Historically the nursing profession originated within a rich context of Christian values and beliefs. For example, in the Canadian context where I work and teach early Canadian nursing was managed and conducted by religious denominations, especially by Roman Catholic female orders.1 As followers of Christ, their patient care was guided by Christian theology and ethics. They viewed every human as made in God’s image and believed every patient deserves love, care, and respect. Since all nuns are expected to follow poverty, chastity, and obedience, they would care for their patients with ultimate humility, and self-sacrifice thus illustrate Christian love, care, and respect.
As years have gone by, two developments have undermined this original foundation. Canadian healthcare underwent many reforms in policies and protocols, which thus changed the focus to reducing financial costs and the budget. Also, secular individuals have joined the nursing profession and amended both the originally theologically guided vocation and care delivery model in several ways.
As a bedside nurse in Canada for over fourteen years, I have noticed that patient care is consistently affected by a workload that pushes a nurse to do the minimal amount of care for each patient. For example, a decade ago the nurse–patient ratio in acute care settings was 1:4 or 5. Presently, the nurse–patient ratio in an acute care setting is 1:6–8. This ratio will be different at night—as high as 1:9–10. Since I worked in many acute care settings as a bedside nurse, my testimony comes from my own work experience. As the workload increases, the nurse’s focus on patient care changes accordingly. For example, in an acute care setting, if a nurse gets more than five patients to care for within a shift, the nurse will change the focus of care to the tasks with the highest priority thus delivering a task-oriented care.
I have seen and experienced in my clinical life that care based on priority often lacks compassion and love. There is no time for compassionate care which demands both time and space. For example, nurses simply administer medication to a patient and fail to give enough time to the patient to ask questions or share their concerns. The nurse simply makes sure the patient takes the medication and quickly leaves the bedside. If that nurse has time to explain what medication it is, and why it is ordered, allowing the patient to ask questions for informed consent, making sure that the patient has taken the medication, and using that opportunity to have a meaningful conversation about their condition or upcoming tests or even about their overall health will exhibit the compassionate care.
After the pandemic, nursing shortages are highly visible in acute and critical care settings. As a critical care nurse, I have witnessed that due to poor working conditions and burnout, many bedside nurses are leaving the profession or changing positions other than bedside nursing. Furthermore, the Canadian Association of Schools of Nursing (CASN)2 recently stated that the current Canadian health care system is facing nursing shortages due to poor working conditions. Since nursing in Canada is a regulated profession, where all practicing nurses have to follow the professional standards in order to maintain their licensure,3 the bedside nurses are trying their best to follow these standards just by completing patient care priorities assessments, medication administration, feeding and personal hygiene rounds, and documentation of care. The other patient care interventions such as assistance with mobility and having meaningful conversations become secondary.
At times, bedside nurses focus on certain professional standards more than broader forms of care. For example, if a patient is fast asleep, the bedside nurse often wakes up the patient for a routine assessment. As patient assessment is one of the priorities under the accountability and responsibility standard, the nurse will not wait until the patient wakes up from sleep, rather they rouse the patient and complete the assessment. I doubt that this is really a patient-centered care or client-focused provision of care, as mentioned in the professional standard; I am certain it is because of lack of time at hand that the nurse has woken up the patient for the routine assessment such as taking the vital signs. Furthermore, bedside nurses in acute and critical care settings are sacrificing compassionate care for their health care authority’s or health agency’s demands such as continuous bed movement, staff redistribution, resource limitation, and managing the budget.
As a follower of Christ Jesus, I always wanted to give my full attention to patient care and listen to their concerns and issues through meaningful conversations. But I am challenged with both patient care and my health agency’s demands. For example, I currently work in a critical care unit, and on one occasion when I was giving a bed bath to a patient, the Patient Care Coordinator (PCC) asked me to move that patient to a medical floor as the patient is now under the responsibility of a medical doctor or hospitalist. The PCC also informed me that there was an admission waiting in the Emergency to come into that room. I had only one option: cut short the wash and give a report to the receiving unit about the patient. Therefore, at times my professional agency’s demand for bed movements—admissions and discharges—really constricts the time for patient care.
