On May 12, T&T cel­e­brat­ed In­ter­na­tion­al Nurs­es Day along with the rest of the world.

On so­cial me­dia, these front­line work­ers who are tasked with car­ing for those sick and dy­ing from the COVID-19 virus were on the re­ceiv­ing end of high praise and ap­pre­ci­a­tion.

Health Min­is­ter Ter­rence Deyalas­ingh al­so joined in and of­fered praise when he post­ed a mes­sage on his Face­book ac­count, say­ing, "To­day we recog­nise our Nurs­es, we say thank you to our 'Flo­rence Nightin­gales'. You are a part of our front­lin­ers in this pan­dem­ic. May God give you spe­cial Bless­ings for all you do for us..Thank You...We Love You..."

In an­oth­er mes­sage the same day, Deyals­ingh said he was proud of the coun­try's health care work­ers, es­pe­cial­ly the nurs­es. He said it would be "dif­fi­cult" to thank the nurs­es for their un­selfish sac­ri­fices.

But Pres­i­dent of the T&T Reg­is­tered Nurs­es As­so­ci­a­tion (TTR­NA) Idi Stu­art was adamant the Gov­ern­ment was do­ing lit­tle to im­prove the work­ing con­di­tions of nurs­es.

The Sun­day Guardian spoke to a few nurs­es who con­firmed that the sit­u­a­tion at the Cau­ra and Cou­va hos­pi­tals has been over­whelm­ing.

One of the nurs­es at the Cou­va Mul­ti-Pur­pose and Train­ing Hos­pi­tal echoed Stu­art's state­ment, say­ing de­spite the out­pour­ing on so­cial me­dia, that love has not been felt in­side the hos­pi­tal walls.

In­stead, she said, she and her fel­low nurs­es are over­worked, un­der­paid and forced to car­ry out their du­ties with lim­it­ed PPE (Per­son­al Pro­tec­tive Equip­ment).

The nurse, speak­ing un­der the con­di­tion of strict anonymi­ty for fear of be­ing vic­timised or los­ing her job, said she and her col­leagues are strug­gling to car­ry out their du­ties un­der the cur­rent con­di­tions.

They are paid a ba­sic salary of $7,500 a month and re­ceive a nurs­ing in­cen­tive of $1,800 a month–this in­cen­tive in­cludes al­lowances for meals, laun­dry and a liv­ing-out al­lowance.

"We are work­ing un­der the worst con­di­tions for the same salary, over­time is paid at the same rate of reg­u­lar pay, we don’t have enough re­sources, we don’t have enough staff, all of these are con­cerns we need to have ad­dressed," she said.

She said most of the nurs­ing staff at the hos­pi­tal have less than a year of ex­pe­ri­ence on the job and too lit­tle train­ing to treat pa­tients in the In­ten­sive Care Unit.

She said the se­nior nurs­es on shift re­main in the "cold zone" or ar­eas where there is lit­tle to no chance of com­ing in­to con­tact with the virus.

"It is on­ly the ju­nior nurs­es work­ing in these con­di­tions, there are no se­nior nurs­es, they hired all of these nurs­es last year and it's on­ly the new nurs­es that are work­ing, most of us are scared of los­ing our jobs. They gave some peo­ple a crash course in ICU and then put them in ICU to work, some didn’t get the crash course, they just went straight in­to the ICU."

The nurse said once they don haz­mat suits at the be­gin­ning of their shifts, they can­not re­move them for the en­tire six-hour shift be­cause there is not enough in sup­ply.

"I can’t even drink wa­ter be­fore I go, I have to wait un­til I fin­ish work for six hours and then I can eat and drink. You can’t use the toi­let when you in­side there, it’s an un­com­fort­able sit­u­a­tion for us but we have no oth­er choice. Some­times you stay in­side there for more than six hours, for ten hours be­cause we are short-staffed and we can­not get re­lief on time," she said.

But she said they do every­thing they can to keep their pa­tients alive.

With COVID-19 deaths sky­rock­et­ing in the past weeks, the nurse said she and her col­leagues are al­so car­ry­ing the emo­tion­al bur­den of see­ing their pa­tients de­te­ri­o­rate.

"It is very hard to watch peo­ple die. Work­ing in­side there is no easy task, some­times you end up with over 20 pa­tients to one nurse, in those cas­es, how much can you re­al­ly do for a pa­tient?"

She said the young nurs­es have been told they will lose their con­tracts if they speak to the me­dia.

