It's a damning, disastrous cycle: Not enough nurses to fill shifts. Rushed and harried staff who must scramble to provide proper care for patients. Young nurses scared off by poor working conditions, just when they are desperately needed to fill vacancies. Mid-career nurses who burn out and flee the profession, creating even more empty spaces.

This interminable sequence has dogged the nursing profession for more than 10 years in Canada, ever since cutbacks in the early '90s culled nurses and nursing students from the health-care system to help balance budgets.

There have been myriad calls for help from nursing unions and organizations, from academics and policy analysts, and from the front-line nurses themselves.

Five-and-a-half years ago, Roy Romanow's landmark report on Canadian health care highlighted the need for immediate action to stem the tide of dissent and dissatisfaction in the nursing profession. The report called for major investment in nursing and other health professions, along with a comprehensive, cross-country plan for the future of Canada's health-care workers.

Yet, experts say little has been done to shore up the flailing workforce. Roughly 20,000 nurses are currently needed in Canada and upwards of 40 per cent of the country's 250,000 nurses are eligible to retire in the next five years. And they warn the real crisis, which will affect all facets of health care, is still to come: Retiring nurses are poised to leave the profession just when they'll be needed most to care for the country's aging population.

"The situation has gone from worse to worse," says registered nurse Linda Silas, who represents 158,000 of her colleagues as president of the Canadian Federation of Nurses Unions.

Right now, she says, Canadian nurses are working 18 million hours of overtime every year – the equivalent of 10,000 full-time jobs.

A new, comprehensive study of the nursing situation, commissioned by the federation and obtained by the Star , will be released Monday. It includes 10 recommendations to governments and policy-makers on how to deal with the ongoing shortage.

"We're saying to governments across the country, you've studied nursing to death, now it's time to talk and to implement action, real action," says Silas.

Victor Magdalena, the report's key author and assistant professor at Dalhousie University's school of health service administration, says the problem requires change and co-ordination by all levels of government – something Romanow also recommended – and something that hasn't yet been accomplished. So far, he says, there have only been piecemeal, stopgap solutions to stem the shortage. Almost always, the main strategy to fill the holes is to draw on nurses already in the system.

"That will fail really quickly because you burn out the nurses you already have," says Magdalena.

The biggest problem, and one that has had the least attention, is the poor working environment for nurses. Magdalena says no one would expect an airline pilot to work double shifts or to forgo vacation time or to only go home for four hours between shifts.

"You would never put your pilots in a situation where they are overworked to where their own health is at risk and the safety of patients is put at risk the same way that is being done with nurses."

Studies have shown overwork and poor working conditions lead to decreased care for patients. The 2005 National Survey of the Work and Health of Nurses found strong links between medication error and both work organization and work environment. Twenty-two per cent of nurses who usually worked overtime reported medication error, for example, compared to 14 per cent of those who did not work overtime.

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A 2002 study published in the Journal of the American Medical Association found patient mortality increases by 7 per cent for every patient added to a nurse's average workload. Also, cuts in nursing administrators mean nurses now spend more time at a computer and less at the bedside. And more and more nurses are required to take on porter and housekeeping duties.

Registered nurse Heather Cross has worked for 32 years at the Greater Niagara General Hospital. She hadn't seen much positive change on the front lines since the Romanow report came out. Rather, she says, there has been a notable decline in the work environment in the last five years.