Health Committee on March 28th, 2022

[The Chair, Liberal, Sean Casey]

I call the meeting to order.

Welcome to meeting number 13 of the House of Commons Standing Committee on Health.

Today we will meet for two hours to hear from witnesses on our study of Canada's health workforce.

Before I introduce today's witnesses, I have a few regular reminders on hybrid meetings.

Today's meeting is taking place in a hybrid format, pursuant to the House order of November 25, 2021. Members are attending in person in the room, and some are attending remotely using the Zoom application. Our witnesses are, of course, using the Zoom application.

I would like to take this opportunity to remind all participants to the meeting that screenshots or taking photos of your screen is not permitted. The proceedings will be made available on the House of Commons website.

In accordance with our routine motion, I'm informing the committee that all witnesses have completed the required connection tests in advance of the meeting.

With us this afternoon for two hours are the following witnesses. As individuals, we have Sylas Coletto, registered nurse; and Brenda Payne, experienced nurse, educator, senior executive, and rural and urban consultant. We have Dr. Martin Champagne, hemato-oncologist and president of the Association des médecins hématologues et oncologues du Québec. From the Canadian Association of Occupational Therapists, we have Giovanna Boniface, president and registered occupational therapist; and Hélène Sabourin, chief executive officer. We also have Cynthia Baker, executive director of the Canadian Association of Schools of Nursing; and Bradley Campbell, president of Corpus Sanchez International Consultancy Inc.

Thank you to all of our witnesses for taking the time to be with us today.

We're going to begin with opening remarks from each witness in the order they appear in the notice of meeting. This means we're going to start with Mr. Coletto.

For the next five minutes, the floor is all yours. Welcome to the committee.

[Sylas Coletto, Registered Nurse, As an Individual]

Thank you very much, honourable members, for having me.

I am a settler, cisgendered, white heterosexual male. I am a critical care registered nurse with an honours bachelor's degree in kinesiology and a Bachelor of Science in nursing. I am currently working full time on a Master of Science in nursing.

I have been working as a nurse since January 2018. [Technical difficulty—Editor] in cardiac ICU, emergency and, during the main waves of the COVID-19 pandemic, general ICU work in both Saskatchewan and Ontario.

There is a saying among my colleagues: “Health care: destroying my life to save yours.”

I have elected to discuss three themes. These are abuse, balance and value.

First, on the theme of abuse—it happened to me within the last week—I have been sexually, physically and verbally assaulted. I've had various parts of my body groped and fondled. I've been punched and kicked. I've had verbal profanity and threats that I would be followed home and my family hurt. I've had blood splashed in my mouth. I've been spat on and had feces thrown at me. The list goes on. I have been repeatedly assaulted.

This is not an infrequent thing. These patients are completely aware of what they are doing, many times, and it's often much worse for my female colleagues. Like many nurses, I have stopped reporting these incidents. Nothing happens to the assailants. People continue to take advantage. Additionally, I do not have a permanent position. I do not have the benefit of taking paid sick days or personally seeking counselling. However, being constantly assaulted affects my mental health and my family life.

In terms of my mental health, I frequently witness death. That was exacerbated during the COVID waves. I have put many deceased people into body bags to be transported to the morgue. During COVID waves, there was not enough time to mentally process all of the death. I have had limited access to supports, and my mental health has suffered.

For example, I had two patients who were dying at the same time. This was the last time the family members would see their loved ones alive. I was holding up a FaceTime camera to one of them, and I had to tell the family to end the call—again, this was the last time they would see their family member alive—because I had to go and do it with another patient simultaneously. I wanted them to be able to say goodbye one last time. That was one of my very tough days.

In terms of balance, shift work is a very difficult thing to become accustomed to, with rotating days and nights and working 12 hours or more in a shift. I have little time to spend with my family. I have to rest so that I can be at top performance when I next go to work. I am accustomed to top performance. I have represented Canada for rowing internationally. But in this case, if I don't perform every day at work, people die, as we are currently seeing demonstrated in Tennessee, U.S.A. During COVID, I'm working in rooms with the sickest patients 12 to 16 hours continuously, hoping my mask stays sealed and I don't lose that seal, and scared that I will unknowingly contract COVID and bring it home to my family.

