Only loss teaches us about the true value of things.
Arthur Schopenhauer
I’m working my way through Mark Carney’s book entitled “Value(s)” right now. In that book he addresses how the economic markets and the world should reconsider what it means to rightly express value. In the front of the book jacket alone he asks “What do you value? Why is it that often the things we value the most – from front line nurses to the natural environment to keeping children well fed and educated – all seem of little importance to economic markets?”[1]
In Alberta and across the world, we have been dealing with the effects of the COVID-19 pandemic for nearly 20 months. We are all frustrated, overwhelmed, and tired but none are more depleted than those health professionals who are our first responders and our front-line staff. But recently the climate has changed as our nurses, physicians, and other health professionals appear to be under attack. That may not be the intent but that is undoubtedly the impact and that’s certainly how it seems to those of us who watch in dismay from the sidelines. It seems as if the money we pay our health professionals is under scrutiny at a time when we’ve never needed them more. It’s come to the point where nurses and physicians are being held accountable for the rising costs of healthcare. You’ll hear executives and ministerial officials often claim that ‘human resource costs make up the biggest percentage by a wide margin of all budgets and that our nurses and physicians in Alberta are the highest paid in the country so… we need them to negotiate in good faith to bring down these costs because they cannot be sustained.’ I’m paraphrasing here but you get my drift.
In addition, further attacks on the minds and hearts of our front-line staff are underway by members of the public as anti-vaccination protests have been taking place in front of hospitals, directly outside the windows of the people who are trying to keep us alive and well. One physician reported receiving hate calls from the family members of people who were critically ill with COVID-19 while she was on duty in an urban ICU. Another physician I know said that he’s cried three times since COVID-19 began. The first time was early in the pandemic when he feared for the life and safety of colleagues and friends because of a super-spreader event. The second time he cried while watching a patient in ICU say goodbye to his family via face time. And the third time was when an anti-vaccination protest was taking place outside his window – at a hospital. Admittedly our government has recently outlawed these protests, but this action frankly came a day late and dollar short.
I don’t disagree at all that the health system has become too costly to sustain. I also don’t disagree that change is needed. But it’s also becoming clear that the public needs to have a better understanding about the structures and processes associated with the work of caring for people in hospital settings. So before we attack the salaries of the nurses who care for us or the fees that physicians charge, particularly family physicians, intensive care, and emergency department physicians, let’s talk about the workflow and the processes associated with how nurses provide care in our health system. Then perhaps we can all think about the absolute value we should be placing on all health professionals.
In the 1980’s when I was a young nurse on a complex medical and cancer inpatient unit, we were assigned 6 patients on the day shift, 8 patients on the evening shift, and 10 patients on the night shift. In those days, the concept of team-based care had largely been lost. There were no longer any orderlies or Licensed Practical Nurses (previously known as Registered Nursing Assistants) on the units. Registered Nurses were held accountable to coordinate and deliver all care for their assigned patients, to identify and respond to risk and to provide for the basic needs of their patients on any given shift. On surgical units, the assignments were even larger, rationalized by the idea that if some patients spent hours away from the unit in the operating room, nurses could care for more patients. Eventually and before I left the bedside, the system had come full circle and we enjoyed working in partnership with LPNs and unit assistants once again – but with larger case loads and greater shared responsibilities. And over time, the acuity on every unit in every hospital had climbed markedly. Patients were sicker and more acute care beds were filled with those who were waiting placement in continuing care facilities, so every discharge was immediately followed by a new admission. No inpatient bed ever sat empty and that remains the case to this day. But let’s stick with the assignments I remember from my early days as a registered nurse.
Having an assignment of 6 patients on the day shift on a medical unit doesn’t sound too bad, right? Well, let’s take a closer look. That nurse might be infusing a chemotherapy protocol to 2 of those patients. Each protocol could include 3 or more drugs delivered over hours by intravenous. Those high-risk protocols also often included delivery of other supporting medications and occasionally additional IV fluids. Another patient was recovering from a serious systemic infection and required monitoring, antibiotics, and ambulation to help him gain back his strength. Yet another patient was anemic and required transfusions of packed cells (blood products) which required constant monitoring. A patient who was waiting placement in long-term care was physically strong but suffered from dementia, was incontinent, and wandered. Finally, a patient recovering from pneumonia was up walking and relatively independent and needed IV antibiotics every 12 hours along with an assessment of his lungs and vital signs.
