Elizabeth Renzetti is a Globe and Mail columnist. Her latest book is Shrewed: A Wry and Closely Observed Look at the Lives of Women and Girls.
This is what Naila Shaikh, registered nurse, wants you to know about the intensive-care unit where she works in Peel, just outside Toronto, one of the regions in Canada hardest-hit by COVID-19: It is full. It is full of patients who are younger than they were during the first wave of the pandemic. Many of them have no underlying health conditions, and are put on life support shortly after they show up in the emergency department.
She has never seen anything like it. The situation is “insane.” When she arrives in the morning for her 12-hour shift, her team is already talking about intubating one, two or three patients. Patients are being transferred from her hospital to others around the province to make room for the freshly sick. Sometimes staff shortages mean that one nurse is looking after two fully ventilated patients. She’s had multiple members of the same family on her floor.
She and her colleagues have little time to update family members about their loved ones’ conditions, which leaves her feeling distressed. Sometimes those family members show up at the ICU. Sometimes those family members have COVID, too, and become enraged when they’re denied the chance to visit.
That’s not even the worst part. Looking after the seriously ill is her job, a job she loves and has been doing since she graduated from nursing school in 2014. The worst part is that when she leaves the hospital, she hears people denying that the disease even exists. They complain about having to wear masks. They refuse to get vaccinated. It’s like she’s living in two parallel worlds.
Ms. Shaikh is 31. She’s worked in the ICU through the waves of the pandemic – waves that, she notes, nurses saw coming. Last year she was hospitalized and off work for two months with stress-induced shingles and meningitis. She describes her current state of mind as “survivor mode.”
Last week, she received a notice from the Ontario College of Nurses telling her that under the Emergency Protection and Civil Management Act, the province’s nurses may now “provide patient care services outside their regular scope of practice.” She’s not entirely sure what that means.
The supervising nurses on her floor are doing all they can with the resources they have. Every morning at the team huddle, they say that their doors are always open if anyone needs to talk. But Ms. Shaikh doesn’t really want to talk, not right now. “Sometimes I feel like talking about it makes it worse, because then I have to think about it. I can’t even think about my mental health until this is all over. When you’re in survivor mode and the community depends on you, you can’t afford to think about your feelings.”
Whenever the end does come and the final wave crashes on shore, it will carry with it a reckoning for the people who bore the heaviest burden of care in this pandemic, Canada’s 440,000 nurses.
In conversations with nurses and nurse-educators across the country, the same words and themes arise: burnout, exhaustion, anger, frustration. Nurses, particularly those in critical care, feel stretched to the very limit, and yet unappreciated by the governments who employ them and undervalued by decision-makers who don’t listen to their expertise. They see patients harmed by short-sighted political decisions. Some nurses have died from COVID, most recently 57-year-old Vancouver nurse Diana Law. Many more are leaving the profession.
They worry that the crisis has deepened the cracks that already existed in their profession: the lack of mental-health supports, flexibility around scheduling, inability to accommodate work-life balance, chronic shortages of resources. At the same time, there are staffing shortfalls around the country, with Statistics Canada reporting in February that thousands of nursing positions were unfilled.
The reasons for the shortage are complex, and not unique to Canada (the International Council of Nurses predicts a global shortfall of six million nurses within the next 10 years.) The issue is more one of retention than recruitment. In Canada, nurses may leave hospital jobs to work in public health, the private sector or teaching, or take early retirement. They’re driven to leave by a variety of factors including exhaustion, inability to balance family life with punishing shift work and lack of career advancement.
The crisis that the pandemic heightened, largely hidden behind hospitals’ walls, is coming into public view. Ontario has put out a desperate call for health care workers from as far away as the Philippines, and a team of nine doctors and nurses arrived this week from Newfoundland and Labrador. In Abbotsford, B.C., nurse Kendall Skuta’s poignant Instagram post about treating COVID patients went viral. “I don’t know how much more pain my heart can take,” she wrote.
“Critical care nurses in many parts of Canada are on the brink of collapse,” the Canadian Nurses’ Association warned this week.
Yet this moment also offers a chance to heal broken systems and address historic missteps. Across the country, applications to nursing schools have risen dramatically. Young nurses are entering the profession who refuse to tolerate hierarchies, racism and bullying. Perhaps most important, professionals who have long been silenced are finding a public voice to advocate on behalf of themselves and their patients, and for a better health care system.
But first the public will have to acknowledge what has been hidden inside Canada’s hospitals and long-term care centres. That is the devastating toll that the pandemic has take on the country’s registered nurses, nurse practitioners, psychiatric nurses and licensed practical nurses.
At the height of the pandemic’s first wave, Natalie Stake-Doucet answered the call to help out in Quebec’s beleaguered long-term care homes. A registered nurse, she’d worked as an orderly in long-term care to help finance her PhD studies. She thought she was prepared for what she’d find. She wasn’t.
