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Two sides of the same coin?...

Left: Paul Pace. Photo: Chris Sant Fournier, and, right: Joe Cassar. Photo: Matthew Mirabelli.

Left: Paul Pace. Photo: Chris Sant Fournier, and, right: Joe Cassar. Photo: Matthew Mirabelli.

The two protagonists in the nurses’ dispute deny there is a personality clash. Health Minister Joe Cassar and Malta Union of Midwives and Nurses president Paul Pace give their sides of the story.

Joe Cassar

At some point patients and relatives will be turning to you for solutions. What will it take for the government to start negotiating with nurses?

The government is prepared to start negotiating at any time but it is our policy not to do so under the threat of industrial action. If the union stops its actions at one minute past midnight, I will start negotiating at two minutes past midnight.

Some months ago the union had stopped industrial action after you promised back-to-back meetings. The MUMN has said that only one meeting was held.

More than one meeting was held but if there is goodwill we should not look back. We have to look towards the future. We have to understand there are long-term problems, like human resources, that have no short-term solutions. There are other short-term problems like the generator issue that can be resolved easily. The most important thing is that we understand the main problem that has spurred this industrial action.

What is the problem?

We thought the main problem was the shortage of nurses. This is something that my predecessor and I have acknowledged. However, the MUMN is not even agreeing with us on the number of nurses required.

Figures bandied about publicly indicate that between 300 and 500 nurses are required to run the health service efficiently. What is the government’s estimate?

The MUMN even spoke of 700 nurses. However, when we speak of human resources in healthcare professions we also have to speak of an evolving job. When trying to establish a number we have to ask what job a nurse will be doing in the next two decades and which duties can be done by other carers. We will shortly engage phlebotomists, who are qualified technicians trained to draw blood, to relieve nurses of this duty.

To determine the exact number, government wanted to embark on a human resources audit to have a clear picture of what duties nurses are doing. At first I thought the union was on our side because they agreed to this. I asked Mater Dei’s management to start with the outpatients department and the moment nurses received the survey all hell broke loose. The union stopped us by directing nurses not to participate in the survey.

The union wanted to perform the audit itself. It wants to act as a union and also as the hospital’s management. The union told its members that the audit was being done to transfer nurses with 20 years of service at the outpatients department to other areas of the hospital. We have to revisit today’s processes and move nurses according to the requirements of the service. Will the union let me do this?

Is there an underlying monetary motive for these actions?

MUMN president Paul Pace made it very clear that this is something we had decided not to discuss and I leave it up to journalists to decipher non-verbal behaviour.

Does it make sense in this day and age to expect nurses to run around with gas lamps if the lights are out at Mount Carmel Hospital?

No, it does not make sense. I do not think the directives to nurses not to administer medicines to patients or not collect methadone from a pharmacy are linked to the generator issue.

But this is one of the issues raised.

Can the generator problem be put on the same level as a much bigger problem such as nursing shortages? We are getting a generator but Mount Carmel Hospital has very different wards to Mater Dei hospital. Generating electricity in an emergency situation for chronic wards at Mount Carmel is very different from ensuring that an operating theatre continues to function during a power cut.

Is there a personality clash between you and Mr Pace?

Not at all. Mr Pace and I talk all the time over the phone. The problem is there are no clear boundaries of what a union should be doing when it comes to management in hospitals.

The country has a nursing shortage and the University imposes a numerus clausus on its nursing course. Does this make sense?

My ministry, the Education Ministry and University have for the past two years been meeting regularly to determine how we can increase the number of students taking healthcare courses.

We can only increase numbers after going into international ratios of mentoring – the number of student nurses per patient while doing their practical work at the bedside. Healthcare students have to deal directly with patients... literally invading their privacy to learn.

Is this the problem or is the university not flexible enough in managing its courses?

The university is totally flexi­ble.There are two nursing courses: a Bachelor of Science course and a diploma course. Obviously, there is an academic difference between the courses. This year the University was prepared to take 165 students for the bachelor of science nursing course but only 23 applied.

