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Unfortunately, that's how many hospitals operate. Inadequate staffing is a nationwide problem, and with the exception of California, not a single state sets a minimum standard for hospital-wide nurse-to-patient ratios. Dozens of studies have found that the more patients assigned to a nurse, the higher the patients' risk of death, infections, complications, falls, failure-to-rescue rates and readmission to the hospital -- and the longer their hospital stay. According to one study, for every 100 surgical patients who die in hospitals where nurses are assigned four patients, 131 would die if they were assigned eight.

In pediatrics, adding even one extra surgical patient to a nurse's ratio increases a child's likelihood of readmission to the hospital by nearly 50 percent. The Center for Health Outcomes and Policy Research found that if every hospital improved its nurses' working conditions to the levels of the top quarter of hospitals, more than 40,000 lives would be saved nationwide every year.

Nurses are well aware of the problem. In a survey of nurses in Massachusetts released this month, 25 percent said that understaffing was directly responsible for patient deaths, 50 percent blamed understaffing for harm or injury to patients and 85 percent said that patient care is suffering because of the high numbers of patients assigned to each nurse. (The Massachusetts Nurses Association, a labor union, sponsored the study; it was conducted by an independent research firm and the majority of respondents were not members of the association.)

And yet too often, nurses are punished for speaking out. According to the New York State Nurses Association, this month Jack D. Weiler Hospital of the Albert Einstein College of Medicine in New York threatened nurses with arrest, and even escorted seven nurses out of the building, because, during a breakfast to celebrate National Nurses Week, the nurses discussed staffing shortages. (A spokesman for the hospital disputed this characterization of the events.)

It's not unusual for hospitals to intimidate nurses who speak up about understaffing, said Deborah Burger, co-president of National Nurses United, a union. "It happens all the time, and nurses are harassed into taking what they know are not safe assignments," she said. "The pressure has gotten even greater to keep your mouth shut. Nurses have gotten blackballed for speaking up."

The landscape hasn't always been so alarming. But as the push for hospital profits has increased, important matters like personnel count, most notably nurses, have suffered. "The biggest change in the last five to 10 years is the unrelenting emphasis on boosting their profit margins at the expense of patient safety," said David Schildmeier, a spokesman for the Massachusetts Nurses Association. "Absolutely every decision is made on the basis of cost savings."

Experts said that many hospital administrators assume the studies don't apply to them and fault individuals, not the system, for negative outcomes. "They mistakenly believe their staffing is adequate," said Judy Smetzer, the vice president of the Institute for Safe Medication Practices, a consumer group. "It's a vicious cycle. When they're understaffed, nurses are required to cut corners to get the work done the best they can. Then when there's a bad outcome, hospitals fire the nurse for cutting corners."

Nursing advocates continue to push for change. In April, National Nurses United filed a grievance against the James A. Haley Veterans' Hospital in Tampa, which it said is 100 registered nurses short of the minimum staffing levels mandated by the Department of Veterans Affairs (the hospital said it intends to hire more nurses, but disputes the union's reading of the mandate).

Nurses are the key to improving American health care; research has proved repeatedly that nurse staffing is directly tied to patient outcomes. Nurses are unsung and underestimated heroes who are needlessly overstretched and overdue for the kind of recognition befitting champions. For their sake and ours, we must insist that hospitals treat them right. ☐

The number of "medical incidents" - hospital jargon for treatment errors - has spiked, said the nurse, who agreed to be interviewed on condition that his or her name not be published for fear of reprisals. The nurse said the hospital has prohibited stafffrom speaking to journalists about problems in the ER. In perhaps the most glaring case, a patient who was "gushing blood" arrived by ambulance in the ER and was supposed to undergo a transfusion immediately, but the blood supply was not ready even though it had been ordered in advance 30 minutes earlier, the nurse said. The girl ended up dying because of the severity of her injuries, not the delay in receiving the blood transfusion, but the case nonetheless illustrates the risks involved, the nurse added.

A second source described other "botched" cases, including a boy with a badly fractured femur "who sat in the ER for (eight) hours without it being set until someone actually looked at the X-ray." The are multiple causes for the problems, said the ER nurse and the second source - a lack of staff and unfamiliarity with the new medical equipment, lab technicians who haven't been trained in processing pediatric blood samples, and glitches in the facilities. And all those problems have occurred amid cost-cutting imposed by the provincial government.

"It's a zoo, it's dangerous," the ER nurse told the Montreal Gazette. "Before we moved in, we were told three things: the new ER was going to be more patient-centred; the doctors, nurses and clerks would be working better together; and it was supposed to be more comfortable. I haven't seen any of those things. Nobody works together because we're all preoccupied with our own things. We're running around like dogs. For me, it's falling apart. Patients' lives are in danger."

Officials at the Montreal Children's denied that lives are in jeopardy, but acknowledged that there have been problems in the processing of lab samples, some staffing shortages as well as glitches. At the same time, the medical team has been treating an unseasonably high number of patients with serious illnesses, said Dr. Harley Eisman, director of the emergency department. "I think we all recognize that moving to a new house is a big deal for everybody, and actually, our emergency department has had some significant cases," Eisman said. "We've dealt with many sick children over the past couple of weeks. We've had pretty brisk numbers as well. It hasn't been a quiet summer for us."

