bit more about the problems for nurses?

Dr. Judy Morris

Yes, for sure. The shortage of nursing staff is the biggest challenge we’re facing in the health care network right now, I’d say. And you can see that across the country and in every region. In fact, rural areas are being especially hard-hit by the shortages of nursing staff. And that makes the challenge even bigger for the years ahead, because this is staff that’s really essential to the care we provide. They’re a really versatile resource who, in certain rural areas, they sometimes… they’ll take care of a whole community in places where there’s less access to doctors. So the challenge is in making sure we have sufficient numbers, that we’re training people who can come in and add to our nursing care resources in our health care system. We’ve got staffing shortages all throughout the network. Yes, we’re short on doctors, we’re short on administrative staff and other health care professionals, but the challenge we’re facing with nursing staff is a big one. And also, for these workers, the fact that they’re tired, they’re understaffed, their workload is heavier, that’s all kind of an indicator of the risk that they’ll leave us for the private sector. For all types of private health care jobs, we’re losing our qualified staff that we currently have in our hospitals, on top of the current challenge of just not having enough.

Alya Niang

That’s something we’re clearly experiencing right now.

Dr. Judy Morris

Yes. And a concern that… it’s something that governments really need to prioritize.

Alya Niang

Dr. Morris, let’s talk about the effects on patient care. Is there an impact on the way that patients are treated?

Dr. Judy Morris

Yes. When we’re short on resources, we know, and the data tell us, that patient care is often endangered. The Association des infirmiers et infirmières d’urgence du Québec also pointed this out by saying: If we don’t have enough staff in our health care facilities, especially in emergency rooms, well, that’s going to affect the nurse-to-patient ratios. And that’s going to increase the workload, it’s going to increase fatigue and the risk of errors. And we also know from our studies that when we’re over capacity, when our emergency rooms and hospitals are overflowing, well, the care we provide isn’t as good. There are more risks, longer wait times, longer hospital stays, adverse effects and even deaths, all due to a lack of adequate resources on-site.

Alya Niang

They’re always in a rush, basically.

Dr. Judy Morris

Always in a rush, and never enough resources. Or resources that are inadequate for the demand, let’s say. And then, the other aspect of this is that one of the realities in emergency care is that emergency rooms are often making up for the lack of resources elsewhere. That’s something we saw during the pandemic. So if there was no home health care, if there wasn’t enough room in long-term care or other alternative residential settings, if there wasn’t enough access to front-line resources, then patients had nowhere else to go but to the emergency room, which is always open. So that’s another added burden that people don’t necessarily see when we talk about figures in the media, as far as what emergency room teams have to deal with.

Alya Niang

And where in the system are these front-line staffing shortages being felt the most intensely?

Dr. Judy Morris

Ah. Honestly, I’d say it’s just everywhere. It’s been… We experience it in the ER because that’s what we see. People often say that emergency rooms are just the tip of the iceberg. We see shortages everywhere, but in front-line care, it really hurts. It hurts in specialized care. And it hurts in long-term care too. But certainly the hospital network has suffered a lot from not being able to meet the demand.

We know that too. When the flu season came around every year in January, we knew it’d be like, “Oops! We’re overflowing.” You know, the ER was overflowing, the hospital was overflowing, we had to open temporary long-term care centres. So we knew that all of us were often at the limit in terms of the care we could provide. And then came COVID, and that brought us into a period where we were chronically unable to meet the demand. But even a few years back, people were already saying, we can’t… If at some point we have a catastrophe or situations like the flu season on a recurring basis, as we experienced with COVID, we won’t be able to keep up with the demand. And so that’s what’s come to light, shall we say, in the past 2 years.

Alya Niang

Let’s talk a bit about immigration. We’re constantly hearing in the media that increasing our immigration quotas would be a way to resolve the labour shortage. But CIHI’s data shows that the percentage of registered nurses in Canada who were trained abroad hasn’t really changed over the past 5 years, around an average of about 9%, and the percentage of doctors is about 26%. Do you think we need more foreign nurses and doctors?

