Bleeding nurses dry

Mater Dei may be a state-of-art building but it won’t function as a hospital until 200 new nurses are recruited, says the president of the Malta Union of Midwives and Nurses Paul Pace. In the meantime, experienced nurses are leaving the profession because of burnout and the health minister is nowhere to be seen By Karl Schembri

As the prime minister cut the ribbon last week at what is arguably the largest building ever built by a Maltese government, to the backdrop of spectacular fireworks and ceremonial splendor celebrating Lm250 million of construction extravaganza, hundreds of nurses and their patients kept asking when they will be moving to the new state-of-the-art hospital in Tal-Qroqq.
The 17-year project reads like a whole calendar of missed deadlines, moving goalposts and shocking corruption allegations that make for the stuff of political thrillers – from the quintessential conman who tried to deceive the nation with fabricated reports, to the lonely superhero who acted as the exemplary whistleblower.
And like every respectable plot, there are the secondary characters: little heroes appearing here and there almost as an afterthought, such as the nurses; and chapters that have yet to be written, such as migration.
Paul Pace knows something about being a secondary character. A nurse for more than 20 years and president of the union of midwives and nurses since March, he represents a largely snubbed, underpaid and understaffed profession that has been clamouring for recognition for ages.
Case in point is the total lack of agreement with medics about their new working conditions at the new hospital, where we have been promised totally new facilities and all-day-round operations, without the hint of agreement with their representatives.
“My first priority is definitely to tackle the shortage of nurses,” Pace says. “The shortage is causing us stress and burnout in such a way that a workload meant for three people is being carried out by one person, and nobody can take leave. The feeling out there is that we’re blowing things up because of Mater Dei and it’s as if we can threaten the government, as if now is the time to grab all we can. It’s not the case. For three years we have been repeating that there is a nurses’ shortage, and the Health Division has repeatedly denied it. Then what happened was not Mater Dei merely coming in – the shortage has been there for ages – but Mater Dei was the pinnacle of everything, the straw that broke the camel’s back. When we started discussing the migration to Mater Dei, the figures given by the people at Mater Dei themselves showed that another 200 nurses were needed to keep the same services we have at St Luke’s and upgrade for Mater Dei.”
Pace explains that what this effectively means is that even if 200 nurses had to be recruited overnight, all the other hospitals and primary health care services will remain understaffed.
“The recruitment coming up in mid-August will not be filling up the vacancies we’ve been accumulating all along, yet staff shortages are spread out everywhere,” he says. “Even worse, at San Vincenz we ended up with patients in corridors and between beds, just like at St Luke’s where it is the norm. At San Vincenz this is a totally new scenario – we’re getting more patients and the staff hasn’t been increased. The figures released by the Health Division itself don’t even add up. Unless a miracle happens or we start cloning nurses, I can’t see an immediate solution.”
As things stand, however, not even Mater Dei can operate to its full capacity, which was the whole point behind opening such a massive scale hospital in the first place.
“Like the rest of the public I received the plan for the next four years from the Prime Minister in the Mater Dei leaflet. On paper it’s a good plan, because we will be increasing the oncology capacity by five times as much, the rehabilitation unit will be much bigger than the existing one at Zammit Clapp – you can’t say it’s not a great plan, the health service needs to expand, definitely. But from where are we going to get those nurses? We’re already in critical condition maintaining our service. We know that in the next two to three years all the recruitment will be going to Mater Dei because otherwise we won’t be able to use it at its full capacity as regards operating theatres. With the shortage there is, we only can operate in 11 theatres, we need an extra six nurses to operate in all of them, so there will be certain wards that cannot open. When I say we need an extra 200 nurses it’s just to keep the same service there is at St Luke’s at Mater Dei. Not the Mater Dei service we’ve been promised. Mater Dei will have 25 operating theatres, at St Luke’s there are about 11. So at the moment we can only cope with 11. We’ll have much more casualty facilities, but yet again there aren’t enough nurses to provide the service.”
