Health care workers walk through the hallway as staff care for patients suffering from COVID-19 at Humber River Hospital's Intensive Care Unit, in Toronto on April 28, 2021.COLE BURSTON/AFP/Getty Images
The amount of money Ontario hospitals pay private nursing agencies has more than quadrupled since the first year of the pandemic, with agencies charging an average of $140 an hour for a registered nurse, according to new data provided exclusively to The Globe and Mail.
The number of hospitals in Canada’s most populous province that rely on agency nurses ballooned to at least 78 last year, up from 31 in 2020-21. Together, they sent more than $168.3-million in public funds to for-profit nursing agencies in the first three quarters alone of last year – a 341-per-cent increase over the $38.1-million hospitals spent on agency nurses in all of 2020-21.
The steep rise in the use of agency nurses in Ontario is more evidence of how the pandemic-era staffing crisis in health care is hobbling Canada’s medical system. Behind every headline about a closed emergency department or surgical backlog is the same root cause: Burned-out health care workers are retiring, switching to part-time schedules or leaving the public sector for what some consider the greener pastures of private staffing agencies.
“The nurses did not disappear in some kind of cosmic rapture,” said Alan Drummond, an emergency physician in Perth, Ont., whose rural hospital is counting on agency nurses – many of them living in hotels – to keep its emergency room open this summer. “They’re just voting with their feet, saying, ‘There’s no future in this.’ ”
Health leaders in other provinces, several of which also rely on temporary nurses, have complained openly about the high cost, with Quebec going so far as to pass legislation banning the use of private staffing agencies in the health care system by the end of 2025.
The long-term care industry is struggling, too. In February, AdvantAge Ontario, which speaks for non-profit nursing homes, released the results of a survey that found its members were being “gouged” by “predatory temporary staffing agencies.”
Private health care staffing agencies have played a small part in providing medical care to Canadians for decades. Traditionally, they shored up hospitals and nursing homes in an ad hoc fashion, supplying nurses, personal support workers and other crucial health workers for single shifts when an employee called in sick and nobody else was available to fill in.
The unpredictable nature of the work, coupled with its lack of benefits or a pension, used to make agency jobs less attractive than staff jobs, said Erin Ariss, a veteran ER nurse and president of the Ontario Nurses’ Association (ONA) – even though agency work paid more per hour.
But as COVID-19 simultaneously made hospital working conditions more punishing and nurses more sought-after, private agencies ramped up their recruitment efforts, raised the rates they paid nurses and persuaded some hospitals to offer agency nurses predictable schedules.
Agencies also increased the rates they charged hospitals, according to ONA’s figures, which don’t cite any of the private companies by name.
“Our tax money is going to these corporations,” Ms. Ariss said. “This is for-profit care. This is more privatization.”
ONA asked the Ontario Hospital Association (OHA) to instruct hospitals to share figures on their use of private agency nurses with ONA as part of contract negotiations, which ended in arbitration. In a decision released Thursday, arbitrator William Kaplan wrote that “the vast expansion of overtime and agency nurse usage – demonstrated by a truly astonishing growth in both – establishes a true recruitment and retention problem” for hospitals. He awarded nurses an average wage increase of 11 per cent over two years.
ONA shared the hospital data with The Globe, providing a rare glimpse into how heavily some hospitals have come to lean on contract workers to keep their emergency rooms, intensive-care units and other departments afloat since the pandemic began. The data cover the fiscal years 2020-2021, 2021-2022 and the first three quarters of 2022-2023.
Total reported hours worked by agencies
In thousands
Hospitals
449.7
2020-2021
31
2021-2022
649.0
58
1,187.6
2022-2023*
78
Average hourly amount paid to agencies
2020-2021
$74.38
2021-2022
$134.91
2022-2023*
$140.47
Total reported amounts paid to agencies
In millions
2020-2021
$38.1
2021-2022
$70.2
2022-2023*
$168.3
*April 1, 2022 to December 31, 2022.
MURAT YÜKSELIR / THE GLOBE AND MAIL,
SOURCE: ONTARIO NURSES’ ASSOCIATION
Total reported hours worked by agencies
In thousands
Hospitals
449.7
2020-2021
31
2021-2022
649.0
58
1,187.6
2022-2023*
78
Average hourly amount paid to agencies
2020-2021
$74.38
2021-2022
$134.91
2022-2023*
$140.47
Total reported amounts paid to agencies
In millions
2020-2021
$38.1
2021-2022
$70.2
2022-2023*
$168.3
*April 1, 2022 to December 31, 2022.
