Archive for category Health Care Policy That Matters to Nursing

“We Don’t Care What’s On Your Head. We Care What’s In It.”

So there’s this thing in Quebec which I’m sure my Canadian readers have heard of and maybe also a few of my American readers, which involves the Quebec government devising some legislation called the Charter of Quebec Values. I have to say “charters” and “values” are nice happy positive words, and Quebec is filled with deliciously cheesy poutine, hockey, maple syrup, and those devilishly sexy Québécois men, so what’s there not to like (except for les Habs, boo, hiss!)?

The thing is, this Charter of Quebec Values wants to ban wearing obvious religious symbols for all public employees, including nurses and other health care professionals. This, I have to say, has ABSOLUTELY NOTHING TO DO with some nice Ladies of Muslim persuasion cheekily wearing hijab in broad daylight in Montreal and everything.

From the Government of Quebec website. Top: acceptable. Bottom: Va te faire foutre (You can Google Translate that too.)

(Just so you know, American readers, I must also officially tell you is NOT racist, and the fact the proposed legislation targets Quebecers with brown skin is merely, um, an unfortunate coincidence.  We say this because the Quebec government is acting from the purest, noblest of intentions. This is a Fact, because the Quebec government has told us so. (You can Google translate it or something.) It is well-known that the separatist, ruling Parti Québécois has long been offended by clerical collars, Jewish kippahs, wimples and garish Roman Catholic crucifixes. This is also a Fact, which you can also Google.)

The proposed charter will affect health care professionals, including nurses. My question, then, does the wearing of religious symbols or associated clothing have any place in the provision of health care? Should nurses don hijab on the hjob?

Before you run off to start raving, maybe you should consider a few things. First, banning headscarves (or whatever) has a distinct element of authoritarian nastiness about it. Should the nursing profession be that coercive? There’s probably no getting around the fact that if the legislation is passed, it will be nurses enforcing the ban against other nurses.*  (The irony of having the Quebec government telling Muslim women how to dress, partly, it is argued, to ensure gender equality, is beyond these guys.)

Another thing: nurses have a long history of wearing weird things on their heads. It’s safe to say that if you look over the course of the history of nursing, no crazy headgear has been the exception, not the rule.

Like this:

Or this:

Or this:

Which reminds me: some of you might say, oh it completely different! it’s a religious thing! Muslims shouldn’t be pushing their faith in our faces!

Well, there’s this:

+

And this:

But not this? (Love this ad, by the way. It was created in response to the proposed Quebec law..)

We’re always looking for the highest calibre health professionals to come join our team. This is our newest recruitment ad that will be running in Montreal.  So for anyone looking to work in a leading hospital focused on safety and quality, check us out.

So if you’re offended by women in hijab but not by Catholic nursing sisters, what’s the difference? Do you really believe the hijab (or any other piece of religious accoutrement) sucks out the nursing from the nurse?

So dear readers, hijab for nurses and other health care professionals, yes or no?

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*The Quebec nurses union, FIQ, has courageously taken the position of taking no position at all. In other words, the union won’t defend members running afoul of this law. I’m pro-union, but holy Sam Gompers, sometimes their leadership are dumb as stumps.

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Protect Your Love

Via Osocio, a very likeable ad for HIV prevention and awareness from the Toronto-based Alliance for South Asian AIDS Prevention. Osocio notes the ad is less about sex than and more about love, and in this way, I think, it manages to get its message across effectively, without being preachy or didactic.

(Incidentally, the short scene filmed in the Scarborough RT is very funny.)

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Having the Talk about Birth Control

One of a series of YouTube videos from Bedsider, a program of  the U.S. National Campaign to Prevent Teen and Unplanned Pregnancy,  on having the birth control discussion with a physician.

[More videos can be found here.]