Lyne St-Martin, nurse manager at the Children's ER, said although "we have occasional shortages (of nurses), for the most part our quotas are met and our nursing staffis rather stable." Still, St-Martin warned that staff and patients will have to make adjustments for months to come at the Glen site, following the Children's move there from its old address on Tupper St.

"I do want to highlight that we transitioned three months ago, and that in speaking to other hospitals that have actually moved as well, they spoke about a one-year transition time where there is a very steep adaptation, and it will continue for several months to come," St-Martin said. "So none of this is surprising." Among the problems identified by the ER nurse:

At one point, water started pouring from a pipe in the ceiling of one of the treatment rooms. Staff closed the room and protected the medical equipment, but the leak hasn't been repaired yet. In the meantime, staffcan't use the sinks in the adjoining rooms to wash their hands. Eisman said there are other treatment rooms available and the ER flow hasn't been hampered. An emergency psychiatric room for agitated adolescent patients - some of whom are suicidal - has a bathroom that locks from inside and can't be opened by staff, the nurse said. There have been two cases where patients locked themselves in the bathroom and security was called but the guards arrived late. Eisman said that there is now a protocol in place to post a guard next to the bathroom in such cases. He added that glitches like the bathroom lock are being addressed quickly, although some parts are on back order.

Some of the lab techs, who used to work at the old Royal Victoria Hospital, have not been trained fully to process blood samples for children, resulting in delays as long as four hours for medical issues that must be addressed immediately, the nurse said. Eisman responded that "when we opened we certainly raised issues about lab performance. We opened a line of communication with the lab and were immediately on it and the lab performance has improved dramatically."

The Children's ER is consistently understaffed by nurses, and yet more than a dozen have not yet been fully trained to perform all tasks in the department, and there have been delays "in working up infants for signs of meningitis," the nurse said. What's more, many ER nurses are assigned to accompany patients on other floors, resulting in longer waits for emergency patients. As a consequence, frustrated parents have ended up shouting at nurses in the ER. Some of the nurses have reacted by seeking solace in the bathroom and crying in private for up to half an hour.

St-Marin said the ER nurses have been trained to deal with parents who are in crisis, and added "that our numbers show that (patients) are not waiting longer. In fact, we're tending to our sicker patients faster." She did not cite any statistics. The ER nurse accused the McGill University Health Centre of mismanagement, saying it had been planning the Montreal Children's move for years but has not trained staffproperly in using some of the new equipment. For example, some X-ray technicians continue to use portable X-ray machines rather than the new equipment in the ER. The MUHC has also balked at paying nurses to work overtime, yet the ER has ordered great quantities of rarely-used IV filters at $500 a box that sit mostly unused on shelves, the nurse added. aderfel@montrealgazette.com twitter.com/Aaron_Derfel

At Chartwell, a chain of 27 homes, chief operating officer Karen Sullivan said the pharmacy that services the chain, MediSystem, pays for "many additional valued-added services" such as employee education, nurse leadership sessions and conferences for leaders of homes. MediSystem also pays for Wi-Fi systems and therapeutic care equipment at the homes, Sullivan said in an email. The Star asked pharmacies what they are told the money is used for. Among the responses from pharmacies were "staff education," "resident programs" and payments toward Wi-Fi systems. Classic Care, a pharmacy, said the money it pays covers monthly rent of an area in the nursing home, staff education, technology and "donations and sponsorships" for conferences and other training. Other pharmacies, such as Rexall, say their fees have paid for diabetes education, for example. The largest pharmacies serving long-term-care homes in Ontario include Medical Pharmacies Group, MediSystem (owned by Loblaw), Classic Care (Centric Health) and Rexall. The fees are not new. Pharmacies have willingly offered money or agreed to demands for years. But there's a growing outrage among some who say homes are more interested in "inducements" than "clinical excellence" that pharmacies can provide seniors. Last year, after the Ontario government cut each dispensing fee by $1.26 (it is now $5.57 per prescription in nursing homes), sources said some pharmacies wanted to stop paying the fees. The problem was, the sources said, that the homes refused to give up the extra cash flow and other drug companies were willing to pay, so nothing changed.

It's usually the larger companies that can afford to pay. One insider said smaller pharmacies now ask the homes, "Do you want the money or do you want good service? Because we can't afford to give both." Sources said the Ontario Ministry of Health and Long-Term Care knows the money changes hands but does nothing to stop it. Instead, pharmacies are "held hostage" by the homes, the source said. One home that no longer charges the fees is John Noble Home in Brantford, a municipally operated 156-bed facility. The Star obtained a 2010 request for proposals (RFP) that noted "only proposals with a minimum rebate of $20,000 annually will be considered for the project." A spokesperson for the city said the RFP "references a previously approved practice employed by several long-term care homes." A recent RFP did not ask for a rebate, though some offered to pay. The city spokesperson, Maria Visocchi, said it chose a pharmacy that "demonstrated qualifications and experience, project understanding, approach and methodology, medication system processes and quality control." This pharmacy did not offer a rebate. Not all pharmacists pay. Teresa Pitre runs Hogan Pharmacy Partners in Cambridge and serves long-term-care homes that don't ask for money. Instead, she signed contracts with several homes in the People Care chain to provide a "highly personalized approach." Pitre sends a registered pharmaceutical technician into each home daily to relieve nurses of much of their work regarding medication, confusion over communications and extensive paperwork. Her company also puts a bookshelf-sized dispensing machine in each home, which holds medication (pain relievers, antibiotics or insulin) that residents need on short notice but, in the traditional system, often can't get for hours. "I really wanted our pharmacy to be a partner with homes instead of servicing them and just meeting the requirements," she said. Meadus says the added cost of bed fees means pharmacies have no reason to reduce their rates, either by lowering dispensing fees or not charging the $2 co-payment.