"A lot of peo­ple are afraid of los­ing their jobs so they are just do­ing what they have to do and stay­ing qui­et," she said.

She said the nurs­es want the Health Min­is­ter to ad­dress their con­cerns.

"We want bet­ter salaries and we want job se­cu­ri­ty, when they hire po­lice of­fi­cers, they don’t put them on con­tract, why should nurs­es be on con­tract? We are fed up of wait­ing on a con­tract, hav­ing a wait­ing pe­ri­od be­fore you can get your con­tract re­newed and you’re al­ways feel­ing in­se­cure, we want to be work­ing with­out that ex­tra pres­sure on us," she said.

Idi stuart, president of the TTRNA receives meals prepared by the private sector for the nurses on duty on the frontline. The initiative was partly sponsored by the SEWA charitable foundation.

Nurs­es over­whelmed

One of the rea­sons why we are see­ing the death rate go­ing up is that nurs­es are be­ing stretched thin, Stu­art said.

On Fri­day, there were 18 ad­di­tion­al deaths to COVID-19, bring­ing the to­tal num­ber of deaths in the coun­try to 458. There were 295 deaths in the last month–from April 28 to May 28.

The coun­try al­so record­ed 633 new pos­i­tive cas­es, bring­ing the to­tal amount of pos­i­tive cas­es to 22,620.

"The re­al­i­ty in T&T is one nurse or pos­si­bly two nurs­es to 24 pa­tients on the med­ical wards. Three pa­tients to one nurse ra­tio in ICU, and four to sev­en pa­tients to one nurse in HDU," Stu­art said.

He ex­plained that while there would be two nurs­es on the ward, one would be in the "hot zone" while the oth­er is in the "cold zone."

"So that one nurse who has to work in the hot zone for six or eight hours, she has to see about 24 COVID-19 pa­tients. This in­creas­es the risk, er­rors, stress, fa­tigue, and be­com­ing sick her­self from COVID-19, hav­ing to treat so many pa­tients.

"This short­age of nurs­ing per­son­nel is not new in T&T. It just has been made worse by the pan­dem­ic, as we are both short on the num­ber of gen­er­al nurs­es and spe­cial­ist ICU nurs­es."

He de­scribed the dif­fi­cult con­di­tions that nurs­es–the ma­jor­i­ty of whom have been giv­en short-term con­tracts be­tween three to six months and no ben­e­fits–face while tak­ing care of COVID-19 pa­tients.

"So they put on these haz­mat suits and gog­gles and they are ful­ly en­closed in this body­suit. They have to be prepped go­ing in and san­i­tized com­ing out. There is a sep­a­rate per­son to put on the suits and take them off to pre­vent the risk of be­com­ing in­fect­ed.

"Be­cause of the short­age of nurs­ing staff, there was a move to make nurs­es work from six hours in­side the hot zone to ten hours. Even­tu­al­ly, they re­lent­ed on that pro­pos­al. The chal­lenge is if you are in that suit for ten hours, you are not drink­ing flu­ids or eat­ing and you can­not sim­ply take off your clothes and go to the wash­room.”

Stu­art said 100-plus nurs­es have been in­fect­ed with COVID-19 and their fam­i­lies have been placed in quar­an­tine.
Many nurs­es on the front­line have not been vac­ci­nat­ed, he said, de­spite their at­tempts to get it done. "They still have to call, sched­ule an ap­point­ment and find their way to the health cen­tres like every­one else to get vac­ci­nat­ed," Stu­art said.

"The St James Med­ical fa­cil­i­ty the­atre was down be­cause nurs­es con­tract­ed COVID-19. That is an on­go­ing prob­lem that we have where nurs­es are pick­ing up the virus both with­in the com­mu­ni­ty and with­in the health fa­cil­i­ty."

Stu­art was al­so con­cerned about the lim­it­ed ac­cess to PPEs out­side of the of­fi­cial COVID treat­ment ar­eas, which has been putting nurs­es' lives in dan­ger.

"When cas­es arise with­in the gen­er­al set­ting, the same nurs­ing per­son­nel who are treat­ing the non-COVID pa­tients are al­so ex­pect­ed to treat the sus­pect­ed and con­firmed COVID pa­tients on the same ward.

