Nurses Under the Gun
It is the worst possible time for the cell phone batteries to die. The messages blaring out of the emergency room intercom demand a response: "Ambulance on the way - traffic accident victim. Charge nurse call triage re incoming car accident." Janet Spence, the registered nurse running the emergency room at the new Halifax Infirmary, presses and re-presses the buttons on her cell phone. Dead. A paramedic steps forward to help, and in the half-minute it takes him to fix her phone, Spence surveys the hectic scene, assessing the priority of cases in the 28 beds and the pressures facing the 10 bustling nurses. "Over there we have three sick cardiac patients - they all need to be seen as soon as possible," she says, a stethoscope dangling over the white jacket that only partly covers her pink sweat suit. "And there's an overdose here. We are full and about to overflow."
Twenty minutes later, Spence receives another alert. "The police just brought in somebody with sexual assault, which means tying up a nurse and a doctor with double evidence," she groans. "It could take two hours - we can't take a nurse and a doctor out of this mess now." When Spence discovers that a physician has cleared a patient for discharge, she pushes an incoming patient - slumped in a wheelchair - towards the bed. There is a moment of confusion when the pink curtain is drawn back to reveal a grey-haired woman, surprised to hear about the doctor's decision. "I thought she was being admitted," says her young companion. But nurse Glenda Keys - who has been busy with three critically ill patients - confirms she is to go home. "Sixteen years ago, when I started, nurses had time to spend at the bedside," she says wearily as she changes the sheets. "Now, they just get basic care. We're running all the time - nursing has gone to hell."
That was the frantic scene one recent night at the Halifax Infirmary, part of the huge Queen Elizabeth II Health Sciences Centre complex. Versions of it are played out at hospitals across Canada every day. Nurses - the front-line care-givers in Canada's beleaguered health system - are burning out. "Nursing is in crisis," says Heather Henderson, president of the Nova Scotia Nurses Union. "Workloads are increasing and patients are sicker. Nurses are starting to be very worried that they cannot provide care to all their patients in a safe way."
Frustration, fatigue and anger are common among Canada's 262,400 registered nurses. "Enough is enough," states Rachel Bard, Moncton-based president of the Canadian Nurses Association (CNA). "We've gone far enough in terms of reductions. The health of Canadians is clearly at risk and Canadians have reason to be concerned."
Nurses, and the people who train them, are watching the pressures on the profession with alarm. Thousands of full-time jobs have disappeared in the past five years as hospitals have closed beds, merged or, in some cases, shut down completely. "Patient care is suffering," says Jim Rankin, associate dean of nursing at the University of Calgary. "The grassroots-level staff nurse is getting burned out." In Ontario, as many as 15,000 nurses could lose their jobs over the next three years. In some hospitals in New Brunswick, Quebec and Nova Scotia, RN staff has even slipped below agreed-upon essential-service levels during a strike.
At the same time, pressures to send patients home earlier mean that those who remain in hospital are in greater need of care. Henderson, 42, an obstetrics nurse at Halifax's Isaac Walton Killam Grace Health Centre, recalls "the good old days" at the start of her career. "If you had eight patients, four may have been there for over a week and on the road to recovery, and another four on the first day of post-op," she says. "Now, all your patients are very sick - and you may have 10." Many doctors express sympathy. "There is so much stress on nurses," says Halifax surgeon Vivian McAlister. "They are working longer hours under less than fair conditions, many of them casual and part time." Life in hospitals, he adds, "isn't as fun or as happy" as it used to be.
To take a close look at the pressures besetting nursing, Maclean's spent a week observing conditions at two respected Halifax hospitals - the 1,100-bed QE II complex and the 377-bed IWK Grace. Nurses are feeling the crunch of four successive years of staff and funding cutbacks at the QE II, which has merged six facilities into five, including the new infirmary. At the complex's Camphill Veterans' Memorial building, Helen Gillis's voice falters as she recalls the early days of her 37-year nursing career. "It was a little romantic," she says, with a hint of a Cape Breton lilt. "When I started here, the nurses wore veils and they were called sisters." Gillis - who only recently stopped wearing a traditional white nurse's cap, feeling subtle pressure from the capless majority - thinks the profession has lost some of its pride. "Years ago, a nurse wore a cap and a white uniform and patients knew who you were," she says. "Now, they even wear jeans - white jeans, but they are jeans," she adds disapprovingly. Gillis, who plans to retire in May, also feels nursing being drawn away from the bedside. "Thank goodness my time as a nurse is behind me, not ahead of me," she says.
Nurses just beginning their careers face enormous changes. Medical technology, health reform, research developments, the Internet, preventive and alternative medicine, a more informed public, feminism, increased education - those are just some of the factors transforming the profession's traditional roles. Today, most nurses - 62 per cent - work in hospitals. But hospital jobs are disappearing, and new needs are developing in community health care. Helen Mussallem, 77, a widely respected former executive director of the CNA, predicts that hospital nurses will become fewer in number and more highly specialized. She also envisions "neighborhood nurses" running 24-hour clinics offering a range of services from the diagnosis of simple ailments to medical testing and the promotion of health. "I see nurses as the leaders of health services in the community," says Mussallem.