There was, first of all, the disconnect between what the Quebec government was saying about personal protective equipment, and what was actually happening in the Montreal facility where she worked. One day, on a TV at the care home, she heard a government minister say that there was enough equipment for all workers; her own supervisor had just told her there were not enough gowns to go around. “It was really hard on morale,” Ms. Stake-Doucet says. “We had to fight for everything. Gloves, trash cans, thermometers.”
But that paled next to the sheer human tragedy that unfolded at the care home. On one of Ms. Stake-Doucet’s shifts, three residents died. Ten died in total that day. When asked what effect that had on her mental health, she pauses before answering. “It was brutal, I’m going to be honest. My rapport to death has changed completely.” She had worked with palliative care patients before, and had seen what a good death could look like. “The pandemic really ripped that away, professionally and emotionally. … It’s like I’m afraid of seeing more death. I feel like I’ve had my quota and if I see one more I’m going to lose my mind. I’m going to be broken for real.”
Ms. Stake-Doucet was lucky enough to get counselling through a study on nursing burnout that she was participating in. She did not want to be diagnosed with post-traumatic stress disorder, worrying that it would affect her future employment.
Through her work as president of The Quebec Nurses’ Association, she’s been able to channel her frustration into advocacy in the province, where nurses have been fighting with governments for years over issues such as forced overtime, and where many have fled the public system for better pay and working conditions with private agencies. She has a list of things that could improve nurses’ lives: more autonomy over their own scheduling. No more forced overtime. Better pay for nurses and orderlies. National standards for long-term care facilities.
“The [provincial] government keeps saying there’s a shortage of nurses but there’s not. There’s never been so many nurses in Quebec. But the conditions are so bad that nurses are fleeing. They’re still working as nurses, they’re just working in the private sector for agencies.”
Across the provincial border in southwestern Ontario, registered nurse Lynnsie Gough works in the intensive-care unit of a hospital, not a long-term care home, but the emotional toll is similar. Ms. Gough came back to work in the ICU after a year’s stress leave to find herself confronting the first wave of the pandemic.
There, she found patients requiring the highest level of care. Sometimes one or two had to be intubated on a shift. Nurses would sit and hold the hands of those who were dying alone. At the beginning, pre-vaccines, there was the terror of catching the illness.
At the same time, says Ms. Gough, there was a disconnect between the “hero” narrative of pot-banging for health care workers on the street and the belief that nurses should just suck it up. “You’d hear, ‘This is what you signed up for, you get paid enough, you’re lucky to have a job.’ That’s all true to some degree, but people have no idea what we deal with. Not just at work, but you bring it home and it takes a toll on you and your family.”
By January, 2021, she was exhausted and burned out. The prospect of going back to a brutal rotation at the hospital – two 12-hour days followed by two 12-hour nights – left her anxious and in tears. The employee assistance program at work, which involved trying to book an appointment with a counsellor over the phone, proved “very useless.” In January, Ms. Gough moved to part-time work in the ICU, “and it’s been a life-saver.” Still, she’s thinking about transferring to a different area of practice.
She is not alone. Every nurse tells stories of colleagues who have quit to work in the private sector, or taken early retirement. There are stories of nurses who have simply walked out in the middle of shifts. The guilt associated with that is immeasurable, because nurses describe their solidarity in pandemic times in terms that soldiers normally use. To walk out on a comrade in the midst of the battle is an act of desperation.
And yet that desperation doesn’t surprise Doris Grinspun, chief executive officer of the Registered Nurses Association of Ontario. “They’re exhausted and they’re angry,” Dr. Grinspun says. “They’re not angry at their patients, they’re angry at politicians.” Every day during the third wave she fields calls from front-line nurses who tell her about what they’re seeing: patients on oxygen sitting on chairs because there are no beds, children who are sick, young parents who are deathly ill.
Even before the pandemic, Ontario had the lowest ratio of registered nurses to population. Still, when they were called upon, they answered the summons. During the first wave, more than 400 nurses who were not employed or were employed part-time volunteered to work in Ontario’s hard-hit nursing homes, before the extent of the danger was known – and before there was a vaccine. As the third wave hit, the RNAO put out a fresh call for help, and again more than 400 nurses responded. Some of them have already been deployed to Ontario’s besieged hospitals.
A recent survey by the RNAO highlighted dangers to the profession coming down the pipeline. For one thing, more than 60 per cent of respondents reported high or very high levels of job-related stress during the pandemic. Even more alarming were the numbers that indicated how much turnover the pandemic has caused. In a normal year, 3 per cent to 4 per cent of young nurses might say they’re leaving the profession. During COVID, that number has tripled. “Those are people who have years ahead in their careers,” Dr. Grinspun says. “That is a mega loss for the province.”