From Bedsiders webpage:

Babies are great…when you’re ready for them. We think in the meantime women should have the right to a healthy, happy sex life without having to worry about unplanned pregnancy. For that to happen, women need to take an active role in their own reproductive health. We want to help with that.
Bedsider.org (Bedsider) is an online birth control support network for women 18-29 operated by The National Campaign to Prevent Teen and Unplanned Pregnancy, a private non-profit organization. Bedsider is not funded by pharmaceutical companies. Or the government. Bedsider is totally independent and the info on it is honest and unbiased. Our goal is to help women find the method of birth control that’s right for them and learn how to use it consistently and effectively, and that’s it.
Right now, seven in 10 pregnancies among unmarried women 18-29 are described by women themselves as unplanned. That sounds like a lot to us. We hope that Bedsider will be a useful tool for women to learn about their birth control options, better manage their birth control, and in the process avoid getting pregnant until they’re ready.

That any of this would still be controversial in this the year of God’s grace 2012 boggles the mind, especially the part where it’s okay for women to be sexually active and enjoy it.

One small quibble to Bedsider: nurses get to talk about birth control too.

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Nurses Practice Beyond Their Scope — And It’s Not a Bad Thing

A very good, if obvious, idea on the use of RNs: nurses should be used to the full extent of their abilities. From the Toronto Star (and kudos to the paper for their Nursing Week insert in Saturday’s edition):

“The bottom line is that we’re wasting valuable resources with our RNs,” says Doris Grinspun, the Registered Nurses’ Association of Ontario’s chief executive officer. “European countries like the U.K. have been using RNs to their full capacity for years. It will be a missed opportunity for the public, taxpayers and patients if we don’t move to full utilization of our nurses.”
[SNIP]
[Grinspun] wants the province to recognize the education and expertise of registered nurses, and to agree that they could be doing more within the scope of their practice, like diagnosing patients, ordering diagnostic and lab tests, conducting pelvic exams and prescribing medications.
Though the mandate of Ontario’s action plan for health care is to find ways to maximize the system, full utilization of care providers isn’t possible until the government revamps policies about who can bill for certain medical procedures. “We should be using nurses and all health-care providers to open access, increase the timeliness and quality of care and to contain cost,” she says. “But if a nurse does a pap smear, the doctor doesn’t get paid. If a nurse diagnoses a child’s ear infection and prescribes antibiotics, the physician doesn’t get paid. I go berserk when I see doctors taking blood pressure,” she says. “Nurses have the training to free up a doctor’s time in primary-care settings so she can focus on more complex situations.” Plus, the move to grant registered nurses more autonomy on the job would lower the waiting times for patients to be seen, meaning there will be fewer patients showing up at walk-in clinics and emergency rooms.

Not exceeding their scope of practice

The (somewhat) amusing thing about this idea is that nurses (or least those working in in high acuity areas like ICUs or Emergency Departments) already do all much of this in an highly unsanctioned, unregulated and unofficial way. Let me provide a simple example. Suppose I am triaging an exceedingly anxious patient with chest pain, and decide the patient requires an ECG — which incidentally I can order under medical directives. I explain the test to the patient. I tell her ECGs measure the pattern of electrical activity in the heart and therefore can show dysfunction. I place the electrodes across her chest and limbs, and carry out the test. The printout shows a patient in a regular sinus rhythm with no acute abnormalities.

Do I tell my agitated patient, whose anxiety is growing by the second, that (A) the ECG shows her heart is performing in a normal way and that we need to do some blood tests to confirm everything is okay, or (B) that the physician will discuss with her the results of the ECG when he sees her — which might be in a couple of hours?

When I was a new nurse, some years ago and being a good, diligent practitioner, I would have told this patient (B). This was not to dog my responsibilities or pass off work to the physician. (B), in fact, is the correct answer. Interpreting a test for a patient is considered a form of diagnosis, and in Ontario and most jurisdictions, making and communicating a diagnosis is considered the exclusive preserve of nurse practitioners and physicians.