Anna Svendsen has seen the future - and she is already there. "I was the first one," says the tall redhead, pointing to the "ERN" - for Extended-Role Nurse - on her nameplate. Svendsen, who has a master of science degree in nursing, is one of a new breed of nurse practitioner, with an expanded role that occasionally overlaps the once-exclusive territory of the doctor. Working in admissions in the Halifax Infirmary's cardiology department, Svendsen takes detailed medical histories of patients and performs "head to toe" physicals as well as a number of procedures, including cardiac catheterization. A large part of her job is patient education and follow-up, to encourage a healthy lifestyle. "It is well documented in the literature that patients are more comfortable talking to a nurse," says Svendsen. "They feel like they are wasting a doctor's time or the doctor talks over their head."
Institutions in several provinces have informally enhanced the roles of nurses in some specialties through pilot projects, without waiting for new licensing guidelines. Nova Scotia formalized its licensing only this month. Marilyn Bacon, vice-president of nursing at IWK Grace, waves the newly received announcement from the Registered Nurses Association of Nova Scotia like a victory flag. "This represents three years of work," she says.
But even RNs who do not take the practitioner route are finding themselves doing jobs they never dreamed of. "Technology has changed my life as a nurse," says Philip MacDougall, squatting to adjust one of a dozen electronic pumps at the bedside of an elderly patient undergoing a bone marrow transplant for advanced cancer. That patient, he explains later, is on a continuous morphine drip for sores in his mouth. "It's excruciating pain," he adds. "It's serious stuff - the patients know if it doesn't succeed, they will die." MacDougall is a technical whiz, handling intricate computerized instruments. He also provides information and counselling to seriously ill patients and their worried families - in a ward where death is almost a daily event. And he empties urinals, mops the floor and bathes patients - traditional nursing tasks that are now a source of conflict and controversy. Increasingly, hospital administrators are hiring not just less fully trained Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) but also unregulated, less-skilled and considerably lower-paid personal-care workers to carry out "non-nursing" duties.
What, then, is the role of the nurse? Few would disagree with Ann Miller, a nursing director at IWK Grace who says that "mopping a floor is definitely not nursing." Still, some "menial" tasks are important in the "art" of nursing, she adds. "You can learn a lot about a patient and their situation when you are taking away a bedpan or doing a bath," Miller says. Others are happy to be relieved of the basic tasks. "I am a degree-educated nurse," says Jill Yates, a cardiology nurse at the Halifax Infirmary."I don't need a degree to put a patient in a clinic room, carry the chart around or clean up." Chris Power, vice-president of nursing at the QE II, says the hospital is considering hiring people to do some non-nursing chores. While acknowledging that basic tasks may provide insight into a patient's health, she asks: "Can't we find a way to do that assessment in five minutes, instead of the 25 minutes it takes to do a bed bath?"
In fact, nurses interact with patients in many ways. During a busy shift at the infirmary, emergency nurse Carole Daulton prays with a critically ill patient. "She insisted," Daulton says later with a broad grin. "I said the Our Father, the whole thing." On the same day, in an operating room on the eleventh floor of the Victoria General - another part of the QE II complex - nurse Michele Singer takes time out from setting up the instruments for an operation to comfort a frightened patient until the anesthetic takes effect. "The bottom line is, the patient is scared and they need you," says Singer. "The day this job becomes all technique is the day I have to stop."
Time of any kind is at a premium. In the post-partum unit at IWK Grace, the alarm sounds at the nursing station shortly after 10 a.m. Nurse Debbie Trimper races down the hall towards the door with the flashing red light, joining a nurse who arrived seconds earlier. A pale young mother looks relieved - her infant, born only a few hours earlier, is fine. "Choking baby," explains Trimper, who has seen it all - and seen it all change - in her 23 years as a maternity nurse. Now, mothers and babies room together for their short hospital stays - generally only 24 hours, compared with nearly a week just a decade ago.
And while Trimper cares for fewer mothers, their needs, in the immediate aftermath of childbirth, are great. "The frustrating part is that sometimes two moms need you at once," she says. "It's a question of who needs you the most." For one mother, leaning against a corridor wall clutching her hungry baby, it means waiting a little longer for help with breastfeeding. "I'll be there as soon as I can," Trimper assures her. "Oh, I know, you're busy with patients," the tired mother says.
Some of the stresses of nursing are unavoidable. Paula Ernst remembers her first week in the bone marrow transplant unit of QE II's Victoria General building six years ago. "When I came out of nursing school, I was going to save everybody," she says. "I started at a time when everyone was dying, two one day, three the next. I had a couple of drinks at a party that weekend and I burst into tears. It all came out. Nearly everybody dies on BMT. Then I learned that part of the job is to help people die."
