Why Are We Failing Health-Care Workers?

April 22, 2020 by David Nitkin | Categories: Public Participation and Governance | Tags: decision-making, Healthcare, Leadership

We all stand in admiration of health-care providers who selflessly put their own lives at risk in order to treat patients. Physicians and nurses, paramedic staff, lab technicians, public-health officials, and other emergency-care workers consciously and compassionately strive to save lives—it is their vocational calling. They do so in hospitals, nursing homes, correctional infirmaries, physician offices, homeless shelters, and other clinical settings. There are reasons to conclude that we are failing them.

The Issue:

These workers trust that the rest of us will “have their back” – that is, allow no threat to their own safety and that of the patients they treat. That vital trust has come into question, as more and more cases get reported of “front line” health-care providers being told by administrators that emergency compromises must be made because there are shortages of personal protective equipment, staff, tests and other resources. They are being challenged as they are required to learn more quickly, work overtime, support one another in applying personal protective equipment, and substitute for infected colleagues.

There are anecdotal and professional survey data that confirm the existence of a growing number of care-provider complaints. They include:

(a) inadequate training on emergency critical care procedures;
(b) insufficient numbers and dangerous under-allocation of masks of the right type;
(c) forcing staff to treat patients where there is inadequate separation of COVID and non-COVID patients, which adds to the risk of cross infection; and
(d) insufficient personal hygiene resources like showers for staff.

Other issues reported include:

(e) insufficient co-ordination and transparency between the federal and provincial/territorial governments to ensure supplies are making it to the front lines;
(f) emergency government mandatory orders have temporarily but radically broken collective bargaining rights—including powers to re-assign individual workers anywhere to do anything at any time in a hospital or other care facility; and
(g) questions about sufficient long-term counselling resources for health-care providers’ psychosocial and mental health, especially those who self-admit to questioning their willingness and ability to continue such unexpectedly stressful work.

This sounds very much like a crisis threatening to overcome us because that’s the language being used almost everywhere by everyone. The results of a survey this week of almost 5,000 physician members of the Canadian Medical Association (CMA) highlights issues such as:

Over a third of physicians in community care (e.g., office-based, walk-in clinics) believe they will run out of masks, including the N95 masks, eye/face shields and goggles/glasses within two days or fewer, or had already run out.
More than two thirds (71%) of physicians in community care have tried to order supplies in the past month, and fewer than 15% received confirmation that supplies were en-route or had been received.
When it comes to alternate supply sources, only one in ten Canadian physicians waiting on supplies was aware of a government source of supply, with the rate being highest in Alberta (26%) and lowest in Nova Scotia (5%) and New Brunswick (0%).
Physicians in hospital settings were largely unaware how long the current supply in their practice would last and many respondents admitted that they are being asked to ration supplies.

Ethical and Moral Difficulties:

Ontario and other provinces are working out criteria for ICU rationing — how do we save the most lives? Should the young leapfrog the old? How much time should people be given to show signs of recovery before life support is removed? Three days? Seven? Reports from Italy describe doctors weeping in hallways. “The angst that clinicians may experience when asked to withdraw ventilators for reasons not related to the welfare of their patients should not be underestimated — it may lead to debilitating and disabling distress for some clinicians,” the authors of a recent New England Journal of Medicine perspective article wrote.

As intensive care units here begin to fill, some primary care workers have begun isolating themselves at home to avoid bringing COVID-19 home to their families. Many doctors like my own have started to see patients in their private practice offices only by prior appointment.

Photo source: NIH Clinical Center

There is criticism among professionals of effective and absent official guidance for care givers who provide cross-border services or serve in more than one nursing home. There is a current low-level anxiety in various communities as doctors and nurses confront the two most pressing worries facing the system now:

(a) the prospect of having to severely ration personal protective equipment (PPE) and mechanical ventilators, and
(b) questions about the morale, health, empowerment and availability of health-care providers who have never before faced such a looming health-care crisis.