A recent Star story revealed that pharmacies serving nursing homes typically charge dispensing fees for drugs once a week, rather than once a month as they typically do in a community pharmacy. Long-term-care pharmacies told the Star they charge the weekly fee because the medication for frail residents can change weekly. That was a claim hotly disputed by some family members the Star spoke to, including Margaret Calver, who has spent years documenting the costs of dispensing fees at Markhaven Nursing Home, where her husband is a resident. "This needs oversight and that's the problem," she said. "Nobody is doing the checks and balances." Moira Welsh can be reached at mwelsh@thestar.ca.

The CDC is launching a public education campaign for nursing homes aimed at preventing more bacterial and viral infections from starting and stopping others from spreading. A similar effort was rolled out for hospitals last year.

"One way to keep older people safe from these superbugs is to make sure antibiotics are used appropriately all the time and everywhere, particularly in nursing homes," said CDC Director Tom Frieden in announcing the initiative. Studies have estimated antibiotics are prescribed inappropriately 40 per cent to 75 per cent of the time in nursing homes. Here's why that worries the CDC: Every time someone takes antibiotics, sensitive bacteria are killed but resistant bacteria survive and multiply - and they can spread to other people. Repeated use of antibiotics promotes the growth of antibiotic-resistant bacteria. Taking antibiotics for illnesses the drugs weren't made to treat - such as the flu and common colds - contributes to antibiotic resistance.

Antibiotics also wipe out a body's good infection-fighting bacteria along with the bad. When that occurs, infections like Clostridium difficile can get out of control. C. diff. leads to serious diarrhea that each year puts 250,000 people in the hospital and kills 15,000. If precautions aren't taken, it can spread in hospitals and nursing homes. Health-care facilities already have infection-control procedures in place, such as providing private rooms and toilets for infected individuals. But the CDC is pushing them to do more on the prescribing side, advising nursing homes to track how many and what antibiotics they prescribe monthly and what the outcomes were for patients, including any side-effects.

Other recommendations include placing someone, such as a consulting doctor or a pharmacist, in charge of antibiotics policies and training other staff in following them. Some of the CDC's suggestions could challenge nursing homes' culture and how staffs, residents and their families interact. While nursing home residents and staff are among the people most at risk for the flu, annual shots aren't mandatory. Nor do homes always track who gets them.

That's starting to change at Evangelical Lutheran Good Samaritan Society, a nonprofit that provides a spectrum of senior care services in many states. Starting this year, it will collect data on staff vaccinations at one of its 167 nursing homes and share the pilot project's results with other homes, said Victoria Walker, chief medical officer. But better handling of antibiotics in nursing homes may also require tactful communication with residents' families and nursing home doctors accustomed to treating antibiotics as a default remedy.

"There's a real fear of undertreatment and that it is better to err on the safe side, and that means treating with antibiotics but forgetting about all the harms. But giving antibiotics can be just as harmful as not," said Walker. Family members may push for an antibiotic treatment when they visit a loved one in a nursing home who seems sick, even if they don't know precisely what's wrong. Doctors and nurses may go along because they don't know either and it's easier to treat than not. "The family will check in and ask what the doctor did and the nurse will say 'nothing' because they don't see monitoring as doing anything," said David Nace, director of long term care at the University of Pittsburgh, who contributed to the CDC guidelines.

"Practitioners are guilty of saying, 'it's just an antibiotic.' ... We don't appreciate the real threat," he said. Antibiotics are routinely prescribed to treat urinary tract infections, which are common in nursing homes, but too often when a UTI is only suspected, not confirmed, studies have found. The Infectious Disease Society of America is developing guidelines to help institutions implement programs to better manage antibiotics. In addition to fostering antibiotic resistant bacteria and causing C. diff infections, antibiotics also can produce allergic reactions and interfere with other drugs a nursing home resident is taking. Those risks aren't always fully considered, says researcher Christopher Crnich, who has published articles on antibiotic overuse. He is a hospital epidemiologist at William S. Middleton Veterans Hospital in Madison, Wisconsin. "Bad antibiotic effects don't come until weeks or months later, and frankly all we [prescribers] see is the upside when we're dealing with a sick mom or dad," Crnich said.

The Centers for Disease Control in the United States has raised concerns about the use of antibiotics in nursing homes.

"It shows that people here really care about the Miramichi and it's too bad that politicians don't care about it as much," Driscoll said. "They want to privatize the nursing homes, they want to cut to the Education Department, their cutting the highway budgets and they're cutting to every service they can think of, so where are we going to go? They don't seem to think that matters." The Liberal government, come the fall, is expected to have a deal in place that will see all hospital food and cleaning services being outsourced to a private firm.

