The year of the nurse: ‘We’re drained, we’re stressed, but we will keep going’

When the World Health Organisation designated 2020 as the International Year of the Nurse and the Midwife, they could hardly have imagined that nurses would face the most challenging pandemic of their lives, with many dying around the world.

The International Day of the Nurse and Midwife on May 12th marks the 200th birthday of Florence Nightingale, the woman who turned handwashing into a weapon of public health, and who founded the first professional school of nursing.

“Nurses are the largest cohort of health workers in the world”, says Irishwoman Annette Kennedy, president of the International Council of Nurses. “In some countries the only health professional a person will see in their entire lifetime is a nurse.”

Having nursing at the heart of health policy is coming through in tackling Covid. You see it in how we've been able to upskill nurses quickly to work in critical care, in using advanced nurse practitioners to keep people out of hospital

According to the WHO, the world needs nine million more nurses to achieve the sustainable development goal of universal health coverage by 2030. The shortage of nurses is a worldwide phenomenon and Ireland is no different. As of mid-April, 78,300 nurses were registered with the Nursing and Midwifery Board of Ireland (NMBI). However, not all are working as nurses.

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The Health Service Executive (HSE), together with Section 38 (Voluntary) Hospitals and agencies, employ 45,066 nurses, some of whom are part-time, amounting to 38,780 whole-time equivalents. The NMBI estimates that about 15,000 nurses work outside the HSE (including private hospitals and nursing homes), which implies a further 18,000 are not practising as nurses.

As of April 19th, 345 nurses and midwives had been hired from thousands who responded to the Ireland on Call appeal.

“We are still not back up to 2007 levels of staffing in the HSE, yet the population has grown in the meantime”, says Phil Ní Sheaghdha, general secretary of the Irish Nurses and Midwives Organisation. “The Safe Staffing project in conjunction with UCC [University College Cork] has shown that increased staffing improves patient outcomes, reduces patient mortality and length of stay, as well as nursing retention. It makes economic sense.”

The HSE says it is supporting the phased introduction and implementation of the Safe Staffing framework in general and specialist medical and surgical care settings in adult hospitals, and a second-phase pilot of emergency care settings is under way.

Even when new positions are funded, one of the biggest challenges is to recruit and retain nurses. Of the NMBI register, 70 per cent of nurses are Irish, 10 per cent are Indian, 7 per cent are Filipino, 5 per cent are from the UK, 2 per cent are from other EU countries and 6 per cent from other non-EU countries. Overseas nurses are valued, but as Irish nurses retire the health system is becoming more dependent on them, creating problems elsewhere.

"We talk to our colleagues in the Philippines and India and they tell us they're short of nurses", says Kennedy of ICN. "It's not right that high-income countries are taking all the nurses."

Ireland has about 6,475 student nurses and midwives, according to the HSE. Nursing has been a four-year degree programme since 2002, running in 13 third-level institutions, with standards set by the NMBI.

“A degree-educated nurse is trained to synthesise a large amount of clinical information,” says Sheila McClelland, chief executive of NMBI. “They process that against scientific evidence and can propose solutions and add more value.”

Nurses are operating at a higher level than ever. For example there are 1,244 Registered Nurse/Midwife Prescribers involved in prescribing medicine and in referring patients for ionising radiation.

In the last 20 years there's been a huge emphasis on the economy, on wealth. What this crisis has shown us is that we have to look after our most vulnerable. People in our lifetime will never forget this period

While everyone is now familiar with Ireland’s chief medical officer, the post of chief nurse is less well known. The post is vacant, but three deputies work within the Department of Health on nursing policy.

“Having nursing at the heart of health policy is coming through in tackling Covid,” says Rachel Kenna, deputy chief nurse. “You see it in how we’ve been able to upskill nurses quickly to work in critical care, in using advanced nurse practitioners to keep people out of hospital, in our students going in to work on the front line, in the use of technology.”

Caring for people in their community is providing an opportunity for the development of nurses and midwives to practise at the top of their licence, according to Dr Geraldine Shaw, nursing and midwifery director at the HSE. “This also supports the vision of Sláintecare, by facilitating integrated care services across hospital and the community”.

In the midst of a pandemic it’s difficult to know what the long-term impact will be on the profession and on healthcare in general, but there’s a consensus that things can never be the same. The impact of the crisis on older people in care is just one example.

