As the headlines continue to profile the shortages of nurses in Canada, it is sobering to recognize my province has the lowest RN to population ratio in the nation even before the pandemic. The provincial government trumpets that the highest number of new nursing registrations have been processed, but there is denial that the nursing ranks are in dire straits. The fall surge brought headlines; crisis in progress, crisis has happened, staffing shortages, critical care at 200% occupancy. Now this week we’re digesting the plan to increase outpatient surgery capacity in for profit settings in some specific geographical areas. The provincial health card will indicate your eligibility; no one wants to confirm these clinics many have upsell tactics to increase their bottom line.
As I listen to nurses and follow Twitter and LinkedIn the prognosis of nursing is uncertain at best. The vulnerable exit points are the number opting for early retirement and those nurses in the 2-5 year experience range. I admire the younger generation, they are not averse to hard work but they are not going to tolerate massive workloads and insufficient support to ease workloads. There needs to be structures i.e., clinical ladders, career opportunities that balance point of care with teaching, research, and advanced roles such as nurse practitioners, clinical nurse specialists, educators, management and leadership.
Work life balance, we need to apply cutting edge evidence based practices for shift workers, perform a deep dive into the efficacy of 12 hour shifts, and explore the ways continuity of care and having a life can be balanced. Right now our backs are to the wall and operationalization looks very functional–the patients reduced to tasks and efficiencies.
Saying it again; the funding of nursing services needs to be viewed as an investment not an expense, when new beds are announced to be opening in Who Knows Where there needs to be an equal and robust announcement of the staff resources to be invested. A critical care nurse and one ICU bed takes 4.5 Full Time Employees (RNs) to staff that bed. Usually 80% is the 1:1 ratio beds and 20% is the 2:1 ratio beds and flex for unforeseen admits i.e., strokes, in house cardiac arrest. A modern ICU is a dynamic environment with a number of ERs able to bridge critical care patients until ICU is able to receive them. The post-pandemic phase has operationalized diverse and altered staffing models in a number of organizations, what is unknown is the impact on staff morale and patient engagement.
In Ontario, the lack of respect to public sector employees (including nurses) Bill 124, as the courts ruled it was unconstitutional yet the government announced it will appeal the ruling. The premier has led the government as it has underfunded the health care system and daresay contributed to the dire staffing situations that necessitated closing some ERs (especially in smaller communities) and added more wait times for surgical procedures. The unmeasured suffering for citizens waiting for procedures to heal, sustain, or ease suffering is acknowledged by nurses but as mentioned the workload continues to grow and burnout and compassion fatigue are some of the outcomes.
A panacea is to limit nurse to patient ratios, that is a partial solution as it does not fully capture acuity and complexity. Let’s examine an acute medicine unit (census 20) can be very different on a Monday if there’s 7 discharges, 9 admissions, 10 patients need total care (positioning/continence/feeding/bathing) and Tuesday there are 3 discharges, 1 transfer from ICU (more complex than standard medicine patient) and now it’s 12 patients on total care, a patient is showing signs of an infection, and 3 of the new admissions are high risk for falls and cognitively challenged. If days was mandated as 4:1 there would be 5 nurses, or the model could be 1 Registered Nurse, 3 Registered Practical Nurses and 2 Personal Support Workers. Workload measurement is a multi-faceted algorithm; length of stay, age, morbidity factors, number of medications given, number of interventions i.e., suctioning, dressings (complex), isolation complexity. What is an unknown is missed tasks, assessments, safety issues due to overload of work. The documentation systems can capture some elements but nursing has a subjective element that considers experience, competence, self-awareness and values of resiliency and altruism. How to capture this workload and optimize and sustain patient safety? Stay tuned. Namaste
Registered Nurse Storyteller, Healer, Scribe, Transformational Leader