I have two degrees. I am working on a third. I have considerable on-the-job training. You would be lucky to be around me if something were to happen and you needed my help. But I do not have access to much assistance, be it financial or scheduling, to pursue my further education. I've had to put pause on many aspects of my career and compromise my work, not really being able to amalgamate the two. It's give up my income to support my family or go to school to try to elevate health care delivery, myself, and the profession to better people's lives. It's very difficult to accommodate both.

On the theme of value as a profession, with regard to representation on decision-making panels or boards, I have not seen very much of it throughout the COVID-19 pandemic. I was being told what to do by people who have never done my job. For example, on the COVID-19 advisory table in Ontario, there are 33 members. There are three leaders and only one RN on the panel, but 22 physicians. Nurses are the ones who are implementing what these advisory boards put forward. I am very confident that there are a lot of smart, well-educated nurses who could have contributed. This tells me that nurses do not matter and we cannot contribute. We have no value in decision-making.

On the theme of fiscal value, I have 13 years of post-secondary education and training. In Ontario, I make $36.53 an hour. In Saskatchewan, I make $6.20 more per hour, and that will go up at the beginning of April. It helps, but I am still underpaid. In Ontario, there's Bill 124, the 1% wage increase. I have been working harder and harder to save people's lives, especially during COVID. I believe I am worth far more than 1%.

As an example, during the COVID waves, we were so short of nurses in the ICU that we had residents, doctors in training, to work underneath us, assisting. They had no prescription rights and could not give medications unless I was right there with them. We were still making our same wage, but the residents were being paid $100 an hour. I felt undervalued.

The same thing was going on in the COVID vaccine clinics. Physicians were making $170 an hour during the day and $215 during the afternoon. We were doing the same job, but I was still making my same wage. I felt undervalued.

This job is taking my family time, deteriorating my mental health through abuse—physical, emotional and financial—and making me feel devalued. I am constantly wondering why I choose to continue to do this work, even though I believe I do good work.

That is what I have to say. Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Coletto.

Next, we have Brenda Payne. You have the floor for five minutes.

[Brenda Payne, Experienced Nurse, Educator, Senior Executive and Consultant (Rural and Urban), As an Individual]

Thank you.

I'd like to first thank the standing health committee for the opportunity to provide my perspective on this really important question surrounding what the federal government can do to address, as we've just heard, the acute and very critical recruitment and retention issues and workplace issues for many health care providers throughout our country, particularly with an emphasis on urban and rural communities.

I'm not representing a particular perspective but a whole perspective, in that my perspective has been influenced by my clinical knowledge, training and background—being a nurse. I have both knowledge and extensive experience in many aspects of our health system, which has enabled me to see truly a whole perspective, one that is inclusive of being a provincial public health servant as well as being a patient.

What I'm hoping to contribute to the discussion is an understanding of experiences related to this issue. Throughout this country we're hearing—not as eloquently as from the first witness—from all providers, the public, patients, clients, residents and their families that we are in a critical condition as it relates to recruitment and retention.

I wish I could say that this is the first time we have heard, or I have heard in my career, that there are issues with both the recruitment and the retention of providers, but I am here to say that in fact this is not a new issue. This is an issue that we have been wrestling with for many years and, as a result of the work that was done previously.... The federal government did some extraordinary work leading both the provinces and the territories in 2000 and onwards towards dealing with this same issue.

The issue for us today, however, is further compounded by the fact that we knew this was coming. We predicted—it was a known factor—that our retiring baby boomers would leave a big gap in the system, and a study that was done in 2009 actually predicted that there would be a shortage of 60,000 registered nurses. That is without the consideration of a pandemic, which truly has had a deleterious effect on our health care providers.

Before going into what the federal government can do, the next point is the acknowledgement that in our health systems—and we've studied them, whether on a provincial basis or a national basis, on a regular opportunity—our initial reaction is a very reactive one. We have tended to look at issues as if they were single entities that occur outside of the system.

