Nurse shortage impacts patient care
Nurses who work on the fourth floor of this Toronto hospital are all too aware that a large part of their daily duties consists of trying to keep a lid on the chaos that is forever threatening to burst forth.
The patients who pass through the unit all suffer from severe forms of dementia and require extremely high levels of attention. They’re largely unable to function on their own and often display disruptive or violent behaviour. To maintain order, the nurses must work at a daunting pace, tending to their patients’ medical and personal needs as well as keeping them under constant surveillance.
But on the day of our visit, any semblance of order has disappeared. A patient has stopped breathing and the nurses have all rushed off to revive him. In their absence, pandemonium erupts. One man bangs his fists violently on his chair, shouting for his dinner. Another frail patient manages to slide out of his wheelchair seatbelt and staggers around the ward like drunken man – it’s a miracle he doesn’t fall. A third begins to disrobe, to the consternation of patients and visiting family members.
It’s obvious to even the deched observer that there simply aren’t enough nurses on this floor to cope with emergencies. Too few nurses are expected to handle increasingly heavy and acute patient loads – hang around any nursing station long enough and you’re bound to hear that complaint.
As the recent outbreak of SARS in Toronto brought painfully to light, it’s becoming clear to all that our overstretched nursing workforce isn’t equipped to handle a crisis situation. And as the ratio of nurses to patients continues to flounder at historically low levels, doubt is growing about how much longer they’ll remain capable of handling even routine duties.
Not enough nurses
Canada is experiencing the first grips of a severe nurse shortage that’s being increasingly felt in emergency rooms, intensive care units, operating theatres and nursing homes across the land. Veteran nurses, unable to handle what’s become an unbearably stressful job, are leaving the profession. Desperately needed recruits are being turned off, choosing careers that offer a better quality of life.
The nurse shortage affects every province in Canada with the northern territories being particularly hard hit. Right now, nurses are most scarce in hospitals, a sector that employs 63 per cent of Canada’s 231,000 registered nurses (RNs), though, not surprisingly, rural communities, long-term care and home care (which pay as much as 20 per cent less than hospitals) also feel the pinch.
“It’s not unusual to hear stories of one RN for every 50 patients in a long-term care facility,” says Rob Calnan, president of the Canadian Nurses Association (CNA). “This whole situation needs to be corrected.”
The seriousness of the shortage depends on which study you look at. A Canadian Institute of Health Information/Canadian Federation of Nurses Unions report finds we need about 16,000 more nurses across Canada to bring the nurse-to-population ratio (ideally, 80 nurses per 10,000 Canadians) up to an acceptable level. Still another study by the College of Nurses of Ontario suggests Ontario alone needs 15,000 more RNs to ensure the delivery of quality care.
Next page: Where have they gone?
Either way, we don’t have enough, and close observers predict the situation will only get worse if nothing is done. A recent study carried out by the CNA found that if current hiring and workforce trends continue, this country could be short as many as 78,000 nurses by 2011 and 113,000 by 2016. And this shortfall could not come at a worse time. “As the population ages, the demand for nurse services continues to grow,” says Calnan. “Yet, at the same time, our nursing workforce is shrinking.”
It’s easy to envision the potentially disastrous effects this could have on our quality of health care. “With declining numbers of nurses, hospitals will have to close beds and cancel surgeries,” predicts Calnan. “There won’t be enough staff to cover the workload.”
And what a workload it is. Our nurses, who account for over half of our health-care system’s labour force, also do the lion’s share of the work – from following up on doctors’ treatment orders, charting vital signs, administering medication, dressing wounds and generally performing all of the gritty tasks that make most of us faint. If they’re doing their work properly, we’ll have fewer health complications and get out of hospital in good time and on the path to recovery.
Where have they gone?
The seeds of the nurse shortage were sown in the ’90s when the provinces began cutting back on the number of nursing school spaces in an effort to save health-care dollars. In 1990, 10,000 RNs graduated from Canadian nursing schools. In 2002, because of limits placed on enrolment, only about 5,000 went on to become registered nurses. On top of this, hospitals instituted a hiring freeze. Full-time positions became scarce, and more and more nurses were asked to accept part-time or casual work, which allowed hospitals to save on salaries and benefits.
Under these conditions, it’s not surprising that a lot of nurses (as many as 10 per cent of each graduating year) decided to pack up their scrubs and move to the United States, lured by economic incentives, full-time positions and educational opportunities offered by wealthy American health-care institutions.
With the educational cutbacks, hiring freeze and flight south all happening simultaneously, the shortage began to grow more serious. And the nurses who remain have been asked to work double shifts and massive overtime hours to pick up the slack. On top of this, their labour force is aging: in 15 years, half of all nurses will be at retirement age, and many will be at a stage in their lives where they’re unwilling or unable to work overtime.
Effect on patients
Studies showing that a nurse shortage can have a detrimental effect on patients’ health are now beginning to surface. A 2002 New England Journal of Medicine article concludes hospitals that are understaffed with nurses have higher mortality rates and longer patient stays as well as more “failure-to-rescue” incidents (occasions where a patient failed to receive timely treatment because there weren’t enough nurses to catch emergency signs and symptoms as they developed).