Dr. Judy Morris

I think we just need more of everything, period. And that will certainly involve increased training. But yes, if we can get people who are qualified, who meet the requirements or who can get up to speed and train up when they arrive here, then definitely. We’re not the only ones thinking about these things. Other countries like the UK and France are doing it too. What we find difficult is that beyond that, what we’ve already seen on the ground is that people would tell us: I can work, I’ve got my certifications. But often, for technical reasons with immigration and visas and all that, they weren’t able to stay. So can we maybe facilitate access for those people, accelerate access for those people who are qualified and who could come into our network tomorrow morning to help us out? Since it’s often these technical reasons, I’m sure there’s a logistical process that I’m not familiar with, some sort of administrative red tape, and couldn’t that be accelerated or made easier to access for these people so that they can come and help us in a network that really needs their help?

Alya Niang

So, streamlining the administrative side a little bit so we can really fill those positions and let those people get to work much more quickly?

Dr. Judy Morris

Yes, if we’re saying that the health care system is in a crisis, well, maybe we need to prioritize health care workers to come and help us in our network. That certainly won't be the only response, but it needs to be one of many other responses that are put forward to help us in terms of health care personnel.

Alya Niang

Dr. Morris, let’s turn now to your own personal perspective, your experience. How have you managed all this chaos — the stress, balancing your family life, seeing your friends quit, and working mandatory overtime? Has this shortage of resources caused that kind of moral injury for you, when you see people not getting care on time?

Dr. Judy Morris

Yes, for sure. The past 2 years have been very hard for a lot of people, including myself. First, there’s the anticipation, COVID, all the challenges and uncertainties. At first, people weren’t quite… but then they prepared themselves. People said: We’re going to tackle this challenge. But then there’s the aftermath. After a few waves of COVID, we’re seeing where people are tired, we’re facing challenges in terms of resources like we’ve never seen before. And then, yes, we see that impact on our colleagues. It’s really a tough thing to see. The Canadian Medical Association recently did a survey which showed that burnout rates have increased across all types of doctors. But emergency doctors have been hit by that too. Front-line doctors are often hit with that problem, actually. So it’s really tough to see that impact every day, and seeing people’s morale declining. And after all that, we’re being asked to… We have to work on rebuilding our network, on putting new processes in place, and doing more with less. It gets to be a lot. For the people on the ground, it’s hard to find the motivation. So from a personal perspective, it’s just a lot for everyone to bear.

Alya Niang

And so how have you managed to keep your family life in balance as you deal with all these problems?

Dr. Judy Morris

Well, often it’s a matter of protecting yourself. For one thing, at the start of COVID, it was about protecting yourself, and making sure… There was that fear of bringing an infection home and hurting our loved ones. Just an incredible source of stress for everyone. Over time, of course, we kind of got used to it, and got to know COVID a little better. What’s difficult then is to stay connected and work together with your team. I’d say that that’s been a challenge. With the family, there are definitely often challenges with not bringing our concerns back home. But one of the big challenges that every team is facing in their day-to-day work is, how do we work together, and how do we get back to enjoying our work? Because in my work setting, for example, in emergency care, it's a kind of medicine that's all about teamwork, it’s fascinating work and involves all kinds of challenges. But what we’re feeling now is just this sense of fatigue. People are maybe just running out of motivation or interest, like: I still enjoy doing my job, but everything that comes with it is just so much to deal with. The work environment, people quitting, the professional burnout we see in our colleagues all throughout the network. And it’s a vicious circle, because it increases the workload for the people they leave behind. It’s an enormous weight on everyone. And it really… We’re also going to need to focus on health care workers’ well-being, because the quality of care inevitably depends on that. Teamwork and quality of care… and actually, the quality of how we work together as a team, and then we’ll be able to move forward together.

Alya Niang

Today, we’re seeing a significant number of health care workers leaving the profession because of exhaustion, and the system has come to a point where we need to take immediate action to keep it from collapsing. What strategies are being put in place to reduce the impact on the system and on patient care?

