Introduction
The Ontario Public Service Employees Union/Le Syndicat des employés de la fonction publique de l’Ontario (OPSEU/SEFPO) represents approximately four-thousand Registered Practical Nurses (RPNs) who practice in a variety of settings. From correctional facilities to developmental service agencies, homecare, long-term care, psychiatric care and hospital settings, our members offer their professional services, a helping hand and a friendly face in thousands of workplaces across Ontario. The World Health Organization (WHO) earmarked 2020 as a time to celebrate and recognize the important contributions made by nurses all over the world. The year was declared the “International Year of the Nurse and the Midwife” in honor of the 200th anniversary of Florence Nightingale’s birth.[1] Florence Nightingale was an influential nurse and leader, who dedicated her life to helping others and elevating the profession of nursing. The WHO chose the anniversary of her birth to launch a year-long effort to celebrate the work of nurses and midwives, highlighting the challenging conditions they often face, and the need for increased investments in nursing and midwifery.[2] While this was meant to be a year of celebration, our RPNs, like every other health care professional, have had to deal with the tragedy of COVID-19. On March 11, 2020, the WHO declared a pandemic.[3] Coronaviruses are a large family of viruses which may cause illness in animals and humans. In humans, several coronaviruses are known to cause respiratory infections ranging from the common cold to more severe diseases, such as Middle East Respiratory Syndrome (MERS), and Severe Acute Respiratory Syndrome (SARS).[4] This year, as we mark Nurses Week again, we are still mired in crisis. Our health care system is teetering on the verge of collapse, COVID-19 numbers continue to rise at alarming rates, and our front-line heroes are feeling the mental, physical and emotional effects of the COVID-19 pandemic. However, calls to invest in nursing remain largely unanswered. OPSEU/SEFPO’s RPN Occupational Division is drawing attention to the challenges nurses face every day. RPNs have been working tirelessly in long-term care or retirement homes, homecare settings, correctional facilities and in hospitals. Our members are uniquely positioned to observe how various employers have responded to the COVID-19 pandemic. They know what worked and what didn’t when it came to keeping people safe, including those battling on the front lines. Drawing on the collective experience of the RPN Occupation Division, this paper identifies the key challenges RPNs have faced and offers recommendations on how to address those problems. The Division hopes that by highlighting what worked and what didn’t work, we can be better prepared to respond to a future crisis.Click here to download the PDF.
Mental Health of Frontline Workers
“Burn out” is a phrase used to describe the physical, mental and emotional deprivation caused by working in the health care field. This state is characterized by emotional exhaustion, depersonalization, and low sense of personal achievement, and can be brought on by prolonged involvement in emotionally demanding and stressful situations.[5] Nurses across all classifications are vulnerable to burn out because of the requirements of their job. As the war against COVID-19 continues, our front-line heroes are burned out. When the pandemic was declared, front-line workers, including RPNs, answered the call to arms and prepared to battle this virus. Our members described feelings of stress and anxiety because little was known about COVID. Fear of the unknown made it stressful to determine what was best for patients’ health outcomes. Our members were also worried about their health and the health of their families. The sentiment of OPSEU/SEFPO’s RPNs was echoed by others. In December, 2020 the Registered Practical Nurses Association of Ontario (WeRPN) conducted an online survey amongst its membership, examining the impact of COVID-19 on RPNs in Ontario. The survey looked at 765 participants and the findings were staggering. They reflected what RPNs represented by OPSEU/SEFPO have been saying all along:- A clear majority of nurses (71 per cent) have admitted to reaching their breaking point both at work and at home.