My knowledge and my extensive experience have shown that in order to address this issue, we must work collaboratively and co-operatively to address what is before us, acknowledging that all levels of government in Canada—the provinces, the territories, our indigenous peoples and other under-represented groups, our education system, our employers in health professions and other relevant stakeholders—can actually come together to help solve this problem.

Having looked at what the federal government has done, we have actually had extensive work done with health human resources, and a strategy that was developed can continue to serve as a foundational document from which to jump-start some work.

My significant worry is that, as we speak, provinces and territories are having to address the shortage of critical personnel in order to provide care. As a result, they're coming up with lots of very innovative ideas. We just heard of one in terms of the increase in compensation, although at 1%. My worry is that unless the federal government takes a facilitating role to bring all parties together, we're going to be left with a further fragmented system and provinces functioning very differently from one another. As was done in the past, I would recommend that we bring folks together. We can do a number of things.

The other point I would like to make is that with the health system, if we're singularly focused, we are not going to be successful in addressing the issues that are before providers, patients and families. I'm recommending a pan-Canadian approach. I would offer that there are a number of things that we can do together to address.... Number one is really confirming, on the demand side, what the pan-Canadian vision is for health. We can begin to look at, identify and share what some really good strategies are to not only recruit, but retain our current providers.

In addressing some of the key workplace issues that have already been addressed by our first witness—

[The Chair, Liberal, Sean Casey]

I'm going to get you to wrap up, Ms. Payne.

[Brenda Payne]

I believe that there are greater risks for not using a pan-Canadian approach to the critical issue that we face. Canadians, our providers and every citizen in Canada are counting on all of us to be able to provide the services when they need it.

Thank you very much.

[The Chair, Liberal, Sean Casey]

Thank you, Ms. Payne. I'm sure you will get lots of opportunities to elaborate during the questions and answers.

Dr. Champagne, you now have the floor.

[Dr. Martin Champagne, President and Hemato-Oncologist , Association des médecins hématologues et oncologues du Québec]

The Association des médecins hématologues et oncologues du Québec represents 350 members aged 47 on average. Recruitment for this specialty is booming, as the need for oncologists is increasing all the time. We have 55 residents and 22 fellows in medical subspecialties because we must deal with the aging of the Canadian population. As you know, it is expected that approximately one in two Canadians will develop cancer in their lifetime.

People studying in the field have clinical responsibility for the diagnosis and treatment of a variety of hematological diseases, both cancerous and non-cancerous, as well as for cancer care. These people practise mainly in hospital settings. Unlike our colleagues in English Canada, in Quebec, we are also responsible for laboratory operations. The people in that environment have to absorb an explosion of knowledge, which has major repercussions.

The pandemic has had an impact on cancer care because, as has been pointed out, the health system has been oversaturated and a lot of activity has been offloaded. In Quebec, for example, 100,000 people were waiting for colonoscopy before the pandemic, the test used to diagnose colon cancer. Now, over 150,000 people are waiting for this test. We therefore estimate that a significant number of cancer cases have not yet been diagnosed including about one in five cases of colon cancer.

To put things in perspective, a colon cancer screening program is expected to reduce mortality by approximately 20%. In Canada, in 2021, an estimated 28,400 Canadians have been diagnosed with colon cancer and 9,400 will die from it. If offloading has had a significant impact, it means that many more people will die. In addition, because of the delay in diagnosis, the diseases are more advanced and require more intensive therapies. This leads to more morbidity, more complications and more mortality in patients.

At present, we hear of waiting lists for orthopaedic surgery that have grown much longer. But unlike patients who undergo orthopaedic surgery, cancer patients are in the health system for years. So it is not a one-off investment that will solve the problem; it will be necessary to make investments over a long period. Staff shortages have already been alluded to. In some key areas such as pathology, it will be essential that staff are well supported so that oncology recovery capacity is not limited.