Other negatives don’t readily turn up in academic studies, but they exist. Nurses are being asked to stretch themselves far beyond what time and their training allow. Besides patient care, they are expected to look after dietary needs, keep accurate patient charts, liaise with doctors and specialists, prepare lab requisition forms, update family members, contact social workers, arrange for home care and make sure that patients’ discharge requirements are covered. But with more patients and fewer nurses, it’s almost impossible to fulfill all of these tasks.
Patients’ needs sacrificed
“At times, I can barely keep my head above water,” says Paula, an RN working in a busy oncology unit in a Toronto hospital, who asked not to be identified. “Everything is always being rushed.” Though no one has suffered on her watch, Paula feels there’s a potential for mistakes to occur. “A patient’s health could be jeopardized simply because I can’t give them enough time.”
For example, a tired and overworked nurse may not have enough time to see each patient on a timely basis, may misinterpret doctor’s orders or may even dispense the wrong medication. Obviously, any or all of these limitations are detrimental to the patient but, if serious enough, can cost the nurse his or her licence.
Veronica, who also preferred to comment anonymously, works in a cardiac unit in Vancouver. She feels the nurse shortage is creating a log-jam throughout the entire hospital. “There aren’t enough nurses so we close down beds,” she says. “When beds are closed, patients must wait in emergency for longer periods of time. Longer waits at emergency mean more patients are being sent home untreated.”
Next page: Service without a smile
Service without a smile
While most nurses continue to perform their duties professionally, there’s little chance they’ll be mistaken for modern-day Florence Nightingales. Both Paula and Veronica admit that because of work conditions, a morale-sapping virus has spread through the nursing ranks, often manifesting itself in friction between nurse and patient.
“When we’re short a nurse, we get mentally and physically exhausted trying to do everything,” says Paula. “We don’t have enough time or energy left over to be polite to our patients.”
Veronica agrees. “It’s hard for people to understand why a nurse who’s working a double shift to cover a shortage on the unit may not have the energy to smile or make small talk.” Unfortunately, we always remember these short-fused and disrespectful nurses, not the cheerfully efficient ones, but it seems the shortage has created a lot more of the former.
Paula, whose patients have told her horror stories of bad nurse experiences, always encourages people to file complaints with the floor manager or the hospital if they feel they’ve been mistreated. But she thinks that good nurses are still the norm: “Most nurses I’ve worked with,” she says, “carry on professionally and have a great deal of passion for their job.”
Canadian Nurse Association president Calnan admits the shortage “has put a strain on morale.” In other words, nurses are burning out, developing bad attitudes toward patients or just quitting altogether. Both Paula and Veronica found their full-time positions were too physically and emotionally draining and have scaled back to casual weekend work. “Because of the working conditions, I could never devote as much time to the patients as they needed,” says Paula, “and I wasn’t professionally satisfied.”
Winning back the nurses
So the nursing profession has lost yet two more workers, and the shortage gets worse. Are the provinces reacting to this? It’s only recently that they’ve accepted the fact there is a nurse shortage, says Calnan, but steps are finally being taken.
“We now recognize nurses are under stress,” says Sindi Hawkins, minister of health planning in British Columbia, the province with one of the worst nurse-to-patient ratios in Canada as well as the oldest workforce (a 2002 Canadian Institute for Health Information study shows B.C. had 75.4 nurses per 10,000 Canadians, with an average age of 44.8). “We need to make it easier for people to enter the nursing profession, to stay in the nursing profession and to advance in the nursing profession.”
Last year, Hawkins’ department launched a $21 million package of nursing initiatives aimed at improving work conditions and addressing the shortage. This included creating more nursing school seats, reaching out to nurses who are not working in their profession, recruiting more foreign-educated nurses, expanding educational opportunities and, interestingly, funding new hospital equipment that will help nurses avoid workplace injuries.
Hawkins says these initiatives will help the province “meet our current needs and renew patient services for all British Columbians.” Good first steps, agrees Calnan, and he hopes other provinces follow suit.
Doris Grinspun, executive director of the Registered Nursing Association of Ontario, is working closely with the provincial government to ensure nursing remains a strong force. “The situation is bad, but there are real solutions,” she says, adding that the provincial government has been “very forthcoming in funding a variety of initiatives aimed at solving the shortage.”
The solutions, which are being actively discussed by the Ontario Ministry of Health, include increasing the number of full-time positions, dissuading nurses from taking early retirement, allocating funds to increase the nurse-to-population ratio, creating more first-year nurse education seats (up 100 per cent from last year) and going into high schools to attract younger Canadians to the profession.
Plus, Grinspun feels the time for dithering is over. “There are so many studies [on how to solve the crisis] that are collecting dust on the desks of all the ministers of health in this country,” she says. “No more strategies, no more studies. We just need action.”
It’s practical solutions and straightforward talk that should eventually bring healing to the beleaguered nurses and patients across the country.