The RNAO and other nursing organizations are working on projects to improve retention, including building mental-health programs for their members. They’re also working with governments to increase the number of spots open to those applying at nursing schools. In the meantime, as the pandemic rages, they’re pleading with governments for better public-health measures, including paid sick days, closing of non-essential workplaces, targeted vaccinations and restrictions on interprovincial travel.
Until better working conditions are in place -- if they’re ever in place -- the retention of experienced professionals remains a huge problem. Losing nurses who have years left in their careers represents an immeasurable loss of clinical knowledge, and the evidence of that can be seen in the ICU of a small hospital in southern Ontario where Teresa Marini works. The registered nurse worked for decades at a large teaching hospital in Hamilton before moving to a community hospital. Three other experienced nurses moved to the smaller facility at the same time, and their collective decades of knowledge about critical care, including looking after ventilated patients, proved invaluable.
“The older ones remembered SARS, and we used that,” Ms. Marini says. “We remembered things that would best protect us.” Still, nothing could prepare them for the intensity of care that COVID patients required. Ventilated patients were at least sedated, she notes. For some patients, the BiPAP non-invasive ventilator, which covers much of the face, was worse. “When people can’t breathe they become hysterical and start ripping at you and pleading with you. You can walk away from that at the end of the day, but you can’t leave it behind any time soon.”
She was confronted with angry and heartbroken family members, some of whom stormed the hospital’s doors. For all the extra hours she worked last summer, she brought home a total of $400. But for Ms. Marini and the 20,000 nurses on a Facebook page she runs, the issue isn’t just money: The pandemic has exposed chronic shortages in resources and respect.
Ms. Marini is 53, with many years of nursing ahead of her. She’s planning on retiring next year, however. “The pandemic has ruined it for me,” she says. “Nursing is the only thing I’ve ever wanted to do. I love it in every capacity. I loved dealing with people in their most vulnerable states. It’s the most beautiful thing. … But now you’re afraid of it. It’s not about getting sick. It’s about being emotionally fragile and so exhausted.”
The pandemic has offered one positive change for those frustrated with their working conditions: Many have found a public voice, advocating for their profession and their patients. Nurses work in a gendered field that has historically been silenced by tradition and fear of repercussions, and the business of speaking out can be liberating -- or unsettling. Stories abound on nurses’ forums about employers and regulatory bodies reprimanding those who speak out about working conditions, and yet the voices have never been louder or more insistent.
“When you’re working as a nurse, you’re not really encouraged to speak up. That whole silencing starts with nursing school,” says Amie Varley, who is co-host, with Sara Fung, of The Gritty Nurse podcast. As racialized women working in health care who had experienced racism, bullying and disempowerment, they felt (as Oprah might say) not only silent, but silenced. They wanted to hear more stories like their own. So, in late 2019, they began the Gritty Nurse series to discuss all the elements of nursing that they weren’t hearing discussed.
At first, it was hard to find Canadian nurses who wanted to speak out, and they relied on American colleagues. But the past year has changed that. Their profession has been galvanized by the inequalities exposed by this past year of crisis. They have started to see nurses, traditionally sidelined in the media in favour of doctors, recognized for their particular expertise.
The other encouraging change they’re seeing, Ms. Fung says, is the increased interest in nursing as a profession, especially from mature students, people from diverse backgrounds, and men. She’s not surprised, because she – like most of the nurses interviewed for this story – is still in love with her vocation. “Being a nurse is such a privilege,” she says. “You could be part of the best day of someone’s life, or the worst day, all in the same shift. What other profession could you say that about?”
It may seem counterintuitive, given the exhaustion and heartbreak many nurses are publicly expressing, but applications to nursing programs are on the rise, for positions that were already highly competitive. At the University of British Columbia, the nursing faculty would typically see around 500 applicants for 120 spots. For the September, 2021, intake, there were more than 800 applicants, says Elsie Tan, associate director of undergrad programs at the UBC School of Nursing. On their application essays, many of those hopefuls cited the pandemic as their reason for wanting to join the profession.
Halfway across the country in Toronto, Diana Mugambi is one of those who felt called. Ms. Mugambi, who studied engineering in her home country of Kenya, has been a personal support worker since 2013, and has been working in a long-term care facility in Scarborough during this crisis. The pandemic caused her anxiety – there was an outbreak at her long-term care home, and she has two small children at home – but it also awakened a desire to be part of something good and hopeful.
“I was watching the whole pandemic unfold before my eyes, and it felt like a call for action for me to join and do more,” Ms. Mugambi says. “I’d see interviews on the TV from exhausted nurses and physicians talking about what was happening in ICUs, or I’d see nurses walking out on the job, and it made me wish I was out there doing more.”
In September, Ms. Mugambi will join the four-year Bachelor of Science in Nursing program offered jointly by Ryerson University and George Brown College. “Doing the RN puts me in a place where I can do more for my community,” she says. When she graduates, she’ll be 37. She wants to work in a hospital, which is a good thing. They could use all the help they can get.
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