Recalibrating healthcare to create a more equitable post-pandemic work environment

Initial impact of COVID-19 on work

The early days of the COVID-19 pandemic brought about a rapid and dramatic impact on work routines for many Canadians. In the months from February to April 2020, COVID-19-related losses in hours worked reached 32%, with a corresponding 15% decrease in employment. ¹ The losses were disproportionately experienced in sectors that could not deliver services through remote work such as hospitality and service industries. ² These sectors often employ staff who have lower income levels, and these workers are more likely to be younger, racialized, and have lower income.^1,3 Between February and April 2020, 1.7 million workers across Canada were laid off or had their work hours reduced due to COVID-19. This group included 1.2 million women, or 69% of affected workers. ³ Workers in this group were more likely to be recent immigrants, racialized, or working in jobs that carry a high risk to exposure to COVID-19, ⁴ with dramatic losses in jobs. It should be noted that industries such as oil sands and meat packing with similar risks did not see similar layoffs or loss of hours as these sectors remained open during the early months of the pandemic. Statistics Canada data show that one year into the pandemic (March 2020 to February 2021), this unequal impact remained: the largest declines in year-over-year employment occurred in service industries, with women accounting for 53.7% of these losses. ²

The specific impact of COVID-19 on the healthcare industry

The key role of healthcare in the COVID-19 pandemic could logically lead to the conclusion that the industry would be relatively immune to job losses. In fact, Canadian healthcare has largely been buffered overall, showing a small number of job losses early in the pandemic that were recovered by the end of 2020. ⁵ The lack of increasing unemployment among healthcare workers, however, is a somewhat misleading statistic when it comes to the impact of the pandemic on the industry. In some cases, such as personal support workers, COVID-19 restrictions limiting work to single healthcare sites caused significant reductions in the numbers of hours available and pay for the women who occupy nearly 90% of these positions. ⁶ Although these changes dramatically impact healthcare workers, the changes are not reflected in employment rates.

While overall employment numbers pretend a level of stability, employee demographics and other emerging challenges for women in particular suggest a looming problem in healthcare. The national nursing shortage in Canada—a field in which 87% of the positions are filled by women ⁷ —has been exacerbated by the pandemic. A survey of 2102 nurses in Ontario found that 15% were likely or very likely to leave the profession after the pandemic, with an additional 25% indicating that they were somewhat likely to leave. ⁸ If only those who indicated that they were “very likely to leave” actually left nursing, this would represent twice the typical annual loss in the profession. Against the backdrop of an existing crisis in nursing, significant declines in qualified practitioners would be catastrophic.

The negative impact of COVID-19 on women in healthcare may have long-lasting consequences. A recent systematic review of occupational stress and burnout found that female healthcare workers were more likely than males to experience psychological stress and burnout. ⁹ The removal of women from the workforce as a result of mental stressors whose impact is similar to post-traumatic stress disorder is likely permanent. The severe mental stress and anxiety resulting from working during the COVID-19 pandemic will create workers who are uninterested in returning to an environment that was seen as inflexible in its ability to prioritize the mental health of its employees.

Although some women who exited the job market may have intended to do so temporarily in order to deal with the acute pressures of child or family care that worsened during the pandemic, re-entry may be difficult. It is widely recognized that women, in particular women with families, experience a “motherhood penalty” because of societal beliefs surrounding the inability to balance work and family commitments. This view would limit the ability of women to re-enter the workforce, depriving female-dominated professions like healthcare of highly qualified and needed employees, and negatively impacting the socioeconomic status of women.

The biology of COVID-19

The disproportionately negative effects of the COVID-19 pandemic on the socioeconomic status of women could be explained by a more significant impact on health associated with SARS-CoV2 infection. In fact, the Global Health 50/50 Sex, Gender, and COVID-19 Project ¹⁰ reports that as of August 24, 2021, cases are equally distributed between men and women across the globe. In the United States, women account for 52% of confirmed cases, and in Canada, cases are split 50–50 between the sexes. In contrast to the relatively equal distribution of confirmed cases between the sexes, men have higher case fatality rates across all age groups,^11,12 and ICU admissions are almost three-times higher than women. ¹² These studies suggest that the more negative socioeconomic impact of the pandemic on women cannot be explained by greater rates of infection or more severe illness.

Despite better acute outcomes in women with COVID-19, the emerging long-term consequences are not as positive. Prolonged symptoms of SARS-CoV2 infection—commonly known as “Long COVID”—are up to five-times more likely to occur in women than men. ¹³ The chronic nature of this post-infection condition has and will continue to have an inordinately negatively impact on women, both at work and home.

Lingering impact of COVID-19 on employment for women

When exploring the disruptions of the COVID-19 pandemic, Qian and Fuller ¹⁴ identified that women had higher pre-pandemic employment levels than men in nonparents (92.7% and 90.2%, respectively). In March 2020, employment fell to about 87% for both genders. ¹⁵ Their second report extends the study horizon, detailing the inequitable impact on women’s employment relative to father’s employment between February and October 2020. While fathers of younger (below age 6 years) and older (6–12 years) children saw employment levels rebounding to pre-pandemic levels by October 2020, women fared less well. By October 2020, employment rates for women with younger children remained 4.9% below February 2020 levels. Women of older children experienced more recovery, although employment rates remained 2.9% lower, even as schools largely reopened.

