The pandemic is exacerbating problems that our health care system has long known.
Posted at 1:00 p.m.
“Compulsory overtime” (TSO) refers to eight-hour overtime shifts that nurses cannot refuse to work in French-speaking hospitals. For several years, nurses have been calling for an end to OSI. The shortage of nurses is invoked to justify maintaining the status quo, without considering that it is the difficult working conditions, including schedules, that are the cause of this shortage. We can think that salary increases or performance bonuses would provide a solution. However, these means will not solve anything, since it is the working conditions resulting from organizational and administrative decisions that are in question. As a result, nurse-to-patient ratios have increased, full-time positions have declined in favor of part-time positions, and the use of compulsory overtime has become a mode of management. However, OSI is associated with more absences due to illness or accidents, which is costly in terms of salary insurance and leads to more medication and other errors.
In 2006, the Caron affair reported a nurse’s error that occurred in 2000; the nurse in question had worked 16 hours in a row, that is from 8 am in the morning to midnight in the evening, and another 8 hours the next day. In this case, the court recognized a lack of quality of care and blamed the institution in question, indicating that it contravened section 16 of the Code of ethics of the Ordre des nurses du Québec by imposing mandatory overtime shifts. Article 16 mentions among other things that “nurses must refrain from practicing their profession when they are in a state likely to compromise the quality of care and services”. The article refers to a state of drunkenness or a daze that would be due to the use of substances that impair the intellectual faculties, without mentioning the extreme fatigue caused by difficult working conditions such as excessive nurse/patient ratios. elevated or TSO. However, codes of ethics have the force of law in Quebec because they come under the Professional Code. Imposing unacceptable working conditions is neither ethical nor legal.
In 2009, a survey was conducted as part of doctoral research to determine why 52% of new nurses had left the CHUM within 24 months of being hired. The results published in 2010 by Brunelle-Agbeti, Hurtubise and Rivard identify the following factors: the heaviness of the task, the nurse/patient ratio and the instability of schedules.
Nurses who are asked to work overtime face a difficult choice and a double ethical dilemma. Whatever they do, they too often find themselves faced with the paradoxical choice of violating their Code of Ethics in one way or another: when they refuse to extend their shift to overtime, this choice constitutes patient abandonment (art. 43), but when they decide to work several shifts continuously, they risk jeopardizing the patient’s safety, given their state of great fatigue (art. 16) . They also face a double ethical dilemma: refusing to work overtime, not favoring the well-being of the patient and leaving a heavier burden to their colleagues by favoring their family at the expense of their work, on the one hand, or accepting the extra shift, depriving their family of their presence and working in an advanced state of fatigue, which does not promote the well-being of patients, on the other hand. When the TSO is imposed, only the second alternative applies.
More and more studies focus on the moral distress of caregivers who want to act in accordance with the goals and values of their profession by adequately meeting the needs of patients, but who are prevented from doing so by administrative and institutional constraints. A large number of study results expose the factors of moral distress among caregivers.
Unethical work climate tops the list of these factors; it includes: reduction in staff, increase in nurse/patient ratios, retention and mobility of nursing staff, decline in the quality of care and conflicting interdisciplinary or intra-disciplinary relationships.
English-speaking hospitals avoid some of these problems by giving any nurse the choice of working day, evening and night shifts during a work period, rather than working by seniority as in French-speaking hospitals, where new nurses first work on night shifts, before being able to access evening shifts, and several years later on day shifts. In addition, in Anglophone hospitals, nurses have the opportunity to work 8-hour or 12-hour shifts. A work schedule consisting of 12-hour shifts involves working a more limited number of days in a week, facilitating work/family balance and limiting travel. 12-hour shifts also give management teams greater freedom when a nurse has to be replaced. If one of them is already working an 8-hour shift, it will be less restrictive for her to agree to work 4 hours more and the nurse on the next shift can agree to start her shift 4 hours more early, thus replacing a full 8-hour shift.
By offering a more flexible system in terms of working hours and giving access to day/evening or day/night shifts to all nurses, workers in English-speaking establishments are not faced with compulsory overtime.
Overtime is offered on a voluntary basis. Those who agree to work four additional hours have the possibility of modifying their work schedule at the last minute, in order to fill an absence or an increased need for personnel. The Anglophone management mode establishes more equality between nurses, makes it possible for young nurses to be supported by those who are more experienced, especially during night and evening shifts, and avoids the problems resulting from the shortage of nurses.
When working conditions are intolerable, burnout, moral distress and leaving the profession are on the rise and well documented. To counter the shortage of nurses, they must be given better working conditions, which implies adequate hospital budgets, lower nurse/patient ratios and better management of schedules and overtime. For this, collaboration between nurses’ unions, professional associations and academia would be appropriate. Without changes to the current mode of management, leave due to illness and exhaustion, flight to private agencies, even abandonment of the profession, will increase. It is a matter of fairness towards professionals who are at the heart of health services.
* Co-signers: Gary Mullinshealth management and organization consultant, and Maxime Boutin Caronnurse and manager