Shelly Dev is a writer, speaker and ICU physician at Sunnybrook Health Sciences Centre in Toronto.
Amid the societal calamity around this latest pandemic wave, we as a public are not nearly as worried about running out of the most essential resource keeping us going: nurses. Nurses, the backbone of the Canadian health care system, are working under conditions that are brutal and unsustainable. Many will experience burnout, or leave the profession altogether. But the weightiest burden will undoubtedly be suffered by patients themselves.
We are falling far short of the gold standard for nursing our sickest patients in Intensive Care Units (ICUs) at a time when the number of these patients is increasing daily. That standard, in Canada and internationally, is a model of nursing that anticipates and reflects the needs of the sickest patients; in short, one nurse for one patient. We are nowhere near meeting that standard consistently. Instead of one nurse looking after one critically ill patient, one nurse often has to look after two or three or four such patients. In ICUs, this is called a “doubles shift.” When this happens, nurses skip much needed breaks and meals; many stay hours beyond their regular 12-hour shift to help transition to the next team of nurses, who are also short-staffed.
What makes this situation worse are the demographics of the nursing work force. The latest data from the Canadian Nurses Association (CNA) shows the nursing work force is 91 per cent female. Based on a 2018 Statistics Canada report on work and gender, women are still carrying most of domestic and caregiver duties at home, a disparity that has only grown during the pandemic. This means that most of the frontline nurses ending their punishing shifts will go home to start the second shift: taking care of children, household work or tending to other dependent family members. There is not only no time for personal rest and recovery, but these days there is nowhere to go to seek solace outside of work and home.
It doesn’t help that prior to the pandemic, our nurses were already grappling with psychological distress. Pre-COVID data revealed that almost one third of working Canadian nurses reported clinically significant symptoms of burnout. After the first wave of COVID, a 2020 study from the United States reported severe PTSD in 55 per cent of nurses. It’s not a reach to presume these statistics will worsen as COVID rages on. And when nurses are suffering, their patients will too. As an intensive care physician, I have lost count of the number of times I have heard a nurse colleague exhale heavily and say, “We can’t go on like this. It isn’t safe for the patients.”
These exhaled words of foreboding are supported by evidence. A 2020 British review on studies between 1979 and 2019 found an association between nursing burnout and terrible consequences for patients in their care, including increased infections, falls and medication errors. Again, this is pre-COVID data. We do not yet have the data on patient care. But common sense suggests, to put it mildly, it would not be good.
Nursing attrition is another devastating blow; an extensive survey of nurses done in the U.S. in 2018 showed that more than 30 per cent of nurses who left the profession did so because of burnout. Fewer nurses mean more of those doubles shifts and increased errors, compromised standards of care and bad outcomes for patients. The CNA reported that the nursing work force between 2018-19 shrank by 1.5 per cent while the overall population grew by 1.4 per cent. Again, this is pre-COVID data. Based on these trends, a shortage of 60,000 nurses was already predicted by 2022. As the pandemic grinds on, how many more will leave, physically and emotionally broken by the unprecedented and unrelenting conditions of today?
While many nurses will leave, many more will stay and continue to struggle, with some opting for harmful coping strategies. This was seen in follow-up of frontline workers of the 2003 SARS crisis, where many mitigated the long-term effects of post-traumatic symptoms and psychological distress with self-isolation, excessive smoking or alcohol use. If post-traumatic symptoms could be seen in frontline workers up to two years after a relatively mild health crisis (SARS lasted six months), in what state will they be after a pandemic that has gone on for more than a year, with no end in sight? How severe will the fallout be for patients?
Health care workers, and especially our nurses, are doing the best they can with rapidly diminishing personal reserve and dangerous levels of distress. They need tangible deliverables from hospital organization leaders in the form of rapidly available mental-health support, training for fellow health care workers to provide real time peer support and spaces for rest and recovery. They need the rest of us to stand by them in solidarity by wearing our masks, practicing physical distancing and taking whichever vaccine is available. This investment in the workers is an investment in ourselves and our loved ones; we are all patients in this health care system. And we must finally wake up to the one truth that we have been far too slow to realize: The most reliable way to ensure the provision of excellent patient care is to equally and urgently champion the care for the valiant providers.
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