Government officials, including Health Minister Victor Boudreau have maintained that the changes are needed in order to help the province get its finances in order and will save the province millions of dollars through efficiencies that will be brought in under private management. Driscoll says those efficiencies, CUPE fears, are simply going to amount to job cuts at hospitals throughout the Horizon Health Network. The union learned from the province earlier in the summer that food and facilities management giants like Sodexo, Aramark and Compass Group are involved in the bidding process.

"If they privatize these services, then these corporations are going to come in and say 'you don't need all these people' ... we're going to cut because they're going to want to make at least a 20 per cent profit. Driscoll said the hospital is just one example of the trend toward the greater privatization of public services the union is seeing. Nursing home workers at Mount St. Joseph Nursing Home and the Miramichi Senior Citizens Home have been protesting at various points throughout the summer after learning the Department of Social Development would be using a private-public partnership (P3) model in building a new 280-bed nursing home that will replace both of the city's current facilities, which are run by a volunteer board of directors. Workers at both homes will have to reapply for positions at the new nursing home if that's what they choose to do and, with a private company running things, the membership has said it is concerned that those who do catch on at the new place could be subject to reduced pay and benefits.

The government is expected to open up a request for proposals (RFP) in the coming weeks to begin the process of determining which proponent will build and operate what will likely be New Brunswick's largest nursing home by the time it opens. Currently, each of the three privately run nursing homes in the province are owned by Shannex. The unions have also warned that the move to a P3 model would lead to a reduction in the level of community outreach programming offered to local seniors through things like Meals on Wheels and adult daycare. Tourism Minister Bill Fraser, the Liberal Miramichi MLA who advocated heavily for the new nursing home to be built and the man at the centre of much of the unions' ire, has shot down those concerns in previous interviews. Fraser has reiterated that regardless of whichever proponent emerges with the right to build and manage the structure, the initiative represents a major upgrade in terms of nursing home infrastructure.

He said the standards of care are dictated by the province and will remain, at the very least, on par with what has existed at the two current nursing homes over the last several years. Programs like Meals on Wheels, adult daycare and lifeline, would remain in place and potentially even enhanced and in terms of jobs, he said there will be provisions written into the RFP asking that priority be given to local applicants and that with an increase of 26 beds, even more staff will likely be required. As for pay and benefits, he said staff at two of the three Shannex properties have already unionized and the third was in the process of doing that.

Nursing home staff have called on the province to force the boards at the Mount and the senior citizens home to amalgamate together and operate the new facility using a model similar to what was undertaken in Edmundston when two nursing home boards melded into one in order to operate the new $48 million, 180-bed Residence Jodin. Danny Legere, the president of CUPE New Brunswick, was on hand for the vigil and urged the Miramichi workers to keep up the fight. "I want to congratulate the people of the Miramichi for taking a stand - the fight that you have started is a fight for all New Brunswickers," Legere said. "The militancy that you are showing is exemplary and it has to be carried on from one end of the province from one end to the other."

Andy Hardy, a Miramichi native and the president of CUPE 1190, said his sector is used to certain services being contracted out to private interests but when it comes to health and senior care, he said it was "flat out wrong." "You're looking after the most vulnerable people in that building right there," Hardy said. "When you privatize the food services and the cleaning services all it is is for profit - the service goes down and the profit goes up, and for nursing homes as well." Length: 1090 words

A number of other locals joined in on the demonstration, including representation from CUPE 1277 and 1256 of the Miramichi Senior Citizens Home and Mount St. Joseph Nursing Home, respectively, CUPE 1190, which acts on behalf New Brunswick's highway workers, the New Brunswick Federation of Labour and staff from Hebert's Recycling.

"If they privatize these services, then these corporations are going to come in and say 'you don't need all these people' ... we're going to cut because they're going to want to make at least a 20 per cent profit. Driscoll said the hospital is just one example of the trend toward the greater privatization of public services the union is seeing. Nursing home workers at Mount St. Joseph Nursing Home and the Miramichi Senior Citizens Home have been protesting at various points throughout the summer after learning the Department of Social Development would be using a private-public partnership (P3) model in building a new 280-bed nursing home that will replace both of the city's current facilities, which are run by a volunteer board of directors. Workers at both homes will have to reapply for positions at the new nursing home if that's what they choose to do and, with a private company running things, the membership has said it is concerned that those who do catch on at the new place could be subject to reduced pay and benefits.

The Liberal government, come the fall, is expected to have a deal in place that will see all hospital food and cleaning services being outsourced to a private firm. Government officials, including Health Minister Victor Boudreau have maintained that the changes are needed in order to help the province get its finances in order and will save the province millions of dollars through efficiencies that will be brought in under private management. Driscoll says those efficiencies, CUPE fears, are simply going to amount to job cuts at hospitals throughout the Horizon Health Network. The union learned from the province earlier in the summer that food and facilities management giants like Sodexo, Aramark and Compass Group are involved in the bidding process.

The government is expected to open up a request for proposals (RFP) in the coming weeks to begin the process of determining which proponent will build and operate what will likely be New Brunswick's largest nursing home by the time it opens. Currently, each of the three privately run nursing homes in the province are owned by Shannex. The unions have also warned that the move to a P3 model would lead to a reduction in the level of community outreach programming offered to local seniors through things like Meals on Wheels and adult daycare. Tourism Minister Bill Fraser, the Liberal Miramichi MLA who advocated heavily for the new nursing home to be built and the man at the centre of much of the unions' ire, has shot down those concerns in previous interviews. Fraser has reiterated that regardless of whichever proponent emerges with the right to build and manage the structure, the initiative represents a major upgrade in terms of nursing home infrastructure.