MURAT YÜKSELIR / THE GLOBE AND MAIL,
SOURCE: ONTARIO NURSES’ ASSOCIATION
Total reported hours worked
by agencies (in thousands)
Total reported amounts
paid to agencies (in millions)
Average hourly amount
paid to agencies
Hospitals
$74.38
$38.1
449.7
2020-2021
31
$70.2
2021-2022
649.0
$134.91
58
1,187.6
$140.47
$168.3
2022-2023*
78
*April 1, 2022 to December 31, 2022.
MURAT YÜKSELIR / THE GLOBE AND MAIL, SOURCE: ONTARIO NURSES’ ASSOCIATION
Over all, the union found that the average actual cost per hour of an agency RN for hospitals almost doubled to $140.47 last year from $74.38 in 2020-2021. (The actual cost includes the amount paid to the nurse and the agency’s share.) A handful of Ontario hospitals reported paying more than $250 an hour for agency nurses, a figure that could include accommodations and travel costs for out-of-town nurses.
By way of contrast, the top rate last year for a full-time ONA nurse employed directly by a hospital was $49.02 an hour, plus benefits and a pension.
Timmins and District Hospital has the distinction of spending the most on agency nurses last year. It paid almost $18.1-million for 110,014 hours of agency nursing between April 1 and Dec. 31. Two years earlier, in all of 2020-2021, it spent just over $2.4-million for 16,015 hours.
Other hospitals that have seen significant spikes in their spending on agency nurses include William Osler Health System, which oversees the Brampton Civic and Etobicoke General hospitals; Quinte Health Care, which oversees hospitals in Belleville and three nearby towns; Muskoka Algonquin Healthcare; Trillium Health Partners in Mississauga; and the Sioux Lookout Meno Ya Win Health Centre in Northwestern Ontario.
Those hospitals and half a dozen others The Globe reached out to declined interview requests. Most sent statements via e-mail describing the challenges that led to their greater reliance on agency nurses, including the nationwide nursing shortage and a steady rise in demand for medical care from a population that is both growing and aging.
Some cited local barriers to recruitment. Muskoka Algonquin, for example, has struggled to attract young nurses to cottage country, where housing is expensive and daycare scarce, said Diane George, vice-president of integrated care, patient services and quality at Muskoka Algonquin, which oversees hospitals in Huntsville and Bracebridge.
The hospital in remote Sioux Lookout, meanwhile, used to have “the advantage of being able to offer new graduates full-time positions, whereas the major centres had mostly part-time and casual opportunities to offer,” said president and chief executive officer Dean Osmond. “Today nurses are able to find employment in their home communities and don’t need to relocate.”
Hospitals that did not report agency use face similar headwinds – they’ve just opted to navigate them in a different way.
Instead of leaning on agencies, London Health Sciences Centre decided, beginning last November, to offer double overtime to staff nurses willing to work more than 75 hours in two weeks. Some small-town hospitals have resorted to occasional night and weekend emergency department closures rather than hiring private nurses whose presence might undercut staff morale.
Nurses who choose agency work often do so for the higher take-home pay and ability to control their schedules and vacation time, even though their jobs generally don’t come with benefits or a pension. Such flexibility is not usually available to young nurses on staff at the bottom of the seniority ladder.
Staff nurses sometimes find it frustrating that their temporary colleagues earn more per hour despite knowing less about their hospital’s processes, said Kat Anastasiou, an emergency nurse at Belleville General Hospital. She spoke to The Globe in her capacity as the ONA bargaining unit president for Quinte Health Care.
ONA’s arbitration brief mentions that Quinte Health – which went from using no private staffing before the pandemic to paying for more than 65,000 hours of agency RN time in the first three quarters of last year – was so desperate that it resorted to offering four- and six-week schedules and onsite parking to agency nurses, leapfrogging staff nurses who had been told onsite parking was not available.
Still, Ms. Anastasiou said, “I don’t think that this is a Quinte issue. I think Quinte, like many other hospitals, has just had to use the resources that are available to them because of what the province has done.”
She was referring to Bill 124, a controversial law that capped public-sector wage increases at 1 per cent a year for three years, including for nurses. In November, a court struck down the bill, and the government is appealing.
Ontario Health Minister Sylvia Jones declined an interview request. Her office also declined to respond to e-mailed questions. Instead, Hannah Jensen, a spokesperson for the minister, sent a statement saying the government had increased the health care budget by more than $18-billion since 2018 and that “the proportion of agency nurses has decreased from 3.8 per cent in 2017 and remains to be under 2 per cent of total hours worked in hospitals.”
Ms. Ariss of ONA disputes those figures. She said the data provided to the union show agency nurse hours and the proportion of those hours compared with staff nursing hours effectively tripled between 2016 and 2022-2023.