The combined pandemic toll of a nursing shortage, an exhausted and increasingly inexperienced hospital workforce and a lack of hospital presence for family and friend patient advocates may be a precursor to increased risk of harm while in hospital.
“Lives are at stake,” the Registered Nurses Association of Ontario (RNAO) wrote recently to Ontario Premier Doug Ford in an open letter in January.
One in 17 hospital stays in Canada involved at least one harmful event in 2020-2021 – 132,000 hospitalizations (out of 2.2 million hospital stays) – according to the Canadian Institute for Health Information (CIHI). These events occurred in four categories: patient accidents, like falls (4 per cent); procedure-related, like bleeding after surgery (20 per cent); infections, e.g., after a procedure (30 per cent); and health care and medications, like bedsores or getting the wrong medication (46 per cent).
While there was a marginal rate increase of harmful events in 2020-21 (5.9 harmful events per 100 hospitalizations compared to 5.3 to 5.4 per 100 the previous six years), ideally there would be a downward trend, says CIHI in an email. “We encourage patients, clinicians and health-system leaders to monitor this information closely, particularly as hospitals across the country continue to face pandemic-related stresses.”
When registered nurses are safe and well, evidence shows better patient outcomes. But RNs are over-worked and burnt-out and many have left the profession. Nursing students, new inexperienced nursing graduates and other health-care team members are stepping up.
“It definitely doesn’t feel like the safest situation,” says a recent nursing graduate working in women’s health and obstetrics in a Winnipeg hospital. Since graduating in October, she works between two to four 12-hour shifts per week, often three 12-hour night shifts in a row.
“It’s been a crazy time to learn and be a new entrant to the workforce,” she says. “In the beginning, you’re not sure what is happening and 90 per cent of the shift you’re feeling very anxious, but nothing bad happens and, over time, you slowly start to build your confidence.”
Short-staffing, fewer days off and increased patient load has an inevitable impact on care, says Doris Grinspun, RNAO’s CEO. Nurses need time to think, to use their expertise and compassion, she adds.
“Now if you are rushed, that’s gone. Patient safety is directly linked to staffing,” says Grinspun. “Nurses are exhausted, patients are exhausted. Ontarians are exhausted, we’re all exhausted.
“The problem is that nurses have to practice clinically, emotionally and physically in the context of this exhaustion.”
When registered nurses are safe and well, evidence shows better patient outcomes. But RNs are over-worked and burnt-out and many have left the profession.
The necessity of retaining Ontario’s depleted nursing workforce was the focus of a Feb. 3 discussion between Ford and the Ontario Nurses Association (ONA).
“Our frontline members who have been going above and beyond the call to care for Ontarians – not just during the pandemic, but every day – expect to see action. Their patients’ care depends on it,” says Cathryn Hoy, ONA president. The Premier did not commit to repealing Bill 124, but will continue meeting with the ONA.
Meanwhile, a recent U.S. study found that understaffing and missing expertise jointly shaped near misses among nurses during the pandemic. Near misses are known to precede and contribute to accidents and injuries.
Another U.S. study, this one on RN experiences in intensive care units, indicates that nurses perceived that patient safety and quality of care have been compromised during the pandemic, which causes ethical stress among nurses and may affect their physical and psychosocial wellbeing.
In Canada, seven in 10 health-care workers have reported worsening mental health during the pandemic.
“What we do know, in general, is that fatigue, working in areas you’re not familiar with, absence of family and other essential care partners, are among known risks for patient safety,” says Jennifer Zelmer, president and CEO of Healthcare Excellence Canada, an independent, not-for-profit charity funded by Health Canada that offers mental health and resiliency resources for health-care providers, staff and leaders.
“Thinking about how we ensure safer care, particularly in challenging times like now, really does require us to act on many fronts so that we’re putting in place layered safeguards, so that if there are near misses, they don’t get through those safeguards and cause actual harm.”
Zelmer says the critical factors for a safe work environment include leadership that allows the organization to identify and learn from near misses; front-line actions that enable safety, including patient and family engagement; and learning practices that reinforce safe behaviour, such as education, measurement and reporting.
Another important component that has been compromised is family support for hospital in-patients, says Zelmer. Pre-pandemic, seven in 10 hospitals had accommodating visiting policies for family and supportive friends. In the first wave of the pandemic, this went to zero, adding further burdens on health-care staff and patients.
“Things fell off a cliff in terms of basic expectations not being met,” said one mother of two about her recent Toronto hospital experience following brain surgery. There were no staff at night in the ICU step-down unit as a serious event occurred in an adjacent bed. The unit did not have a call button, so the mother, 36-hours post-operation and in serious pain, struggled down the hall calling for help.
“The situation terrified me and I’m thinking ‘I need to get out of the ICU because I don’t feel safe.’”
Now recovering well from her brain surgery, the Toronto mother of two wishes her husband or mother could have been with her in hospital to make her post-operative experience better.
“It makes you realize how much families really plug holes in health care.”
Numerous studies conducted through the pandemic demonstrate family presence does not increase rates of COVID-19 transmission when supported by infection and prevention control measures.
In fact, “We know that the presence of essential care partners has a whole bunch of benefits, including reduced anxiety, improved continuity of care, reduced falls, improved taking medication as prescribed, and of course the benefits to an individual of someone they love being there,” says Zelmer.
RNAO’s Grinspun concurs. “It helps in many ways … it helps because it’s help. Help with taking care of the patient. It provides emotional support for patients. It helps because it’s a safety valve. It’s not a nice thing to do, it’s a necessary thing to do.”