He said the standards of care are dictated by the province and will remain, at the very least, on par with what has existed at the two current nursing homes over the last several years. Programs like Meals on Wheels, adult daycare and lifeline, would remain in place and potentially even enhanced and in terms of jobs, he said there will be provisions written into the RFP asking that priority be given to local applicants and that with an increase of 26 beds, even more staff will likely be required. As for pay and benefits, he said staff at two of the three Shannex properties have already unionized and the third was in the process of doing that.

Nursing home staff have called on the province to force the boards at the Mount and the senior citizens home to amalgamate together and operate the new facility using a model similar to what was undertaken in Edmundston when two nursing home boards melded into one in order to operate the new $48 million, 180-bed Residence Jodin. Danny Legere, the president of CUPE New Brunswick, was on hand for the vigil and urged the Miramichi workers to keep up the fight. "I want to congratulate the people of the Miramichi for taking a stand - the fight that you have started is a fight for all New Brunswickers," Legere said. "The militancy that you are showing is exemplary and it has to be carried on from one end of the province from one end to the other."

Andy Hardy, a Miramichi native and the president of CUPE 1190, said his sector is used to certain services being contracted out to private interests but when it comes to health and senior care, he said it was "flat out wrong." "You're looking after the most vulnerable people in that building right there," Hardy said. "When you privatize the food services and the cleaning services all it is is for profit - the service goes down and the profit goes up, and for nursing homes as well." © 2015 Telegraph-Journal (New Brunswick)

The numbers underscore the need for improvements to hospital staff safety measures, something the Ontario Nurses' Association (ONA) has long been calling for to better protect health-care providers. "Violence isn't part of this job. It shouldn't be part of this job," said Andy Summers, vice-president of health and safety with ONA. "Eventually, somebody will get killed."

Summers called the current situation of violence against nurses in Ontario "completely unacceptable." At UHN, which includes Toronto General Hospital and Toronto Western Hospital, there has been a consistent increase in reports of assault in the past three years. The number of reported violent incidents doubled in two years, jumping from 166 incidents in 2012 to 331 in 2014, according to data provided to the Star. In 2014, 11 workers who were injured were unable to return to work for their shift following the assault. Spokeswoman Gillian Howard said changes in reporting standards probably account for the rise. The changes include a Behaviour Safety Alert, implemented at UHN in 2014, which requires staff to put an alert on patient records if the patient has aggressive or violent behaviour. Howard also said increased reporting could be attributed to the fact that unions are encouraging staff to report every incident: "a very good thing," she said.

"We do not want any staff member at risk from a patient, but given the care we provide, the medications used, the fact that some patients have cognitive impairment as a result of injury or aging, the impairment of some patients when they arrive, and the risks associated with some of the treatments, it is not likely that we will see a year with no incidents," said Howard, adding that UHN employs approximately 13,000 staff and has over one million patient visits per year. But ONA lashed out at this explanation, saying employers are trying to downplay the issue.

Erna Bujna, occupational health and safety specialist with ONA, said some employers "absolutely" still discourage staff from reporting incidents, by telling workers that violence is just part of the job. ONA wants to see a violence strategy implemented at hospitals across the province. The strategy would include mandatory reporting of every violent incident reported to the Ministry of Labour - currently, employers are only required to report fatalities and critical incidents to the ministry - mandatory risk assessment of every patient, increased security and more health-care providers hired. They also want the Ministry to charge individual hospital CEOs when workers are not adequately protected from violence.

He added that legislation requires employers to assess the risks of workplace violence, create workplace violence and harassment policies, develop programs to implement those policies, and take every precaution reasonable to protect workers from workplace violence. ONA's call for an updated safety strategy comes on the heels of a decision by the Ministry of Labour to lay charges against Toronto's Centre for Addiction and Mental Health (CAMH) in December 2014. The charges - made under the Occupational Health and Safety Act and relating to failure to protect workers from workplace violence - stem from a violent incident in January 2014 in which a nurse was dragged, kicked and beaten beyond recognition, according to ONA.

Toronto police later charged the patient, who was found guilty of assault causing bodily harm, according to court documents. "We don't want staff ever to feel that aggression is the norm," said Rani Srivastava, chief of nursing and professional practice at CAMH, in response to the comments. "We are committed to a culture of safety and recovery and that means safety for staff and patients." Jean Dobson, a nurse at University Hospital in London, Ont., said she's been strangled with a stethoscope, stabbed with a metal fork and spat at by patients over the course of her 42-year career. "People think that they can hurt a nurse and that's OK," she said. "We have to smile and take it."

In one incident, Dobson had her nose broken when she was kicked in the face by a patient. She was forced off work for weeks and suffered from PTSD, she said. Dobson said she's seen the frequency of patient-on-nurse assaults and the severity of violence increase during her career. At Sunnybrook Hospital, reports of abuse against staff by patients and visitors jumped from 140 in 2012 to 320 in 2013. The hospital attributes the increase mainly to their move to electronic reporting, which makes it easier to record violent incidents, a spokesperson told the Star. According to a 2005 national study from Statistics Canada, 34 per cent of nurses surveyed reported being physically assaulted by a patient in the previous year, and 47 per cent reported experiencing emotional abuse. For those working in psychiatric and mental-health settings, 70 per cent of nurses reported experiencing emotional abuse.

