Posts Tagged Health care provider

Fat Nurses Need Not Apply

A Texas hospital has declared war on the scourge of obese nurses:

A Victoria [Texas]  hospital already embroiled in a discrimination lawsuit filed by doctors of Indian descent has instituted a highly unusual hiring policy: It bans job applicants from employment for being too overweight. 

The Citizens Medical Center policy, instituted a little more than a year ago, requires potential employees to have a body mass index of less than 35 — which is 210 pounds for someone who is 5-foot-5, and 245 pounds for someone who is 5-foot-10. It states that an employee’s physique “should fit with a representational image or specific mental projection of the job of a healthcare professional,” including an appearance “free from distraction” for hospital patients.

“The majority of our patients are over 65, and they have expectations that cannot be ignored in terms of personal appearance,” hospital chief executive David Brown said in an interview. “We have the ability as an employer to characterize our process and to have a policy that says what’s best for our business and for our patients.”

It all sounds so, well, high-schoolish, and I don’t think the CEO is seventeen, though he’s acting like it. I mean, can you get any more shallow? Since when does physical appearance have anything to do with competence or worth or dignity of any health care professional?

Or maybe David Brown doesn’t really believe nurses actually have skills — we just stand around as decoration, lookin’ pretty.

And fitting the  “representational image” of hospital employees to meet patient “expectations?” What the hell does that mean, anyway? If  patients expect this (and this is a pretty common “representation”)

A representational image of a nurse

then hiring practices should make sure all nurses are boobalicious? What if the patients want all-white nurses? Or all females? Or no Muslims?

The man is a bit of a dink, obviously. I can only imagine how valued overweight nurses employed by this hospital must feel.

The article goes on to note that this David Brown, CEO of Citizens Medical Center, has some issues. In 2007  he wrote memo about some foreign-born physicians in which he  stated: “I feel a sense of disgust but am more concerned with what this means to the future of the hospital as more of our Middle-Eastern-born physicians demand leadership roles and demand influence.”  He continued, “It will change the entire complexion of the hospital and create a level of fear among our employees.”

Needless to say, there is a discrimination lawsuit over that.

So let’s summarize what the leadership at Citizens Medical Center believes: scary scary fat nurses scaring patients. Scary scary dark-skinned physicians scaring employees and patients.

Clearly a place where I would want to work. Or be treated.

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How Hospitals Punish Nurses for Being Sick

I admit it: I’ve gone to work sick when I should have stayed at home. I’ve gone with hacking coughs, sore throats, Fevers Not Yet Diagnosed, and probable gastroenteritis. I’ve gone in with migraines. Once when I was being treated for an I & D’d abscess, I went in with a saline lok, a kind of intravenous access to give me antibiotics. Should have stayed home, I confess, I know better, but there it is.

So I listened attentively to Brian Goldman’s CBC Radio show White Coat, Black Art this week (you can hear it at the link) on health care professionals coming in to work sick. We do it for reasons perhaps not unique to health care: we don’t want to let down the team, there’s no one to replace us, we’re indispensable. He mentions physicians being expected to show up unless dead or nearly so; nurses, when I was a student at least, were inculcated from our first clinical day that calling in sick was tantamont to being a bad nurse.*

However, the consequences of having sick health care professionals are, of course, unique: we tend to infect patients who are already compromised. As bad, or worse, we compromise our judgement: who can think clearly with a temperature of 39.8C, or while having to run to the toilet every ten minutes? Goldman suggests that a massive culture change in hospitals is necessary to let health care workers take sick days as needed. I agree. But it’s not going to happen any time in the near future: hospital administration itself is the biggest obstacle. There are clear choices in creating a culture that gives permission for nurses in particular to take sick time. I don’t believe hospitals have the will to make that cultural shift.

Let me explain: the problem of sick nurses, other health professionals and ancillary staff coming to work — I’m leaving out physicians, because in Ontario hospitals, they aren’t subject to the same scrutiny as nurses — highlights an internal conflict within hospital administration. In an ideal world, Infection Control in all hospitals would dearly like nurses and the rest to stay home if they’re sick. Patient safety, after all comes first. In the real world, however, hospital Human Resources departments do not consider infection control as a priority. Human Resources views sick time as a controllable cost, and frankly, sick nurses a problem to be managed.

It’s true in general that nurses take higher than average rates of sick time. The reasons for this are complex: we are, after all, exposed to infection on a daily basis, the nature of our work is highly stressful (which in of itself has health consequences), and sick time is an indicator of nursing morale which in many hospitals is quite poor. The job of human resources is to provide strong disincentives to nurses (and others) calling in sick. They d0 this in a couple of ways. In Ontario, hospitals cut sick pay for nurses by up to a third, depending on seniority. If you’re a sole-wage earner living paycheque to paycheque, it’s a substantial amount. Pragmatically speaking, if it’s between feeding your kids, and coming in sick, even if you are a conscientious nurse, guess which will win.