The pandemic has had other major impacts. Prior to the pandemic, a survey of Quebec hematologists and oncologists was conducted. More than 80% of them said they had the support and recognition of their colleagues. However, there was a high rate of burnout. Of the respondents, 11% reported depersonalization, 40% reported emotional exhaustion and 16.5% reported psychosomatic problems, giving an overall burnout rate of 57%. These statistics are from before the pandemic, and at that time people were still committed to the profession. We felt Mr. Coletto's passion during his speech. People are still passionate and they still find their work fulfilling.

However, we are very concerned that the pandemic has resulted in less physical contact with patients and colleagues, and this will likely have a significant impact on burnout for all health care workers. According to a study of 153 doctors in Quebec, their stress level is unprecedented, at 61% compared to 35% before the pandemic.

What are the solutions?

Diagnostic standards of treatment and supervision already exist in oncology. So we don't need new standards. But we do need resources. This means investing in health care to improve infrastructure, train staff and facilitate automation in laboratories. I think that the federal government will be able to increase its contribution to health care, not only on a one-time basis, but on a recurring basis to meet the needs in hematology and oncology.

The health care system must be focused on value, not just cost reduction, to maximize patient outcomes with the resources available. This means having an organized and integrated continuum of care. We need information systems. Currently, we are in the Stone Age. We still have systems that are difficult to consult and not complementary. We must therefore facilitate the integration of data through artificial intelligence.

This requires incentives, particularly financial incentives, aimed at aligning the objectives of health care institutions with value. This requires investments in artificial intelligence and computer networks.

In addition, we must facilitate access to the medical professions for new immigrants who are properly qualified to facilitate recruitment and integrate them into a process of onboarding and socialization.

Finally, I would like to highlight the distress of people working in the health sector. We must increase support for organizations that help professionals, such as the Québec Physicians' Health Program. I am referring to doctors, but this applies to all health sectors. We feel that this is essential to combat the psychological distress observed among health professionals.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Champagne.

Next, we're going to hear from the Canadian Association of Occupational Therapists. Ms. Boniface or Ms. Sabourin will speak for the organization.

[Giovanna Boniface, President and Registered Occupational Therapist, Canadian Association of Occupational Therapists]

I will make the remarks for today. Thank you.

[The Chair, Liberal, Sean Casey]

Welcome.

[Giovanna Boniface]

Thank you.

Good afternoon, everyone, and thanks for the opportunity to present to you today.

I'm Giovanna Boniface, president of CAOT and an occupational therapist who has been practising for 25 years.

I'm joining you today from North Vancouver, which is situated on the lands of the Coast Salish people.

[Hélène Sabourin, Chief Executive Officer, Canadian Association of Occupational Therapists]

Good afternoon.

My name is Hélène Sabourin.

I'm a registered nurse. I'm currently CEO of the Canadian Association of Occupational Therapists.

I'm speaking to you from Ottawa, on the traditional lands of the Algonquin Anishinabe peoples.

Thank you for the opportunity to meet with you. I have had the privilege of meeting some of you.

[Giovanna Boniface]

We would like to talk about two things today: OT workforce issues and challenges, and making the case for universal access to OT.

The OT workforce in Canada has grown from some 7,500 therapists in 1997 to over 20,000 in 2021. Although we have seen good growth, this is absolutely not enough. OTs are an essential part of the primary care team, supporting seniors to age in place, providing vital mental health services, supporting kids with autism, helping to tackle the opioid crisis, supporting indigenous communities and providing long COVID rehab services, to name a few.

Only 3.7% of our workforce is in rural settings, which is very misaligned compared to the 20% of Canadians who live rurally. Eighty-five per cent of our workforce is frontline professionals, delivering vital care in hospitals, community health and long-term care settings.

Demand continues to grow exponentially, and supply simply has not kept pace. The 2013 national survey of 60,000 Canadian physicians found that over 70% expressed difficulties in referring patients to publicly funded OTs. In addition, the Government of Canada's Canadian occupational projection system validates that OT is one of the professional categories where demand will exceed supply until at least 2028. During this time, OT job openings are expected to outpace the workforce by at least 20%. Further validation comes from our provincial and territorial OT associations, who consistently report difficulty in securing therapists for vital positions. For example, earlier this year in Edmonton alone there were over 70 OT positions that were posted and couldn't be filled.

