The Canadian Association of Emergency Physicians (CAEP) feels dutybound to make public its concerns over the perfect storm that has arrived and engulfed our colleagues in emergency departments (EDs) across Canada. Without a viable workforce, the ultimate casualties will be our patients; thus, we are compelled to speak out.

This storm has been brewing for many years. Even prior to the COVID-19 pandemic, ED patients in Canada were facing long waits, with admitted patients blocking beds, limiting access to care for sick patients in the waiting room and on ambulance gurneys in hallways. This “access block” and the inability to provide proper care is but one of many factors that have led to staffing shortages and high rates of burnout. During the COVID-19 pandemic, we have heard ED staff described as health care heroes, but in truth many are suffering from PTSD and are poised to leave their profession.

We are witnessing this in physicians and allied health professionals, but most markedly in our nursing colleagues. Often the highest risk procedures, such as intubation of COVID patients, occur in the ED before admission to critical care units. Our ED nurses have borne the brunt of these challenges, assisting our doctors, while supporting their patients as they suffered alone, with no relatives allowed.

The ongoing pandemic has affected vulnerable populations in other ways, as well. Increased drug abuse has led to unheralded levels of psychosis and agitation within EDs, with physical and verbal aggression happening at unprecedented levels. Most nurses have reported being physically or verbally assaulted at work. Many of these patients require prolonged, direct contact and multiple high-risk procedures. In this context, it should be no surprise that hundreds of senior nurses have resigned and unprecedented numbers of others are planning to leave.

Our workforce, although resilient, has reached its limit, and we are alarmed at the exodus of our colleagues. Morale and staffing are at all-time lows. When departments are unable to adequately staff, it creates a domino effect of reduced access to care, increased burden on the remaining nurses on shift, increased infection risk and decreased patient safety. Mandated 16-hour shifts exacerbate physical fatigue as well as moral distress, heightening the domino effect. We view the situation as unsustainable and in need of immediate action.

Like many things in our complex health system, the reasons ED nurses are leaving are multifactorial and predate the advent of COVID-19. However, the pandemic’s effects have created a perfect storm, in which our nurses feel undervalued, unsupported, and disrespected by their hospitals, regions and provinces, and neglected by their national government. There are many examples across the country of provincial governments excluding ED nurses from COVID-related benefits, while making excessive demands on their time, paying only lip service to the notion of support when they need it the most. In the context of exhaustion from consecutive shifts and mandated overtime many have lost their sense of commitment to their EDs, and worse, their sense of commitment to the system. Nurses’ collective bargaining is largely limited by the fact that, as essential workers, legislation removes their right to strike. They can, however, leave the profession and many are voting with their feet, quitting in unprecedented numbers.

To fill nursing vacancies, departments have turned to hiring newly graduated nurses. While we value and respect their training and enthusiasm, they cannot immediately replace the experience and wisdom of a seasoned ED nurse. In fact, newly hired ED nurses require additional experience and mentorship from senior nurses before looking after the sickest patients, placing an additional strain on the remaining veterans. The loss of even one experienced ED nurse on a busy shift affects the functioning of the entire team and, by extension, patient care. The loss of multiple such nurses in the midst of a pandemic is clearly dangerous.

Although there have been many local media articles addressing this crisis, we believe this issue is a national one, affecting patients and healthcare workers across the country. Our hope is that immediate action will stave off a deeper crisis. As such, CAEP strongly recommends:

1. An urgent federal-provincial dialogue directed at providing support to emergency departments across Canada during wave 4.

2. Sustained efforts at addressing ED staffing, support, and mental health.

3. Acknowledgement of the essential role that nurses have, and continue to play, in the care of COVID and other critically ill patients and adjustment of their wages and benefits in a manner that is commensurate with their contributions to the health of Canadians.

4. Increased support for vulnerable populations who use ED resources, and for ED staff who are victims of violence in the workplace.

5. Federal leadership in instituting strategies to address access block and a renewed commitment to accessibility as a pillar of the Canada Health Act.

*** If you would like more information about this topic, please contact Christina Bova at 613- 523-3343 x17 (office), or email at cbova@caep.ca

Related Statement: Position Statement on Violence in the Emergency Department