This is how the coronavirus made nursing more visible in Colombia

The International Council of Nurses (ICN) has warned that there may be massive trauma in the union. Photo: Natalia Pedraza

They remember that the first thing they felt was uncertainty. If anyone was going to have to be around coronavirus patients, especially the most critical ones, it was nurses and nursing assistants. Then came the guilt. The feeling that perhaps they were bringing the virus home and putting their families at risk. Later there were excessive hours of work: exhaustion and frustration of seeing so many deaths in a single day. Today, there is some calm. (You may be interested in: Coronavirus in Colombia: this is how health personnel live the third peak)

If I had visited the Hospital Infantil Universitario de San José, in Bogotá, three or four months ago, the scenario would be different. In the emergency room, through the consultation corridors, there would not be 35 patients, but double or triple. And in the observation room, which is still isolated, they would have more than forty people with advanced symptoms of COVID-19, exceeding its capacity of 16 cubicles. She could not have seen the eyes of the head of service, Daniela Ortiz. She would be covered behind plastic goggles, an N95 mask, a face shield, a cloth cap, shoe gaiters, and an anti-fluid gown.

That's how they had to stay the six hours of the shift, when it didn't get longer. “As we could not take anything from this team, due to the risk of contagion, being in that service meant not going out at any time, not even to rest or eat. It was difficult,” Ortiz recalls. Carrying out procedures that they already consider basic, such as putting in a catheter, was complicated. "The visor fogged up because of the mask and one couldn't see," says Valentina Rodas, head of emergency coordination and who, as a precaution, stopped seeing her ten-year-old daughter for twelve months. "I even missed her birthday."

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A year and a half after the World Health Organization (WHO) officially declared the coronavirus to be a pandemic, concern has grown about the consequences it could have on nurses and nursing assistants. Although all the health personnel faced the risk and experienced the collapse in the hospitals, the nursing personnel, in the end, were the ones who had to be with the patients 24/7. If someone could not walk, they were bathed in bed. They also reached out and picked up the chamber pots. They kept an eye on their medications and became the only contact patients had with their families. Nurses, nurses and auxiliaries isolated themselves from the world.

But the true cost involved in having these days is already beginning to be noticed. According to a report by the International Council of Nurses (ICN), by December 2020, 2,262 nurses had died from the coronavirus globally. In countries like Brazil, the prevalence of anxiety in the profession reached 50%, while 25% suffered from depression, and evidence is already emerging that there is a massive trauma in the profession due to extended hours, greater dependence on patients, increased mortality, occupational exhaustion, lack of social support and even the discrimination they have experienced. (We suggest: This is what a nursing shift is like since the Covid-19 appeared)

In countries like the United States, for example, the figures indicate that, as a consequence, nurses are deserting: they leave their profession due to exhaustion. A report this year by NSI Nursing Solutions found that in 62% of hospitals in that country there is a vacuum of nurses greater than 7.5% compared to the previous year.

In Colombia it is not easy to know if there are similar data. But chief Rodas, from the San José Hospital, says that, at the beginning of the pandemic, when she was in the surgery service, six of the ten nurses who worked there decided to leave. A scenario that, if repeated in other services and hospitals, would be discouraging.

“Colombia has a rate of 12.7 nurses per 10,000 inhabitants, of which 8.5 work in health care. However, according to the WHO, to achieve a good basic health service for the population, 23 nursing professionals are needed for every 10,000 inhabitants”, explains Gilma Rico González, president of the National Association of Nurses of Colombia (ANEC).

The question then is whether the pandemic made this shortage in the country more critical.

The only contact with the world

Chief Ortiz graduated from Nursing in December 2020 and came to work in San José in March 2021. In other words, she began her working life in a pandemic, right at the third peak in Colombia, one of the most aggressive. “She was a first nursing contact with many deaths in a row,” she says. A video call she made with a patient's family, before intubating him, is one of the moments she remembers most from that time. “When they are conscious, it is explained to them that they will be intubated and sedated until they recover, but the risks are also discussed: that the probability of leaving is 50%. That scares and many ask to speak with relatives.” Since these were people who had to be isolated, the only option was the video call.

