As my father spent the final few months of his life in and out of the hospital, I experienced up close and personal the role nurses play in a patient’s day-to-day routine.
Illness is a state of extreme vulnerability, both for patients and their loved ones. It’s nurses and orderlies who are at the front lines when you are at your lowest, most uncomfortable, most worried, when you are awake in the middle of the night needing pain medication, need help navigating the washroom, seek answers to questions about your treatment, or even just the calm reassurance of another human being. The doctors, although vital, are not there around the clock and usually breeze in with their 10-minute consultation and breeze out.
It is the nurse’s face a patient sees most often and it’s them they often rely on for most of their basic needs. Years later, I still remember that my father’s favourite nurse was named Hope. I remember how his face would brighten up when she came by because she would always kid around with him. She treated him with dignity and kindness and I remember thinking that her name suited her and her profession well because, when you’re seriously ill, hope is sometimes all you have.
Nurses at the end of their rope
I have been thinking a lot about the precarious state of Quebec’s healthcare system ever since a selfie from a tearful nurse in Quebec’s Eastern Townships went viral, drawing attention to the heavy work burden and subsequent risk of burnout that nurses face in understaffed hospitals. Emilie Ricard’s emotional and deeply moving cri de coeur was quickly shared by thousands of Quebecers, who, like her, and unlike Health Minister Gaetan Barrette, don’t seem to feel that healthcare reforms have been a success at all.
Over the past 20 years, working conditions in healthcare have been steadily deteriorating and the latest rounds of budget cuts implemented by the Liberals in 2015 have resulted in a triple whammy of increased workloads, increased implementation of forced overtime, and the gradual increase of nurse-patient ratios. Nurses are buckling under the strain of a healthcare system that is failing them – and the patients that they serve.
Since January, healthcare workers fed up with the status quo, have been mobilizing, speaking out courageously about their inability to provide proper care, and blowing the whistle on what they say are unsafe working conditions, despite threats of sanctions for insubordination.
Last Friday, nurses, nursing students and researchers organized a general assembly and open mic in downtown Montreal on the state of healthcare in Quebec. The evening’s goal was to create a formal list of suggestions and possible easy-to-implement improvements for presentation to Quebec’s National Assembly. The assembly is a grassroots initiative supported by Quebec’s nurse’s union, the Fédération interprofessionnelle de la santé du Québec (FIQ).
I spoke to one of the organizers about the urgency of the situation and what needs to be done to rectify the many issues plaguing healthcare professionals in the province right now. A PhD candidate in nursing and a teaching lecturer at the Université de Montréal, Natalie Stake-Doucet, is deeply worried.
“The problem isn’t that nurses are merely overworked,” she says. “The problem is that they’re forced to work in conditions that make them provide sub-par care. It’s extremely difficult for a nurse to go through that day in and day out, and I think that’s really what made the abscess burst in terms of what we’re seeing right now. There’s real fear in terms of repercussions, because nurses are technically not supposed to make our employer look bad in the media. But my position on that, and I think most nurses’ position on that, is that our loyalty should be to our patients first and to our employers second. If our employers won’t give us the means to provide our patients with the proper care, we should be allowed to inform the public without fearing for our jobs. The government needs to start listening to nurses. We’re highly trained professionals, we can identify problems. We should be allowed to talk about them.”
The situation is currently so bad that the only free drug and alcohol detox centre in Montreal was recently forced to close a third of its beds after half of its nursing staff resigned because they were constantly being asked to work double shifts, something they could no longer handle physically and emotionally.
Mandatory overtime should be abolished
“The most basic way to solve this problem is to no longer accord power to managers to suspend or discipline or reprimand nurses for things that make no sense and don’t respect basic human rights,” says Stake-Doucet. “If I refuse overtime I shouldn’t get suspended, which is something that’s happening now all the time. They refer to it as ‘insubordination.’ It’s just mind-blowing, they treat us like high school kids in a courtyard, not competent, smart professionals.”
Stake-Doucet firmly believes overtime should never be forced. “That’s one of the reasons why there aren’t enough people in the healthcare sector right now,” she says. “Who wants to work in an environment where your manager can just impose however many more hours of work on you? It’s just not human, it’s not any way to treat people. We have a lot of nurses that are fleeing or burning out; especially the hospital system because of the work conditions. It’s why I left. I was so disheartened. Everyone is willing to do overtime occasionally, but when it’s every single day that someone asks you, ‘Can you stay?’ it becomes overbearing. I would be doing evening shifts from 4 p.m. to midnight and would be asked to continue working another shift until 8 a.m. the next morning. I would be driving home completely exhausted.”
The McGill University Health Centre has no forced overtime, according to Stake-Doucet. Its “solution” is to simply not replace people who call in sick or don’t show up, so they end up operating with severe shortages in staff. In either scenario – overworked nurses or too few of them to go around – the results can be deadly for patients.
A Sherbrooke University study made public last year warned that nursing overtime can lead to an increase in the death rate among patients. Researcher Christian Rochefort found that a five per cent rise in nursing overtime contributes to three per cent increase in patient mortality.
Unsafe nurse-patient ratios
Aside from nurse overtime, another huge concern is the nurse-patient ratio. Stake-Doucet points to California and Australia where the ratios are low and doesn’t understand why the same isn’t happening here. She finds that nurse-patient ratios are particularly problematic in emergency rooms and long-term care in Quebec.
“In long-term care, nurses on the night shift can have up to 300 patients,” she says. “They have a few orderlies and LPNs (licenced practical nurses) helping them, but there’s no way you can see all your patients in an eight-hour shift. When I worked in long-term care I felt like I was working in a factory, just ‘go, go, go.’ Nobody wants to deal with an assembly line of humans; that’s not a job anyone would want. You want to be able to take care of people, to make them feel better, it makes you feel better too, but when you can’t anymore, it’s horrible, it makes you feel like crap. It’s undignified for both patients and healthcare professionals.”