While this may not be surprising when it comes to gender norms and the prevalence of caring expectations for women, it is worthy of further exploration when taken in concert with data regarding the opportunity for remote work in Canada. Research indicates that approximately 40% of Canadians hold jobs that can be performed remotely. ¹⁶ This prevalence generally increases with income and education levels. ¹⁷ Women are more likely than men to hold positions that can be done remotely. This is consistent across unattached (50% of women vs 33% of men) and dual earner families (62% of women compared to 38% of men). ¹⁷ Given that women are more likely to have the opportunity to work from home, it becomes more urgent that we address the underlying reasons that this possibility is not coming to fruition, particularly in healthcare.

An ethical path forward

It is clear that the COVID-19 pandemic has more negatively impacted the social and economic status of women, compared to men. While the acute consequences of COVID-19 in terms of illness severity and mortality are unable to explain this discrepancy, the lingering effects of Long COVID will likely continue to disrupt the lives of women for some time. A return to “normal” where the social and political factors that made women more vulnerable to socioeconomic turmoil are re-established is an inherently unethical path to follow. Recreating social and economic environments that are known to destabilize the lives of women and consign them to greater risk for economic injury, without efforts to mitigate recognized hazards, would be an immoral choice, particularly while the health challenges of Long COVID place women in a precarious position.

The combination of chronic medical concerns and societal structures that put women at greater risk for socioeconomic turmoil demands sociological and political change. While much remains unknown about COVID-19 from both a biomedical and social perspective, it is clear that the path forward requires a dramatic rethinking of medical and societal structures to prevent an inevitable catastrophic repeat with another health emergency.

The moral basis for these necessities stems from obligations to employees and patients alike. Creating a supportive and flexible work environment allows for the retention of workers, especially those who require accommodations to balance work and life commitments. Otherwise, these employees will have no choice but to exit the job market to meet family and other personal obligations, while simultaneously increasing their vulnerability to economic danger. Furthermore, the retention of experienced and capable employees allows for the maintenance of care provided to patients. Knowingly ignoring changes that could be accommodated by the healthcare system puts employees and patients at risk—albeit different risks—and is an ethically unsustainable path.

The COVID-19 pandemic has accelerated the need for flexible arrangements, including asynchronous work and working from home. These arrangements were initially necessary to comply with public health directives and over time and have shown themselves to be manageable and effective for workers and employers alike. However, there are challenges. It can be difficult to lead in an environment when team members have divergent core working hours and are not available for collaboration. This can be compounded by the perception of inequitable treatment of employee needs or preferences by management, which can further strain team dynamics. As the pandemic eases (or more likely continues to ebb and flow), it may be difficult for all employees to revert to a fully on-site arrangement: some may be unable and others unwilling. Leaders need to consider and prioritize ethical issues in reaching organizational goals in this new reality. Specifically, equity, diversity, and inclusion principles are critical when balancing the needs of the individual and the team, and a failure to weigh these elements in creating new work environments would unfairly put the most vulnerable workers at risk for stress, anxiety, and even job loss. Supportive arrangements and a culture of inclusion are key to retaining top talent and are core ethical considerations for creating an equitable work environment.

For those in direct service or care provision there are roles where remote options are scarce or do not exist. This inherent inequity requires broader policy interventions. Government directives or supports may be necessary to ensure workers in these sectors have sustainable options for service and care delivery. In smaller or remote communities, barrier reduction to facilitate remote administrative work or provision of virtual care may need government intervention or infrastructure investments such as reliable high-speed internet capacity, or more consistent cellular service. Individual employers can impact these obstacles through inclusion of internet or cellular plans to ensure reliable work-from-home options.

Where remote options do exist, it is our ethical imperative as leaders to be creative, flexible, and responsive to the needs of workers, and to facilitate collaboration in ways that were less practised prior to the pandemic. For direct care roles, creative work arrangement will be an important lever for minimizing burnout and fostering retention, issues that particularly impact women in healthcare. ⁹ For example, non-traditional job-sharing arrangements could see employees sharing both a frontline role and an administrative or management position. While this can offer relief from the demands of direct care provision, it may require allowances within collective agreements where employees occupy both a union and non-union position. In all areas, this will include managing employee expectations of their co-workers. Coming together for work can be meaningful without being in person. These strategies are critical to maintaining women in the workforce. Adding benefits or restructuring total compensation packages to include support for caring responsibilities can create stability for women in the workforce by redistributing risk and reward with more gender equity: more flexible childcare arrangements, flexible work hours, overnight childcare to support shiftwork can be critical success factors.

There is a price for these interventions and shifts. Some are more significant than others. We cannot allow the COVID-19 pandemic to undo long strides in gender equality or maintain a reality where parenting young children is generally incompatible with meaningful employment. Societal norms for women still include the larger share of caring responsibilities. The most significant cost would be to lose the presence and contributions of women in the workforce and create instability and risk for future generations. Leaders must not only support, but champion the differential needs of employees with the goal of preserving financial autonomy for women and families. Modelling appropriate boundaries within teams working asynchronous and leveraging technology for success rather than ubiquitous work will be foundational tenets for the leadership as we emerge from this pandemic and prepare our workplaces and workforces for the next significant disruption. This must be accompanied by investments in data collection on service provision, clinical outcomes, patient satisfaction and the impact of the pandemic on our workforce. Only then will evidence-based decisions be available to those that chart the course to our new normal.