May 4 2021

To the Government of Ontario,

[RE: ONTARIO NURSES’ MORAL DISTRESS CRISIS DURING COVID-19 PANDEMIC]

I would like to speak on behalf of nurses in Ontario, providing insight on our experiences and challenges that we have faced since the beginning of the pandemic. In this letter, I am going to address how undervalued nurses in Ontario feel, despite being called “healthcare heroes”. Due to the increasingly difficult and dangerous work we are tasked with, we feel that words of encouragement are no longer enough to appease us. There must be systematic changes within the Ontario healthcare system to not only increase patient safety but retain the staff that you deem as valuable to keep fighting the pandemic.

Working in the intensive care unit (ICU) is not an easy task, it requires a special individual to handle its everyday hardships. Healthcare workers, especially those working in emergency and intensive care services, have faced the brunt of the responsibilities to protect and save those affected by COVID-19. This virus has caused a multitude of changes in the lives of Ontarians, we are facing endless lockdowns, extreme isolation, daily dosing of negative information on the news and notification of death and distraught around us. This has been demonstrated by the increase in suicide during this unprecedented time. Job vacancies in healthcare and social assistance have increased by 56.9% during the last quarter of 2020, hospitals leading the mass exodus with 15,700 vacancies. We, as nurses, feel powerless and uncertain about the future. We are anxious about PPE shortage, the higher possibility of infection and bringing the virus home^[1]. There is a massive increase of absenteeism among colleagues due to burnout and moral distress, and distrust in the system due to constantly changing policies and contradictory messages delivered by the government and by employers.

The World Health Organization (WHO) defines burnout as a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It’s characterized by 3 dimensions: 1. Feelings of energy depletion/exhaustion 2. Increased mental distance from one’s job 3. Feelings of negativity or cynicism related to one’s job and reduced professional efficacy. In the ICU, we are seeing more and more preventable deaths, as we are faced with the negligence demonstrated by the general public who disbelieve the validity of the virus and its vaccines. As a result, we bear the emotional and physical burdens of these choices. We are well aware that we are reaching a point where doctors are deciding who will receive life saving intensive care treatments (including ventilators, ECMO) but ICU nurses have such high nurse to patient ratios, that we’re deciding on who we prioritize in our care. Every shift, there will be a patient that receives less attention than other patients due to the physical inability to manage multiple ICU patients with varying complexities. This leads nurses to believing that we’ve “let down” patients and their families, that we are doing a disservice to them. At the end of the day, this lack of careful attention from an ICU nurse will lead to irreparable medical errors and deathly patient outcomes^[2]. ICU patients are on extremely potent medications that require monitoring every minute, they rely on a machine to breathe for them, and are basically helpless without nursing intervention. With strict visitor restrictions, families heavily rely on nurses to provide and translate medical information while catering to them on an emotional and spiritual level but with higher patient ratios we lose the ability to do this. Imagine anxiously calling for an update on your mother, only to be told your nurse is busy for the third time. A majority of Ontarians do not have enough medical education to understand the treatments and interventions provided in the ICU but these family members are tasked with having to make life changing choices for the patient (ex. Whether their family member should be intubated or not). These are just some of the examples of what goes on during a shift in the ICU.

The reallocation of staff from the operating room, medical-surgical units, labor & delivery, and pediatrics has been a great help to our efforts in the ICU. It must also be acknowledged that redeployed staff are taken out of their field of expertise and thrown into ICU with minimal training. In Ontario, to receive the critical care nursing certificate, 4 months of specialized education including a practicum is required. Additionally, it may take a new ICU nurse another couple of years to be accustomed to the unique practices within their ICU. A majority of the redeployed staff do not have such training and lack the knowledge, skills and judgment to make necessary critical decisions while working with ICU patients. In France, early in the pandemic (March – April 2020), their country went from 5000 beds to 10,200 beds. They also reallocated staff, and suspended elective surgical and medical activities to support the pandemic. Experienced ICU nurses became key players in mentoring redeployed and new ICU nurses, while also supervising all critical care nursing activities. Although the redeployed nurses’ roles expanded, they could only provide care for relatively stable patients without invasive support (ex. Vasopressor titration, ventilator troubleshooting, adjusting sedation and paralytics). It became clear to France that experienced ICU nurses were essential and irreplaceable to ensure quality clinical care.

At this point, I would like to make it clear that, the redeployed physicians have had a change in salary to support nursing efforts (i.e., physicians redeployed to intense care units shall received $385/hr from 7am to midnight and $450/hr from midnight to 7am). Nursing efforts including: turning of patients, proning of patients, cleaning patients, and other activities of daily living. As one of the largest bodies of professionals in Ontario, we are once again, asking for just financial compensation and for exemption from Bill 124 for heroic nurses that have endured the extreme burdens of the pandemic (mentally, emotionally, physically). Staffing shortages are further exacerbated as ICU staff are leaving their hospital positions to sign on to agencies who are willing to pay $50-65/hr to work as an agency nurse at the same hospital. As nurse-to-patient ratios increase with no remuneration, Northern Ontario nursing salaries offering $93-111K/yr for med-surgical nurses become more attractive. These rates are still a fraction of what the Ontario government is currently paying redeployed physicians to fill nursing gaps in a care model led by an ICU nurse who’s average hourly wage is $41/hr. It is increasingly impossible to retain experienced ICU staff who are burnt out as their government fails to provide appropriate financial compensation for their efforts.