The challenges are exacerbated by the complexity of health care. Unfortunately, the goals of front-line, health-care workers may not coincide perfectly with those of other stakeholders, which add to their stresses. For example:

ISSUE		STAKEHOLDER
	Health-care workers	Hospital administrators	Patients and their Family	Government Public Health officials
Duty of Care Priority	Patient care, and the health of themselves and their families	Most appropriate allocation of staff, equipment, tests and resources; Quality of patient care	Survival, recovery and quality of care; Ability to be together (which may be ill-advised)	Exercise responsibility to manage the crisis
Legal Rights	These have largely been stripped under current emergency regulations	Accept and implement macro management directives from governments that fund them	Prohibitions on mobility and visitation rights	Provide prudent advice to elected officials and the public
Professional standards	Code of conduct: doctors, nurses, EMTs, physiotherapists, social workers, others	Professional code: hospital administrators	No	Treasury Board and public service standards
Public Perception in a crisis	Compassionate, professional	Distant, bureaucratic	Vulnerable	Knowledge-based advice

There are other stakeholders and many dimensions to these conflicting interests that are the subject of individual forthcoming blogs, including

The role of governments in Canada which control the flow of funds to hospitals, medical doctors, other health-care professionals, and nursing homes.
The role of LHINs in distributing funds, ranking priorities, and preparing for disasters and emergencies.
Remuneration for physicians, some of whom are working wholly or largely by phone, which is a modality not normally covered by OHIP and like plans in other provinces.
Remuneration adjustments for surgeons, anaesthetists and other lost-wage workers for lost earnings due to cancellation of procedures.
Calls for Revenue Canada to specially treat tax returns of committed and dedicated, essential service workers like farmers, truckers, grocery store clerks, cleaners, and others.
Chronic under-funding and under-staffing for RNs and PSPs (personal support professionals) at nursing homes, including inadequate training of staff in infection control.

Moral and Legal Dimensions:

Epidemiologists are issuing “crisis language” pandemic warnings about hospitals being unable to care for masses of virus patients, as large numbers of patients transfer from emergency rooms and clinics to ICU units. In doing so, they have overshadowed and usurped policy-making alternatives and skewed our perspective on managing the full health-care system to be focused almost exclusively upon COVID-19, which unfortunately is a “narrowing” problem, in terms of decision-making options, health-worker satisfaction, and the health needs of all our citizens.

There are reasons to fear this “narrowing” of options. While the numbers of COVID-19 victims were supposed to peak last week, Ontario is only using 60% of its capacity in terms of ICU beds (as of earlier last week) as intensive care treatment beds have been reassigned to exclusively treat COVID-19 patients. There are hundreds of unused available beds. In the current epidemic-only-focus media climate, Canadians should be wary of excessive rhetoric and inaccurate fear mongering. We are not – or not yet– at the point where our health-care system and the workers at its centre are about to be tested beyond anything imaginable as numbers of patients and need for supplies increase exponentially.

It is not only our health-care workers but also patients with other serious illnesses who aren’t being listened to enough. There is every reason to believe that a number of health-care providers who are treating coronavirus patients may develop and carry personal emotional scars that may last for periods far beyond the epidemic itself. Separate and apart from adequate personal protective equipment, where are the announcements of health-care money that should be spent on counselling, PTSD and care reinforcement for providers in nursing homes rather than just hospitals?

In our preoccupation with the coronavirus, what about the health care needs of others in our system — those with heart attacks, accident victims, and cancer? Don’t they deserve attention? Are we setting up dilemmas for care providers like cardiologists, physiotherapists, and orthopedic surgeons that specialize in this care? Do they feel their skills are wasted (because they are not allowed to practice at usual capacity)? Are the patients who need their care at greater risk for worsened health?

Living today is a very anxious time for everyone, as all stakeholders are in this together. You can’t help escape continual references to a “war”, a “crisis”, and daily mortality statistics. No one knows this better than our heroic front-line care workers. Their courage is being put to the test because, in simply doing their job, they are increasing the risk of their own personal infection.

Eventually we will look back on this time for better understanding of how we got here. If some experts are right, the virus may swarm through our population in cycles, each of about three week to two month durations, looking for uninfected or health-compromised victims. Until then, where is the current, urgent and open and meaningful dialogue about the holistic needs of all our citizen stakeholders, care providers and patients alike?

The Issue:

Ethical and Moral Difficulties:

Moral and Legal Dimensions:

Further Reading