Another part is the role of patient advocate. In what many perceive as a disintegrating health-care system, nurses are convinced it is a more important function then ever. "It's up to the nurse to speak up," says operating room nurse Carol St. Clair, an outspoken 60-year-old who believes it is her duty to act as a role model. "Junior nurses are timid about asserting themselves - the doctors are the age of their fathers. But in OR, we watch their competence." All hospitals have problems and St. Clair says it is important to deal with them. "Doctors are not gods," she says firmly. "Some have their addictions and their weaknesses."
IWK Grace's Miller believes that, for the most part, the relationship between nurses and physicians has improved since she began her career nearly 30 years ago. "In the early days, there was a lot of respect between doctors and nurses," says Miller. "But there was a very clear understanding of what their roles were - the doctor was at the top of the heap and the nurses' role was largely what the doctors left for them to do." Now, nurses are more aware of their responsibilities as licensed practitioners. "We don't always agree with a doctor," notes Daulton, who says that if she suspects an error, she will "check it out" and ask the physician to "clarify" an order. "I'm not a chattel," she adds. "I'm a nurse, God help me."
People take up the calling for a variety of reasons. MacDougall did it because he wanted to travel. "It was the '80s, you could go anywhere and immediately get a job," he recalls. But now, MacDougall plans to stay put, because "you just don't get permanent jobs any more." Job security has become a major concern. "If you have a specialty like this under your belt," says Singer, an experienced operating room nurse, "you have a much better chance of getting a job." But even then, possibly not a full-time job with benefits. "In many hospitals across Canada, the trend is to hire casual nurses," says union leader Henderson. Some nurses say they like the flexibility of casual work. "It suits me just fine," says operating room specialist Merete Hansen, who plans to return to university part time next fall.
While jobs disappear, many nurses, lured by active recruiting, are leaving Canada for full-time positions with higher pay and better benefits in the United States and abroad. Joanne Moser leaves next month for Saudi Arabia on a five-year contract that will net her more than $50,000 a year - more than an experienced general duty nurse might expect to earn before taxes in Nova Scotia. "I love my job," says Moser, an operating room nurse at the Victoria. "But the salary is only enough to go paycheque to paycheque." Meanwhile, Donna Miller has just spent eight years working as a travelling nurse in the United States, where she enjoyed good money and benefits. But she returned to Canada because U.S. patient care was not as good, she says. "Bed sores are common there," Miller recounts. "Patients may have to wait up to two days in emergency wards. They bring in food, blankets."
While job prospects dwindle, RNs will soon require more extensive training. More than 80 per cent of nurses currently practising in Canada are "diploma-prepared" - that is, they trained in one- or two-year hospital or community college programs. But starting in 2000, RN candidates in Canada will have to have a BA or BSc degree. Many working nurses feel a degree is unnecessary for bedside work - and may be an expensive deterrent for some candidates. Dalhousie University nursing professor Gail Tomblin-Murphy says she has even heard criticism from physicians. "The cry is, 'Oh, my God, those university people are not going to be happy at the bedside.' " But she and others argue that a degree will provide "the independent thought, the critical decision-making" that nurses need to take an active role in the formation of health-care policy.
Thousands of hospital-trained nurses are upgrading their education. Trimper - who trained in a hospital 25 years ago and is now studying part time for a BSc - feels that she has no hope of advancement without a degree. "Nursing is a dead-end job if you work in an institution," says Trimper. But others, like Barb Egan, who works with MacDougall in the bone marrow unit, see little point in taking nursing courses. "I can't advance anyway," she argues. "There are no jobs." And the financial reward is slim. In Nova Scotia, nurses with degrees earn a premium of just $25 a month.
Nurses acknowledge - in fact, they boast about - the "sick sense of humor" that helps them deal with trauma. It may amuse them, then, in the midst of job shortages, to see that some planners are predicting a shortage of nurses in just five years. That is because high unemployment, low salaries and higher educational requirements are discouraging young people from entering the profession. Governments, in turn, are planning to reduce class sizes in nursing schools. As Nova Scotia health department official Mary Jane Hampton puts it: "Why glut the market when you have people already trained who are unemployed?"
Meanwhile, as the number of nurses needed in hospitals shrinks, long-promised community and home-care nursing jobs have not - and may never - materialize. "One of the greatest myths in health care," says Hampton, "is that jobs lost in hospitals will be picked up in the community." Still, many nurses argue that although their profession is ailing, it is far from dead. There is in fact a growing emphasis on health promotion and community-based nursing, notes Dalhousie's Tomblin-Murphy - "what nurses have been advocating for 20 years." And it is a challenge that many of her young students are willing to embrace. Tanya Brown, in her fourth year, is forming a company to offer first-aid courses to parents and day-care workers. She calls herself a "nurse entrepreneur," and she may be helping to define the nurse of the 21st century.
Maclean's April 28, 1997