On Jan. 31, Sudbury.com ran an article by reporter Len Gillis featuring Dr. Maurice St. Martin, a story that was quite revealing about our health-care system. (You can read that article here.)
The disconnect between patients being discharged from hospital to a nursing home, which doesn’t allow a smooth transfer of care, was the main message. This demonstrates neither the sending hospital being sensitive to the needs of the nursing home, nor the reverse, resulting in a less-than-smooth transfer of care. Risking harm.
To this end, Dr. St. Martin felt compelled to hold up the admission to the nursing home until everything could go smoothly and safely. As a result he ruffled some feathers.
I commend him for speaking up about this. It begs the question whether this type of inter-institutional behaviour is acceptable.
This brings up a topic that is making a lot of waves for our colleagues (for better or worse) to the south of the border. Most people here haven’t heard of it yet, but you can be one of the first.
It is called “administrative harm”. It was first described by Dr. Huan Chang and Dr. Matthew Liang in an academic article called “The Quiet Epidemic” (JAMA, 2011. The article is available here behind a paywall).
The article refers to the gradual recognition that patient harms were being done in spite of the best-intentioned hospital care. In other words, patient outcomes after discharge from hospital didn’t measure up to the known benefit of their treatment. These harms occurred in spite of best efforts and the cause was hard to pinpoint.
Since then, the idea of administrative harm has been expanded upon in research by doctors Marisha Burden, Gopi Astik, Andrew Auerbach (et al) that was published in the Journal of The American Medical Association in June 2024. The full article, “Identifying and Measuring Administrative Harms Experienced by Hospitalists and Administrative Leaders” is available here.
Broadly speaking this outlines the consequences of administrative decisions within health care facilities that directly influence the care and outcomes of health care, usually in the negative for the patient. It has been adopted by the U.S. Centre For Disease Control and is set for more investigation.
It is no secret that one of the few areas of growth within the health care field has been a huge increase in the number of administrators relative to the number of actual health care workers (physicians and nurses). We hear about this in Canada as a decrease in the number of working nurses while the ranks of administrators grow.
Just ask any hospital nurse. Between 2003 to 2022 in the U.S., the increase in health care workers has been on the order of 40 per cent while the increase in administrators has been on the order of 2,800 per cent.
Of course, there are no corresponding statistics in Canada that are easily accessible. But why should there be? Our health care system is not managed. However, there is likely a correlation, if weaker.
So what do we make of this?
If we go back to Dr. St. Martin’s dilemma (which I have shared) a simple meeting of the minds of hospital and nursing home administrators (at the corporate level) could go a long way to solving the problem. So when does this happen? Or better yet, why does this not happen? Is there a perception at the hospital that the needs of the nursing home are less important? Is the converse true? Is this another example of a failure of health care system management?
You can read that as a failure of health care system integration.
But what do we do with other issues such as battered nurses? Nurse Birgit Kuhle’s letter to the editor published by Sudbury.com in February casts more shadows.
She writes that she was assaulted and forced to bear the brunt of the episode, at considerable personal cost. What’s more, she was prevented from going public with this. This end is achieved by means of a “Confidentiality Agreement” which all hospital employees are required to sign. In effect this is a gag order.
As nurse Kuhle pointed out, if the nurse does not comply with hospital wishes they stand to lose their job and their license. Nurse Kuhle retired as soon as she could.
That’s staggering.
Administrative harm has three main themes according to Dr. Burden.
First of all it is pervasive, coming from all levels of management. From government (the payer) to administration and down the ladder. Administrative decisions affect all aspects of care within a hospital, whether they are a benefit or not. Often, they appear to be little more than an attempt to appear politically correct. They affect patients, the workforce and the organization. They are the practice of the organization, which largely trickles down from the demands of the cost payers. In our case this is the Ministry of Health.
Second, organisations lack methods of identifying poor administrative decisions, measuring their outcomes or receiving feedback. There are no Morbidity and Mortality Rounds for hospital administrators, like there are for doctors. There aren’t even any Bad Management Review Meetings for administrators. In effect, there is a lack of leadership accountability for administrative harm.
Third, organizational pressure drives administrative harm. This speaks to the second theme, cited above. Decisions are often made in communication or organizational “silos” (from government to administration, on to programmes and downward), where there is little concern for the end result of administrative decisions. The important thing is that decisions are made and implemented, so that progress appears to be made, and can be paraded in public. This is often the case with external consultants or government edicts.
In the case of nursing complaints of understaffing or staffing with unprepared (read undertrained or new) staffing, the complaints are handled internally and otherwise don’t seem to reach the light of day, in public.
When this leads to assaults on nurses or other staff this invariably leads to the nurse being held accountable for the harm to them. “They should have learned to duck.” Is this just a trickle down administrative practice from the top? Are nurses expected to be able to fight or at least avoid a fight — even if the fight threatens another patient’s wellbeing?
Would assault be acceptable anywhere else? Say at a mine site or at an industrial complex? I think not.
The National Post published “What The Hell Are We Doing Here? Inside Canada’s Shockingly Violent Hospitals,” by Sharon Kirkey on March 18, 2025. The article stated that from 2006 to 2021, only 12 court cases in Ontario found guilt in attacks on nurses. Largely because few complaints reached the light of day. The article explores further a negative hospital culture toward nurses, which appears ingrained and unchangeable. According to the article, the same applies to doctors.
Do we really need to ask ourselves why understaffing is so pervasive and leads to closures of emergency departments? The answer is simple: Because nursing staff and doctors aren’t willing to put their health and the wellbeing of a public they can’t serve to an accountable standard, on the line.
So, just because a politician says their province is going to hire so many thousand nurses, why don’t I believe that?
As Nursing Week is upon us, is it not time that these issues be put out in the open where they might be dealt with more sympathetically and effectively? Is this not the way to support our nurses and other staff? Perhaps if we did, we might have more uptake into the allied health professions.
If we do nothing else we should support our health care staff. If we do nothing, do we deserve what we get?
Dr. Klaus Jakelski is a retired family physician and author. He resides in Greater Sudbury.