In a 2021 report, Canada's chief public health officer said that COVID provides an opportunity to address long-standing gaps in the health care system, and we could not agree more. OTs, because of their education, competencies and scope of practice, can make an invaluable contribution to transforming the current expensive hospital-centric medical and sickness care model to a less expensive patient community-centric health and wellness model of care. The latter, emphasizing health promotion, disease and injury prevention and management, is well within the scope of function and occupation-focused OT practice. COVID has also demonstrated the critical need for interprofessional, team-based primary care models that include OTs.

So what's the problem? OT services are not widely covered as part of public and private extended health benefits plans, with only five major insurance companies having OT coverage listed as a flex option, meaning that it's not automatically included in plans. Many employers, including the Government of Canada, do not cover OT services in their health benefits plans. With so little coverage, we are seeing Canadians incur out-of-pocket expenses to access services for their autistic child, their teenager who may be struggling with suicidal thoughts, or their parents who want to age in place and need home modifications, to name only a few scenarios.

What's the solution? Occupational therapy must be part of the basket of publicly administered, universally provided health care services. The status quo is absolutely not acceptable and inaction is no longer an option. Canada needs a comprehensive and integrated primary care strategy that includes OTs on all primary care teams across Canada. This will positively impact the health care system by improving the patient experience: the right quality of care, the right time, by the right regulated health professional in communities where Canadians live, study, work and play. This also delivers positive health outcomes, all while reducing per capita health care costs.

At no other time has the impact of disruption on daily lives and function been more apparent. Everyone has been affected by COVID. OTs are function- and occupation-focused regulated professionals. This is in our DNA. Ensuring that Canadians have access to this necessary service is critical to their health.

The time is now. OTs should no longer be considered a nice-to-have option in health care. OTs are must-have health care professionals who can help transform the health care system to better meet the needs of Canadians.

Thank you very much for the opportunity to present to the standing committee today.

[The Chair, Liberal, Sean Casey]

Thank you, Ms. Boniface.

Next we're going to the Canadian Association of Schools of Nursing.

Cynthia Baker, executive director, you have the floor for the next five minutes.

[Dr. Cynthia Baker, Executive Director, Canadian Association of Schools of Nursing]

Thank you.

My name is Cynthia Baker. I'm the executive director of the Canadian Association of Schools of Nursing.

I'd like to respectfully acknowledge that the CASN national office is located on unceded Algonquin territory.

Thank you for providing me with this opportunity to speak on behalf of our 95 member schools of nursing in Canada offering baccalaureate and/or graduate programs in nursing.

The CASN is the national voice for nursing education. We work to promote high-quality nursing education in every territory and province of Canada, in both official languages.

Personal care workers, practical nurses, psychiatric registered nurses, registered nurses and nurse practitioners are all important members of the nursing health care team.

As registered nurses form the largest group of health professionals in Canada, and as vacancy rates for this category of nurses are soaring across the country, I will focus my presentation on them.

COVID-19 has been filling hospital beds. The number of older adults requiring care is increasing, and experienced nurses are leaving the profession in large numbers. Schools of nursing in all provincial and territorial jurisdictions are responding to government demands to increase seats, open new sites and/or offer additional programs of nursing.

This follows a two-year period of repeated curricular disruptions with the pandemic shutting down—

[The Chair, Liberal, Sean Casey]

Ms. Baker, I'm sorry to interrupt. Can you drop your mike down maybe about a quarter of an inch? Let's try that and see if that works. We're getting a little bit of static. Go ahead and see if that's okay.

Don't worry; we'll add to your time.

[Dr. Cynthia Baker]

Okay.

As I said, there have been repeated curricular disruptions—

[The Chair, Liberal, Sean Casey]

Just a second, Ms. Baker. I took you the wrong way. Can you put the mike between your nose and your top lip?

