A Personal Message for Jack Layton on the Gun Registry

Dear Jack

I’ve written a couple of times on the proposed abolition of the long gun registry, now before Parliament. I have argued gun control is very much a health care issue, and that real lives are at stake. From my perspective as a Registered Nurse, working in an urban Emergency Department, the issue is not about rights or rural culture, but about protecting the vulnerable from harm.

You’ll have to forgive me, Jack, if I am a little emotional on this issue. You see, unlike you and probably all anti-gun-registry MPs — Conservatives and New Democrats alike — I have actually seen gunshot wounds, up close and personal. I have the seen the devastating trauma they have on individuals, families and communities, the lasting scars they leave which never can be repaired. For you, I think, it’s an issue you can debate with Olympian remoteness. It’s all an abstraction, a game of politics played with the lives of your constituents, not a reality of death and mutilation. “Ah,” you say, “It’s a matter of conscience, MPs should vote as they like: who knows the rights and the wrongs.” You know better than this, Jack. You know there is a direct correlation between the gun registry and deaths from firearms. You know the death rate from shotguns and rifles declined an astonishing 44% from 1995 when the Firearms Act was proclaimed to 2008.

From down here in the trenches, your “freedom of conscience” looks a lot like cant and hypocrisy.

Expert opinion, ranging from nurses to police chiefs to Emergency Department physicians have all spoken in favour of retaining the gun registry. They — and I — don’t have any dogs in this fight. I doubt at this point any appeals to reason or even common sense will change your mind, Jack, or get you or your caucus to do the right thing. But when I’m busy getting the trauma room ready for the next gunshot victim — and I know the numbers will increase, as sure as stupidity reigns in Ottawa — I’ll be thinking of you, Jack, and shaking my head. You guys just don’t get it.

Sincerely,

TorontoEmerg

At This Hospital, The Stupid is Strong

St. Joseph’s General Hospital in Comox, British Columbia is having some problems with opening up a new transitional care unit. It’s evidently understaffed and poorly planned, and of course, in planning this new unit, hospital administrators neglected to consult the most important people working there, i.e. the staff. Despite a rosy picture painted by the hospital’s CEO, the nurses are having none of it. Money quote:

By way of example, [B.C. Nurses Union Rep Juanita] Munroe noted that dispensing some medications requires the signature of two nurses. There will only be two nurses on the entire TCU. When one of them is on break or otherwise occupied, how will those medications be dispersed?

Munroe said that one hospital administrator told a member of staff who asked the question to get a housekeeper to cosign.

Get a housekeeper to co-sign. I read this twice to make sure I got it right. Yes, truly. The stupid here is breath-taking. When nurses double-check medications, it’s because the drugs in question are dangerous. Would you trust a housekeeper to double-check medications? Well, unfortunately, gob-smacking asshattedness happens when administrators don’t involve nurses in planning, or worse, analyse their function in terms of what they do, not what they know.

In the event, I’d like to know what kind of hospital administrator is down with the housekeeping staff to co-sign medications. Because, after all, nothing says quality care and patient safety like getting the housekeeping staff to check meds.

Unbearably Unhappy, Cont’d [Updated]

Wade Schuette at Perspectives in Public Health submitted a lengthy and thought-provoking comment on my post  a few days ago about bad nurse-managers. He suggests the issue, by default, needs to be addressed through professional organizations like (in Ontario) RNAO or nationally, CNA, or in the United States, ANA. He wrote:

I’d say it’s more than an “indicator of poor patient outcomes” … it’s a direct cause.

It’s fascinating, in a morbid way, that a unit with a leak in the ceiling and wet floor would be cited by JCAHO as a patient risk,  but a unit with a manager who clearly damages the psychological-safety and open feedback teamwork required to catch errors and deliver safe care is allowed to continue without comment.

[snip]

So, assembling the fragments of thought here, it would seem that (1) nurses (or anyone) could substantially improve patient care if they could take effective action that would remove rattlesnakes, wet floors, and dangerous managers from the system.
(2) For anyone to try this alone, unaided, by pushing UPWARDS is a proven no-win approach.
(3) Don Berwick is the right guy to lead an effort to put teeth in a move to deal with such managers, and CMS certainly has the clout to threaten to cut off all medicare funding for a hospital that refuses to listen. So that part is in place, finally.
(4) So how can individual nurses contribute to this nascent action coming to fruition. Probably, that’s what professional organizations are about and for.

Conclusion — it’s within nurse’s professional duty to lean on and assist their collective professional organizations to put pressure on Berwick to “do the right thing”, and to rally other nurses to join them in this move to improve patient care AND, as a side effect, to improve working conditions, retention, cost-effective care, hospital survival, etc.