"These sus­pect­ed and pos­i­tive cas­es be­ing man­aged out­side of the par­al­lel sys­tem is in­creas­ing more and more as there is ex­treme dif­fi­cul­ty in find­ing bed space. There­fore, the nurs­es who are now ex­pect­ed to treat these pa­tients must be giv­en the same lev­el of PPEs that would have been ex­pect­ed at Cou­va and Cau­ra hos­pi­tals."
Stu­art added, "It is not that nurs­es are scared, but they are just con­cerned that they are putting them­selves out con­tin­u­ous­ly day by day and they have not seen that lev­el of con­cern com­ing back to them from the Re­gion­al Health Au­thor­i­ties and the Min­istry of Health. It both­ers nurs­es that they are ex­pos­ing them­selves and their fam­i­lies with­out the req­ui­site safe­guards in place."

Short of 1,600 to 2,000 nurs­es

T&T's health sys­tem is short of ap­prox­i­mate­ly 1,600 to 2,000 nurs­es.

These are the num­ber need­ed to ful­ly staff hos­pi­tals and health fa­cil­i­ties through­out the coun­try, ac­cord­ing to the cal­cu­la­tions of the TTR­NA.

The TTR­NA pres­i­dent, in an in­ter­view with the Sun­day Guardian, said there were 7,851 ex­ist­ing posts be­fore the new hos­pi­tals–Point Fortin, Ari­ma and To­ba­go–came on stream. With the need for nurs­ing per­son­nel to man these fa­cil­i­ties, the num­ber has in­creased. And the short­age ex­ists notwith­stand­ing the 300 to 400 tem­po­rary nurs­ing per­son­nel re­cent­ly hired ex­clu­sive­ly for the COVID-19 re­sponse in the coun­try. This hir­ing was done un­der the In­ter Amer­i­can De­vel­op­ment Bank.

Stu­art added, "There is the new Ari­ma Hos­pi­tal, new Point Fortin Hos­pi­tal, new Rox­bor­ough Hos­pi­tal. Where are the nurs­es to staff these hos­pi­tals? The Min­istry of Health has not done a re­view of the re­quired num­ber of peo­ple need­ed to prop­er­ly run these in­sti­tu­tions to date. The COVID-19 pan­dem­ic made it worse see­ing that no new nurs­es are com­ing in­to the sys­tem.

"The small glim­mer of hope is that the Min­istry of Health was able to hire nurs­es at home to come out to work dur­ing the pan­dem­ic," he said.

In 2018, the TTR­NA wrote a let­ter to Prime Min­is­ter Dr Kei­th Row­ley in­form­ing him that the coun­try was des­per­ate­ly in need of more nurs­es.

At that time, three years ago, there was a need for an ad­di­tion­al 1,079 Reg­is­tered Nurs­es and Reg­is­tered Men­tal Nurs­es in the Re­gion­al Health Au­thor­i­ties, ac­cord­ing to the let­ter.

Ac­cord­ing to a pre­lim­i­nary draft of the "Man­pow­er Plan for the Health Sec­tor of T&T 2013 to 2022," the va­can­cy rate for nurs­es at the time the doc­u­ment was com­piled was 37.3 per cent. They had pro­ject­ed that the de­mand for reg­is­tered nurs­es would in­crease by 24.4 per cent over the ten years due to the planned ex­pan­sion of the health ser­vices in the pub­lic health sys­tem, new health fa­cil­i­ties, and the ex­pan­sion of pri­vate health ser­vices in keep­ing with in­creas­es in the pop­u­la­tion over the pe­ri­od.

Stu­art lament­ed that the Gov­ern­ment did lit­tle, if any­thing, to in­crease the num­bers of nurs­es and im­prove work­ing con­di­tions.

While nurs­es nor­mal­ly work un­der stress­ful con­di­tions, the sit­u­a­tion has wors­ened as we face the COVID-19 pan­dem­ic with ris­ing in­fec­tion and death rates in the coun­try.

Hos­pi­tal fa­cil­i­ties are burst­ing at its seams and health of­fi­cials have been plead­ing with cit­i­zens to do the right thing by wear­ing their masks, san­i­tiz­ing and so­cial dis­tanc­ing as they are over­whelm­ing the health care sys­tem where beds are run­ning out and doc­tors and nurs­es are burn­ing out, many of them con­tract­ing COVID while on du­ty.

Some nurs­es have even tak­en to Face­book plead­ing with the pop­u­la­tion to do the right thing as their lives are be­ing threat­ened or at risk.