Dr. Judy Morris

Again, it’s all about protecting the workers. There have certainly been papers and publications on this topic, among others, during COVID. That sense of security, even though there were lots of unknowns when we were first dealing with COVID, one of the best ways to protect workers or to give them that sense of security, was to make sure they felt that their employer, their colleagues or their administrative team were protecting them or prioritizing their well-being. For the future, to ensure that people will want to come and work in our public network, in our hospitals or front-line care or elsewhere, we’ll need to put workers at the centre of everything. They’ll need to be involved in the decisions. We’ll need to protect them in certain hospital centres where they force people to stay and work overtime. That’s not compatible with having a family life or other obligations. So, we need to protect workers as much as possible, and tell them that their environment needs to be safe for them and not lead to overwork. And we’ll maybe need to get the people on the front lines involved in the decisions instead of just saying, “We’ve decided to have you work this schedule.” In terms of nursing staff, that’s often one of their demands: Let us manage our own schedules, let us organize our own work together, and we’ll find solutions. So that needs to be at the centre, in addition to recruitment — giving people adequate support for the work they’re doing.

Alya Niang

Do you know of any strategies that have been implemented to attenuate the impact on the system right now?

Dr. Judy Morris

What’s interesting, actually, is that during certain waves or critical periods in the network over the past 2 years, there have been solutions that are often very innovative. Students were brought in for internships or to start work earlier to help the people on-site. Obviously, training orderlies en masse in Quebec, for example, so that they can come and help out in our various facilities, as well. So there are all sorts of tools. Calling on the public sector to give us a hand in the health care network from time to time. Breaking down the boundaries around certain professions, and saying, OK, maybe certain professionals can come and help the nurses or doctors to try and work more as a team. So there have been some innovative solutions. But now, you get the impression that since we’re no longer in a big wave of COVID, there’s a fear that things will stop, and that innovative solutions or ideas like making it easier for people from outside Canada to get to work here more quickly, that those things will be put on pause and we’ll go back to business as usual. Like a little bit more of all the administrative work that's a little bit slower, whereas during COVID we can point to a ton of examples where people got together and found solutions to really urgent problems. Cases where an emergency room was about to be shut down or the like, and people said: Let us work on this, we’ll find a solution. And the administration said, all right, we’ll support you, go ahead with your solutions.

Alya Niang

And what does all this mean for the average Canadian?

Dr. Judy Morris

It will be essential for regular Canadians to find solutions. In the years to come, that’ll be extremely hard. We’re short on workers in every part of the health care network. We’ll need to be more innovative. We’ll need to try new things. As we were saying earlier, we’ll need to put the focus on health care workers, because otherwise, as we’ve seen, if the system is overloaded, if the system can no longer keep up with patients’ demands, then the quality of care will suffer, unfortunately.

Alya Niang

CIHI’s data shows that patients admitted across Canada waited over 38 hours in emergency rooms at the start of the pandemic, and there are reports of certain patients waiting days before being admitted to receive care. Are we headed for longer wait times?

Dr. Judy Morris

Wait times were already increasing, but the figures from the past few months… the trend is continuing, and people are having to wait to be seen. And that has a perverse effect of driving certain patients away even though they should have stayed and been seen, because they often don't have access elsewhere. The wait time for a hospital bed is also increasing. So that's also causing delays, complications, and longer hospitalizations. It really has an impact on patients. It’s always important to try and take the patient’s perspective. Because all too often, when we see those figures of 150%, 180% in ERs, when we see wait times increasing by 10 hours, let's say, then often the people reading the newspaper or the political decision-makers and so on become desensitized. “Oh, well that’s not as bad as yesterday. Yesterday it was 200%.” So we really need to come back with a patient’s perspective and admit that it makes no sense to have to wait 8 or 10 hours to see a doctor. It makes no sense to wait on a gurney in the ER for 3 days with noise all around you and the lights on 24 hours a day while you wait for a hospital bed and proper care. We have to be careful not to get desensitized to these things. We can’t let them just turn into numbers on a page, because these are real patient experiences that are extremely difficult and unacceptable, actually.

Talking about wait times: You can't imagine how much it adds to a health care worker’s moral distress. Because you come in to work, there’s a 10-hour wait for patients, you’ve got 30 or 40 patients in the waiting room and you know that more patients will be coming in, some of whom will have critical needs and may require 30 minutes of our attention. It’s a mountain of work.