One of those reports was released earlier this year by the federal Auditor-General. It found, among other things, that just one in 45 nurses working at a sample group of onreserve nursing stations had completed all of the government's mandatory training courses; that nurses are being asked to do jobs they are not authorized to do; that the stations had numerous health and safety deficiencies; and that Health Canada does not know whether individual reserve facilities are capable of providing essential services. Several of those issues seem to have been at play when Brody fell ill. His father Fraser Meekis and Ms. Keno have five surviving children - three boys in primary school and two girls still in diapers. Just as the reserve school began a break week in the spring of last year, all of the Meekis boys came home with fevers and sore throats. Mr. Meekis took his ailing children to the nursing station, but the nurse did not take throat swabs, he said. She instead advised him to give the boys Tylenol, to rub their chests with Vicks VapoRub and to come back for a second appointment the following week. Sandy Lake has just one medical vehicle to ferry people to and from the facility. It is a van that sometimes breaks down on the rough dirt roads of the reserve and is often diverted by emergencies. It didn't arrive on time to get the kids to the follow-up visit and the family doesn't own a car. So they missed the second appointment.

"It was a student nurse who was watching my son there," Mr. Meekis said. "I kept asking, 'How come he looks like that?' And the nurse was like, 'I don't know.' And the next thing you know, I saw foam coming out of his mouth and I said, 'He's not breathing!' The nurse panicked. I ran out of the room and said 'emergency, emergency.' "But it was too late: Although the nurses managed to revive Brody once, he died later that morning. The problems at the Sandy Lake nursing station are well known to the community. Council members say the facility was constructed for a reserve of 500 people that is now home to nearly 3,000. Local residents have been trained to perform duties that would normally be done by medical professionals. "So you could have your janitor taking X-rays - when he's available," said John McKay, a councillor who was once in charge of medical administration.

He was sent back home with a couple of Tylenol and Advil and he was told to rub Vicks VapoRub on his chest," Mr. Kakegamic said. Wesley Kakegamic died on March 10. He had been a drug user and his family believes that was a factor in the lack of treatment he received. They are angry at the nurses. But the leaders of the community stress they do not believe the nurses are to blame. "It is the health system that we know today that is failing the First Nations," said Bart Meekis, the Sandy Lake Chief. "We're not asking for more than what the normal Canadian gets for health care," he said. But "we're losing people needlessly." Brody Meekis, he said, was one of them. "I want you to know that this is not about pointing fault at one person to help ease the pain that I feel," Fraser Meekis said of his decision to go public with Brody's story, "but to let you know that the system failed my son."

Nova Scotia Government & General Employees Union president Joan Jessome, who represents the majority of Capital Health nurses, said Glavine is attempting to hide the fallout of legislation.

Many nurses are leaving because they weren’t given a say about their representation under the new provincial health authority, not because of propaganda, said Jessome. “They’re fed up.”

An arbitrator’s decision Friday will all but certainly place all nurses with the Nova Scotia Nurses’ Union.

NDP health critic Dave Wilson said Glavine should acknowledge that some of the Liberals’ moves since coming to power are hurting health care. More focus should be placed on workplace concerns and staffing levels rather than union reorganization, he said.

Glavine said steps continue to address shortages, including adding seats at nursing schools and a proposal at Dalhousie University to condence the nursing program from four years to three.

Hospital management says it will monitor the implementation of the cost reduction measures carefully and could even reverse some of them if that is deemed necessary. The petition, which had already garnered some 50 signatures as of midday Tuesday, says BGH faces "major direct care cuts" to areas such as the intensive care unit, operating room, complex care, palliative care, emergency, the stress test clinic, day surgery, diagnostic imaging, medical/surgical, and the switchboard. It adds the provincial government has "cut hospital funding in real dollar terms for the last eight years."

The petition calls on the legislature to stop the planned cuts and to "improve overall hospital funding in Ontario with a plan to increase funding at least to the average of other provinces." Local supporters plan to hold a rally in downtown Brockville in coming weeks to circulate the petition on a Saturday morning at the Brockville Farmers'Market, said Mary Jane Froats, the Ontario Nurses' Association's (ONA) bargaining unit president at BGH. Hospital management earlier this month announced its latest cost-cutting measures: A reduction of more than 26 full-time equivalent (FTE) positions, including 9.1 FTE registered nurses, 7.9 FTE registered practical nurses, 6.4 FTE personal support workers and 3.2 FTE support service jobs.

Anne Clark, ONA's regional vice-president for Eastern Ontario, said the cuts will hurt patient care by creating "severe understaffing." "In my professional nursing opinion, hospitals should never cut at the bedside, should never cut jobs that provide direct care to patients," said Clark. She added the cuts in nursing will result in more than 16,000 person-hours of nursing care gone from BGH, a workload that will be shifted onto remaining nurses. "We are seeing health-care decisions being driven by dollars and not our patients' needs," added Clark. Louis Rodrigues, first vice-president of the Ontario Council of Hospital Unions, cited tragic stories from patients' families left on a patient care hotline created by CUPE.