- Ninety-six per cent of nurses felt their daily work experience had become more stressful since the pandemic began, with 83 per cent of respondents stating that they believe their day-to-day nursing work has changed dramatically due to the pandemic. [6]
- Eighty-three percent of respondents reported that their mental health had been adversely affected by this crisis. The same number of people reported that their family life has suffered too, as nurses try to limit their families’ exposure by minimizing the amount of time they spend with their loved ones.[7]
Revoke Bill 124 and compensate RPNs fairly
Staff shortages and an overall increase in workload demands has many RPNs working longer shifts than ever before. Despite their increased commitment to their jobs, very few RPNs reported a corresponding increase to their salaries. Most have been left out of wage enhancement programs or pandemic pay programs. To make matters worse, Bill 124 – Protecting a Sustainable Public Sector for Future Generations Act, 2019 – caps increases at the bargaining table to one-percent total compensation. This means RPNs who are bargaining their collective agreement during the pandemic are unable to make gains greater than one-percent. Our RPN Division recommends repealing this unconstitutional legislation. Parties who are in negotiations should be able to bargain in an unfettered environment, with gains made that recognize the important contribution of all front-line workers during this difficult time. The provincial government can show its support for our front-line heroes by compensating them fairly.Offer access to Employee Assistance Programs
Employee Assistance Programs (EAP) can be an excellent tool for employees who need to talk to someone. An EAP is a confidential, short term, counselling service for employees with personal difficulties that affect their work performance.[9] Workers can call in and receive access to someone who can tend to their unique needs, and get a referral to additional resources, as necessary. Most EAP programs run 24 hours per day, making services accessible to people who work non-standard hours, like RPNs. An employee can access services and schedule appointments to take place during regularly scheduled break times in the workplace. Employee Assistance Programs are a flexible, anonymous, and easily accessible counselling service provider that can be of immense use to people.Approve reasonable requests for time off
Taking time off to mentally and physically recover from work is a challenge for many in this current climate. Many health service providers were granted the authority to take “any reasonably necessary measures to respond to, prevent and alleviate the outbreak of COVID-19 for patients”.[10] This authority is bestowed upon health service providers by an order passed by the provincial government on March 21, 2020. The order included the ability of an employer to “Defer, or cancel vacations, absences or other leaves, regardless of whether such vacations, absences or leaves are established by statue, regulation agreement or otherwise”.[11] As a result, pre-approved vacation plans had to be cancelled, and many workers have had difficulty getting so much as one day off. During periods of calm in the storm, the RPN Division urges employers to listen to employees who say they are tired and burning out. Try to work out a compromise that allows the employer to maintain service levels while allowing exhausted staff a chance to rest, recover and recuperate.Bring mental health supports into the workplace
As the COVID-19 numbers began to drop through the summer months of 2020, some of our RPNs reported that their employers recognized that the pandemic was a particularly stressful and challenging time. Some facilities brought mental health practitioners into the workplace for staff. While such an arrangement may not be available for all settings due to COVID-19 restrictions on outside visitors, we urge employers to consider this option, where possible.Take advantage of online resources
With lockdown orders, shift work and family obligations, taking time out for self-care is difficult for most health care workers. OPSEU/SEFPO’s RPN Division has found a number of great online resources that can be accessed at any time. Some resources have allowed members to tap into mental health programming, while others have made people feel as if they are not alone in these uncertain times. Other resources, such as Instagram accounts and podcasts have provided a much-needed laugh during a break or at the end of a difficult shift. Below is a list of online resources recommended by the RPN Division:- The Canadian Mental Health Association (CMHA) offers an anonymous mental health check-in self-assessment tool on their website to help users decipher whether or not to seek further care. They also provide users with a wealth of information about free and low-cost services that are easily accessible to people living in Ontario. Additional online tools to help people learn how to manage their feelings of stress and anxiety are also offered.
- Crisis Text Line: this text line is available to anyone experiencing a crisis, twenty-four hours per day, seven days a week. Users can connect with a Crisis Counselor via text message. Users can access their services by texting “HOME” to 741741.
- There are a number of apps available that can help reduce stress and anxiety. Calm and HealthyMinds are two examples of such apps. Physical activity is a well-known form of relieving stress. Others have taken advantage of the numerous fitness apps such as Peleton, iFit and BellaBeat.
Personal Protective Equipment – Keeping Us Safe, so we can Keep You Healthy
Each new wave of COVID-19 has brought new stories of personal protective equipment (PPE) shortages. In nearly every workplace setting, PPE supplies were grossly inadequate. It put the health and safety of everyone in jeopardy. RPNs who sit on OPSEU/SEFPO’s Occupational Division know all too well how ill prepared Ontario was for this crisis. Everything was in short supply, including masks, hand sanitizer, gloves, gowns and goggles. From being issued too few pieces of equipment to safely get through a day, to being asked to reuse equipment; every single member had their story about rationing PPE. Based on their collective experiences, the RPN Occupational Division has a number of recommendations related to PPE.Provide adequate PPE for all employees, in all classifications
