Paul Pace knows a thing or two about how new ways can easily slip back into the old. A nurse for the past 22 years, the president of the Malta Union of Midwives and Nurses has done his time in casualty, since 1992 he has been an infection control nurse. He still remembers writing his university thesis on MRSA: the multiple resistant bacterium which was still almost non-existent back then.
“And today it has exploded,” Pace says… much like the problems for the healthcare profession he defends, whose Mater Dei honeymoon seems to have already ended post-migration.
A new hospital brings with it a chance to start afresh, even in the control of infections, Pace says.
“Our lifestyle has indeed changed, and with that we have started consuming even more antibiotics, liberally, developing a greater resistance to medication and eventually becoming carriers ourselves. My part of the job also involves educating staff, doctors and nurses, because MRSA is very contagious inside a hospital. That’s why hand washing is so crucial. On one hand you have people walking inside the hospital who are increasingly more resistant to penicillin – once you get infected with this bug, it becomes more difficult to treat. But on the other hand, you can get infected at hospital itself. And that’s where compliance comes in.”
What’s worrying is that a study carried out between 2005 and 2006 had found the abysmal levels of hand hygiene among doctors to be a possible factor in the high incidence of MRSA at St Luke’s hospital. Out of some 898 direct observations by a group of medical students, whose precise assignment was unknown to doctors under surveillance, only 22.7% of doctors were observed washing their hands before contact with patients, and only 33.5% after contact. Overall, before patient contact compliance ranged from a low 9.9% in obstetrics, to 45.6% in surgical specialties. After patient contact, compliance for these same specialties showed rates of 11.3% and 59.5% respectively.
“Today I can categorically state there is no health worker in Malta who is unaware of the importance of hand-washing. Mater Dei Hospital is geared towards this end because you will find hand basins in every corner of the hospital. At St Luke’s you would have ended up having to walk from one end of the ward to the other, and you wouldn’t have done so because you’d tire yourself out. So instead health workers carried their alcohol rubs around. At Mater Dei, there is a sink in literally every patient room. There is no excuse not to wash your hands. Still, research shows that 60% to 70% is the most compliance you can expect to get. The fact that we have removed those large, Florence Nightingale rooms, and now that we don’t have ceiling fans – where the dust was literally hanging over the fans – makes it logistically possible to control MRSA well,” Pace says.
But MRSA may be the least of the problems for the nurses at Mater Dei: and especially for Pace, whose union may well go down in history for never having been granted a meeting with the former health minister Louis Deguara in the last legislature. Just months into the opening of Mater Dei, nurses are complaining that the old problems are rearing their head inside the shiny new wards at Tal-Qroqq, where a spill-over of patients is already clogging up wards, without enough nurses to even take care of them.
“We always complained that the only aspect of Mater Dei being debated in the media had been the money. It was mentioned ad nauseam, and we were just simply orientated to the financial cost of this hospital. And yet, nothing was said of the most important factor: human resources. I mean, what’s the point of going to a five-star hotel and you can’t even be served a cup of coffee? You’d say the service was crap. The human resources aspect at Mater Dei was simply not discussed.
“But there was one aspect at Mater Dei that became daunting. Not that it took us by surprise, because we expected it, but it was never tackled. Basically, the logistics of the place, being so big, would make taking care of even the same number of patients as we had at St Luke’s a challenge. And basically we need more staff,” Pace adds matter-of-factly.
“Certain units have grown in size. In theatre for example we have uploading bays, but we need more staff to manage the system. So it is expected that the same level of staff as we had at St Luke’s, basically does more tasks.”
But apart from that, Mater Dei has managed to bridge the great gap between St Luke’s and private healthcare, Pace says. He rues the burgeoning number of beds that St Luke’s staff placed in the hospital corridors. “Not only was it an eyesore, but it was highly unethical for the patient, having no privacy at all and sleeping in a corridor.”
That sounds like a thing of the past. After all, the same doctors working at the private hospitals were also working at the state hospital, so the same level of care was there. What Mater Dei has given patients are the so-called hotel services that private hospitals vaunt. Patients now can watch Cable TV in hospital, and they have their own rooms. But the logistics of human resources persist, and the problem does not start at Mater Dei, but before, namely at the primary healthcare level.
The new social policy minister John Dalli has already hinted at this, arguing that Mater Dei should far as possible not be overloaded with patients who could otherwise be treated inside polyclinics.
“We still have some 70 beds at Mater Dei that are ‘blocked’ because of social cases. As an acute hospital, when you are sick you get cured, and then discharged and taken home by your relatives. In these social cases, there are no relatives to take the patients back,” Pace says.
And just less than a year into the new state-of-the-art acute hospital, Malta’s nurses still face problems they thought would be left behind at St Luke’s Hospital. Staffing is thin, and unable to cope with the extra 30-bed ward recently opened in the day care unit (DCU). Just weeks before the elections, the ward turned into a “round-the-clock” ward: patients who cannot be given beds in other medical, surgical and special care wards are being kept in the DCU, defeating the cope of the “special” unit.