Students were happier to apply for other healthcare courses and not be accepted because of oversubscrip­tion rather than take up nursing. All the others have applied for the diploma course. It is all a question of quality. Something is not attracting students to the bachelor course.

Are conditions for the nursing profession right?

The 2007 collective agreement with nurses was very good. The govern­ment is paying good money to nurses.
There are other healthcare professions which pay less but students still prefer to join them instead of nursing. Maybe it is the negative vibe that we are giving out that is putting people off nursing. I do not get this bad vibe when I meet nurses. There seems to be disson­ance between nurses and the MUMN executive that gives off this negative image. But we also have to go to sixth forms and talk to students about nursing.

The government said it was committed to bringing over nurses from abroad. What has happened to this proposal?

A year ago we issued an open call for applications that is still open until December next year. We have received applications from various countries. But any non-EU citizen first has to obtain a nursing warrant in Malta approved by the nursing council. It takes around six months to approve the qualifications of non-EU citizens. Once the approval is given the nurses would then have to be engaged by government through the normal channels. The governmentis trying very hard to solve the problem.

We have also had a number of Maltese nurses who worked in private practice and wanted to return to the public service. Some asked to perform particular jobs, where we need personnel. The union objected. They prefer losing people instead.

People expect answers from you. Who is calling the shots; the union or you?

I am calling the shots but people have to understand that the minute I decide to get a nurse from anywhere and place him in a post that he desires the union issues directives at the expense of losing the services of that person.

So what is the way out of the situation?

We have to meet around the table, communicate better and have clear definitions. I have one priority: the patient. I will let nothing get in the way. I will continue to do everything for the benefit of patients but if everything I do does not please the MUMN and they continue issuing directives, that is a problem.

Mr Pace accused you of lacking leadership. How do you respond to this accusation?

These are his personal ideas. I have been elected by the people and they will judge me.
The problems at hand are long-term and I will continue having sleepless nights trying to figure out ways to help ease the burden on nurses. But I plead with the union to allow me to help them, because until now it has shot down every proposal made by the government.

Paul Pace

The union said it is ready to start discussions with the government; however, without preconditions. The government is insisting you stop your directives before talking. Where is this heading?

The union has long been talking about the issues at the centre of the industrial action. At the start of this legislature in 2008 we had presented then Health Minister John Dalli a document highlighting the problems and proposing solutions.

We have long been asking for discussions to be held and when a couple of months ago Health Minister Joe Cassar asked us to suspend directives to hold back-to-back meetings, we complied. Only one meeting has been held since.

The government gave us the impression that problems in the health sector were not a priority. The minister tricked us the first time when he promised us meetings on the condition we stop industrial action. Now he cannot expect us to do the same again.

Is this a personality clash between you and the minister?

Absolutely not. The minister is very approachable but he lacks leadership and the people around him are unreliable.

These actions are not in the interest of patients.

We have to look at the whole picture. The media regularly report situations of overcrowding in hospital, interminable waiting lists and operations that have to be cancelled because not enough beds are available. These are not the result of industrial action...

But you issued a directive for nurses to leave Mount Carmel Hospital if the lights go out even if a patient may require life-saving CPR treatment.

In pitch darkness a nurse would not even know if a CPR is required let alone whether it could be administered. In Mount Carmel we do not even have CPR trolleys or defibrillators to perform CPR treatment. These are not available in broad daylight let alone when there is no electricity and there is no generator to provide emergency lights.

We had informed the health ministry over a year ago about the need for a generator at Mount Carmel. The government lied when it said there was never a generator that covered the whole hospital in the past. The generator is there but it is not working.

The minister described your directives as abusive and illegal because they put patients’ lives in danger.

As a politician it serves the minister’s agenda to describe the actions as illegal because he does not have solutions to the problems. The directive to nurses not to pick up medicines was an electoral promise of this government that recognised it was a waste of resources to have nurses running around corridors transporting medicines and files instead of looking after patients.

The minister was unfair with the people when he said nurses were instructed not to administer medicine to patients. We never issued a directive of that sort. Nurses are administering medicines as long as they are brought to the wards.