As one RPN involved in the preparation of this paper stated, “We all want to go home to our family at the end of the day”. Whether you are a Doctor, RPN, PSW or Aide, everyone’s contribution to the overall health care system matters. Everyone deserves access to the personal protective equipment necessary to stay safe and healthy. Every person, from the top of an organization down, takes a risk when they report to work during a pandemic. Every single employee deserves to be treated equally when it comes to allocating resources.Maintain an adequate supply of PPE at all times
Long after COVID has become a distant memory, we cannot allow the lessons we have learned fade away as we did with the severe acute respiratory syndrome coronavirus 2 (SARS) crisis. After the SARS outbreak in 2003, a Commission was tasked with identifying what needed to be done more effectively in the event of a future infectious disease outbreak. A shortage of adequate PPE was identified as a risk factor, and it was recommended that PPE be kept in adequate supply, at all times. The COVID crisis has shown this clearly wasn’t happening in a number of settings. The news was fraught with stories of PPE shortages, and members of the community at large trying to step-up and fill in the void.[12] We cannot let this happen again. Health care providers must ensure that there’s enough PPE on hand, at all times, for all workers.Don’t let your guard down: keep PPE requirements in place until COVID is a thing of the past
The RPN Occupational Division at OPSEU/SEFPO believes heightened PPE provisions must be kept in place until a vaccine and/or cure for COVID is found. Workers involved at every level need to keep their guards up, and masks on, no matter how high or low the COVID case count. RPNs in a variety of settings reported how much of a nuisance and a disruption that PPE requirements can be. However, like many others, they are happy to do it to keep their families, friends, clients, residents and communities safe and healthy. Our RPNs maintain that this level of vigilance, coupled with the right PPE, is the only thing that will keep COVID at bay.Create a culture of COVID safety that includes input from all parties in the workplace
It is important to create and maintain a workplace culture where people work hard to keep themselves, and each other, safe. Including front-line workers in the process of responding to a crisis is key. Regular meetings of the Joint Health and Safety Committee and soliciting feedback from workers as new directives are issued, will go a long way toward creating a culture where everyone feels safe, and free to share their ideas about how to make the workplace better. After all, it is those on the frontlines and not people in boardrooms who really know what is working, and what is not. This recommendation mirrors one of the SARS Commission:“That in any future infectious disease crisis, directives involving worker safety be prepared with input from the workplace parties who have to implement them, including employers, health worker representatives, and Joint Health and Safety Committees”.[13] In a study identifying what organizational factors contribute to a culture of safety, Doctors Yassi and Bryce (2004) found that safety related attitudes and action of management play a critical role in creating a good or bad safety culture.[14] This study reinforced what many already knew to be true: safety starts at the top. Employers must step up and actively create a workplace culture that embraces, and values, the principles of health and safety.Treat Public Health recommendations and guidelines as the baseline, and build up from there
Building on their previous recommendation, the RPN Occupational Division suggests that Public Health directives and guidelines be treated as the base level for workers and employers to build upon. While Public Health authorities often issue sound advice, they are not the experts in workplaces where health care services are offered. Employers should use the guidelines and directives issued as the foundation and build upon it using the front-line know-how of their workers. Going above and beyond what Public Health recommends would create a safe, healthy workplace for everyone.Violence in the Workplace
RPNs are often on the frontlines caring for the patients that they serve. They are one of the professionals that patients interact with the most. RPNs are responsible for tasks such as medication administration, blood draws, starting intravenous lines, coordinating care and tests across various departments and health care providers, and providing emotional comfort and support to both the patient and family. Given the intimate roll RPNs play in the delivery of health care, they are often in situations that leave them vulnerable to workplace violence. According to a national survey on workplace health of nurses, far too many nurses experience violence while working. This survey incorporated feedback from 19,000 participants across Canada. It was the first survey of its kind to try and capture the unique working conditions of nurses. The data derived from the participants paints a picture of how dangerous nursing work can be. The survey found that 29 per cent of participants (an overwhelming majority of which were RPNs) reported they were the victims of physical assault by a patient in the last 12 months of work.