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Some institutions even purchased a tablet for this. Others let patients enter their equipment. But on many occasions it was the same nurses who lent their cell phones. They all seem to have a similar story.

“With the calls, one tried to cheer them up,” says nurse Diana Sánchez, who works in a clinic in Bogotá. “It is always hard and emotional when they are going to intubate. They usually grab one's hand and the only thing left to do is breathe. It was difficult, because it was a situation where we were intubating thirteen patients and there were twenty more waiting. One deteriorates emotionally, because there is a lot of connection with people”.

The mental and emotional burden in nursing has always been heavy, but the coronavirus has increased it. In April of this year, the Colombian Nursing Magazine published an article in which one hundred professionals and nursing assistants from Medellín and other municipalities of Antioquia participated. The conclusion reached by the researchers is that they had to care for COVID-19 patients with great uncertainty and without support. The best way they could deal with the situation was "to have a positive attitude with hope, to isolate themselves from the media or to think about quitting their job."

One nurse for every three patients (or for every thirty?)

Among nursing researchers there is a concept that is widely used: the Nursing Activity Score (NAS). It is a tool that seeks to quantify the workload of the nursing staff, including the hours spent educating the family and the patient, management activities, and care itself. In Colombia, says Andrés Guzmán Gutiérrez, a nurse specialist in critical care and a master's degree in Nursing, it is an idea that has not been studied as much.

For this reason, part of his master's degree work consisted of analyzing how the nursing workload (before the pandemic) could affect patient care indicators in two intensive care units in Bogotá. What he found was very clear: “Statistically, the more patients a nurse is assigned to, the greater the risk of lower quality care,” he notes.

With COVID-19, his findings became more acute. “In 2017 in Colombia there were only 1,571 critical care nurses and specialist nurses: a minimal sum if you take into account that, for Bogotá alone, during the last peak, there were 2,000 critical care beds,” he comments. In other words, the workload had to be much more intense.

One of the requests that both ANEC and other associations have made to the Ministry of Health is that a minimum amount be established for the nurse-patient relationship that must exist in clinics and hospitals. Although there is a rule that says how it should be for the ICU and surgery rooms (one nurse for every three patients and one nursing assistant for every two), in the other services the proportion is arbitrary. A nurse can have from twenty to thirty patients in charge in the service. “This way the attention cannot be the same”, concludes Guzmán.

The paradoxical year of nursing: 2020

The office of Sandra Ochoa, coordinator of the Nursing Department of the San José University Children's Hospital, is almost hidden on the second floor. She, despite the exhaustive challenges that the coronavirus has brought, believes that she has been of some use: “she has made us visible. Before the pandemic we were hidden, now the family knows that we are needed. See our work.”

Three years ago, in 2017, the WHO and other organizations launched the Nursing Now campaign, in order to make this profession visible. The idea was to begin to solve structural problems of nursing that are experienced both in the world and in Colombia: little investment, limited access to make public policy decisions, more professionals in leadership positions and show what are the obstacles that prevent nurses and nurses specialize. In Colombia, for example, a professional with a specialization or master's degree does not earn more than one who does not, which discourages them from wanting to specialize in topics such as critical care.

In fact, 2020 was declared the Year of Nursing and with the arrival of the pandemic, the profession ended up being made visible, although not in the best terms. It was a great paradox. While they were applauded for sales or campaigned as heroines and heroes, irregular contracts and non-payment remained the norm in a large percentage of the country. The shifts were extended. Some did not have biosafety equipment. They were barred from entering their buildings, and if they did get COVID-19, they didn't count it as an occupational disease.

But Rico, president of ANEC, is another of those who has seen an opportunity in the coronavirus: that the Government listen to them. In fact, on June 11, the Minister of Health, Fernando Ruiz, gave the go-ahead to a National Nursing Policy and the 2020-2030 Strategic Plan, which is in the stage of being recognized as a public policy. If it comes to light, it could be a good sign for nursing in Colombia, a profession that many consider the backbone of the health system.