Ontario has a severe shortage of registered nurses. How did we get here?

Years of government restraint in health-care funding have contributed to a loss of more than 7,300 registered nurse positions in Ontario in a 10-year span, according to data from the Ontario Nurses' Association.

The data shows that 75 per cent of those RN positions - more than 5,500 - were cut from 2013 to 2016, a time when the former provincial Liberal government, led by Kathleen Wynne, tried to rein in health spending in an effort to balance the budget.

We were trying to balance the needs of the health-care system with the fiscal needs of the province," said Wynne in a recent interview with the Star.

Knowing what I know now about COVID, and had I been able to see that coming or had I understood that, then I might have made different decisions," said Wynne. But I never stopped and our government never stopped increasing funding to health care."

Wynne said hospital budgets went up by between one and three per cent every year. But those increases didn't keep pace with increases in the three main drivers of health-care costs - population growth, an aging population and inflation - according to a Financial Accountability Office of Ontario report from 2018.

Ontario currently has the lowest ratio of registered nurses in the country working in direct care, 609.3 RNs per 100,000 population, according to the Canadian Institute of Health Information.

Meanwhile, the ratio of lower-paid registered practical nurses to population went up by nearly 50 per cent in the decade from 2011 to 2020, as hospitals and other health facilities looked to cut costs.

Health care is the heaviest hitting item on the provincial budget, and we unfortunately have had successive governments that really haven't wanted to invest in it," said Cathyrn Hoy, president of the Ontario Nurses' Association.

The education and scope of practice for a registered practical nurse differs from that of a registered nurse.

Registered practical nurses have college diplomas and typically deal with stable patients, said Hoy. Registered nurses, who have universities degrees, get the unpredictable patient assignments," and are making assessments which they can then act on, she said. If a stable patient becomes unstable, then an RN takes over.

The ONA said that over the last decade it has seen a steady erosion of what was once considered RN work in hospitals, in units such as cardiac care, being given to RPNs.

For instance, during the pandemic in September 2020, Southlake Regional Health Centre in Newmarket came under immense fire from the union for eliminating 97 RN positions and hiring RPNs instead. The hospital said no RNs lost their jobs. Some retired or the positions were eliminated because they were vacant.

The hospital blamed financial challenges - it looked for savings in other areas first - and an inability to recruit RNs for the positions in the face of a shortage.

Wynne said provinces have struggled due to a decrease in federal funding for health care, from a 50-50 split to something closer to 75-25, with provinces paying the bigger share, which she said was not the original deal."

We were in a pretty ferocious battle with the federal government about health-care funding," said Wynne. We had not had any success as premiers with Prime Minister Harper. We had the conversation with Prime Minister Trudeau and we went on the record saying that we'd like to see the federal government step up and pay a greater share," she said. That's still the case. And I think that it's something that in the wake of COVID, it's going to be a renewed discussion between the federal and provincial governments."

There is no ratio in hospitals to dictate how many RNs should be on staff in relation to the number of RPNs, although historically, before the shortage, acute care departments staffed higher numbers of registered nurses.

Despite the elimination of positions, by 2020 the number of RNs in the workforce in Ontario had increased from the 2011 total by a small margin, but not enough to keep pace with the increase in the population.

And more were working in hospitals. But the gains during those years were slight - from just over 58,000 RNs in hospitals in 2011 to 64,176 in 2020, compared to a 50 per cent increase during that time frame of registered practical nurses, from 13,126 to 19,585.

It's estimated that more than 10 per cent of RN positions in Ontario hospitals are vacant, according to the nurses' association, and that there is a deficit of more than 20,000 RNs in the province.

The Ontario Hospital Association said many years of funding restraint within the province" has led to the current model of patient care, which includes a mix of RNs and RPNs, as well as other health professionals.

The irony is that the shortage of RNs has now forced hospitals to rely on even more expensive agency nurses to fill the gap.

The escalating cost of staffing agencies is of great concern to the OHA however hospitals in Ontario currently have no choice but to utilize agencies to provide coverage that ensures safe patient care," said Anthony Dale, president and CEO of the OHA. Immediate government funding to bolster staffing models would create more manageable workloads for staff, help increase retention rates, and allow hospitals to better respond to patient needs."

The Ford government has funded a limited expansion of positions for RNs in nursing schools and a program to fast track licensure for some internationally trained RNs who hold the right credentials.

But the situation could get worse amid a worldwide shortage of nurses.

In Ontario, nurses are leaving the profession because of higher patient workloads and burnout. And the Ontario Nurses' Association said more than 20 per cent of registered nurses are eligible to retire.

Many experts say repealing Bill 124, which holds salary increases of public sector workers, including nurses, to one per cent is key to retaining the current workforce.

Wynne called the bill ridiculous."

Bill 124 has created an enormous amount of trouble," she said.

Nurses have always been the front lines of health care but never more critical than during the COVID-19 crisis. In this ongoing series, we explore the many issues affecting nursing.

Patty Winsa is a Toronto-based data reporter for the Star. Reach her via email: pwinsa@thestar.ca