Chickens without heads
Press items highlight nurse staffing crisis in Quebec
The Montreal Gazette says understaffing is so bad that some nurses have reported themselves for unsafe care. A Public Radio International piece reports that 700 physicians signed a petition urging that their own raises go to address the problem.
March 8, 2018 – Recent press pieces have described severe nurse understaffing in Quebec. Apparently, some nurses have reported themselves for inadequate care, and hundreds of physicians have offered to turn over their own pay raises to address the problem. On February 26, the Montreal Gazette ran a Presse Canadienne item headlined “Quebec nursing crisis is out of control, professional order says.” The short article relied mainly on quotes from a press conference held by Ordre des infirmières president Lucie Tremblay. She reportedly confirmed that some nurses had reported themselves to her group because they felt they could not meet their professional obligations. She also said that the public had complained that nurses “seem to be running everywhere, unable to respond to our needs.” Tremblay endorsed a Quebec nurses’ union proposal to impose minimum staffing ratios. And today, Public Radio International’s The World program aired a five-minute report that led with the news that 700 Quebec physicians had signed a petition urging that their own budgeted pay raises be redirected to address nurse understaffing. But the great majority of the PRI piece was host Marco Werman’s interview with nurse and “current PhD student” Natalie Stake-Doucet. She ably explained basic aspects of understaffing, making strong points about the general threat it poses to patients, including nurses’ inability to cope when more than one patient has a crisis at the same time. She also described the moral distress and burnout nurses experience, with some specifics about hospitals’ efforts to squelch their complaints. The report might have had more on the causes of the understaffing and more detail about how unsafe staffing threatens patients—how do nurses make the difference between life and death, whether in a crisis or simply in their daily work of monitoring, caring for, and advocating for patients? On balance, however, both pieces make strong basic points about this dangerous and widespread situation. We thank those responsible.
Nurses seem to be running everywhere
The unsigned Montreal Gazette piece consists mainly of quotes from Tremblay:
We have nurses saying, ‘I am going to report myself. I can’t meet my professional obligations and I find the situation very serious and I don’t know where to go, so I will report myself.’ We have never seen a movement like this,” said Tremblay, whose organization has 74,500 members. At the press conference, she also said that requests to investigate the quality of care and resources have gone up by 7 per cent in the last two years. “The public itself is also calling us, saying, ‘Nurses are not capable of caring for us to the degree of our needs — not because they don’t want to, but because they seem to be running everywhere, unable to respond to our needs’,” Tremblay said.
The short item concludes by noting that the Order has been pressing the provincial government to address these issues “for years.” Tremblay reportedly said that “a proposal by the Quebec nurses union to establish patient quotas is a step in the right direction.”
This is a good basic report. It lets Tremblay make the key points about the “crisis” in her own words — especially the part about what it looks like to the patients — and it provides a few key bits of context, including the recent increase in complaints and the proposal about staffing ratios. On that last point, it may have been helpful to clarify that this type of measure is not a “patient quota” in the sense that each nurse must always be assigned a fixed number of patients. Instead, such measures typically set a maximum number of patients that a nurse on a given type of unit can have, to ensure that no nurse is too overwhelmed to provide safe care, as now appears to be common in Quebec and many other places worldwide. More fundamentally, as is often the case with short press items, it would have been better to have more specifics about how understaffing can threaten patients and nurses, and what has been done elsewhere to address the issue.
This is not care, this is maintenance
Public Radio International’s program The World had more time to explore these issues. Host Marco Werman first explained that more than 700 physicians had signed a petition urging the Quebec Ministry of Health to redirect their budgeted pay raises to address nurse understaffing. But he quickly moved to an interview with Montreal “nurse and current PhD student” Natalie Stake-Doucet. Werman asked her how nurses got started protesting this situation. Stake-Doucet explained that a couple months earlier, a nurse had posted a cry for help that she had had 70 patients on her night shift. When the nurse woke up, 50,000 Quebec nurses had shared her post. Other nurses shared their own stories of poor conditions, forced overtime, and having to choose between safe care and, as Stake-Doucet put it,“ending the shift with our mental health intact.” Werman remarked on the physicians’ unusual recognition of the intolerable conditions, which he thought constituted recognition that nurses are “at the tip of the spear.” Stake-Doucet said that themain issue now was getting safe patient ratios. Werman asked if nurses face repercussions for speaking out, and Stake-Doucet said that is a widespread problem, noting that a colleague had been suspended for a day because she refused to do a whole extra shift of overtime. Stake-Doucet said that it is also now common for health care employers to include loyalty clauses in contracts, barring nurses from making the employer “look bad in the media.” She questioned whether that was ethical, since Quebec has a publicly-funded health care system, and the public should be able to hear about problems in that system.
Stake-Doucet herself had worked for several years in the clinical setting, she said, but she now taught nurses while getting her PhD. She had worked in long term care. In the evenings, she would sometimes have up to 178 patients, with a team of LPNs and orderlies, but she was the only RN. She said that her team would run around like “chickens without heads.” She got out, fearing burnout. She stressed that the system was also burning through its young nurses, who work for 2-3 years and then leave. Werman referred to nurses “reporting themselves,” and Stake-Doucet agreed that was happening because they could not maintain a high standard of care. Nurses are “legally responsible” for patient safety, she said, but they can’t ensure that with a patient load of 178. She explained that if more than one patient “starts to complicate” at the same time, there is no way to deal with that. She also stressed that this causes “moral distress” because nurses are forced to make impossible choices, in a health system that is supposed to be based on “equity” and “accessibility.” She pointedly observed: “This is not care, this is maintenance.”
Werman came back to the 700 physicians, asking if that would add pressure on the government.Stake-Doucetsaid that it would, and that nurses had gotten some positive responses from the government, adding that the upcoming October election would help spur action as well. And with the “beautiful show of unity” from the physicians, she was very hopeful.
This piece provides a good look at the distressing situation in which Quebec nurses now operate. The action of the 700 physicians is a great hook, and of course it is an admirable gesture. But the show does not belabor it, choosing instead to examine the working conditions that led to it, if not the underlying reasons for those conditions. The item commendably relies on an articulate and knowledgeable nursing leader for expert commentary, someone who teaches and is getting a PhD (it would have been good to state clearly that she is getting the PhD in nursing). Stake-Doucet makes a number of helpful observations, including her description of the awful staffing ratio she confronted in the clinical setting and how it affected her. Her insight that nurses are able to provide “maintenance” rather than “care” is a good one to the extent listeners understand it. We assume she means that nurses may be able to meet patients’ custodial needs but cannot deliver the therapeutic care needed to help patients regain health. Here and in the remainder, more detail on what nurses actually doin the clinical setting (assess, intervene, teach, advocate) would have been helpful. Werman mostly stays out of Stake-Doucet’s way, although his “tip of the spear” comment was problematic. Even aside from its martial association, an odd way to describe nursing care, the expression may suggest that nurses are just physical tools being wielded by physicians. Nurses have often been described as physicians’ “eyes and ears.” Even so, the report effectively conveys the dangerous understaffing that Quebec nurses and patients now face.