[15] The number ballooned to 44 per cent when emotional abuse was factored in. These numbers are far higher than the national average for many other health care professions. The COVID-19 pandemic exacerbated some of the conditions that facilitate violence. Patients are spending long periods of time alone; many are frightened and afraid and don’t feel that they have anywhere to turn. As patients in hospitals, and residents in various institutional settings were kept separated and in isolation for long periods of time, RPNs reported experiencing an increase in verbal and physical violence from people who were stressed out, lonely and afraid. This problem is intensified for nurses in community settings who visit and care for patients in their homes. With the health care system pushing patients out of the hospitals and into their homes at a faster rate to minimize exposure to COVID-19, community nurses are dealing with increasingly complex cases. Healing at home from an illness or injury is tough. Having to do it without the support of visiting friends and family members is even worse. Community nurses are often left in a position where they are vulnerable to verbal and emotional abuse, as patients lash out and vent their frustrations at their visiting care professionals. As COVID made its ways through the halls of hospitals, psychiatric facilities, nursing homes, retirement homes, jails and developmental service facilities, testing was brought in-house to screen residents for potential cases of infection. The responsibility of administering COVID tests often fell to RPNs, who would be subject to physical abuse by residents who actively resisted the evasive nasal swab required to test for COVID. To address some of these challenges, the RPN Division at OPSEU/SEFPO has drawn on our members’ collective, lived experiences on the frontlines to make the following recommendations: Maintain adequate staffing levels at all times. Many RPN Division members have noted how thinly stretched they were long before the pandemic took hold. This problem was exacerbated by the COVID crisis, particularly in long-term care, retirement and group home settings. During the height of the first wave of the pandemic, the news was fraught with stories of institutions operating with inadequate staffing levels.[16] COVID made an already stressful situation significantly worse. Adequate staffing levels would allow front-line workers to spend more time with patients, residents and clients, and diffuse potentially difficult situations. It would ensure no one walked into a difficult situation alone or had to deal with a difficult person on their own. Front-line workers could work in pairs when dealing with such patients, residents or clients, as strength and safety can often be found in numbers. Allow staff to spend time with their residents, clients and patients. As one of our Occupational Division members said, “Our patients are like our family”. Many RPNs, like other health care professionals, went into their respective fields to help others. This altruism, coupled with a professional responsibility to provide the highest quality of care, has led many of our members to treat patients as if they were family. During times of isolation and quarantine, oftentimes the only human interaction in-patients and residents were the people administering care. Maintaining adequate staffing levels, combined with extra time for staff to chat and care for the mental and emotional needs would go a long way towards diffusing tense, stressed-out and lonely patients, residents and clients. More time spent with patients would mean less frustration and, hopefully, fewer violent outbursts as a result. Provide better information to nurses about the patients they are tending to, especially in community or out-patient settings. Maintaining patient privacy is paramount, particularly when it comes to something as intimate as health care. However, the right to privacy becomes problematic when a nurse or other community health practitioner is going into a patient’s home and they don’t have the full story about the patient. When assigning patients to community health practitioners, it’s paramount that the Local Health Integration Network (LHIN) gives the community health provider the full story, including any past history of violence. Such information will help determine adequate staffing levels and ensure that a nurse does not walk into a potentially violent situation, alone, and unaware of the dangers that may reside within.Conclusion
The recommendations in this paper represent sound advice and the practical experience of skilled front-line RPNs working in a variety of settings. As the fight against COVID-19 continues, our Occupational Division urges all employers to consider our recommendations and work with their staff to address the issues outlined above.Works Cited
[1] World Health Organization Website. Accessed: September 21, 2020.[2] Ibid.
[3] Global News Website. Accessed: September 21, 2020. https://globalnews.ca/news/6800118/pandemic-one-month-timeline/
[4] Worth Health Organization. Accessed: September 21, 2020. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-a-coronaviruses#:~:text=symptoms
[5] McLeod, C. (2019). “Nursing burnout: We are not doing enough” as taken from Canadian Nurse Website. Accessed: September 19, 2020. https://www.canadian-nurse.com/en/articles/issues/2019/october-2019/nursing-burnout-we-are-not-doing-enough
[6] Registered Practical Nurses Association of Ontario. (2021). Nursing in Ontario during COVID-19. https://www.werpn.com/wp-content/uploads/all-images/WeRPN_NursingDuringCovid_Report_Jan27_V2.pdf. Accessed: April 26, 2021. Pg. 8.
[7] Ibid. Pg. 9 and 10.
[8] Ibid. Pg. 5
[9] Canadian Centre for Occupational Health and Safety Website. Accessed: September 22, 2020. https://www.ccohs.ca/oshanswers/hsprograms/eap.html
[10] Sheppard, Daniel. (2020). “Emergency Powers in Response to COVID”, last revised March 30, 2020. As taken from Goldblatt Partners website. Accessed: September 23, 2020. https://goldblattpartners.com/wp-content/uploads/Emergency-Powers-Memo-March-30-pm.pdf
[11] Ibid.
[12] For example, see Frangou, C. (2020). “The Race to get Personal Protective Equipment to Health Care Workers “in Macleans Magazine. March 22, 2020.
[13] SARS Commission. “Volume One: Spring of Fear”.
[14] Bryce, E and Yassi, A. (2004). “Protecting the Faces of Healthcare Workers: Knowledge Gaps and Research Priorities for Effective Protection Against Occupationally-Acquired Respiratory Infectious Diseases” in Occupational Health and Safety Agency for Healthcare in B.C., April 30, 2004. Pg. 67
[15] Shields, M and K. Wilkins. (2006). “Analysis in Brief: National Survey of the Work and Health of Nurses.” Statistics Canada.
[16] For example, see: https://www.theglobeandmail.com/canada/article-ontario-relying-on-volunteers-to-help-staffing-shortage-in-long-term/