“In the last 20 years there’s been a huge emphasis on the economy, on wealth,” says McClelland. “What this crisis has shown us is that we have to look after our most vulnerable. People in our lifetime will never forget this period.”

While an Irish Times poll last year found that nursing is the most trusted profession (at 95 per cent), it has always had to battle for recognition and pay. Nursing is very much female dominated, with less than one in 10 nurses in Ireland being a man.

“Nurses had to go on strike twice, and they’re still not paid as much as other healthcare workers who also have an honours degree,” says Ní Sheaghdha. “When all this is over, the expectation has to be that they will never be taken for granted.”

The celebrations for the International Year of the Nurse may have to be put on hold, but this year has shown the importance of their role.

“We’ve really seen the values of care, compassion and commitment come through during this crisis,” says Kenna. “But what we’ve also seen is the value of a highly educated workforce. That goes back to Florence Nightingale, it goes right back to her.”

Aoife Byrne

Fourth-year student midwife, Dundalk Institute of Technology

Aoife Byrne was working in insurance when her first baby was born prematurely. "I was fascinated by the supports I got, the way the nurses took care of him and me. I thought, I'd love to do that."

Nine years later she acted on that instinct and went back to college at the age of 33, having another baby during her college years. Now she’s a fourth-year midwifery intern, working as a healthcare assistant during the pandemic like many other student nurses.

She was on placement at Our Lady of Lourdes Hospital in Drogheda when the crisis hit and has been moved to Cavan General Hospital to help out there.

“It’s a very scary time for mothers, especially first time mothers. They want to know they’re safe and that the baby is safe. Most of them want to have the baby and get home as quickly as possible.”

With a husband and three children at home, Byrne is very conscious of the risks.

“I’ve a system; I don’t wear my uniform home. I shower when I come in. I’m taking precautions and we’re doing everything we can.”

Fourth-year interns like Byrne were being paid about €10 an hour, but have been put on the first point of the healthcare assistant scale, reflecting the fact that they are working on the frontline of the crisis. Byrne say the camaraderie among healthcare workers is phenomenal. “It’s really great to be part of it.”

Sisi Shinith

Clinical nurse manager, St Columba’s Community Hospital, Thomastown, Co Kilkenny

When Sisi Shinith arrived from Kerala in India she planned staying two years. Thirteen years later she’s still here.

My boyfriend, now husband, didn’t want to move to Ireland, but I told him how beautiful and friendly it was, and finally I persuaded him.”

When Shinith first arrived, she worked in nursing homes, which was something of a culture shock. “In India the elderly are looked after within the family, usually by the youngest son. But I’m used to it now here.”

Shinith moved to a community hospital in Thomastown two years ago and points out that because it is run by the HSE, she will now have a pension. She’s a qualified nurse prescriber and is a clinical nurse manager in a dementia-specific unit. While St Columba’s has had two Covid deaths involving patients with underlying conditions, there have been no cases in her unit so far.

“It’s difficult to have social distancing in a dementia unit. Many patients don’t understand what’s going on, they want to hug you. We’re putting a big emphasis on hand sanitising and on cleaning.”

Shinith feels for the families of her patients who can’t visit their loved ones. “We’ve one woman who used to come every day to see her husband, even though he didn’t recognise her. She was crying on the phone to me one day about him. That evening I rang her to see how she was doing, and she cried again, but this time it was because someone had asked her how she was herself.”

Shinith hopes that more nurses will take up the call to redeploy into nursing homes. “At the end of the day we have a duty of care to the elderly. Once you’re a nurse you’ve a duty of care to everyone, wherever they may be.”

Essene Cassidy

Director of public health nursing, Dublin North Central

Essene Cassidy first moved into public health nursing to introduce a meningococcal vaccination programme in Waterford, having previously worked as a paediatric and general nurse in acute hospitals.

“It was an amazing time, great teamwork, and I wanted to stay. There’s no standing on ceremony out in the community.”

She's now a director of public health nursing, with 160 staff, covering a huge area in Dublin from the north quays out to Glasnevin and across to Corduff. The work includes everything from primary care teams, care of the elderly, to health screening and public health services in asylum centres. And then came Covid.

“I’ve been blown away by how our nurses have responded. They’re available to do swabbing, they’ve cancelled their leave, and they’re coming up with ways to look after patients, keeping things like dressing clinics going safely.”