"We will not sit by while our acute care hospital system is slowly dismantled and privatized," said Rodrigues. Another speaker, Council of Canadians member Jim Riesberry, placed the ultimate blame for the current "austerity" in the hospital system at the feet of the federal government, blaming both Prime Minister Stephen Harper and his Liberal predecessor, Paul Martin, for starving provinces of health care cash. BGH vice-president and chief nursing officer Cathy Cassidy-Gifford rejected one claim made by Rodrigues, who said successive cuts at BGH had led to bed closures. She said the reductions being implemented between now and the end of the year are based on consultations with similar-sized Ontario hospitals in a "benchmark" group. There is also a steering committee in place meant to monitor patient care once those cuts are implemented, said Cassidy- Gifford. "If you see there needs to be changes, there will be revisions based on the situation, ensuring that our patients are first and that our staff are able to work in a safe condition as well," she said.

Leeds-Grenville MPP Steve Clark, who was away at the Progressive Conservative summer caucus meeting, said in a Twitter message he will gladly present the petition to the legislature. Clark last week sent a letter to Health Minister Dr. Eric Hoskins, saying the minister's failure to act by reviewing hospital funding has led to the most recent BGH cuts. In a statement emailed to The Recorder and Times, a spokesperson for the health minister referred staffing questions to BGH management. "Our government's investments have helped to ensure that there is a stable nursing workforce now and for the future. More than 24,000 more nurses are working in Ontario since our government took office, including more than 3,500 new nurses added in 2013," the statement read. Between 2005 and 2012, the province has added 657 nurses in the region covered by the South East Local Health Integration Network, it added.

Curits Coates, right, representing the Ontario Health Coalition, speaks at a protest over Brockville General Hospital cuts with Jim Riesberry of the Council of Canadians on Tuesday.

Nice, an authoritative body whose recommendations are supposed to be implemented across the NHS, has spent months examining evidence on the impact staff numbers have on both the quality and the safety of the care patients receive.

Leng will also tell hospitals that nurses need to be constantly on the alert for "red flag events", such as patients not receiving help to go to the bathroom or not receiving pain medication, which can trigger an immediate need for more nurses on the wards.

"A 1:8 ratio still means that the nurse only has seven and a half minutes per patient per hour, which is too little. If it's more than eight then patients won't get fed, care plans won't get written, and nurses can't sit and talk to patients and reassure them about their condition. Care just won't be given to a proper standard, and patients can die," said Osborne, a former director of nursing at St Mary's hospital in west London.

Eight should be the absolute maximum number of patients a nurse should have to care for but "if you get to that level it's bordering on unsafe care", so ideally the ratio should be 1:4 or 1:6, she added.

At the same time, nurses who call in sick aren't being replaced, so there are fewer people to deal with aggressive patients, said Linda Clayborne, a forensic psychiatric nurse in Hamilton.

'When you have a patient holding onto your clothes and punching you, 54 seconds is a long time.'

In the last two months, violent incidents in Hamilton included attacks on two nurses who sustained concussions, Clayborne said.

Clayborne witnessed an incident last week and pressed her personal alarm to call for immediate help.

In another incident, a female RPN had hot coffee thrown in her face by a patient. Last week, a male co-worker sustained a black eye and swelling to his cheek and eye, Clayborne said. Now his children fear for him.

In long-term care, the majority of patients are over the age of 85 with Alzheimer's, dementia and other cognitive impairments that require a higher standard of care, Fetterly said. "Cutting back on staff is recipe for disaster," Fetterly said, because when a nurse is slow to answer a call bell, she's the "recipient of displeasure." The Ontario groups are also calling for legislation to protect health-care workers from violence.

“This is my passion,” said Cleveland, 38 years in nursing, 25 of them in palliative care. “I ask the client, ‘What is it you want? How can I help you?’ And I add, ‘As long as it’s legal and ethical, I will support you.’ ” But Cleveland and other nurses know palliative care in Ontario is about to experience a shift of seismic proportions; the recent historic ruling by the Supreme Court of Canada legalizing physician-assisted suicides for the terminally ill has redefined what’s legal and ethical in palliative care.

"People who come to Health Sciences North come from a lot of different areas. I can't jump on the subway and go down to the hospital to make my appointments. Some people come from Blind River, some come from Timmins, we're a referral hospital that's not funded properly and we can't provide the care we expect to be able to provide. We're very proud of what we do and people are struggling. People are going home sick. They're happy to get through a day, not happy to go to work and provide the care they want to provide. We don't think that's proper." According to CUPE, the hospital has cut beds, services and staff because of a five-year funding freeze imposed by the provincial Liberal government.

The union cited an Auditor General's report which estimated hospitals' costs increase by 5.8% annually, rising faster than inflation, because of the soaring costs of drugs provided free to inpatients and medical technologies, among other factors. Thibeault was at Queen's Park in Toronto on Thursday, but forwarded a statement through his communications staff. "I understand that Health Sciences North has made the decision to make changes in its nephrology department, shifting to a model of RNs working alongside renal aides, rather than RPNs," Thibeault said. "I have been assured by officials at Health Sciences North that this decision was made based on surveys of other nephrology departments in Ontario working successfully under similar models, and will not change the terms or quality of patient care.

