Staffing, care, and work organization during COVID: A nurse’s perspective from Northern Italy

Interfaced
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Introduction

Anna (Anonymous) is a nurse working in a general medicine ward in a small hospital in Carate Brianza (Lombardy). During the COVID-19 pandemic, her ward was officially designated as non-COVID, but it frequently received COVID-positive patients due to logistical decisions and the hospital’s small size.

The team cared for both regular medical patients and COVID cases, often without adequate personal protective equipment (PPE), which was prioritized for wards formally dedicated to COVID. Her account highlights the everyday difficulties of working with full protective gear, the psychological burden of caring for critically ill patients, including young people, organizational shortcomings in staff allocation, and the lack of significant structural improvements in working conditions or labor rights even after the emergency period.

Anna, do you authorize me to use what you will tell me in this conversation for the INTERFACED project, the Horizon Europe research project?

I’d like you to tell me about how you experienced the COVID period, especially from a professional point of view. What were the challenges and the dynamics that this situation triggered in terms of work and organization?

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I consent.

You have to consider that I worked in a ward that was supposed to be non-COVID, but on several occasions we also ended up dealing with COVID patients.
This was because the hospital direction decided to use wards that were more easily accessible from the emergency department. Our ward was a bit more out of the way. Even though we work in internal medicine, we are a small hospital and we have always managed all the ventilators ourselves. Still, they kept us officially as a non-COVID ward for the entire period. Then, by rotating staff, we also went to work in COVID wards.

Because of that, we found ourselves without proper equipment. That was the worst thing about our ward: we didn’t have protective equipment, because everything was sent to the COVID wards. Which was understandable, except for the fact that we had patients who were probably COVID-positive for a long time but had never been tested.

The real problem was the lack of materials. We worked with those awful things they called FIPPIs [improvised protective masks], which looked like baby diapers. As masks, I don’t even know what they were supposed to protect.

From a human point of view, it was extremely heavy. People arrived at the hospital in terrible conditions, because they kept saying “stay at home, stay at home.” I still remember the first COVID-positive patient we had in the hospital. She was admitted to our ward and she was clearly symptomatic from a respiratory point of view, but her blood test results were incompatible with life, especially the respiratory values. We had to put her on a helmet ventilator, and she looked at us as if to say, “What do you want from my life?”

You can understand that people who arrived at the hospital were already in very bad condition. That made it very hard. And then having to work completely covered in protective gear, wearing two pairs of gloves, was the most uncomfortable thing I’ve ever experienced in my life, and I’ve been working in hospitals for almost twenty years.

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From an organizational point of view, in terms of everyday work, were there different ways of organizing yourselves to deal with the situation? Were there shortcomings, or were there any positive initiatives?

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From an organizational perspective, daily ward work remained basically the same. In the morning, you still had to take vital signs, administer therapy, and do the usual tasks. It simply took more time, because you had to remove the helmet, administer therapy, and manage everything around it. Patients were monitored much more closely than usual.

The real disorganization, in my view, was staffing. People were sent to work in COVID wards who had not performed certain procedures, such as arterial blood gas tests, for years. They sent in anyone. Many staff members tested positive and had to stay home, and there were many shifts to cover. As a result, people were sent in who, in my opinion, no longer had the necessary skills.

For example, someone who had worked in a nursery ward for fifteen years was sent to a COVID ward. From a respiratory care perspective, what could that person do? They were used to caring for children and newborns. Many people like that were sent in. From an organizational point of view, this created serious problems.

Nothing like this had happened since the Spanish flu.

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And in terms of your labor rights, what was it like to try to defend your profession during that period? You also needed protection yourselves. Were there any initiatives to raise awareness or improve working conditions at that time?

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Honestly, in terms of improving working conditions, the only thing they did to help us at all was to open a psychological support service, where we could speak with a psychologist to better cope mentally. Dealing with so many deaths is not something you experience every day, especially deaths of young people. I work in internal medicine, and many elderly patients die. Seeing a ninety-five or ninety-six-year-old patient die is one thing. Seeing a young person who cannot breathe is something else. That was the one thing they did.

Apart from that, I honestly did not see much support. On the contrary, overall it was managed badly. That is certain. And you can see the aftermath in how things are going now.