An irate Stu­art said nurs­es are over­worked and over­bur­dened. He said nurs­es are now be­ing called up­on to ful­fil du­ties out­side of their job de­scrip­tion–like maids, clean­ers and at­ten­dants–be­cause oth­er mem­bers of staff are not will­ing to work in COVID-19 wards or are not ros­tered on a 24 hours ba­sis like nurs­ing per­son­nel.

"This is an ad­di­tion to the clin­i­cal work that they have to do. For in­stance, one of the signs of COVID-19 is vom­it­ing. When those in­ci­dences present it­self, who will clean it up on the night shift when there is no maid on du­ty?" These sup­port­ive staffs are al­so es­sen­tial, there­fore ought to be re­quired to work 24 hours.

Stu­art said glob­al best prac­tice dic­tates that there should be one nurse to one pa­tient in the In­ten­sive Care Unit (ICU); in the HDU (High De­pen­den­cy Unit) the ide­al is one nurse to two pa­tients; in the sur­gi­cal and med­ical ward, the ide­al is one nurse to four pa­tients. In the psy­chi­a­try area, the ide­al ra­tio is one nurse to nine pa­tients.

He said that sad­ly in T&T’s health sys­tem there are no es­tab­lished stan­dards.

A seam­less hir­ing process be­comes con­vo­lut­ed

Stu­art, in the let­ter to the PM on the need for ad­di­tion­al nurs­es three years ago, stat­ed that "a process that was seam­less un­der past gov­ern­ments, where nurs­es com­plete their course of train­ing and are hired per­ma­nent­ly in ex­ist­ing va­cant po­si­tions has be­come some­what con­vo­lut­ed..." and nurs­es have to wait for more in­for­ma­tion to be pro­vid­ed "when they (the Min­is­ter of Health and oth­ers) come to a po­si­tion" on the mat­ter.

Stu­art said some of the RHAs have re­fused to hire more nurs­es al­though the Min­istry of Health gave them per­mis­sion to re­cruit.

The let­ter to the PM had stat­ed that "three of the five RHAs rarely of­fered nurs­es per­ma­nent con­tracts or have tak­en an ap­par­ent pol­i­cy de­ci­sion to dis­con­tin­ue same."

Stu­art said 50 per cent of all nurs­ing per­son­nel work­ing at the NCRHA are on a three-month to one-year tem­po­rary form of em­ploy­ment ac­cord­ing to Free­dom of In­for­ma­tion (FOI) re­spons­es re­ceived by the TTR­NA.

What nurs­es want

*The TTR­NA has rec­om­mend­ed that the Min­istry of Health al­low and en­cour­age the nurs­ing schools to re­turn their stu­dents on the wards so they can com­plete their train­ing and en­ter the pro­fes­sion."

*An­oth­er ur­gent so­lu­tion that T&T needs to em­bark on, Stu­art said, is for T&T to "swal­low its pride" and go to for­eign coun­tries to tem­porar­i­ly re­cruit nurs­es to work lo­cal­ly.

*The TTR­NA said the Gov­ern­ment has reached out to re­tired nurs­es to bring them back in­to the sys­tem how­ev­er, they are at risk of con­tract­ing COVID-19 be­cause of their age. There has been no up­date on this plan, Stu­art said.

*They are re­quest­ing any form of in­cen­tive or fi­nan­cial com­pen­sa­tion "for nurs­es re­quired to work long hours in this most de­plorable con­di­tion."

*Speed up the process to in­tro­duce health and life in­sur­ance poli­cies for nurs­es.

*Pro­vide tem­po­rary shel­ter for nurs­es work­ing in haz­ardous en­vi­ron­ments so they can be iso­lat­ed to avoid the chance of in­fect­ing their fam­i­lies with the virus. "Sev­er­al of them in Cau­ra, Cou­va, Ari­ma and field hos­pi­tals have rent­ed one-bed­room apart­ments to avoid the risk of tak­ing the virus home."

*The TTR­NA is ap­peal­ing for nurs­es to be giv­en the same sense of job se­cu­ri­ty that mem­bers of the pro­tec­tive ser­vice and teach­ing ser­vice cur­rent­ly en­joy.

COSTAATT pro­duc­ing nurs­es...but long wait for em­ploy­ment, peo­ple mi­grat­ing

Pres­i­dent of the Col­lege of Sci­ence, Tech­nol­o­gy, and Ap­plied Arts of Trinidad and To­ba­go (COSTAATT) Dr Gillian Paul told the Sun­day Guardian that the in­sti­tu­tion should not be blamed for the short­age of nurs­es in the coun­try.