“Well, the concept of the day care unit (DCU) was good. The aim was to have patients requiring operations for them to be conducted within a day. You are admitted to the hospital, operated upon, and set off for home that same day. Even for operations like hernia, where you might still be in pain once you get home; but infection in a home setting is very difficult to happen,” Pace says.
What happened was that people were being admitted into casualty but there was nowhere else to put them. “Casualty was not meant to have inpatients, and we were complaining as a union. That’s when management started using the DCU for medical cases – instead of these inpatients waiting inside Casualty’s area two, on stretchers, they are now being placed inside the DCU. Which is why in the DCU we are short on beds for the medical cases.”
With other patients taking up beds in the DCU, there is no place for day surgery patients to convalesce. The result is that surgery gets cancelled, and more patients have to wait. What was intended as a ward opening from 7am to 6pm, has now turned into a 24/7 inpatient ward.
“Of course it is more comfortable for these inpatients to have a bed inside the DCU while they are waiting to be transferred to a ward. But this became chronic. We did expect more diseases than usual in the winter, but now this has been going on for months, and it has become part of the system. So we have lost the day-care: we have lost beds in the DCU to inpatients. And since day-care unit nurses were not supposed to take care of these inpatients after migration to Mater Dei, we have situations were DCU nurses are not enough to handle the unit. So we are transferring nurses from other wards down to the DCU to assist the team, such as nurses from theatres on Saturdays and Sunday.”
The biggest problem facing the healthcare system, Pace says, is the utter shortage of nurses which the government has not yet addressed. Asked about how foreign nurses could stem the flow, Pace says that until now the number of new foreign nurses is just three, and another 10 are expected to come shortly.
“The shortage of nurses is not just plaguing Malta. Europe was previously draining developing countries of their nurses. And today, it is Europe that is suffering the same fate to the United States, which is attracting its nurses… but even if we need foreign nurses, I cannot allow a situation where the door is partially closed to the Maltese with the numerus clausus at university, and then another door is flung wide open for foreigners. The doors have to be open to all young people, to encourage them to join the profession.
“In Malta the shortage in nurses is owed to the fact that the past health minister seemed inclined to think we had enough nurses. Our university course had a numerus clausus restricting the intake of aspirants to the profession. We were actually classified as unskilled workers so our stipend was the minimum the university was good. As a union we protested against this state of affairs.
“In the last year, we were summoned by the prime minister, and he sort of could see that we were right about this state of affairs. But you don’t make a nurse overnight, do you? We needed a package to attract nurses into the service and keep them there. And the shortage is still there. What the main challenge for the new social policy minister is changing and raising the status of nursing at university. We are saying that all students with the necessary qualifications to enter university cannot be refused entry to the nursing course.
“Mater Dei on its own – and this is not the union’s figure – needs 150 to 170 more nurses today. And this is without relief pools: the nurses required to fill in nurses on sick leave. I’m saying that as things stand, if nurses had to collectively decide to cut out all overtime, we would be cutting down the service by one-third.”
Even with such a threatening state of affairs, nurses in Malta’s healthcare system complain about finding it hard to take leave, often competing for days off months in advance and fighting to sign their leave books as early as possible, ahead of their other colleagues. “At St Vincent de Paule, if a nurse doesn’t find a colleague to replace them for their leave, that nurse does not get any leave,” Pace says. “And this system is pervading the other hospitals, including Mater Dei. And consider that it is propped up by overtime work: if nurses at Zammit Clapp did not work overtime, at least two particular wards would collapse, with patients having nobody to attend to.”
The worrying thing, Pace says, is that unless the system is changed, the shortage of nurses can be expected to continue for years to come: possibly even doubling over time. “This year, if all our undergraduates pass their final examinations, we will have 60 new nurses,” he says, before throwing in the proviso: “However, between maternity and retirement we will lose many more than the nurses we have gained… perhaps not double the figure, but definitely more. And this hurts us badly as a profession.”
Pace says marketing the nursing profession is now urgent. Part of the last agreement negotiated with the nurses at the end of 2007 included funds that had to utilised for the marketing of the profession. “But we haven’t been given the money yet,” Pace says, adding yet another dampener to the supposed historic agreement that so many in the profession had hailed last year. The matter hasn’t yet been discussed with the ministry, but a document is to be presented over a manpower plan. “We’re not against the government’s health plans, but we need to have a proper manpower plan for the next five years at least. Nurses are being hit because it’s an ageing profession, there are limits on their entry into university, they retire or even go into other professions.”
Even worse, Pace says the situation can only further deteriorate the way thing are going: “This year, we could easily close down a theatre with the nurses that have retired and become mothers. In the next five years, we’ll be needing 1,000 nurses. Do the math.”
But you could find no better person than Paul Pace to explain one of the simplest morals of politics. Pace is one of the government workers at the receiving end of a very dear and crucial public benefit: healthcare. And yet, he knows that without putting your money where the mouth is, no grand political plan is going to take place any sooner, lest it should fail.
“Look, we agree with a lot of things the politicians say… the government says it wants to open an oncology hospital, annex Zammit Clapp, have a new rehabilitation hospital, extending primary healthcare. Sure, they are certainly nice things to say in public… but where do they think they will be getting the nurses from? We’re not a rubber band you can just stretch till we break… the government is going to have to do some serious thinking about its plans.”