I would also like to point out how important specialty diversity is in the field of nursing. General knowledge speaks to physicians specializing in different fields to properly care for their patients (ex. Gastroenterology, cardiology), but the general public is not aware that the same specialities apply in nursing. There are special nuances and skills in every field of nursing that make each nurse unique; and the differences in skills needs to be recognized and compensated for appropriately.

In this critical point of the 3rd wave of the pandemic where more and more patients are being admitted and requiring ICU level care, it is important to retain existing staff and recruit new staff. With increased workloads and lack of compensation, new nurses are not attracted to the field and experienced nurses wish to leave the field altogether. For the future of healthcare, the government must recognize that a large portion of positive patient outcomes come from nursing care. In a European study conducted between 2009-2010, RN4CAST, it was found that higher nurse resourced hospitals, with higher labor costs, were able to achieve better patient outcomes at the same or lower cost than hospitals with worse patient outcomes at a lower cost. This is because higher nurse resourced hospitals admitted 40% fewer patients to expensive ICUs and the length of stay was also shortened. In a study by McHugh et al., it was found that RN burnout negatively affects patient outcomes in several ways: 1. Mortality rates in hospitals increased by 19.4% 2. A 6.5% readmission rate 3. 36% of RNs missed essential changes with their patient’s situation or failed to report important information. Though it is tradition for national policymakers and hospital executives to view hospital nurse staffing as an expense that should be minimized as much as possible, they are not taking into account how that greatly affects patient outcomes and patient satisfaction. Patients will suffer when nursing care is taken away.

This pandemic is proving just how valuable nurses are. Although we have failed to prevent this 3rd wave of COVID-19 as a whole, it is imperative to recognize the laborious efforts already put in by Ontario’s nurses who have overextended their practice (1 ICU RN to 3-4 ventilated patients) with their licenses. We cannot keep pushing nurses out of this profession and prevent future attraction to the profession by our failure to support nurses during their most essentially needed times. If not, our healthcare system will deteriorate.

Lack of nursing care in Ontario will affect the health of all Ontarians. Ontario has been the epitome of good healthcare systems funded publicly on the international playing field, but now that vision is crumbling. Money can be put forth towards beds to accommodate more patients, but beds don’t care for patients, nurses do.

For the periods between April 24, 2020 to August 13, 2020 we received retroactive pandemic pay of $4/hr worked on top of our existing hourly wages. The goal was to: “1. Provide additional support and relief for frontline workers 2. Encourage staff to continue working and attract prospective employees 3. Help maintain safe staffing levels and the operation of critical frontline services. This was an appreciated and needed incentive during the first wave, but the 3rd wave brings more uncertainty and distress with emerging variants and the highest number of ICU admissions since the beginning of the pandemic. I would also like to point out that the Ontario government has previously supported nurses in amending the “Supporting Ontario’s First Responders Act (PTSD)” by including nurses into the list of “First responders and other designated workers''. This allowed eligibility towards faster access to WSIB benefits and proper treatment. Although, the issue still remains that for as long as the profession stands, nurses continue to face violence, belligerence and sexual misconduct from patients and their families. This emotional burden is further encumbered by being present to the frequent loss of life, and to the pain and suffering that resonates long after death within ICU walls.

We, “the nurses” of Ontario, hope you recognize our efforts and compensate us appropriately. We also wish for you to provide more funding towards nursing education to encourage diversity in nursing fields. Although the government funds critical care nursing programs, there is a lack of attraction to the field if incentives do not reflect upskilling. ICU nurses have a much greater responsibility for the sickest of patients in the hospital, we are trained in procedures such as dialysis, we are the code blue team for the hospital, we are apart of CCRT team, we run ECMO; these are just some of the things we are uniquely trained in but are not compensated for. This is just one example of a speciality in nursing that requires upskilling but lacks a salary to compensate for it. Other specialties include: pediatrics, labour & delivery, oncology, telemetry, and many others. In Ontario, the only difference between nurses is years of experience regardless of skills and specialty. Ontario should strive to become a leader in Canada, initiating wage equity, supporting nursing specialty diversity and education, and continuing mental health support within the nursing profession in order to advance our healthcare system.

These systemic changes will require time and revision, however, it’s important to start the discussion now and allow nurses to have a voice. We suggest a critical care coalition, whether it’s permanent or temporary, to advocate on behalf of ICU nurses in Ontario during the duration of this pandemic. We are at the front lines fighting against this virus and we understand the needs of Ontarians who have been hospitalized and we share the same frustrations of families of these patients. Giving us a voice to advocate on behalf of Ontario’s patients will reinforce how important nursing care is whether it’s during the pandemic or post-pandemic.

In summary, we urge the Ontario Government to:

1. Exempt Registered Nurses and other frontline healthcare professionals from Bill 124.
2. Provide the justified financial compensation for Registered Nurses that continue to fight for patient safety and quality care during the COVID-19 pandemic.
3. Recognize that critical care nursing and a variety of other specialities require further education, certifications, and qualifications, and therefore should be rightfully compensated for additional skills.
4. Support the building of a Registered Nurse based Critical Care Coalition to advocate for the working environments of ICU RNs and to advocate for the safety of patients and quality of care in Ontario.
5. Begin discussions to support the diversity of specialization in nursing and support the life long education of nurses in Ontario.

Sincerely,

The Nurses of Ontario