Stretched to the limit: Coronavirus adds stress to already burnt-out nurses

The Covid-19 pandemic has drawn public and political attention to the Irish health system and the courageous work of health workers on the front line. Before the pandemic struck, reporters from The College View identified and examined some of the major pre-coronavirus challenges faced by the Irish healthcare system, including waiting lists for some chronic conditions, the dependence on locums (doctors in temporary positions) in short-staffed hospitals, and the difficulty some parts of the population – Travellers, the homeless – have in accessing healthcare. These stories present facts and context to understand the Irish health system have been stretched to its limit as it deals with the effects of Covid-19.

The sudden global surge of the coronavirus has put even more pressure on Ireland’s already stressed nurses.

The levels of stress and burnout in the nursing profession are at unworkable levels due to lack of funding and understaffing, but the recent arrival of Covid-19 has put even more demand on professional and student nurses.

In an interview with the Irish Times, Dr Gabrielle Colleran, vice-president of the Irish Hospital Consultants Association (IHCA) said Ireland already faces capacity issues, and head of the Irish Nurses and Midwives Organisation, Phil Ní Sheaghdha, said it’s “very hard to know” if there will be sufficient levels of staff to deal with the expected number of patients in the coming months.

From March 7th, the official recruitment ban on nurses and midwives was lifted amid the outbreak, which Ní Sheaghdha said “should have happened much earlier.”

Speaking before the outbreak of Covid-19, Ní Sheaghdha said nurses face stress over crucial wards being understaffed, which leads to staff feeling overwhelmed and burned out. 

This point was reinforced by a director of nursing and former staff nurse who cannot be named. She said she used to hold recruitment drives in her workplace, but very few would attend.  The cap on the number of staff members that can be employed she felt was putting patients at risk.

In February of 2019, the INMO organised a nursing strike in relation to disputes with the government regarding pay and staff retention issues.

Steve Pitman, Head of Education and Professional Development for the INMO, said there are problems with the way stress and burnout are measured in the workplace, leading to the results of staff surveys being unrepresentative of the true levels. 

A recent global review found the burnout rate was between 10% and 11%, however other reviews pointed to the levels being closer to 70%.

Pitman said a staff survey is sent out by the Health Service Executive (HSE), but the respondent rate is low at approximately 14%. The 2018 report released in December suggested high levels of satisfaction of respondents, but this could be affected by the number of professionals who fill out the survey and which staff members are asked to answer it. 

One of the factors influencing levels of stress and burnout can be the environment, said Pitman, suggesting the Emergency Department is likely to show higher levels than certain other departments.

Pitman said nurses carry the burden of “emotional labour”, which means they are expected to deal with horrific situations and then carry on and tend to other patients without letting the situation affect them. 

Pitman said if people want “compassionate and caring nurses,” those nurses also have to be kind and caring people. Sometimes it may be difficult for them to process traumatic work experiences and would need time and support in place to do so.

There is also evidence of a link between “good quality nursing care” and a decrease in mortality rates, according to Pitman.

One factor obstructing reform is how large-scale it would be. Pitman said that often instead of trying to fix the underlying issues in the health service, the HSE instead focuses on things that would please more people in the short-term, called “satisfiers”.

Pitman shared Ní Sheaghdha’s belief that the biggest issue facing the profession was understaffing, in particular the recruitment and retention of nurses and a lack of opportunities for them to grow and develop.

For nurses, the stress doesn’t stop when their shift finishes. Ní Sheaghdha said constant worries and paranoia over referrals means it’s difficult for nurses to relax at home.

“When they go home in the evening they’re thinking, ‘Did I do that? Did I give the correct medication, did I give it on time?’”. 

“What a lot of nurses tell us is that they’re terrified of their registration,” said Ní Sheaghdha, which is partly down to staff referrals. Nurses can be referred to statutory bodies by members of the public for lack of due courtesy or lack of due care, lack of privacy or similar issues, as well as being referred when “serious incidents” occur.

The risk of referrals leads to nursing staff being afraid to make decisions that may lead to a member of the public complaining, which in turn leads to their stress levels increasing.

“We want watchdogs, to make sure people are carrying out their jobs correctly,” said Ní Sheaghdha. In some instances, the defense and the hearing might take up to 18 months or two years. The referred nurse is still allowed to practice during this period, “so you’re practising away, but you’re under that strain.” 

Ní Sheaghdha said they represent most of the nurses that go to fitness to practice hearings, which is around 100 cases per year.

The Nurses and Midwives Board of Ireland (NMBI) has a statutory obligation to protect the public, and while Ní Sheaghdha said she understood this, “there also seems to be a level of stress and burnout attached to the whole referral process.”