She said that COSTAATT was the largest in­sti­tu­tion that trains nurs­es in the coun­try and tra­di­tion­al­ly they have trained a sur­plus of nurs­es.

"We have over 400 nurs­es in train­ing at this point. We ac­tu­al­ly were con­cerned as nurs­ing stu­dents who have grad­u­at­ed were seek­ing em­ploy­ment abroad. We were ac­tu­al­ly con­cerned about over­pro­duc­ing nurs­es. The grad­u­ates were not get­ting hired as we have an­tic­i­pat­ed, so I think that the short­age may be linked to the cur­rent sit­u­a­tion with the pan­dem­ic and the cur­rent health work­force be­ing ex­haust­ed and over­bur­dened."

She said many of the nurs­es when trained are mi­grat­ing be­cause of the time they have to wait to get em­ploy­ment in T&T.

"So those who pay high­er salaries will re­cruit our nurs­es. But we at COSTAATT are pro­duc­ing at lev­els what we un­der­stand the de­mand to be. That is the rea­son we lose so many of our nurs­es. When you look at the re­gion­al per­for­mance our nurs­es do very well on the ex­ams com­par­a­tive­ly speak­ing."

She al­so said that of the nurs­ing stu­dents who are in the batch next to be grad­u­at­ed, COSTAATT is try­ing to have them vac­ci­nat­ed to pre­pare them to go out in­to the med­ical sys­tem.

At COSTAATT’s most re­cent grad­u­a­tion cer­e­mo­ny held this month, she said 144 nurs­es grad­u­at­ed–135 at the Bach­e­lor’s lev­el and nine at the As­so­ciate De­gree lev­el.

There were:

*Nine stu­dents in ba­sic Gen­er­al Nurs­ing

*124 stu­dents in Gen­er­al Nurs­ing

*11 stu­dents in Psy­chi­atric Nurs­ing

No re­sponse from Deyals­ingh

Guardian Me­dia called and sent a list of ques­tions on all the is­sues raised by the nurs­es to the Health Min­is­ter via email and What­sApp on May 15 and sent the same ques­tions to the Min­istry of Health’s cor­po­rate com­mu­ni­ca­tions de­part­ment. Ques­tions were al­so sent to the NCRHA, NWRHA. SWRHA and ER­HA.

Up to Fri­day, there was no re­sponse from the min­is­ter, the com­mu­ni­ca­tions de­part­ment, the NCRHA, NWRHA, and ER­HA.

SWRHA re­sponds

What is the South West Re­gion­al Health Au­thor­i­ty do­ing to pro­vide a so­lu­tion for the short­age of nurs­es in your dis­trict?

Be­fore the on­set of the pan­dem­ic, the SWRHA had a ded­i­cat­ed com­ple­ment of nurs­ing pro­fes­sion­als at all our fa­cil­i­ties, to ad­e­quate­ly pro­vide care to our pa­tients. How­ev­er, the chal­lenges of the pan­dem­ic have al­lowed the au­thor­i­ty the op­por­tu­ni­ty to of­fer em­ploy­ment avail­abil­i­ty to more nurs­es to give in­sti­tu­tion­al sup­port, to both the ex­ist­ing reg­u­lar ser­vices com­ple­ment and to meet the needs of the par­al­lel health­care sys­tem.

How many nurs­es are em­ployed with the SWRHA?

The au­thor­i­ty has a cadre of nurs­ing pro­fes­sion­als to man­age ad­e­quate­ly our pa­tient com­ple­ment.

What is the SWRHA do­ing to en­sure nurs­es are pro­tect­ed while on du­ty in the "hot zones" while deal­ing with COVID-19 pa­tients? There are re­ports that some nurs­es are over­worked be­cause of the short­age and this is caus­ing se­vere dis­com­fort among them.

While SWRHA ac­knowl­edges the chal­lenges ex­pe­ri­enced by staff with re­gard to stress man­age­ment, we are work­ing along­side our ded­i­cat­ed staff to en­sure all as­sis­tance is pro­vid­ed. Through ef­fec­tive re­source man­age­ment, staff are pro­vid­ed with req­ui­site Per­son­al Pro­tec­tive Equip­ment, con­tin­u­ous In­fec­tion Pre­ven­tion & Con­trol train­ing, as well as strin­gent ad­her­ence to all Min­istry of Health’s HSE pro­to­cols.

How many nurs­es are vac­ci­nat­ed in the SWRHA?

No re­sponse.