[Dr. Cynthia Baker]

Okay.

The pandemic shut down students' access to clinical placements and their access to in-person classroom and laboratory learning. The demands on nursing educators and on nursing students have been heavy.

CASN conducts an annual nursing student and faculty survey. The number of new RNs—

[The Chair, Liberal, Sean Casey]

I'm sorry, Ms. Baker. My advice is making it worse. Move it up a little higher, please.

[Dr. Cynthia Baker]

How's that?

[The Chair, Liberal, Sean Casey]

I think we're in good shape now.

I'm sorry for all the interruptions. Go ahead.

[Dr. Cynthia Baker]

Okay.

CASN conducts an annual nursing student and faculty survey. The number of new registered nurses entering the health care workforce has climbed steadily from a low of 4,816 in 2000. In the last five years, schools of nursing have been graduating more than 12,000 RNs annually, a higher number than has ever been the case.

This requires qualified faculty, experienced clinical instructors, well-equipped simulation labs, good library resources and appropriate clinical placement sites. Nursing faculty have been stretched to the limit, and clinical placement sites, which are essential to nursing education, are saturated. Additional nursing seats and nursing programs require more faculty, more resources and more clinical placement sites, which currently do not exist.

Canada's nursing schools are facing significant pressures and numerous challenges.

The quality of nursing education, however, is critical to the health and well-being of Canadians. Nursing is a complex and emotionally demanding profession. It requires an in-depth theoretical and scientific foundation, strong clinical reasoning skills, solid clinical judgment, honed technical skills, compassion, caring and emotional resilience. Nursing incompetence or a nursing error can put a patient's life in jeopardy.

The quality of nursing education is also critical to nursing retention. Studies demonstrate that nursing graduates lacking the appropriate academic preparation and lacking appropriate transition support when they enter practice are liable to leave the workforce within a year or two. Cutting corners to increase the number of nursing graduates does not produce a safe or sustainable nursing workforce.

There's an urgent need to increase the number of clinically competent, retainable registered nurses in the nursing workforce in all Canadian jurisdictions. There is also an urgent need to overcome significant obstacles if this is to be achieved.

Given the complexities of nursing education, nursing school administrators need to have a seat at the table.

Investment in nursing education and the inclusion of nurse educators in developing strategies to address the current health care workforce crisis are critical.

The areas of nursing education that offer potential solutions to a sustainable nursing workforce will be outlined.

Number one is to increase the number of new registered nurses without sacrificing quality through advanced-standing baccalaureate nursing programs for individuals who already have a degree in another discipline. These programs run throughout the full year with four terms instead of two and are therefore completed in two years without any reduction in the curriculum. There was a high demand for admission to these programs. Their graduates typically excel as nurses.

Number two is to increase the number of internationally educated nurses entering the nursing workforce through an increase in collaborative and more standardized bridging programs offered by post-secondary institutions.

Number three is to increase the clinical competence and the retention of registered nursing graduates by supporting their transition to practice through six- to 12-month residency programs. Multiple studies in the United States and Australia have shown that such programs increase safety and the clinical competence and the job satisfaction of new graduates, while reducing employers' turnover costs.

In conclusion, with investment in nursing education, collaboration among nursing education, governments and health care services, and a national commitment to conserve the high quality of nursing education that Canada is known for internationally, the nursing crisis can be resolved. The Canadian Association of Schools of Nursing is strongly committed to contributing to solutions.

On a positive final note, despite increasingly complex health care conditions, applications for admissions to baccalaureate programs in nursing across the country are very high. It's a testament to the potential tenacity of our future nurses.

Thank you for the opportunity to shed light on some of the issues related to nursing education and the nursing shortage, and to recommend solutions.

Thank you for your attention.

[The Chair, Liberal, Sean Casey]

Thank you, Ms. Baker.

Next, from Corpus Sanchez International Consultancy Inc., we have Bradley Campbell.

Welcome to the committee. You have the floor for the next five minutes, sir.