But this is the deal. I have been educated how to interpret ECGs. I know how to tell atrial fibrillation from SVT from sinus tachycardia. I know what ischemia looks like, and I can spot ST elevations in a steam bath. More importantly I have the judgement to recognize the borderline cases and defer to the physician. Additionally, it seems to me, cruelty, indifference and bad nursing can be defined by a nurse telling a patient — especially one that is anxious —  that she needs to wait to speak to the physician about her ECG because of “the rules.”*

I am not for stupidity in the form of thoughtless adherence to regulation. I am not for cruelty either. So I decided a long time ago, that on balance, it was altogether better for the patient to have this information, rather than sit in the waiting room in a state of high anxiety. Even if my professional regulatory body has officially determined I can’t because technically it is beyond my scope of practice.

And so it goes. Nurses quietly and unofficially violate the scope of practice all the time. We push the envelope. We add blood work we think the physicians have missed. We slip in chest films because we know they need to be done. We order ECGs on patients we don’t like the look of.  We review lab results with patients. We cajole specialists into “having a peek” at a patient if we are worried about them. We tell patients — sometimes in very circular language, to avoid the damning “communicating a diagnosis” — what really is going on.

Why do we do it? Sometimes we know physicians will support us. Sometimes it’s to avoid difficult conversations with physicians, or because physicians won’t listen to the opinion of a mere nurse. (One physician I know of absolutely refuses to order serum lactates on obviously septic patients, because a positive result means she needs to follow a complicated sepsis protocol — even though the literature is pretty clear that early and aggressive intervention in sepsis saves lives.) Bottom line: we do it in the interests of the patient.

Should nurses be permitted to utilize their full knowledge and skills? Absolutely. It’s better for patient care and better for nursing work life. And also we need to formally regulate what nurses do already, to protect nurses themselves.

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*The College of Nurses of Ontario, my professional regulatory body, would probably, and unrealistically suggest the alternative of getting the physician to speak to the patient immediately after doing the ECG as the “proper” course of action. But think about it this way: my ED probably does 30 ECGs (if not more) in the course of a 12-hour shift; if it takes a physician 5 minutes to discuss the results with a patient, then 30 x 5 minutes = 150 minutes = 2.5 hours.  That’s a pretty big chunk of time, and in a busy department, is not going to happen.  And that’s if you could get the physician to come out to triage to see the patients to begin with. It is simply not good use of his time and is completely unnecessary. Which rather demonstrates the point of the article quoted above.

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A Nasty, Medically Unnecessary, Coercive Procedure

This is just grostesque:

A Republican supermajority has muscled two of the most restrictive anti-abortion bills in years through the Virginia House, despite bitter yet futile objections from Democrats, with one GOP delegate deriding most of the procedures as “matters of lifestyle convenience.”

You want to put what where?

[SNIP]

And the ultrasound legislation would constitute an unprecedented government mandate to insert vaginal ultrasonic probes into women as part of a state-ordered effort to dissuade them from terminating pregnancies, legislative opponents noted.

“We’re talking about inside a woman’s body,” Del. Charnielle Herring said in an emotional floor speech. “This is the first time, if we pass this bill, that we will be dictating a medical procedure to a physician.”

The conservative Family Foundation hailed the ultrasound measure as an “update” to the state’s existing informed consent laws “with the most advanced medical technology available.”

The Oklahoma legislature passed a similar law a couple of years ago. Full disclosure, in case you didn’t know it: I dislike abortion, but I’m strongly pro-choice. Even if you are strongly against abortion on moral or religious grounds, I would like to know how a medically unnecessary, coercive, invasive procedure can be ethically justified in order for a patient to receive health care? (I think we can safely dismiss the Family Foundation’s reasoning as spin.) And if the patient is a 13-year-old rape victim, how is this not despicable and evil?

Another question I would like to ask: if you’re a health care professional, would you excuse yourself from participating or facilitating in enforcing this law?

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Long Emergency Department Admissions Shorten Lives

Via ImpactedNurse.com, another study showing prolonged emergency department stays are less than optimal:

There were 41,256 admissions from the ED. Mortality generally increased with increasing boarding time, from 2.5% in patients boarded less than 2 hours to 4.5% in patients boarding 12 hours or more (p < 0.001). Mean hospital LOS also showed an increase with boarding time (p < 0.001), from 5.6 days (SD ± 11.4 days) for those who stayed in the ED for less than 2 hours to 8.7 days (SD ± 16.3 days) for those who boarded for more than 24 hours. The increases were still apparent after adjustment for comorbid conditions and other factors.

