The Registered Nurses Association of Ontario (RNAO) has prepared this submission to the Independent Commission to Investigate the Introduction and Spread of Severe Acute Respiratory Syndrome (SARS) to ensure nurses’ voices are heard. The submission is a snapshot of RNAO’s full report to be released later this year.
Nurses comprise 60.3% of all regulated health professionals. Nurses are present with their hands, minds and souls in all sectors, from public health to home care, and from acute care to long-term care. Nurses cure and care every day and every hour. Nurses have a unique perspective because it encompasses both an intimate and comprehensive view of our entire system of care, from the needs and concerns of patients and families to organizational and system issues. The nursing perspective is, therefore, critical to understanding the health care system’s strengths and weaknesses. To hear nurses’ voices and act on their advice is critical for the health and wellbeing of all Ontarians. Yet, despite all this, nurses’ voices have too often not been fully integrated in decision making at bedsides or in boardrooms. We hope that this report does not suffer a similar fate and find itself relegated to a shelf.
RNAO’s report, SARS Unmasked: Celebrating Resilience, Exposing Vulnerability answers the need to give voice to the many nurses who worked and lived through the SARS outbreak in Ontario. We listened, we learned and we acted by providing support, advice and advocacy throughout this crisis.
Our report acknowledges that this crisis was unlike any we had experienced before. Our report also argues that we – government, health organizations, and health care professionals – were ill prepared to tackle SARS. Not only did we need to manage an infectious disease, whose origin and transmission were initially unknown, but we had to do this from within a depleted health care system. This is a system weakened from years of funding cuts and a workforce exhausted by a decade of relentless restructuring. SARS further challenged:
- A system that is poorly connected;
- A public health sector that is under-resourced and disintegrated;
- A home care sector that is destabilized;
- A hospital sector that is unprepared for major emergencies; and
- A nursing workforce that battles with dangerously low staffing levels, high workloads, and an over-reliance on part-time, casual and agency staff.
RNAO filed a request with Premier Eves for a full public inquiry and we stand by our call. Much has become public and much more remains private. We continue to be concerned by the level of secrecy regarding the SARS outbreak. If we don’t hear and we don’t know, we don’t learn. And if we don’t learn, we don’t improve. The nagging question continues to haunt us: could we have avoided some of the death and devastation brought about by SARS in Ontario?
The findings of this report are based on what we heard during and since the SARS outbreak. RNAO has supported and advised hundreds of nurses during this period. What we learned during that process was enriched by 15 sector-specific focus groups and 51 individual interviews. The findings reflect a comprehensive view of nursing perspectives across all sectors, from those providing direct patient care, to nursing students, to those in administrative and educational roles.
The Ontario Nurses Association (ONA), the Registered Practical Nurses Association of Ontario (RPNAO), the College of Nurses of Ontario (CNO), the Community Health Nurses Initiatives Group (CHNIG), and the Association of Nursing Directors and Supervisors of Ontario Official Health Agencies (ANSOOHA), also shared their perspectives with RNAO.
The voice of nurses. The key themes emerging from the focus groups and interviews are:
- Nursing patients with SARS -- a sea of emotions: Fear, anxiety and exhaustion; isolation and stigma; commitment and pride; frustration and anger – these were feelings consistently expressed. Throughout the outbreak, nurses endured the underlying fear they too would fall victim to this disease. They feared for their families, the same families from whom they had to be isolated. Anger was vividly expressed over the failure to recognize nurses’ clinical expertise and nurses’ frequent warnings that went unheeded. Our report clearly outlines how – in the face of these strong feelings – nurses demonstrated an amazing commitment to patients, the health-care system and the profession. Although staff nurses and manager were exhausted, they felt proud.
- Work environment: Nurses pointed to major health and safety concerns exacerbated by limited occupational health and infection control resources. During the outbreak nurses expressed serious concerns regarding the access to, and effectiveness of, protective gear. They also described the extreme discomfort from the extended use of face masks. We heard numerous concerns about the quality and timeliness of mask fit testing. We heard, and experienced, the “chaos of communications” during the first phase of SARS, and witnessed the significant improvements made in the second phase. We heard repeatedly about nurses’ concerns not being heeded by senior physicians and others in positions of authority.
- Workforce: The report clearly outlines what nurses in all roles shared with us: staffing shortages were a major issue prior to SARS and worsened dramatically during the outbreak. The over-reliance on part-time, casual and agency nursing was a barrier for staffing and for sustaining staff morale. The significance of multiple-employment took on a new dimension when nurses where directed to work for only one employer to contain the spread of SARS. It meant many employers had to rely on fewer nurses and many nurses could not count on their incomes. Some nurses described how pressured they felt to come to work sick, and to work double shifts, as sick time would not or could not be replaced. A few nurses shared that they were expected to come to work even though they had a “cold” or “flu like symptoms.”
Adding to the workforce constraints was the failure to appropriately utilize student nurses who were nearing graduation. This is an important human resource that could have eased system problems. We heard the disappointment of students, most of whom felt left-out of an important experience and frustrated in their genuine desire to help. While many nurses described their continued commitment to the profession – all too many noted that things must change in order for them to remain in nursing.
Service issues: System-wide we heard about problems in coordinating decision-making and directives between and within sectors. The result was considerable confusion. As all sectors moved to contend with SARS, other programs – and thus the patients and residents who rely on these programs – were neglected. Nurses spoke eloquently about how the restrictions imposed during SARS significantly affected the quality of care they were able to provide. Some of the most heart-wrenching descriptions in this section are of nurses who were themselves SARS patients. Overall, nurses described a system stretched beyond its capacity as it struggled to deal with SARS; a system significantly lacking necessary surge capacity.
On March 31st, RNAO launched the SARS Nursing Advisory Committee. Comprised of a senior representative from all major nursing organizations, affected health care organizations, and the Nursing Secretariat, the committee met every other day in an attempt to streamline communication and co-ordinate timely support. The committee has been formalized on a permanent basis as an Emergency Nursing Advisory Committee that meets monthly in normal times.
SARS was an experience that the nursing profession will never forget. To many nurses, it was the absolute worst of times. And yet – in so many ways – it underscored the resilience and strength of nurses. To be sure, the response to SARS exhausted individual nurses and tested the very limits of their professional commitment. If nursing is to be preserved and enhanced so it can continue to contribute to health and healing, systemic changes must occur. The recommendations that follow outline what nurses need from governments, employers, nursing associations and Justice Campbell so we can be better prepared – and better respond – for the next infectious disease outbreak or other major challenges. The next crisis might be just around the corner and we must be better prepared!