‘Nurses are not a commodity. We are human’: Kari, registered nurse, Toronto

During the COVID pandemic, Kari worked a typical emergency nurse schedule – two 12-hour day shifts, followed by two 12-hour night shifts, and then five days off. After night shifts, she had to stay awake during the day to help her children with their virtual schooling. “I found myself being awake sometimes for three or four days straight,” she recalls.

When she could get childcare on her off days, she’d crash, sometimes sleeping two days in a row. During her night shifts, Kari, a single mom, would pay a babysitter $100 a night to stay overnight at her place.

After calling in sick too many times because of exhaustion or lack of childcare, she was called into a meeting to discuss her attendance. But the human resources representative didn’t offer shifts that would better work with her parenting schedule, nor paid childcare support.

“It was hurtful, because it’s a department that I really love working for, and getting that kind of feedback was like, ‘OK, well, nobody cares. So, girl, you have to take care of you.’ ” Shortly after, Kari quit her job to work for a nursing agency.

“Choosing agency nursing gave me work-life balance and the financial freedom we all want,” says Kari, who requested a pseudonym out of concern for professional repercussions.

Erin Ariss, President of the Ontario Nurses association, says agency nursing is appealing because of its wages and the flexibility of scheduling. “Nurses want the ability to come home and be part of a family rather than feel broken after a shift,” she says.

Agency nursing is the term for staffing companies or agencies that hire nurses and supply hospital organizations when they require extra staff. Pay rates for agency Registered Nurses typically range from $70 to $100 per hour. Meanwhile, the maximum pay for a nurse in an emergency department is $54 per hour and starts close to $35 for more junior nurses.

Kari’s story is far from unique. Canadian hospitals hired outside agencies for 1.5 million hours of work in 2021-2022, more than double the 0.7 million hours in 2019-2020, according to data from the Canadian Institute for Health Information.

Ontario’s Auditor General has also raised the alarm of the ballooning costs of nurses for hire, with use of agency nursing rising several fold in many hospitals over the past five years. In a December 2023 report, an audit found that 30 Northern Ontario hospitals spent $73 million on agency nurses in 2022-2023. And it’s not just nurses that are shifting to fill-in work. The same Auditor General’s report notes that in 2022-2023, doctors filled more than 60,200 hours through Locum Programs at a cost $9.1 million. They are compensated an extra $75-190/hr for shifts above the base rate for covering rural emergency departments on short notice.

Despite the improved finances and work-life balance, Kari recently returned to a different on-staff job that, unlike her previous emergency role, offered eight-hour day shifts. She knows firsthand why fellow nurses pursue agency nursing, but she also sees how the reliance on agency nurses makes it difficult to uphold standards. Agency nurses might receive a two-hour computer training to familiarize themselves with work at a new organization, Kari says. “You’re kind of like a fish out of water.”

She says because agency staff are not part of the hospital organization, the focus becomes, “I’m going to take care of my patients and go home.” Morale suffers, especially when staff nurses know agency nurses are getting paid $100 instead of $50 per hour, Kari says. She has witnessed incidents of medical errors, or situations where protocols weren’t followed, only to find that the person responsible was an agency nurse. “It’s costly to the organization and it’s also detrimental to patients,” Kari says.

“I’m going to take care of my patients and go home.”

Doug Allan, from the Canadian Union of Public Employees, says the reliance on agency nursing necessitates extra work for the staff, since agency nurses new to a facility “don’t know where the washroom is, never mind the procedures in the facility. Hospital staff have to train these people, and they’re training people who aren’t going to be there tomorrow.”

Kari, as well as other nurses Healthy Debate interviewed for this article, says it’s frustrating when hospitals reach out to other organizations instead of offering their own staff incentives. For example, emergency departments, which can be highly volatile and require flexibility of staff to respond to new medical situations quickly, have been hard hit by staff shortages. But staff nurses in the ED, who are frequently on the receiving end of verbal abuse and violence, are paid only $1 to $3 more per hour (depending on their credentials, time of day and role) than nurses who work in more predictable daytime shifts and less stressful working conditions.

Nurses told us that hospital administrators are focused on bodies filling shifts instead of retaining their own staff by increasing pay, offering better schedules or other incentives. We reached out to eight different hospital organizations to comment on their use of agency nurses. All declined or didn’t respond to our request.

Moves to regulate agency nursing have started in some provinces. Nova Scotia aims to limit how often travel nurses fill in shifts and Quebec has expressed interest in banning the practice of agency nursing altogether. 

There are other initiatives to help hospitals retain staff and avoid the over-reliance on agency nursing. For instance, Kingston is providing signing bonuses for nurses who commit to at least two years at the hospital; Ottawa hospitals have offered nurses paid specialized training.

Ariss says “employers need to realize that nurses are not a commodity, that we are humans.” At a time when other professions offer flexible work-from-home or hybrid arrangements, employers should work with unions to bring more flexible, and human, scheduling into staff nurse positions, she says.

As a nurse who initially trained in the Caribbean, Kari says that nurses are highly respected in her culture. “When I go back home now, there are people in my community, some of the elders, who call me nurse,” she says. It makes her proud. She describes it as a “sacred calling,” to be there for people at some of the most difficult times in their lives. “They’re putting, at that moment, all their trust in me to help them navigate everything that they are experiencing.”

Another motivation for her is to be a role model for her children. “I do it for my children because I want them to be like, ‘My mom has a Master’s degree in nursing. Maybe I can get a graduate degree.’ ”

As much as she sees the problems with agency nursing, Kari says she’s tempted to go back for the pay. After rent, childcare, car insurance, student loan repayments and other basic costs, she can’t afford to take her children on vacation. She also can’t afford extracurricular activities for her children. “I had to pull my daughter out of soccer, which she loves,” she says.