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Did you organize among yourselves at all? Was there any kind of collective awareness or attempt to act together, either among nurses, at a union level, or simply as colleagues working together, to make your voices heard?

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What do you mean?

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I mean, as nurses, with your colleagues, on a more general healthcare union level, have you tried to have your voices heard?

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During COVID, there was absolutely no time to do anything like that. What happened afterward is that many people left the profession. It was extremely hard, and there was a real exodus. I know several people who completely changed jobs after COVID, leaving the healthcare sector entirely because it was too heavy.

I want to be clear, though. I do this job and I like it. In my view, if you leave the job after an experience like that, it means you chose the wrong profession. That is my opinion. It was heavy, truly heavy, but during that period we had to support each other as colleagues. The situation was chaos. It was overwhelming.

Working with the protective equipment we had, with the shifts, it was unbearable at times. There were moments when I held my bladder for an entire shift, just waiting to be able to take everything off and wash myself completely. They made extra showers available, because I was afraid of undressing and risking contamination, especially since I had an asthmatic child at home.

Despite all this, among colleagues we supported each other a lot. The people I worked with managed to get through it fairly well. Of course, some people were more fragile.

From a union perspective, nothing was done during COVID. That is certain. Only afterward did we try to obtain some form of recognition. After years without renewing the contract, a renewal was proposed that effectively lowered our wages instead of raising them. CGIL was the only union that refused to sign. We were fewer, and in the end we lost that battle. That was the outcome.

Even after that, nothing really changed. Organization remained more or less the same, both in terms of rights and working practices. The one real improvement after COVID was that the required number of staff per shift was increased. That did improve. Of course, there are still minimum staffing rules during strikes or in cases of illness, which are always used. But the fact that more staff are now required to be present on shift is a real post-COVID improvement.

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You’re telling me about things that were provided to you. This study focuses less on what came from outside, and more on whether you organized more among yourselves or tried to do something collectively, or not. Did everything just continue as before, without any internal self-organization?

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No, I don’t think so. I don’t think much changed. It’s not that we fought to change very much, because basically the way we worked stayed the same. Some training courses were introduced, but that was something that came from above. We had courses on managing respiratory patients, mostly after COVID, of course, and we improved our skills. But from the point of view of work organization, we’re still in the same place. There wasn’t really a change.

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In terms of your own awareness, there weren’t any particular struggles afterward? I am just asking, it’s not a reproach, just to be clear.

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The only struggles we engaged in were about having an adequate number of staff, at a historical moment when the elderly population keeps growing and patients are multi-pathological, critical, and heavy to manage. That’s what we’re focusing on right now too.

I have several colleagues who, from time to time, experience mental breakdowns, and we try to help them by moving them to different positions or shifts. So, let’s say, our job is really not an easy one. And on top of that, it’s poorly incentivized.

Hardly anyone wants to become a nurse anymore. The students who go to university and want to do internships confirm that to me.

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Sure, of course. It’s not one of the most sought-after professions, and the working conditions certainly don’t encourage people.

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When I did it, though, there were many of us. I went to university between 2003 and 2005, and there were a lot of students. Now, absolutely not.

We work in shifts, and they come out of university convinced they won’t have to do shifts. When we ask them: “excuse me, do you understand what job you’re going to do?” they say they don’t want to do shifts. It’s a heavy job, and it’s not adequately paid.

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And nothing has changed?

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No. I repeat, we tried to fight to improve salaries, at least to make the job a bit more attractive, but there was no way. They are destroying healthcare, public healthcare. Many people left the public system to go into private practice, and honestly, the ones I know came back to the public system, because private practice is demanding. To earn a lot, you have to work a huge number of hours.

Nurses have remained nurses, healthcare assistants have remained healthcare assistants. It’s true that nurses who didn’t previously manage emergencies had to learn to do so, and that’s obvious, because emergencies were constant. But in Carate Brianza, there was no mixing of roles. Doctors continued to do doctors’ work, nurses did nurses’ work, and healthcare assistants did healthcare assistants’ work. We never experienced demansioning [being assigned to lower-level tasks], or anything like that. It never happened.

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Did relationships between people in different roles change afterward, or not?

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No, I would say no. In our case, a general sense of respect was maintained, and things didn’t go badly in that respect.