Is that logic solid?

I would agree, with the important caveat of recognizing the limitations of professional organizations. (And incidentally, I wonder if he would include unions in that group of professional associations?) They move glacially, think globally not specifically, and if they are anything like the RNAO, they tend to be somewhat a reflection — unintentionally, I’m sure — of the nursing “leadership”, i.e. managers, educators and such, not front line workers. At the end of it, I fear, the poor nurses I wrote about would only be helped only in a very indirect way, which is to say in the short or even medium-term , practically not at all.

from RNAO's The Healthy Work Environments Best Practice Guidelines

However, there is one particular way organizations like RNAO (and its provincial/state/national counterparts) can be useful: in the development of best practice guidelines. The RNAO, for example, has developed The Healthy Work Environments Best Practice Guidelines, an enormously useful document which addresses this very issue: what is best practice for nurse-managers?

From our review of the literature [writes the RNAO], we identified the following transformational leadership practices that result in healthy outcomes for nurses,

patients/clients, organizations and systems:

1  building relationships and trust;

2  creating an empowering work environment;

3  creating an environment that supports knowledge development and integration;

4  leading and sustaining change; and

5  balancing competing values and priorities and demands.

But again, these are best practice guidelines: evidently the experiences of the nurse on the floor varies widely according to institutional culture and values. I suspect in places where the contribution of  nurses is minimized or demeaned, best practice of any sort would be thrown out the window.

Another thought: it is never clear to me how nurses moving into managerial positions somehow forget they are nurses, and are still subject to standards maintaining patient care and safety (to return to Wade Shuette’s point),  and bad management pretty well precludes providing it: I mean, from a strictly regulatory point of view, becoming a nurse manager does not (or rather, should not) absolve from making decisions that adversely affect patient care, and hospital policy or the priorities of the human resources department does not automatically over-ride professional obligations. Should nurse managers be held professionally accountable for their managerial style when they create poor work environments? Absolutely. However, I have yet to see any nurse manager be formally disciplined by my own professional body, the College of Nurses of Ontario, for poor management. As long the CNO (and its equivalents in U.S. state nursing boards) essentially see themselves as extensions of the management disciplinary process, this is not likely to happen.

I think the best answer, in the end, is as another commenter wrote

we must vote with our feet. Speak our truth politely and respectfully, for our own good, i.e., the knowledge that we’ve spoken and not suffered in silence before slinking away, and then seek out healthy work environments. Not to do this would be hypocritical; we are about health promotion, and need to live and practice what we teach.

It is important to recognize that nurses are not responsible for sick environments and cannot “fix” the negative energy around them. We can speak, and offer to be part of the solution, but there are those who would turn the problem back on the victims, and many nurses, ever eager to help and to be team players, might embrace a problem that is not rightly theirs. A manager who exudes negative energy, and a toxic work setting, are that way for a reason, which others may or may not ever understand. But what it sure is that they are not as they are solely for want of our magic fixes, and we are not likely to save the day with heroic efforts to “help” the leopard change its spots.

Walk, my colleagues! You and your patients deserve better!

Excellent, and I couldn’t agree more. And it has the added benefit of causing real pain to a health care corporation. Bad management has immediate monetary consequences. Filling vacancies, and then hiring and training new nurses is not without real costs: I have heard figures of upwards to $50K per nurse for orientation, incentives, and lost productivity. Enough losses of this sort (one would hope) should be enough to twig someone higher up something is amiss. I know, in practical terms, this is not realistic for many older nurses, who are unwilling to give up seniority, benefits and pension. They have too much invested in their present employer to leave, and I know some managers willingly, even enthusiastically, exploit and abuse this commitment. Younger nurses, and especially new(ish) graduates have far more flexibility, especially if they work in large urban centres like Toronto which have a multiplicity of employment choices.

[UPDATE: Apparent cat-induced post title malfunction corrected. The cat has been spoken to, sternly. The cat apparently doesn’t care. She writes: djpofsaha’of;alllllllllllllllllllguuuuuuuuujf’ashf. So there.]

The Brains Behind the Operation

At least she’s not sitting on the keyboard.

In Which I Irrefutably Prove My Own Idiocy

As I’ve probably mentioned once or twice before, I am a complete Luddite at heart. If I am asked if technology has increased the net happiness of humanity, I would probably give a firm No as an answer. I view computers and such like a gas station attendant eyes a fifty dollar bill, which is to say, dimly. Now I’ve been having trouble with my Interwebs connection these last couple of weeks, stemming from a lightning strike on my local wireless tower (or thingamajig), and I’ve had intermittent outages ever since.

So, my service was down twice last week, for a short period of time Monday, then on Tuesday evening, it gave up altogether. Fine, I thought, it’s been up again (usually) by the next morning. So I waited.