A bedside nurse has other patient care interventions too, such as discussions with allied health professionals, making phone calls to the diagnostic department, covering fellow nurses for breaks, and many petty tasks. I find myself and other nurse colleagues are trying to run with the time. Since all bedside nurses in acute and critical care settings do twelve-hour shifts, within that time, there are many directives to cover. Some are patient care related, and others are health authority’s mandates. It has nothing to do with time management skills. It is simply an increase in workload, increase in nurse–patient ratio, and my professional agency’s priorities and demands.
Since I always try my best to complete all patient care needs within my shift, at the end of the shift I feel exhausted morally and physically. I continue to see that bedside nursing suffers because of nursing shortages, budget cutting, agency priorities, and ever-changing policies and protocols. We all deserve to have competent, ethical, professional, and compassionate nurses to care for ourselves. I keep praying to the Holy Trinity—God the Father, the Son Jesus Christ, and the Holy Spirit—to guide not only my own nursing practice but also nursing in general. I also pray for a healthy working environment for all nurses, especially for bedside nurses in acute and critical care settings.
Footnotes
- Kathy Hardill, “From the Grey Nuns to the Streets: A Critical History of Outreach Nursing in Canada,” Public Health Nursing 24, no. 1 (2007): 91–97, https://doi.org/10.1111/j.1525-1446.2006.00612.x.
- “Residency Program,” The Canadian Nurse Educator’s Institute, accessed August 3, 2023, https://cnei-icie.casn.ca/our-programs/residency-program/.
- “Professional Standards,” British Columbia College of Nurses and Midwives, accessed August 3, 2022, https://www.bccnm.ca/RN/ProfessionalStandards/Pages/Default.aspx.
It is a sign of the changing times that the needs of the State trump those of the individual patient. The documentation required by the healthcare bureaus is staggering in its amount. The time dedicated to filling out required documentation is time lost to direct patient care. As unfortunate as that outcome is just as unfortunate is the fact that no reproducible studies have shown an improvement in care as a direct result of this increased paper gathering. And to those who once believed computerized documentation would decrease the time spent in record keeping…well think again. Computerization has just made it easier to add additional forms for the nurse to complete. Sadly, the nurse involved in day to day patient care is the last person consulted about ways to improve care. How is that individuals who have never spent a day in the clinical practice, or worse, have no healthcare background at all, are making decisions about care delivery?
Hi Mike,
I agree, that the nursing documentation takes more time in spite of computerization. The electronic documentation seems to change often with new addition or omission. Recently there is an addition in the electronic charting called ‘Acuity Assessment’ where the bedside nurse scores their patient’s acuity level. Some of the questions under the ‘Acuity Assessment’ are; does the patient need high oxygen delivery? does the patient need help with washes? etc.
The bedside nurses are completing the Acuity assessment for their patients on a regular basis, but not necessarily understand the impact of their documentation.
Who wants to know the patient acuity? What do they do with that data? How are they using the data? A lot of questions still remain……….
The impersonal nature of this care can be seen in the proliferation of walk-in clinics where there is no sense of personalized care–OR personal responsibility. As one who grew up in Greater Vancouver with VERY personal physicians–and specialists–whose worst sin was their long appointments with the patient preceding you–the current arrangement smacks of a desire to create a system (supposedly) high in efficiency while at the same time designed to protect physicians from personal accountability. (I do not include nurses in that).
Socialized medicine, socialized public education. Both in my province badly broken. And the responsibility does NOT lie with the practitioners but with overgrown and very under-efficient provincial governments elected by too many people who do not remember that the high socialized system in Soviet Eastern Europe broke down as the Berlin Wall broke down with it. Socialized health. Organized by inept governments who ignore the needs of people and create a mess so self-destructive it cannot sustain itself. And fails miserably at caring for people. Will the electorate ever learn?