I tell him the government can always recruit foreign nurses to make up for the immediate shortage, but Pace cautions against stopgap measures that would still leave the rest of the issues affecting the nursing profession unsolved.
“You can’t rely too much on foreigners. From past experience we know they use Malta as a stepping stone to Europe. We have by far one of the lowest salaries within the EU, so once they get registration in Malta they get registration automatically within EU countries. Some of them, even if they are bound by a contract, will board the next plane to the UK or to Spain or to Italy, and now you see them, now you don’t. So we’re saying government has to address the issues it has left pending for ages – we have problems that have never been tackled. This goes back to 1993, when Louis Galea came up with a great package for nurses when there was an exodus from the nursing profession. Since, then nothing has changed and now things are even worse than 1993. So foreigners should only be resorted to when all issues have been addressed. At least you have to try to make nursing an attractive profession. But let me tell you – it would be unacceptable for the union to bring foreigners now as a substitute for long term solutions to our working conditions, when there are so many pending issues that should be addressed in the nursing situation.”
One side of the discussions with government concerns attracting more students to the profession and persuading people who have left the job to return.
“We are working on a package with the government where hopefully, eventually we’ll reduce the shortage. It’s not just a union thing, as it will affect even non-union members such as university students. For example, we’re pressing for a rise in students’ stipends. We get around 100 new nurses graduating every year from the Institute of Health Care. We are urging the government: remove that numerus clausus for goodness’ sake and increase the students’ stipend. At present, nursing students get the lowest stipend there is – Lm32 a month – which clearly sends the message that nursing is unnecessary for the country. Now that the prime minister has come into the discussions and there is a full force working in Castile in negotiations with us, our voice is being heard and they’re acknowledging our requests, and stipends should go back to around Lm81 if an agreement is finally reached. Stipends on their own will not do the whole trick, but at least government should acknowledge there’s a huge problem and start making our profession more attractive.
“We’re also trying to persuade nurses who have quit their job to be reinstated, and we’re working to launch the nurses’ warrant to enhance our professional status. We work long nights with the sick, with the dying, with fragile children – this is all part of the job. Of course the vocation has to be there, but the working conditions must be decent. As it is, it’s already a highly stressful job, but adding more stress to it is unfair. What we’re calling for is a package of retainment, because once enthusiastic students start facing the reality of our neglected conditions they start losing interest and experienced nurses get fed up, too.
“There’s also the problem of the retirement age stepped up to 65 years of age. It’s already very difficult in certain areas to keep on working as a nurse with the demands of the job till the age of 60 – so we’re trying to address these issues, because they are breaking our nurses.
“One might say there are many other demanding and stressful jobs, but the fact remains that you are working with the sick, amidst infectious diseases that make you prone to get sick, in an environment where you keep seeing the bad side of life – people dying and suffering daily – and in an environment where there is no career progression whatsoever. And Mater Dei may be state-of-the-art, but what about the rest of the hospitals?”
Pace suddenly drops a bombshell – the 200 figure is just a conservative estimate, he says.
“That figure can easily go up between 900 to 1,000 new nurses in four years’ time. Taking the Prime Minister’s word about all the expanding services, that’s the figure we should be talking about. With Mater Dei, primary healthcare, the oncology hospital, the new rehabilitation hospital building, and the present shortage, coupled with an ageing population of nurses – we would need roughly those numbers.”
As regards discussions with the government, Pace believes they will be concluded this month although his optimism just stops there.
“By concluded I mean we either reach an agreement or yet another deadlock. I’m not that optimistic, but as long as there is discussion there’s progress. The worst-case scenario is when government refuses to discuss. So far we’re around a table discussing the very issues proposed by my union, so that’s a good thing although there’s no guarantee about the outcome. This month we have to conclude one way or the other. I’m not optimistic because there were other times when we did reach a deadlock and things just stopped. We’re discussing the Mater Dei issues with the new Mater Dei director, CEO, etc., while we’re discussing working conditions with the people at the prime minister’s office.”
