Registed Nurses' Association of Ontario

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Lessons learned from SARS


Lessons learned for the next time

SARS left 44 people in Ontario dead – including three health-care professionals – and exposed a number of serious flaws in the province’s health-care system. Ten years have passed since the outbreak, and while nurses will never forget the turmoil it caused professionally and personally, they also acknowledge many important lessons were learned. The following six touch on what nurses believe will help Ontario cope with future epidemics…

  1. Listen to nurses. Many nurses’ voices were silenced during SARS. The outbreak, which began in Ontario in March, was deemed over by mid-May after the World Health Organization lifted its travel advisory on Toronto on April 30. Safety measures at health facilities began to relax, and nurses were told they didn’t need to wear protective gear anymore. Yet RNs continued to see patients with SARS symptoms (fatigue, a fever, muscle pain, a dry cough and breathing problems) and reported these new cases to administrators. At some health facilities, their comments were ignored. In fact, nurses at one hospital were told by a director “if I need an expert, I’ll ask for one.” Nurses were even denied protective equipment at one Toronto hospital. Some RNs went to newspaper, radio or television outlets to convey the truth, but by the time this information became public, the second outbreak – commonly thought of as a misnomer because it’s been said the first outbreak was never really over – had begun. “Nurses and other health-care professionals are the safety valve in the system,” says RNAO CEO Doris Grinspun. “If you muzzle them, you’ve lost that valve.” Now, nursing voices are heard and respected. As of 2011, nurses have a seat on hospital medical advisory committees. Toronto Public Health RNs also sit on infection control committees, tracking communicable diseases and keeping lines of communication open with hospitals. Legislation also mandates chief nursing officers have a position in all public health units.

  2. Communication is everything. Health professionals on the front lines during SARS needed to be constantly aware of changing precautions and emerging information about the relatively unknown disease. However, communication proved challenging as the government of the day and individual health facilities across the province scrambled to understand and relay accurate information. Many practitioners, patients and members of the public felt they were left in the dark. Nurses even recall reading faxes offering conflicting details about safety measures. Now, in the wake of public health scares such as H1N1 and the ongoing H7N9 bird flu outbreak in China, RNAO and other key health stakeholders participate in routine conference calls with the provincial Ministry of Health, which also launched a 24/7 telephone hotline to field stakeholders’ questions and concerns. The ministry also provides briefings – sometimes daily – about any important developments. RNAO is also asked to distribute updates to members. Some nurses have said they learned the value of keeping patients in the know about any developments during a public health crisis, as it helps to ease clients’ nerves.

  3. Keep infection control top-of-mind. The importance of infection control measures is front and centre post-SARS. Hospitals closely follow influenza cases, and have created more negative pressure rooms to help keep cross-contamination at bay. Hand washing/sanitizing stations are also more prominent. Staffers must undergo mask fit testing – if they don’t do so within a certain timeframe, they won’t be permitted back at work – and occupational health and safety departments monitor workers who have been off sick for more than three consecutive days. Infection prevention and disease control programs have a stronger presence, though in these times of austerity, some fear these programs may be reduced. Pandemic planning has also taken a front seat post-SARS: the province has created the Ontario Health Plan for an Influenza Pandemic.

  4. Reasonable efforts to reduce risk need not await scientific proof. One of key findings in the late- Justice Archie Campbell’s Spring of Fear report is that of the precautionary principle. “When it comes to worker safety in hospitals, we should not be driven by the scientific dogma of yesterday or even the scientific dogma of today,” reads the document. “We should be driven by the precautionary principle that reasonable steps to reduce risk should not await scientific certainty.” Nurses recall thinking safety precautions were lifted too soon right before the second cluster of cases became apparent. Some even went to their administrators to say they were still seeing new cases of the disease. In some instances, this was to no avail. At one Toronto facility, nurses were told to calm down, and that the situation was under control. Yet, days later, the second outbreak began to ramp up. Now, hospitals are more in tune with the precautionary principle, and take steps to ensure appropriate materials – such as masks – are always on hand.

  5. Remedy health-care staffing issues. SARS ripped the lid off health-care staffing issues, particularly low staffing levels in the nursing workforce, heavy workloads and an overreliance on part-time, casual and agency staff. At one point during the outbreak, nurses were told they could only work for one employer to help contain the spread of SARS, meaning reduced incomes and a smaller staff pool to draw from. “The years preceding the SARS outbreak were marked by a dramatic deterioration in nursing human resources capacity; policy decisions led to dangerously low staffing levels. And, in many cases, workloads were unsafe,” reads RNAO’s 2004 report, SARS Unmasked: Celebrating Resilience, Exposing Vulnerability. “Already pushed beyond its limits, the system was in no position to adequately deal with an emergency like SARS.” Though improvements have been made over the years (the measured share of full-time employment for RNs rose from 59.3 per cent to 68.8 per cent between 2004 and 2012), workload and staffing still remain concerning. Ontario has the second lowest RN-to-population ratio in Canada. Many RNs still resort to working more than one job, or picking up extra shifts. Current College of Nurses of Ontario numbers indicate 15.6 per cent of RNs and 24.1 per cent of NPs work for more than one employer.

  6. Pay more attention to public health. The national report, Learning from SARS: Renewal of Public Health in Canada, led by David Naylor, drew attention to significant gaps in the nation’s public health system. “SARS is simply the latest in a series of recent bellwethers for the fragile state of Canada's federal/provincial/ municipal public health systems,” the 2003 document reads. “The pattern is now familiar. Public health is taken for granted until disease outbreaks occur, whereupon a brief flurry of lip service leads to minimal investments and little real change in public health infrastructure or priorities. This cycle must end.” To this day, though, some argue emphasis on public health is still not strong enough. “There has been a shift in ministry funding from acute to community care, but it’s still care – it’s not promotion and prevention,” charges Mary Ferguson-Paré, former RNAO president and retired vice-president of professional affairs and chief nurse executive at Toronto’s University Health Network. “Investments in health promotion and disease prevention are where we need to get in order for us to try to have a strong system of preparedness in place for anything like another SARS event.”