One of the central roles of public health nurses is to visit new mothers. But part of that consultation is now being done over the phone, with mothers and babies now coming into primary care centres for a very short visit.

“People have a precious new baby so they don’t want people in the house. We’re also doing teleconferences using translators with mums who don’t have much English, who need support.”

Cassidy notes the symbolism involved in celebrating Florence Nightingale’s 200th birthday in the midst of a pandemic. “She was a firm advocate of hand washing, and a key proponent of public health. We all know how to wash our hands now.”

Neil Salmon

Staff nurse, Our Lady of Lourdes Hospital Drogheda

Neil Salmon’s earliest memory is being held by a nurse at a window in Mullingar hospital, watching his mother drive his father to work. “I knew then that she’d be in to visit me soon. I was only two-and-a-half and I was in hospital with cardiac arrests and seizures.”

So it's perhaps not surprising that he chose nursing as a career, training with the NHS at Canterbury in Kent.

“I’d been looking at coming back to Ireland, partly because of Brexit. Then my dad died and I made the decision to come home.”

Salmon began work on a Safe Staffing project in Drogheda, where he is a clinical nurse manager, but now finds himself working on a dedicated Covid-19 ward. “We’ve had patients as sick as they come, but they’ve recovered and walked out.” He’s also seen others who are going on to ventilators making phone calls for what might be the last time.

“People making their wills, or telling their family that their funeral is paid for. Irish men who can’t say ‘I love you’ to their families, but you know they do. It’s really tough.”

He moved out of his mother’s house to keep her safe, and sought a room on Twitter, for which he was willing to pay.

“I had 21 offers of a free place to stay. Drogheda has only been in the news for negative reasons lately, but the support was incredible.”

He says he feels safe and protected at work, but that nursing can be very stressful and exhausting. “Some days you don’t want to know what’s happened to patients who’ve had to be transferred, in case that’s the thing that will break you.”

What keeps him going is the relationship with his patients. He once asked a patient who had been in hospital for two years what he could do to help. “She said if you dress up as the Beast, I’ll dress up as Belle. We danced on the ward. It meant so much to her.”

Shella De Los Santos

Clinical nurse manager, ICU, Naas General Hospital

De Los Santos's mother retired from the armed forces of the Philippines as a colonel, having been the army's chief nurse, and De Los Santos followed in her mother's footsteps, specialising in intensive care. When she first came to Ireland in 2001 she worked with the elderly in Sligo, but missed the challenge of ICU and came to Naas.

“Yes, the mortality rate [in ICU] is high, but if the patient recovers there is so much fulfilment. I have patients who still text me every Christmas. There is a bond.”

De Los Santos has had a number of Covid patients on ventilators in her ICU. Even without Covid, ICU is always a challenge.

“You’re just hoping the person will recover; you want the best for them. If there’s no improvement after two weeks, well then it’s heart breaking, and even more so now because families can’t visit. The toughest part is when you’re talking to them, when you’ve given all the possible chances, and they have to decide to withdraw the treatment.”

De Los Santos says there has been a huge team effort at the hospital, but that it’s impossible to switch off, even in her dreams. “Of course I’m scared. I don’t want my staff to see that, but we are all afraid at some level.”

Her parents were due to visit this summer, something that won’t happen now. They too are under lockdown in the Philippines. Her mother understands her work, but her sister has asked her why she doesn’t just stay at home. “I will never do that. We’re drained, we’re stressed, but this is our profession and we will keep going.”

Louise Donohoe

Mental health nurse and CBT specialist, Ballina, Co Mayo

In a normal week Louise Donohoe would see at least 14 people for therapy sessions, either at her base in Ballina or in Belmullet, which she visits once a week. But Covid-19 has put paid to that one-on-one relationship.

She works on a community mental health team and specialises in Cognitive Behavioural Therapy. CBT is a very structured form of psychotherapy, used to treat an array of problems such as anxiety, obsessive-compulsive disorder, post-traumatic stress disorder and various phobias.

“I think there is going to be an influx of patients when this is over. Can you imagine someone with OCD before Covid-19, and how they may be now? I’d also be concerned about elderly people who aren’t getting out, who are likely to be more depressed as a result.”

Donohoe trained as a mental health nurse, following in her mother’s footsteps.