In other words, two consequences from lengthy Emergency department admissions: first, you are about twice as likely to die if you are admitted for more than twelve hours, and secondly, if you stay for longer than 24 hours (and survive, of course) you’re likely to be hospitalized for three extra days.

Clearly something bad happens when patients are admitted in EDs for long periods of time. The study’s authors identify a few reasons for this. Care for admitted emergency department patients are poorly prioritized by both physicians and nurses; a preference bias occurs because less acute patients tend to get beds more quickly (a phenomenon which is a frequent occurrence in my hospital as “easy” patients go off-service to Paeds or Post-Partum or General Surg); there are also delays in the getting appropriate treatment started, which negatively affects mortality.

I would add the obvious, that expecting Emergency departments to run as Emergency departments and simultaneously as ICU/Post-Op/Med-Surg/Urology/Gyne/Surgical Outpatients/Paediatric unit(s) is probably not a reasonable expectation, if for the simple reason acutely ill new ED patients will always take priority over admitted patients, except when those patients are actively crashing. Additionally EDs are not set up to take care of admitted patients. We are not given the resources to do the job properly.

I don’t expect this study would surprise anyone who has actually worked in an Emergency department. We’re used to seeing patients decompensating before our eyes. What it does is give us ammunition. When some manager tells me, “I’m not going to do those bed moves for that patient because you only have seven admits — which I have actually heard fall out of a manager’s mouth — I can cheerfully reply, “You’re increasing the risk of that patient dying to 1 in 20.” When the ICU tells me to wait till after lunch, I can counter with “You are increasing the patient’s overall length of stay with every hour’s delay.” Most importantly it adds a sense of moral urgency. Get the patients upstairs, or increase the risk of killing them. It’s pretty simple.

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Got Mine. Got Yours?

The flu shot, that is.

I got mine yesterday. And no, I did not get any flu-like symptoms. So get it over it, and go get the shot. Now. Especially if you’re a health care professional. What I wrote during the glory days of H1N1 two years ago still applies:

Finally, I won’t tell you to get the vaccine, because it’s professional, or that the hospital is making you anyway, or because it’s the right thing to do, or because you’re saving yourself the misery of having the flu for a week or two, though these are all more or less valid reasons. However, getting the shot will prevent you from being a complete tool when you pass the virus to someone compromised — maybe even one of your colleagues, a patient or even, God forbid, a loved one —  and end up killing them. I think this argument is nearly irrefutable.
So in summary: don’t be a tool. Get the shot.

Don’t make me nag you. Because you know I will.

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Smokers Have Other Problems Besides, Well, Smoking

If you work in the North, you’re familiar with the scene: patients in gowns, riding wheelchairs and trailing IV pumps scrambling over snow banks and icy walkways and braving frostbite-inducing winds to get off hospital property to have a smoke. I suppose for most of my readers, the image will induce a great big “Meh.” But a new article in the Canadian Medical Association Journal suggests otherwise, and that smokers who need to exit the hospital to smoke face special risks and little support in managing their addiction. Money quote:

Study findings affirm evidence that tobacco dependence treatment is inconsistently offered in hospitals and heath providers were uninformed about tobacco dependence treatment, despite availability of nicotine-replacement therapy at study sites. This treatment gap is perplexing, especially as within Canada there exists an evidence-based hospital tobacco dependence treatment program. Unintended patient safety consequences of smoke-free property necessitate effective tobacco dependence treatment during a stay in hospital simply as a risk-management action. Moreover, a health-promoting policy that causes patients to face diverse safety concerns (treatment disruption, infectious disease contact, exposure to adverse weather and possible violence) projects a contradictory health message.