Wednesday. No internet. Also no phone, because I have VoIP service.

I was actually okay with that. An Internet holiday, if you will.  Sometimes you need a break from the constant clamour of vast amounts of indigestible information. No bothersome phone calls was a bonus. Never for a moment did I think of calling my ISP and finding out what the problem was. In August, my motto is “Sans Souci”.

Thursday. Still no access and no phone. I was beginning to get a little annoyed. “Stupid unreliable Internet company,” I muttered to myself.

But I went to my neighbours’ who I knew had the same service. She looked at me quizzically. “Oh,” she said, “We haven’t had any problems.”

So I went home. And I just happened to glance over at my wireless router and — THE DAMNED THING WAS UNPLUGGED.

Seriously. The cable from the outside to the router was disconnected. For three fricking days.

Needless to say, on the idiocy scale of 1 to 10, I score an impressive 9, which is above Lumbering Oaf but only slightly below Slack-jawed Yokel.

What I don’t understand is how it came unplugged in the first place. Ghosts? The cat? Evil neighbourhood children? Bad Internet karma? How does anything like that happen? Sometimes it is, just pure magic.

[UPDATE: On Twitter, mich0485 wrote: @TorontoEmerg I would’ve liked the story better if u had called the internet company and had some sassy bitch tell u check ur connection lol

Better story, yep. Fortunately, this time I was spared that particular humiliation.]

Unbearably Unhappy

Any experienced nurse can walk in to any particular unit and tell almost immediately if it’s a happy place to work. There’s something about the body language, maybe, or the lack of laughter, or how the nurses present themselves. Like pornography or good art, you can’t exactly put you finger on defining it, but nevertheless, you know it when you see it. I like to think (for all of my moaning and biting) my own little corner of nursedom is a fairly happy place to work, or at least, it’s far, far better than most of the places I’ve worked.

My father has a chronic condition which requires fairly regular if infrequent visits to a particular Toronto-area hospital for consultation. So today I spent the day with him and his wife at this hospital while he was getting treatment. While my father was in the procedure room, I remarked to his wife (who incidentally is a retired nurse, and a pretty sharp observer, to boot) that the nurses working in the short stay unit seemed particularly unhappy.

“Oh yes,” she replied. “I’ve talked to a few of them and they’ve all said it isn’t a pleasant place to work.” She lowered he voice. “In fact, I’ve seen the manager come on the floor and ream out a few of them here in front of patients and families. Totally, totally inappropriate.”

At that moment the manager came out. She was short and pale, and looked like she ate nursing licences for breakfast. Hell, she scared even me. There was an immediate stiffening amongst the nurses, and a couple of them, I noticed, surreptitiously left the unit through a back exit. Definitely an authoritarian, then. I felt sorry for this gem’s staff.

If I were a manager, and my staff were avoiding me like the Ebola virus, I might think I may have a problem. She probably thinks she’s doing a good job, and has mastered the voo-doo arts of human resources management.

I emphatically would not work that particular unit, nor would I work in a hospital that supports that management style. It’s bad nursing and bad for nursing.

I wondered though: in choosing between a happy work place and an unhappy one, wouldn’t you choose the former and eschew the latter as being unfavourable for morale and a quality nursing work-life environment, and therefore poor inducement for retention and recruitment, and more importantly, an indicator for poor patient outcomes?

New From K-Tel! The Career Nurse Select-o-Matic!

It slices, dices and juliennes!

Favourite Poems XVI

Let me not to the marriage of true minds
Admit impediments. Love is not love
Which alters when it alteration finds,
Or bends with the remover to remove:
O no! it is an ever-fixed mark,
That looks on tempests, and is never shaken;
It is the star to every wandering bark,
Whose worth’s unknown, although his height be taken.
Love’s not Time’s fool, though rosy lips and cheeks
Within his bending sickle’s compass come;
Love alters not with his brief hours and weeks,
But bears it out even to the edge of doom.
If this be error, and upon me prov’d,
I never writ, nor no man ever lov’d.

— Shakespeare, Sonnet CXVI

Mixing the Sexes

News from Britain: if you’re a gal in hospital, the guy in the next bed won’t be a guy any more.

The government will announce that it is to end the “indignity” of mixed-sex hospital wards in England by the end of the year, it has been reported.

The Daily Telegraph said health secretary Andrew Lansley is to declare that men and women sharing wards is to be ended in all but accident and emergency and intensive care units by the end of the year.

[snip]

Mr Lansley confirmed last night that he would be making a statement on the subject “shortly”, saying that getting rid of mixed-sex wards was in the best interests of patients.