Further, nurses must cope with attendance management programs. In Ontario, and I know this is true in many American hospitals, nurses are subject to punishment if they take as few as three sick days, and made (with union acquiescence) to attend humiliating, disciplinary “attendance-management” meetings. For their part, hospital management and the union — the Ontario Nurses Association — will vehemently deny the attendance management process is disciplinary in nature. Personally, I have never been subject to attendance management. But I have seen nurses leave these meetings distressed to the point of tears, and I know of one nurse who left her position and the hospital because of Human Resource harassment. It’s discipline by other means and it’s a strong deterrent to taking sick leave. I’ve come in sick myself knowing I was close to the threshold of being put on “The Program.”

A conversation I had a few months ago with the Infection Control Nurse illustrates quite nicely this tension between the conflicting goals of Infection Control and Human Resources. The context was a mini-outbreak of gastroenteritis; three nurses were off sick. The Infection Control Nurse got wind of this outbreak, and wanted to ensure the nurses stayed home for 48 hours after the last symptoms, as per hospital policy. She wanted names, which I refused because of confidentiality.  She then wanted me to call the nurses. I refused again. I knew at least one of them was already in some difficulty with the attendance management program, and I was unsure about the rest.

“Well,” she said. “Let me call them.”

No, I said. I explained to her how Human Resources will punish the nurses for following hospital policy.

“Oh,” she said. “That’s a human resources issue, not an infection control issue.”

Actually, I thought, if you have an otherwise diligent, handwashing-fanatical nurse like me resisting infection control directives, human resource policy is an infection control issue.

In the end, hospitals must choose between trying (and mostly, I think, failing) to control sick time costs and making infection control truly a priority. It’s no good telling nurses to stay home if they are sick, only to turn around and punishing them for fulfilling what is really a professional obligation. Half-measures, like telling nurses to mask for their 12-hour shift, or to be “extra-diligent” in handwashing are impossible to enforce. Maybe some innovation is needed on how we look at sick time. One U.S. hospital I know of recognizes only 2-3% of employees abuse sick time, and assigns twelve days a year for “personal use,” no questions asked, after which HR begins to apply the screws. Nurses who leave part or all the personal days untouched get a payout of three of those days on a pro-rated basis. A change like that would indeed entail a massive culture shift. Present practice does not truly address infection control issues raised by health care professionals working sick, and sends conflicting messages to nurses. Either infection control is a priority for hospitals, or it isn’t. Which is it?

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*I’d be interested hearing from new grads whether this is still true.

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A Patient’s Right to Discriminate

The results of an interesting lawsuit, from Off the Charts, the blog of the American Journal of Nursing:

Brenda Chaney brought suit against the nursing home for complying with a resident’s request not to have any black health care workers provide care or enter her room. (She also claimed her firing had been racially motivated. The court agreed that it seemed discriminatory.) The court agreed with Chaney that by acceding to the patient’s wishes, her employer created a hostile workplace and violated her rights. The nursing home claimed it was protecting the patient’s rights and that not doing so “risked violating state and federal laws that grant residents the rights to choose providers, to privacy, and to bodily autonomy.” The court did not agree.

Of course, most people think, in the abstract at least, that it’s pernicious and wrong to believe race affects the provision of health care, and a request for treatment only by “white” staff takes racism to some bizarre extremes.

I would agree. Patients shouldn’t be able to pick their nurses on the basis of race — and yes, I have heard that request voiced more than a few times. Frankly, I don’t see the necessity of pandering to anyone’s bigotry, any more than I would tolerate racism towards a patient from my colleagues. Some behaviour crosses the line, and while nurses must treat their patients with respect and dignity, it’s also a two-way street.

While health care professionals’ indelible personal characteristics may be irrelevant to providing good care, can one apply this point of view absolutely in dealing with patients in all circumstances? Does it override one of the cornerstones of health care ethics, patient autonomy, the right of  the patient to decide the course of their care? Matters are much trickier than they might first appear, for they require providers treading through a minefield of strongly held personal, religious and cultural beliefs. Then there are pragmatic aspects to consider. For example, a nurse might well hesitate before assuming care of a racist patient, on the basis the patient might be more inclined to make false complaints about his practice. Another example: as a charge nurse, I will ask female nurses, rather than my male colleagues, to perform intrusive procedures like ECGs (which require exposure of the chest) on female Muslim patients, because I believe it’s expedient to providing the best possible care for the patient. But in emergent cases, any set of skilled hands will do, for exactly the same reason, which suggests to me patient autonomy is always constrained by patient acuity, regardless of personal attitudes towards those providing treatment and care.

Some thought experiments to consider:

1. A Muslim or Hasidic Jewish patient requests same-sex nurses only, and refuses care from a nurse of the opposite sex. Is this different from refusing care because a patient is uncomfortable with a person’s race? Why?

2. A fundamentalist Christian doesn’t want to be touched by a gay male nurse, on religious grounds. Should she able to refuse care on the grounds of the nurse’s sexual orientation? Is this different from the Muslim or Hasidic Jewish patient?

3. What if it’s your ailing, elderly Gran, normally a sweet, kind lady, except for that adamant blind spot about blacks/gays/male nurses? What would you tell her? What if she was dying?

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