Not helping, of course, are the usual (and sometimes, let it be said, judgemental) opinions of heath care professionals who view smokers adversely and see them as the authors of their own problems.* They tend to take the somewhat cavalier position that if smokers want to go outside for a cigarette, well, that’s their lookout. Elderly woman who falls on ice and fractures a hip while out for a puff? Hell, she brought it on herself by smoking! But is it actually humane to send sick people to the curb in the winter to tend to their addiction? Is it consistent with good nursing practice? And what about the liability and duty-to-care?

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*I will never forget the physician who told a young, pain-wracked lung cancer patient that she was responsible for her suffering, and that she should go home and “deal with it.” But some HCPs like to play the blame game in general and especially with patients with addictive behaviours.

 

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“We Will Now All Be Unwilling Participants in a Social Experiment That Will Undoubtedly Place Canadian Lives at Risk”

My thoughts exactly, from Alan Drummond of the Canadian Association of Emergency Physicians. His full statement on the proposed repeal of the Gun Registry.

It is regrettable that we, as a nation, are about to embark on an unwelcome social experiment. The Conservative government has been very clear that they intend to finally abolish the gun registry. This is regrettable in so far as it is clear to Canada’s emergency physicians that the gun registry has, in fact, worked and the number of deaths from inappropriate firearms use has dropped dramatically since the institution of the Firearms Act. The government has consistently portrayed this act as a victimization of rural long gun owners, conveniently ignoring the clear scientific evidence that rural suicides with long guns are the principal issue in the tragic toll of Canadian firearms deaths. So we will now all be unwilling participants in a social experiment that will undoubtedly place Canadian lives at risk. Our question to our government is that relative to the perceived inconvenience and cost of registration, what will be the true cost, in direct human suffering, of their ideologically driven and scientifically bankrupt legislation.

Some inconvenient statistics, nicely compiled by the CBC:

Homicide by firearm
Firearm homicides, 2009: 179 (0.53 per 100 000 or about 30% of all homicides)
Firearm homicides, 1991 (the year stricter gun control was introduced):271 (0.97 per 100 000 people)
Types of firearms homicides, 2009:
Rifles or shotguns: 18% (36% in 1999)
Handguns: 69%
Prohibited firearms: 13%
Since 1995, when the gun registry became law, until 2009, the reduction in homicides by long guns: 52%
Spousal homicides caused by shootings, 2000-2009: 167 (23%)
Reduction in the rate for spousal homicides involving firearms from 1980 to 2009: -74% from nearly 3 per million spouses in 1980 to less than 1 per million spouses in 2009, according to Statistics Canada
Share of firearm-related spousal homicides involving a long gun: 50%(The rate of long-gun spousal suicides dropped about 80% between 1983 and 2009.)
Share of family-related homicides of children and youth (7 to 17 years), by shooting, 2000-2009: 26%
Of the last 18 police officers killed in the line of duty, as of August 2010, number killed by long guns: 14 (78%)
Suicide by firearm
Number of firearm-related suicides involving a long-gun, 2004: 475 ( 5.4 times the number of suicides with handguns)
Change in number of firearm-related suicides since the introduction of stricter gun laws in 1991 (as of 2009): -43%
Change in number of firearm-related suicides since the introduction of the Firearms Act in 1995 (as of 2009): -23%
Increased likelihood that a home where there are firearms is the scene of a suicide, than a home without a gun: 4.8 times (based on a 1992 U.S. study in the New England Journal of Medicine)

Incidentally, for you fiscal conservative types, the cost of treating a gunshot victim is about $450,000.

So, on one side of the debate, we have scientific and statistical evidence on the efficacy of the gun registry, expert opinion from health care professionals and the police, the physical and emotional cost of trauma, hundreds of deaths prevented and, on the other side, the hurt feelings of rifle owners. That’s pretty well what it boils down to, right?

[Update 29/10/11: Fixed formatting problems.]

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On the Gun Registry

Some people who have never seen a gunshot wound to the face

Globe and Mail headline: “End of long-gun registry seen as victory in war on Big Government.”

The headline could have just as easily read, “Government wants to kill Canadians to make Lanark County gun owners happy.”

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