“I have made clear repeatedly my deep frustration at the fact that mixed sex accommodation has not been eliminated from the NHS,” he said.

“Eliminating mixed sex accommodation is in patients’ best interests, and I made clear the priority I attach to it in the revised operating framework published in June. I will have more to say on this shortly.”

If he succeeds he will achieve a goal which eluded Labour ministers for over a decade.

Oddly, I never realized hospitals in Britain had mixed-sex ward rooms: I had just assumed they were (mostly) segregated by sex, as they are here in Canada.

In any case, I’ve always had a bit of a problem from a purely Emergency Charge Nurse Clinical Care Leader/logistical/practical point of view with sex-segregating patient beds. I don’t know how often I’ve had people rotting in ED stretchers for days at a time, while there were four or five empty beds on 5 North or somewhere, only they were “male” beds or “female” beds, and there weren’t any patients of the appropriate gender who could go up. In my scheme of things, the Emergency Department is never the right place for admitted patients, and there is no such thing as an “inappropriate” bed based on a person’s sex. If there are beds, get the patients up, regardless of sex.

The Title Is About The Power

When I was young and worked at Sticksville General Emerg, we had exactly one dental surgeon on call. I secretly called him Dr. Fabulous, because in his esteemed and respected opinion, he was fabulous. He was fabulously good-looking, and lived in a fabulous house with fabulous wife and children; his practice was fabulous, and of course, his ego was fabulously huge.

As I’ve mentioned before, Sticksville Gen was somewhat reactionary in attitude: the physicians were all men and the real leaders and heroes, and the nurses followed them like meek lost puppies. We had one nurse — Suzanne — however, who didn’t quite fit the mold: she was, truth be told, dangerously mouthy.

One day, Dr. Fabulous made his triumphal entrance, all pomp and self-regard, into the emergency department to look at the smashed mandible of an 18 year-old hockey player.

“Jim,” said Suzanne, “Your patient is in Minor Trauma.”

Dr. Fabulous screwed up his eyes and made a great show of looking at Suzanne’s name tag.

“Suzie,” he said, “You will please address me as Dr. Fabulous!”

Without missing a beat Suzanne screwed up her eyes and looked at Dr. Fabulous’s name tag.

“In that case, Jimmy,” she said, “You may call me Nurse Assertive or Mrs. Assertive. Only the people I like get to call me Suzie!”

I was reminded of this story when I saw this article: Doctorate in nursing causes confusion, resentment.

Shirato, a nurse practitioner, just got her doctor of nursing practice degree at Thomas Jefferson University.

[snip]

Most newly graduating physical therapists now have doctorates, too. Pharmacists and psychologists already made that move. Audiologists, physician assistants, and occupational therapists can also get doctorates.

As nonphysicians with doctorates proliferate, the potential for confusion has grown, and physicians aren’t happy about it. A 2008 survey by the American Medical Association found that 38 percent of patients believed that nurses with doctorates were medical doctors.

The American Medial Association has produced model “truth in advertising” legislation that requires health professionals, including physicians, to wear badges that clearly spell out their credentials.

Yeah, well, yawn. Just do normal practice and identify yourself when you meet the patient. In any case, I’ve come around to the opinion that titles of any sort are antiquated expressions of professional authority. Physicians acquired the title “doctor” — and remember it was originally, and still is, an academic title — over the course of the 18th Century to establish their credentials on par with the traditional professions (and gain entrance to the middle-class). They then spent a good part 19th Century trying to deny the same title to surgeons who were, in their opinion, “mere barbers.”

Titles, in short, are about establishing status and power. Why else worry about them? They are utterly irrelevant to actual patient care and one’s ability to do the job. Insisting on their use can create an atmosphere of professional intimidation that suppresses the free exchange of information. Health care professionals expressing power over patients is definitely not a good way to create therapeutic relationships. Implicitly saying (or believing) the title makes you a better person or supplies you with definitive or superior knowledge about patient care is dangerous as well as destructive to collaborative relationships with other health care professionals. In the end, it results in bad care of our patients, and of each other.

Some physicians really resent the loss of power. Don’t believe me? Check out why the defensiveness of this physician.

James Goodyear, a Lansdale, Pa., general surgeon and president of the Pennsylvania Medical Society, said health care workers who are not physicians should immediately tell patients what they do.

“I am a physician. They are not,” he said. “They trained for hundreds of hours. We trained for thousands of hours.”

And, he said, physicians should still be in charge. “We think that those in the allied health fields that get a doctorate such as in nursing are a very, very important component of a physician-directed … team,” he said. [Emphasis mine.]

Not about power and status? Fer sure. When this guy says, “I am physician” you can almost hear the sub-vocal “I am God”.

Oh, and thanks for the condescension too.