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Chronic overwork has become the new normal in health care - will collective action come next?

Overworked health workers are “past the point of exhaustion”

Healthcare workers logged more overtime in the second year of the pandemic than anytime in the past decade.

More than one in five healthcare workers logged overtime in 2021, according to the Canadian Institute for Health Information (CIHI). On average, workers clocked 8.2 hours of paid overtime and 5.8 hours of unpaid overtime per week that year – making up the equivalent of more than 9,000 full-time jobs.

And workloads appears to be increasing. As of April 2022, some 266,900 healthcare workers reported working overtime – the highest number ever.

Rising overtime signals “system-wide crisis”

A combination of workforce shortages and rising demand for services, in addition to pandemic backlogs, appears to be driving the trend.

“You’re increasing the amount or volume of services that need to be delivered to make up for what was not provided over the past two years, and then you’re adding on to that the overtime hours, which research shows results in burnout,” says Lynn McNeely, manager of health workforce information at CIHI.

Paramedics (45%), salaried family physicians (34%), and respiratory therapists (31%) were the most likely to report working overtime.

Andrew West, CEO of the Canadian Society of Respiratory Therapists, said rising overtime is “yet another signal of the system-wide crisis” exacerbated by COVID-19.

Respiratory therapists are not only providing their own specialized services, “but also they are filling gaps in the system left by other health professionals, including nurses,” West told CMAJ. “We are seeing respiratory therapists in emergency rooms doing double duty filling nursing roles while also providing respiratory care – the situation is untenable.”

Yet, working long hours is often taken for granted in health care. Especially in the context of fee-for-service work, there is no such thing as “overtime.”

“Overtime usually represents time spent at work above or beyond the ‘normal’ working hours – but what are normal working hours for physicians?” said Shannon Rupnarain of the Alberta Medical Association.

“What we are seeing in general is physicians caring for more patients who are increasingly needing complex care,” she said. “Patients have avoided care or have not been able to access care. Patients are sicker and diagnosed in later stages of diseases. Patients are coming to physicians frustrated and angry. Many physicians want to retire, leave the profession, or leave the province.”

Half of doctors working beyond capacity

Nearly half (49%) of family doctors recently surveyed by the College of Family Physicians of Canada (CFPC) reported working beyond their desired capacity, the organization told CMAJ. “High or severe work-related burnout is experienced around four times more by family physicians working beyond their desired capacity (32.1%) than those working at the desired capacity (8.7%).”

Family physicians who reported working beyond their desired capacity were also three times more likely to say they were considering or taking a break from work. And more than 15% of those working beyond their desired capacity said they “generally feel pretty good, but there are trying days,” compared to nearly half (44%) of those working at desired capacity.

In Ontario, doctors do not get paid overtime, “but we do know they work long hours,” according to the Ontario Medical Association (OMA). Almost three-quarters (73%) of 2,649 physicians surveyed by the OMA in 2021 reported some level of burnout, up from two-thirds (66%) the previous year.

“Physicians retiring prematurely, reducing their workloads, changing their scope of practice or leaving medicine entirely in response to burnout will exacerbate the situation for remaining physicians, resulting in a potential domino effect,” the OMA told CMAJ.

Solutions to reduce workloads

The OMA is calling for system-level efforts to address burnout and overwork including streamlining and ensuring fair compensation for administrative work, increasing work-life balance via organizational policy changes, and seamlessly integrating digital health tools into physician workflows.

“Physicians from all over the country are past the point of exhaustion,” said Canadian Medical Association (CMA) President Alika Lafontaine. Most of the 4,121 physicians surveyed by the CMA in 2021 reported unhealthy working conditions, including heavy workloads (60%) and long hours (56%), he noted. Nearly half (49%) said they were considering reducing their clinical hours by this year.

“The most resilient parts of any health system are the providers who work in them,” Lafontaine said. “In the absence of improving working conditions, physicians will be pushed towards shifting their clinical practice.”

Federal and provincial efforts to improve the working conditions in health care over the past two decades have been ad hoc and time limited, according to the Canadian Federation of Nurses Unions (CFNU).

As of last year, 45% of 4,467 practicing nurses surveyed by the organization reported severe burnout, up from 29% pre-pandemic. More than half of early (59%) and mid-career nurses (56%) said they were considering leaving their jobs within the next year. Nursing vacancies have already increased 133% in the first two years of the pandemic alone.

“This leaves those remaining in the profession with little hope unless there is clear, coordinated, and decisive action to change the conditions causing this dire situation,” CFNU warned.

Among other measures to reduce workloads, the organization is calling for legislated minimum nurse-to-patient ratios, minimum care standards, and support teams to take over administrative duties. Patient safety tools are already being used in some provinces including British Columbia and Ontario to flag inadequate staffing.

Will strikes come next?

Without enough staff to go around, however, few provinces are making efforts to reduce workloads. Hospitals across Ontario are offering nurses double pay for additional shifts to cover staffing shortfalls. Alberta has lifted a cap on daily physician billings to incentivize increased workloads. And Quebec policies mandating overtime and forcing part-time nurses to double their workloads have sparked protests.

In January, a sit-in by emergency nurses at Maisonneuve-Rosemont Hospital in Montreal closed the unit to all but the most urgent cases and forced the reassignment of their unit manager over working conditions. Sources told CBC News the emergency team at the hospital had logged more than 400 compulsory overtime hours during the first weekend of January alone.

According to emergency nurse Annie Fournier, the use of compulsory overtime should be an exceptional measure, but it is being used on a regular basis, undermining the quality of care. “This is our dilemma. Do we lose our license because we refuse to work, or do we lose our license because we are going to kill someone?”

Health workers across Canada launched more than 150 discrete protests between 2021 and 2022, according to the Armed Conflict Location & Event Data Project, which tracks demonstrations and political violence.

Strikes have also erupted in other countries facing staffing shortages and high rates of burnout among health workers. Notably, nurses and ambulance workers in the United Kingdom launched the largest strike in the history of the National Health Service earlier this month, with junior doctors set to join the action.

The global nature of labor concerns motivating this crisis “suggests there is something fundamentally askew with health workforce policy,” health policy experts Veena Sriram and Sorcha Brophy wrote in The Conversation. “More importantly, they are a harbinger of forthcoming labor disputes and systemic collapse if our health systems continue to be characterized by austerity, underinvestment, and neglect of health worker voices.”

Photo credit: kupicoo/ E+ via Getty Images

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