What about the health minister?
“We never had any meeting with Dr Deguara.”
So he could have been minister for agriculture as far as you’re concerned.
“Precisely,” he replies, laughing. “We never had one single meeting with him, not even heard one word from him. Actually a long time ago we had a meeting with the Prime Minister and he was sitting there, but the meeting was with the Prime Minister. From then on he just disappeared. He’s not even party to any of our discussions, which is a bit weird. We had initial meetings with the health division and the health ministry's permanent secretary, but that's as far as it went.”
On 29 June we had this celebration of sorts at Mater Dei in honour of the completion of the new building. When do you expect it to start receiving its first patients?
“That will have to be more or less September. We definitely need the new recruitment to happen before even thinking about migration. Although we need 200 nurses, we have no guarantees they will be employed. What might happen is the usual story – we reach an agreement on the complement but it is never actually met; then government would come forward saying it’s not its fault as there are not enough nurses. And as you well know, nurses don’t fall from the sky.”
An issue that so far remains unresolved is the bizarre one raised by the Medical Association of Malta: to have doctors and nurses segregated when it comes to the staff canteen.
“Unfortunately in this country, where there is a heavy medical dominance, a circular issued by the Mater Dei management could not be implemented and instead of the management making sure it is implemented it had to be the nurses’ union to say that it is not being followed,” Pace says. “The circular said there would be one canteen for all hospital staff, but Martin Balzan wants one all for doctors. This is unheard of. In normal circumstances the management would just say ‘this is my circular and that’s how things stand’. But then when MAM said no, things just went according to their demands, treating them as the elite and us as second class. We have to fight for certain issues, while in the case of certain professions they fall onto their lap. In fact I was surprised by the MAM president’s attitude, because lots of doctors are married to nurses or have their children working as nurses and they can’t even eat with them.
“I have travelled and worked abroad with doctors and that’s how things go with them. I can’t see what his issue is. I have been called by so many doctors and nurses telling me they can’t understand why MAM is taking such a hard stand, as abroad they would also be eating with nurses, who are ultimately part of the same team. So you work all day with nurses and you don’t want to eat with them? What’s the issue here? By the look of it, doctors are still going to eat on their own. It’s a pity, and the health division doesn’t even have the gall to stand up to them and take a stand.”
Meanwhile, with the election round the corner there is not only the prospect of all plans being disrupted once again but also the usual unfair practice of subjecting nurses to transporting patients to polling stations.
“It’s unacceptable. We’ve always protested against this with both parties, even with the electoral commission. There should be a ‘mixed box’ in hospital so that patients could vote according to their districts. We are the only country in the world to force patients out of hospital so that they can vote. This is a funny country. In fact I don’t know why migration is an issue because we literally migrate all patients every five years – to the polling booths. It’s actually worse than migration because we take them and return them, while migration is only one-way. The only people who don’t vote are the Intensive Therapy Unit patients. But as long as they don’t get voting facilities in the hospital, patients have a right to go to vote. Now patients can be so weak and depleted that they need medical assistance in case something happens along the way. They’re putting patients through all this, which is both funny and tragic, as things can go terribly wrong. Get the ballot box to the patient, not the patient to the box. They do not care less about the benefit of the patient, the health of the patient, definitely, but just their electoral system. The priority of both parties is not the health of the patients.”
Can’t you just refuse?
“Yes, but then it would be highly unethical to deny a patient the right to vote. It’s their constitutional right.”
It doesn’t mean you have to take them.
“Yes, but then if we don’t offer assistance and the patient dies or something happens along the way, he or she is still legally hospitalised, not discharged, which means the patient is legally under our responsibility. We don’t do it out of respect towards the parties or the electoral commission, we do it out of respect towards the patient.”
So watch out for the nurses and the stretchers come next general election.