"I understand that RPNs who choose to stay in nephrology will be re-assigned as renal aides, while those interested in pursuing RPN opportunities in other departments will be offered any additional training necessary. "I have been assured by officials at HSN that no layoffs are anticipated, and that vacancies for RPN positions in other departments are expected. I recognize, as does our government, that nurses are the backbone of our health-care system, and I will continue to advocate for health-care practitioners and patients in Sudbury."

The move to use renal aides alongside registered nurses, rather than the previous model of RPNs alongside RNs, was made to find efficiencies without affecting patient care, HSN spokesperson Dan Lessard said in a statement. "Nothing changes from a patient's standpoint, in terms of the care provided or quality of care," Lessard said. "The RNs assigned to the patient still oversee the process and their care."

The duties of the renal aide will include preparing, starting, and monitoring the dialysis machines, Lessard said. They'll also help transfer patients around the unit and help them with such things as going to the bathroom. "RPNs were doing these duties before, but these duties don't encompass the full scope of practice for RPNs. "For the RPNs affected by this, we're offered them an opportunity to let us know if they would be interested in receiving additional training in order to qualify for other RPN positions within HSN, where they would be working more fully within an RPN's scope of practice." Lessard confirmed that no layoffs are expected.

"In terms of their salaries, they don't get a pay cut," Lessard said. "They will have their salaries red-circled. That means their salaries will remain the same until the pay scale for renal aides catches up to their present salaries, and at that point they will follow the normal progression up the salary grid, but as renal aides, not RPNs." ben.leeson@sunmedia.ca Twitter: @ben_leeson

Registered practical nurses from Health Sciences North and their supporters hold a rally outside Sudbury MPP Glenn Thibeault's office in Sudbury on Thursday.

Currently 76,000 vulnerable seniors live in nursing homes. Thousands more are on regional waiting lists. Hospitals consider them "bed blockers." Private retirement residences aren't equipped to meet their needs. Their families can't take care of them or get enough home care to keep them clean, safe and stable. "I think we see nursing homes as a symbol of failure - failure of the individuals to care for themselves, of families to care for older people, of the medical system to cure them," Armstrong said. "It's something we don't want to think about because we intend to avoid such places when we grow old." That attitude has led to underfunding, understaffing, low wages and high turnover in nursing homes. Care providers don't have time to listen to residents, respond to their needs, help them eat, talk to them or alleviate their boredom. Food service workers lock the dining room between meals. Clothes vanish in the laundry. Government-required paperwork takes precedence over caregiving. It is not unusual to see a dozen seniors - some with dementia, some in wheelchairs, some heavily sedated - lined up in front of a television staring vacantly at a rerun of I Love Lucy.

"They deserve better," Armstrong thought. So she pulled together a team of 26 researchers from six countries (Canada, Britain, Sweden, Germany, the United States and Australia) to reimagine institutional long-term care. Could it be a humane, dignified, financially viable option? The team included doctors, pharmacists, architects, economists, psychologists, social workers, historians, philosophers and communication experts. It began by collecting success stories from Europe and North America and identifying the most promising practices and best ideas in the field. That was five years ago. Armstrong and her colleagues have now done 25 site visits in 10 jurisdictions; interviewed thousands of long-term care residents, workers, managers, policy-makers and advocates for seniors; published 50 academic papers and released an 86-page public report entitled "Promising Practices in Long-Term Care."

Last week, she and co-author Donna Baines, of the University of Sydney in Australia, led a panel discussion in the dining room of Hart House at the University of Toronto. "The reception was very positive. People are excited by the possibilities." It will take many more community forums - and a lot of public pressure - to change the mindset at the ministry of health and long-term care. It regards the elderly as a financial burden and nursing home workers as an expense to be controlled. For one evening, Armstrong and Baines managed to change the public dialogue from failures and shortcomings to promising practices. They provided proof that nursing homes don't have to be grim, depressing places. They offered hope to desperate families, exhausted caregivers and aging boomers contemplating their future.

Armstrong acknowledged afterward that it will take a prodigious effort and a significant public investment to reach the level of long-term care regarded as normal in countries such Germany, Sweden and Britain. But even without a cash infusion, she argued, there are ways to make life better for the residents of Ontario's nursing homes: Label their clothes properly before sending them to the laundry; allow them to make a cup of mid-afternoon tea or go to the fridge for a beer; let them eat chocolate or ice cream if they wish; make the decor less hospital-like and more like a home. Give personal care precedence over paperwork. Reorganize who does what to bolster teamwork and reduce staff turnover. These reforms are not costly. Three principles are vital for high-quality long-term nursing care, the researchers concluded: It fosters person-to-person relationships. It respects individual differences, while striving for equity. It offers dignity to older citizens regardless of their infirmities.

One of the biggest impediments to progress, Armstrong said, is the province's knee-jerk response to scandals. Any time something goes wrong in one of Ontario's 629 nursing homes, the ministry of health imposes blanket regulations. These one-size-fits-all rules reduce the ability of care providers and nursing managers to tailor their practices to the needs of residents. "We've become so obsessed with safety and standardization that we've taken the life out of living." So far, there's been no sign of interest in the project from Queen's Park. That is not likely to change until Ontarians open their eyes and raise their voices. Instead of complaining after their elderly parent is admitted to a nursing home, they need to speak out for everyone's parents. Instead of giving up on long-term care, they need to push back when policy-makers offer visiting part-time help.