Shouldn’t nurses be handling and transporting dangerous drugs?

In Mater Dei we had six wards where dangerous drugs were transported by carers, not nurses. One of these wards was the intensive therapy unit. This system had been in place for some three years. When I asked for this system to be extended to all wards, management dismantled it instead. The European Federation of Nurses Association said it does not make sense to have nurses acting as porters.

If support staff are engaged to take over non-nursing jobs will the union accept nurses being shifted to other duties?

Nurses do not have to be shifted. Our wards should have six nurses present during the day. Today this number is reduced to two. If I order a strike nobody will leave work because we are working on a skeleton operation that is the minimum required at law to continue the essential service. The union wants support staff. We issued directives at St Vincent de Paul Hospital because there were no carers. They were lifted when carers were engaged.

Will the union accept nurses being transferred if there are surplus numbers in some wards?

With 700 fewer nurses than required I do not know of one unit in hospital that is not facing a serious shortage of staff. Shifting nurses will not solve the problem.

It takes time to train people. This is a long-term problem that cannot be solved immediately.

The government has lacked the resolve to solve this problem over the years. It started when then Health Minister Louis Deguara had advised the government the country had enough nurses and the first numerus clausus was introduced. The stipend, which was at the higher end, was also reduced.

We had warned this was a mistake and last year after discussions with Mr Dalli the intake of students had risen to 144. When we realised that some people were left out of the course we applied pressure and the intake increased to 165. Even this number is not enough to ease the problem. The university has been given autonomy and unfortunately it has been used against patients’ interests.

The university argues that a higher intake of students will lead to lower nursing standards because not everyone will have hands-on experience as part of their training.

I finished my nursing course in 1985 and at the time there were around 300 nurses. According to the university’s argument all nurses my age and who work in wards are low standard. It is incomprehensible why the govern­ment accepts the university’s argu­ment in favour of a numerus clausus when this goes against the country’s interest. The government prefers to attack the union and its directives rather than dealing with the university.

Does the MUMN agree with the engagement of foreign nurses?

In our document two years ago, we suggested a manpower plan for the health division, which also included the engagement of foreign nurses on fixed-term contracts as a short-term measure. We will accept foreign nurses if there are no refusals of Maltese applicants for the university course. This year only 44 nurses graduated and there are 10 others awaiting resits. It makes no sense to stop students entering the nursing course and then poach nurses from Third World countries where nurses are also required.

You say there is a shortage of 700 nurses. Where did you get this figure from?

It was the minister who talked of a shortage of 500 nurses. But this number did not take into account specialisation and relief pools. Today nurses cannot simply take leave because they have to find a replacement. So an additional 200 nurses would be required to establish relief pools, apart from encouraging career progression and specialisation.

Is money at the heart of this dispute?

We are not asking for allowances. The union is asking the government to bring over foreign nurses to relieve us. However, the university has to remove the numerus clausus on the nursing course...

Are you asking for financial compensation?

No, not at all. However, there is a lot of mismanagement which is putting additional burdens on nurses. We have a problem with those patients needing constant one-on-one watch; we have problems in Mount Carmel of a 20-bed ward with 27 patients; we have a problem at Mater Dei when extra beds are placed in the corridors of the emergency ward because nurses from other understaffed wards are transferred to work there. Patients are affected when corners are cut and nurses are under pressure to cut corners.

Are you worried about the forma­tion of house unions and are you trying to adopt a militant stand to prevent members leaving your union?

No. Industrial action brings no joy to nurses and they have been subjected to a lot of pressure and attacks by management. I wrote to the Prime Minister last week to inform him that my members were on the receiving end of verbal harassment from the management. The union is also considering reporting the matter to the police.

Management officials were asking nurses to sign a letter requiring them to breach union directives. My members were threatened with disciplinary action and dismissal. This is what worries me, not the formation of house unions. I never expected this approach from government.

What is the solution?

The minister can call me for a meeting at midnight and I will be there. But he has to come to the meeting with solutions.

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