So being exposed to that day after day as a worker, with the sense that you’ll never see the end of it, that you won’t be able to serve these patients… it’s really hard. And that’s probably why some people quit. This isn’t what I imagined when I became a nurse, or doctor, or orderly. I didn't get into this to be completely buried by the workload. I did it to provide quality care. But now, to go faster, we have to cut corners a bit, maybe provide less optimal care. We’d like to spend time with a mom and her child to give them the right advice, but we feel rushed, so we go faster to see more patients, and that has all kinds of negative side effects, unfortunately, with that kind of workload for health care workers. It obviously leads to frustration. There’s frustration toward… Hey, why couldn’t they just get an appointment at a clinic? Or why does it take so long to get a consultation or an operation that I’ve asked for? So, all the other defects in the system add to this kind of frustration at not being able to serve our patients properly.

Alya Niang

Of course, of course. That is really frustrating. The current prediction is that this fall or winter may be difficult because of COVID and other respiratory viruses, which will increase the pressure on the health care system even more. How might we quickly resolve this to avoid shortages, and do you see any solutions that are being applied?

Dr. Judy Morris

What’s really hard, actually, is the state we currently find ourselves in. As I mentioned before, when we’d have waves of the flu, you know, people were working fine all year long, and then, boom! it gets more intense for a month. Now, every time one of these waves hits — and we even had a somewhat unexpected one this summer with COVID cases — we’re always thinking, hmm, how are we going to deal with these challenges? Are there any solutions? I think we really need to step up and acknowledge that this is a major issue. It needs to be a top priority for the various governments. It needs to be a priority to say: We need to take care of our health system, we need to add staff. And sometimes, it’s really about staff, it doesn't have to always be doctors. Yes, we’re short on doctors. Yes, we’re going to be short on health care professionals. But sometimes, we end up doing extra work because we don’t have enough administrative assistants. Because nobody’s there to take care of prescriptions or answer the phone. So we need to make it a priority for the whole network and ask: What do you need to do your work effectively, and how can we help with that? There needs to be a recognition of the work that people do. So probably… Obviously things are competitive all over, it’s hard to find workers, so we need to value the work that people are doing on the front lines in our health care centres. And probably, again as we were saying, we’ll also need new solutions, to not just keep working with the same old systems and solutions, but to say: Everything’s up for discussion, and we need to come up with initiatives to support our workforce and improve things quickly.

Alya Niang

Indeed. And do you see any solutions that are being applied right now?

Dr. Judy Morris

Ah. Well, it depends on the place. There have been a number of interesting initiatives in terms of recruitment, for example. Looking at how we can do better with less while waiting to get more trained staff. And then there are also places, hospitals or regions that will say: OK, let’s look at the resources we’ve got, what can we do to innovate, what can we do to review our processes and say, yes, here’s a place where we’re maybe not as efficient as we could be. So, let’s be more efficient and collaborate more. And there will certainly be questions that need to be asked in our system as well. Often, we do absolutely everything that we can. There may be a point where we’ll say: we can’t do everything. And there may be some more difficult decisions, let’s say, that will need to be discussed or addressed in terms of the level of interventions and care that we provide. Sometimes we push things to the limit just because we can, but maybe we should sit down and ask, what’s best for the population as a whole?

Alya Niang

Thank you, Dr. Morris, for being a part of our podcast today. I’m curious to see where we’ll be a year from now, because this is a major concern for most health care organizations and for our health care officials as well. So thanks once again for your time.

Dr. Judy Morris

It’s my pleasure.

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Alya Niang

The challenges to Canada’s health care systems will continue long after COVID-19 dies down, because we have a huge backlog of procedures to deal with, for which we’ll need a strong health care workforce. CIHI will be publishing important new data on this topic later this fall. Thank you for listening to our discussion today, and join us for our next podcast when we look at other health topics that are important to you.

Our executive producer is Jonathan Kuehlein. Special thanks to Aila Goyette and Avis Favaro, the host of the CIHI podcast in English. To learn more about the Canadian Institute for Health Information, or CIHI, visit our website at www.cihi.ca, where you’ll find reliable data on important health care measures throughout Canada. Don’t forget to subscribe to the Health Information Podcast and listen to it on the platform of your choice. I’m your host, Alya Niang. See you next time.

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