In many cases, only the INMO supports staff going through the referral process. So if employers do not have support in place and the nurse or midwife is not a member of the INMO, they would have no support during this time.

Ní Sheaghdha said often work rosters don’t put measures in place for sick staff or members of staff on maternity leave, and an increase in outsourcing is putting patients and healthcare professionals in a difficult position.

One example she gave was cervical screening, which was outsourced to Cervical Check, a screening programme providing free cervical screening to women resident in Ireland aged 25 to 60. Ní Sheaghdha said due to the health budget being decided annually, it was cheaper to leave all the decisions to a separate company. About 82% of elderly care is also outsourced.

“If we have an annual budget and we’re trying to stick within it we will make incorrect decisions,” she said. If these services are not in the state’s control, then certain standards cannot be implicated.

Ní Sheaghdha said the clear solution is correcting the staffing levels, as demonstrated in The Framework for Safe Nurse Staffing, piloted in 2017 across 3 hospitals over an 18-month period.

The framework examined the amount of burnout and sick leave in relation to staffing levels. It found if there were constant staffing changes to a ward, the burnout and sick leave levels were higher. 

When staffing levels were corrected and measurements put in place to regulate staff, burnout decreased and sick leave went to 0.1%.

“It works, we know the solution,” said Ní Sheaghdha. “Even speaking to nurses on those wards, it was incredible the difference. All of a sudden they started enjoying their job again, they had very high levels of satisfaction on a job well-done.”

Padraig O’Morain, former Irish Times Health writer, said the two main issues contributing towards hospital overcrowding and burnout are a resistance to hospital reform, and a failure to develop community care.

“We have a massive HSE bureaucracy that we’re paying for,” he said. “We keep twisting and turning and trying to find our way out of that but nobody’s found it. Maybe there isn’t one, I don’t know.”

O’Moráin said Ireland should take health systems like those in France and Germany, that can meet the funding demand, as examples of what we should strive for.

According to his book, “Irish Association of Directors of Nursing and Midwifery: 1904-2004, A History”, the health service has always faced staffing problems. In the 1980s a lack of funding meant staff numbers were low, then in the late 1990s there was enough funding, but not enough nurses.

Between 2011 and 2014, the number of nurses in Ireland decreased by 2,340 according to the Nursing and Midwifery Board of Ireland (NMBI), but began to increase slowly after that.

O’Moráin said an area desperately in need of improvement was community care. He said currently many patients, regardless of ailment, end up in the A&E of band 1 hospitals. This results in over-crowding in what is often an already understaffed ward.

“In terms of making the most of what we’ve got, I don’t think we’re very good at that,” said O’Morain. The HSE was originally built on a county health system, which has not been modernised well since its conception in 2005. “Along the way, we stopped managing resources well I think.”

He also mentioned there were more political benefits for politicians to tackle waiting lists, rather than improving community care. O’Morain said this lack of improvement in a critical area was “appalling.”

One immediate change that could be made to the health service, said Ní Sheaghdha, would be compulsory de-stress classes for healthcare staff.

Due to the lack of funding it would be difficult to implement any changes that would take immediate effect, however, in 2016 the Committee on the Future of Healthcare was established to reform Irish healthcare for the long-term.

The final report of the committee was published in 2017, called the Sláintecare report. It laid out a ten-year plan for reforming the health system in Ireland. As of writing, the Sláintecare plan is two years behind.

Challenges facing the health service identified in the report included many of the issues raised by Ní Sheaghdha, Pitman and O’Moráin: increasing pressure on healthcare professionals due to understaffing and underfunding, waiting times, and poor outcomes relating to costs.

One proposal of Sláintecare is multi-annual budgeting: a health budget spanning multiple years instead of funding being allocated annually.

Multi-annual budgeting, said Ní Sheaghdha, would mean if you can demonstrate you made savings in your area then your budget for the next year increases. “Unless you get rid of your overdraft, you’re never going to be able to develop, to put it simply.”

According to Ní Sheaghdha, the way our current healthcare service has developed is because of annual budgeting, the “what’s the cheapest way to develop this service?” mentality.

Although Sláintecare is set to go ahead, O’Moráin felt the Irish Health System is a tough one to reform. 

“Nobody really controls the system.” he said. “You’ve got the HSE, the Minister has to work through the HSE and quite often we find that they can’t work through the HSE. They take the money and use it for something else.”

“It’s too unyielding a beast” he said.

With the recent pressures put on the health system due to the outbreak of Covid-19, the Sláintecare plan may be delayed further. Ní Sheaghdha said on RTÉ’s Saturday with Cormac Ó hEadhra any nurse hired during this period will be recruited on the agreed rate. “That is not the issue,” she said, “the issue is we need people to be appointed permanently to the health service.”

Sally Dobie, Kirsty Dowdall & Naoise Darby.

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