That reflects what would have been a typical day on a medical / oncology unit with 6 patients. Every patient required their vital signs to be monitored and recorded on the chart. They all needed a thorough physical assessment. Each of them needed some assistance (to greater or lesser degrees) with their physical care. And they all expected compassion, patience, and time. Meanwhile, each had a physician (or two) who would assess and discuss the patient’s progress, and usually update the treatment plan. Care planning meetings were scheduled, respiratory therapists and physiotherapists asked to speak with the nurse, and family members waited at the nurses station for updates.
On the night shift, 3 nurses covered 30 patients. The assumption was that patients generally slept all night so no biggie, right? Nurses just had to do rounds on the unit every hour, peek in on them, change the odd IV bag and that’s about it. The rest of the time most of my friends and family assumed that nurses sat at the nurses station and chatted, read books or magazines, and did crafts. Right? Wrong. Chemotherapy patients and post procedure patients needed monitoring. Dementia patients were often more restless at night. Patients with pending or new diagnoses were often restless and more vulnerable at night. And during the night shift, one of the most critical risk management activities was to complete the mandatory review of the medical charts for each of those 30 patients; to ensure that all physicians orders were processed correctly, and no treatments, medications, or other changes had been missed.
That’s a medical unit. In an intensive care unit where I also worked, I was assigned one ventilated patient who was usually given a paralytic medication to keep them in what’s known as a medically induced coma. Ventilated patients were tethered to IV pumps delivering extremely complex and often very dangerous drugs to keep them alive and to combat the effects of an ICU stay. They had cardiac monitors and arterial lines to assist with monitoring, and catheters in their bladders to assess and manage their urinary output. On any given shift in ICU, I often wouldn’t sit down except when someone else was occasionally available to step in so I could take a bio break or a meal break.
Our job as nurses in any setting was not only to be individually competent to deliver the care, but we were also responsible to be professional observers, critical thinkers, and excellent communicators at a moment’s notice as we advocated for the needs of the patients. None of that has changed. In fact, in the years since I left the bedside, care is more complex, more technically driven, and expectations on the part of the public have increased.
If we expect our health professionals to respond expertly and compassionately when coordinating and delivering care, then how much is that worth to you? What value do you place on those who care for you or your family member and how do you think the system should respond to support them so that they can indeed respond and deliver excellence more often than not? Because let’s face it. The public expects excellent and timely care every single time. There is no room in the hearts and minds of the people we serve for fatigue, error, or failure. To create a system that meets the expectations of the public, we need the public to start by re-thinking what value they place on our health professionals and demand that our decision makers respond in kind.
Do you think that workloads are manageable for our health professionals? What about pandemic workloads? Are they manageable? Current ICU capacity as of October 4, 2021 is 116% over baseline in Alberta.[2] The bigger question is whether that sort of workload is safe or sustainable. Having worked in the past in both emergency departments and intensive care units and having spoken with current providers, I can assure you that it is NOT. How are things at your local hospital? Is it functioning optimally right now so that the care you or your family needs will be available when you need it?
In terms of the economic value we place on health professionals, what do you think a reasonable salary was before the COVID-19 pandemic? Are those salaries still reasonable? Those people are sacrificing their time and their health as they struggle to respond to unpredictable and rapidly increasing demands. Overtime is commonplace. Workloads are excessive, and moral injury is overwhelming our providers. Should nurses sacrifice 2%, 3%, or 5% of their salaries at a time that is unprecedented in more than a century? What about physicians? What do you think is fair? What do you think a highly educated, committed health professional is worth when you need help? What about when your parent or your child needs help?
Saving or redistributing money in the health system to meet the needs of the public is essential. It must be done, or we won’t have a sustainable system. But we need visionaries who will recognize absolute value and implement new ways of organizing and delivering care instead of pencil pushing bureaucrats who know nothing about the delivery of healthcare but who can interpret a spread sheet or negotiate a contract. Carney reminds us that “labor does not give something value; labor is valued because the final good it helps to create is valuable.”[3] So ask yourself, if the final outcome of your stay in hospital or your visit to a clinic was excellent care, what is that ‘final good’ worth to you?
When the system finally recognizes and responds fairly to the irreplaceable value of our health professionals, then and only then will we be able to sustain a workforce of committed people because they are confident we truly understand and value them for the contributions they make to our lives and our communities.
As a health professional, if you have a story to share about your workload or your experiences during the pandemic that may help to educate the public, please reach out. I’d love to share your story on Partners in Health | Conversations.
[1] Carney, M. Value(s): Building a Better World for All. 2021 Penguin Random House Canada.
[2] https://www.albertahealthservices.ca/br/page17593.aspx
[3] Carney, M. Value(s): Building a Better World for All. 2021 Penguin Random House Canada. Page 40