While the health minister has been urging nurses to accept the full-time positions that are available to address the issue of mandatory overtime, there seems to be an unwillingness from the government to understand that the problem may actually be that mandatory overtime has created a dearth of nurses willing to take those full-time positions.
“No one in their right mind would apply to a full-time position right now because a full-time position is not a full-time position,” says Stake-Doucet. “You want to work full-time? Get a part-time position and you are guaranteed to work full-time. You get a full-time position and you’re guaranteed to work way more than full-time. I worked full-time for a few years and it didn’t take me too long to figure out that this would destroy me. Look at Emilie Ricard. She’s 24 years old! We are burning through our young nurses at an incredible rate and this is dangerous for the population, for patients, and for the nursing profession overall. What are we sending our nursing students into? The number of people who are burnt out and depressed in their twenties is outrageous.”
Stake-Doucet hopes that Quebec nurses breaking their silence about these unsustainable conditions and the erosion of patient care, coupled with the province entering a pre-electoral season, will finally make the government listen to them.
FIQ currently in talks with government
“The FIQ is currently negotiating for nurse-patient ratios to be established, not in union contracts, but in the law,” she explains. “It would be great if we had legislation that puts a limit on the number of patients a nurse can take care of at one time, and what I’d really like to see is legislation to protect nurses from abuse from employers who are more interested in their reputation as good and safe institutions instead of having any real interest in being a safe institution. Sanctions for refusing overtime are outrageous, and they should not be allowed to do that anymore. We’re a majority women profession (Quebec’s nursing staff is 92 per cent female) so we already put up with a lot and it takes a lot for us to get to where we’ve gotten.”
A recent Le Devoir article alluded to the inherent sexism a predominantly female workforce faces with an overwhelmingly male workforce of managers and administrators.
“We’re always expected to figure it out and self-sacrifice for the better good, but managers should be there to help us. They’re supposed to give us the tools and an environment where I can perform my job the way I was taught,” Stake-Doucet says.
Since physicians are not employees of the hospital, hospitals can’t suspend doctors for refusing to work overtime because they’re not direct employees. As employees of the government, they can come and go as they want, which is why they receive premiums to be on time. In terms of administrative interference, nurses, orderlies, respiratory technicians, and LPNs, and anyone who’s an actual employee of the hospital have much more to worry about than physicians do.
“When there are government cutbacks, even though physicians cost more, they don’t bear the brunt of cutbacks because the cutbacks are dumped on to the hospital,” explains Stake-Doucet. “Hospitals have to choose where to cut, and their biggest expense is nurses’ salaries, so we’re disproportionately affected by cutbacks because we’re directly employed by hospitals.”
Elections on the way
With Quebec elections eight months away and with a budgetary surplus, the Liberals have started funneling money back into the healthcare system to repair some of the damage. The party’s main rival, the Coalition Avenir Quebec, currently leading in the polls, has seemed lately to focus its healthcare solutions on how to provide Quebecers with more family doctors, and less on the nursing crisis, but it has publicly supported nurses in the past. No actual promises have, however, been uttered yet.
A few months ago, the Parti Quebecois also released plans at a pre-session caucus to lower emergency room wait times and do something about the 24 per cent of Quebecers who don’t have a family doctor. One of its proposed solutions, giving more responsibilities to other healthcare workers and allowing nurse practitioners to open their own clinics, seemed to get the tacit approval of FIQ at the time. It will be interesting to see what other solutions to the nursing crisis are proposed as all parties enter campaign mode. A petition, recently launched by Quebec Solidaire’s Amir Khadir and demanding the resignation of the health minister, Barrette, already has more than 40,000 signatures. While not an official petition (it won’t be presented at the National Assembly), it conveniently also gathers voters’ personal data.
Several proposals were put forward by attendees during the open mic this past Friday:
- Healthcare centres aren't car factories; 'lean management' systems (developed by Toyota) are not appropriate for the healthcare system;
- Re-invest in primary care, particularly CLSCs (centre local de services communautaires, local community service centres). They provide broader care with more professionals then super clinics (which are mostly private, but publicly funded);
- Respect the basic human rights of healthcare professionals. Sanctions for refusing overtime or for speaking out to protect patients is unacceptable in a democratic society;
- Protect stable, efficient teams from being broken up during reforms (a nurse in psychiatry spoke about how, because of mergers, her colleague was forced to take a position in an emergency room (ER) of a general hospital after working seven years on the same team on a psychiatric unit. The psychiatric unit lost an experienced nurse, and the ER gained a nurse with zero experience or knowledge in ER issues);
- Respect the scope of practice for all professionals as defined by law, not at the discretion of managers or physicians in super clinics.
In the meantime, however, nurses remain overworked and deeply concerned.
“I’m incredibly worried,” says Stake-Doucet. “I love teaching, but I have students coming to me crying, talking to me about their experiencing while interning and it makes me so angry that, instead of honouring their commitment to become nurses, honouring their humanity and their intelligence, we just push them down and demean them and treat them like they’re worthless. We expect them to be good at everything, never complain, never expect praise. That's how we socialize nursing students. We should be welcoming them with open arms, the students are so eager to help."
“I love this job. Being a nurse for me is a huge part of my identity, I think it’s the most beautiful job in the world. If you have a happy workforce and you let them work the way they’re supposed to work, the potential to improve the healthcare system in Quebec is huge. If we could just have the tools to do our jobs, people would be healthier, fewer people would die. We’re really wasting a resource that is essential to our healthcare system and I don’t see any reason for that, it makes no sense. It’s wrong on so many levels.”