“You build up a therapeutic relationship over time. You see people at their most distressed, but you also see them get better. The old stigma that you are going to succumb to psychiatric illness for life is gone.”

Donohoe is staying in touch with people by phone, dealing with those who ring, distressed and anxious about the pandemic. “For those who’ve gone through CBT, I try to reassure them and encourage them to use the coping skills they’ve developed. We all worry – it’s part of being human. CBT helps people focus on productive worry, on solutions, things that you can actually do something about.”

While Donohoe loves her job, she feels strongly that her colleagues in in-patient mental health units are undervalued, and often overworked due to a shortage of staff. “Mental health services are constantly underfunded, but after this crisis we’re going to need them more than ever.”

Helen Forristal

Director of nursing services, The Marie Keating Foundation

Helen Forristal grew up on a farm and loved taking care of animals. When she was 11, she heard her parents say that a cow would have to be put down. “I went down to her and rubbed her head until the time came. So I suppose I was drawn to nursing.”

She trained in the UK and specialised in renal urology and oncology.

“Cancer was quite stigmatised back then, and I often felt people needed to open up and have true conversations about how it made them feel.”

She went to work for the Macmillan Foundation who trained her to adopt that approach. Back in Ireland she worked in St Vincent's and the Beacon on oncology wards. "I remember one man who was offered further chemo, but it wouldn't cure it. He was very torn. We had a very frank conversation and he decided not to have the treatment, but to make the most of the time he had left."

She’s now the director of nursing at the Marie Keating foundation, whose philosophy is to make cancer less frightening by enlightening. She and a team of eight nurses work on awareness and prevention campaigns, as well as supporting cancer patients and survivors.

Covid has put a stop to their mobile outreach and face-to-face activities. They’ve adapted by using webinars and small group sessions online, but she says those whose disease has no cure are particularly anxious.

“Women with metastatic breast cancer have huge anxieties. They’re all on treatment, they’re cocooning, they’re fearful of what will happen when the lockdown is lifted and how they might be affected.”

The Marie Keating Foundation is dependent on public support and has had to cancel its fundraising events. "In a time of crisis when you don't have stability, you really see the dedication of our nurses. It has opened my eyes."

Aishling Byrne

Paediatric nurse, Our Lady’s Children’s Hospital, Crumlin

When Aishling Byrne began her training as a paediatric nurse she never envisaged she'd be teaching toddlers about surgical masks using their dolls. Byrne works on St Michael's Ward in Crumlin, which specialises in treating children with Cystic Fibrosis and sickle cell disease.

CF is a chronic lung disease and some children have to come in regularly for IV antibiotic treatment. “We have to screen them for Covid and they have to stay in isolation until the results come back. So in that situation we have to wear PPE. We try to make it fun for them, turn it into a game, so it’s not as intimidating.”

Byrne always wanted to work with children and thought about becoming a school special needs assistant like her mother. “But my mum thought I’d make a good nurse. And I loved it.”

Working with very sick children, she really gets to know her patients. “There are good and bad days. But when it comes to kids sometimes things turn out better than expected. They’re very resilient.”

Byrne was involved in last year’s nurses’ strike and says public support then and now has been amazing. “People are non-stop complimentary at the moment. Nurses’ roles are expanding, we’re showing we can do more than is expected.”

Trish Curran

Director of care, Mooncoin Residential Care Centre, Co Kilkenny

Trish Curran is director of care at a nursing home in south Kilkenny, but began her career as a children's nurse in Crumlin. Now she's responsible for the care of 74 elderly people.

While they have had no cases of Covid-19 at the time of going to press, there have been a few residents who have needed to self-isolate, and of course there are no visits. “Older people are very resilient, they have lived through a lot. But you can see they are starting to pine a bit.”

The centre has about 100 full- and part-time staff with a mix of nationalities. Curran is keen to pay tribute to healthcare assistants. “They really know the patients, they’re like family. They’re the heroes of this crisis, and the country couldn’t run without them.”

Running a nursing home means death is part of life, and two people have died during the Covid pandemic from other causes. Curran understands the wishes of many old people to die in the nursing home rather than be transferred to hospital.

“It’s all about the person. We have modern medicine; there are all kinds of pathways and care plans. But none of it is any good unless you walk in the shoes of the person, and understand their wishes.”

For Curran nursing is a life-long commitment.

“Every day is different. From being there at the start of life to the end of life, I’ve loved every aspect of it.”