Posts Tagged Registered Nurses’ Association of Ontario

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.”
[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.


*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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Out of Sorts

Don’t know if it’s the crazy weather, but just feeling a little whacked today. Got up this morning, all burstin’ to write an epic post about the RNAO’s new best practice guidelines on restraints, wrote about three paragraphs and went bleh. Didn’t care as much as I thought. So maybe Sunday, if at all.

Other stuff: I made the Sunshine List — one of 79,000 —for the first time ever. For those out of province and out of country, the Sunshine List is the provincially-mandated disclosure of salaries over $100K for public and near-public employees. It makes for hours of entertaining reading. Really. Some of my colleagues made near $150K — and I thought I did a lot of overtime! ( I was a few thousand over.)

Also, some big changes coming soon to this blog. Are you excited yet?

Also: I know the great March heatwave is over, though its still 15C (60F) here as I write — about 8C (18F) above normal. More normally abnormally warm, if you know what I mean.  I went out a couple of days ago to take some pictures to document the tremendously early arrival of spring. Not great pics, but you get the idea something is strangely amiss. 

Daphne mezereum. Usually blooms here first or second week of April.

Maple blossoms. Maybe a month early, at least.

Maple blossoms en masse

Magnolia bud break. About a month early.

It would be foolish to attribute one weather event to climate change, the way anti-science types and assorted denialists think snowfall in Toronto in winter invalidates climate change science forever and for all time. However. . .

UPDATE: Minor syntactical fixes, because my hobbit-editor I bought ran away shouting some crazy talk about a magical ring.

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What I Did Yesterday

As you might have noticed, I wasn’t here yesterday. You’ll be glad to know I wasn’t merely frivelling my time away: I was downtown (Toronto, that is) at the swankish and hip world headquarters of the Registered Nurses Association of Ontario, which is mere blocks from ground zero of the Toronto International Film Festival and other cultural hubs like the Royal Alex, Roy Thompson Hall and the opera house; compare and contrast with that other institution for Ontario nurses, the College of Nurses of Ontario, located at the ugly and unfashionable end of Davenport. I was being all professional and nurse-empowering, helping out a friend with a project having to do with best practice guidelines. All very hush-hush and on the q-t, you know. Actually not. But still, it was all very interesting, and I could make a point of telling people I met there, “Yes, I’m a RNAO member!” and be actually telling the truth. For once.

Then off to a long lunch of sushi with said friend, after creating a small(ish) disturbance in an East Asian grocery on Spadina. I avoided re-enacting last year’s sad debacle. All in all, a satisfactory day. But did you miss me?

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Being a Naive Nurse Will Get You Thrown to the Wolves

In matters related to practice, errors, or sentinel events, are nurses far too naïve when it comes to dealing with their employers, regulatory bodies, or police? Nurses falsely assume that all of these authorities will act in, or at least be mindful of, their best interests. The thought that any of them might act solely in their own self-interest (at best) or in bad faith (at worst), is probably beyond most of us. The fact is none of them have a nurse’s interest as their top priority, if in fact they consider it all. Aside from a duty to ensure patient safety, hospitals have a legal, fiduciary obligation to protect themselves from liability issues and legal action. Regulatory bodies act in the public interest. Police decide if behaviour is criminal and lay charges. We should not be shocked (but often are) when any of these lie, manipulate or misrepresent themselves to gain a nurse’s trust and coöperation in order to pursue their own agenda. Woe to the nurse who trusts authority to do right by them!

I’ve written about the Winkler nurses, where this seems the case, and about Brian Sinclair’s death in a Winnipeg emergency department waiting room; here I fear the police will use information obtained from the triage nurses in the original investigation against those same nurses, information incidentally given in good faith that no charges were pending. Or think about what happened to Gita Proudman, who was unjustly charged with killing a dying infant in 1998. The charges were withdrawn over a year later.

Or consider this case, in which  an employer and police  have accused two nurses of deliberately cutting umbilical catheters, a type of intravenous used on newborns:

Two Sunrise Children’s Hospital nurses whose licenses were suspended because of disrupted catheters — which left one newborn in critical condition — are targets of a Las Vegas police investigation into “intentional patient harm,” State Board of Nursing records reveal.

Another infant had to undergo an emergency procedure as a result of a catheter disruption, the hospital reported.

Registered nurses Jessica May Rice and Sharon Ochoa-Reyes were suspended by nursing board President Doreen Begley “in the interest of public health, safety and/or welfare” after the regulatory agency received notice on June 10 from law enforcement officials that each nurse was a “person of interest” in an “ongoing criminal investigation,” according to documents obtained Tuesday under the Nevada public records law.


Katherine Ramsland, a criminologist at DeSales University in Pennsylvania who has long studied health care workers who run afoul of the law, said Sunrise officials now must study incidents and deaths in the neonatal unit “over many months and perhaps years.”

Sunrise officials would not say how many infants had what medical officials term “unexpected outcomes” when Rice or Ochoa-Reyes was on duty in the neonatal unit.

Ramsland said nurses who do harm to patients are very good at covering up what they do. “Often they’re not caught for years,” she said.

Nurses who harm patients are known as “Angels of Death” because after they are caught they say they were putting patients out of their misery.

Angels of death?* Seems straight-forward, doesn’t it? But some salient points in this case: the nurses had complained to the hospital in good faith about problems with the umbilical catheters; the hospital ignored their complaints until infants began to suffer complications from the catheters, when they fired the nurses and called the police to investigate; the hospital in fact knew about problems with the catheters, but was dilatory in addressing the issue; the hospital refused to consider testing the catheters for product failure, but chose instead to have a “forensic analysis” attempt to prove the lines were intentionally cut to build a case against the nurses; the hospital contacted the manufacturers about potential problems, yet refused to disclose the email communications with the manufacturer; problems with the lines ended when the hospital changed manufacturers; and the Food and Drug Administration had issued advisories about the problem previously. Significantly, after initially pulling the nurse’s licences, the Nevada State Board of Nursing reinstated them in September, citing a complete lack of evidence of negligence or wrong doing. The police investigation, unfortunately, is continuing.

Read carefully what the nurses have to say about this nightmare:

Both nurses now say they realize they were naïve in dealing with authorities. Both agreed to police interviews and polygraphs because they said they had nothing to hide.

But in separate interviews with police, each said a detective ended up yelling that she enjoyed killing babies.

“I couldn’t believe what I was hearing,” Ochoa-Reyes said. “I told them over and over I would never do such a thing.”

Rice said she listened to a police detective rant and rave about her being a baby killer for four hours.

Finally, she said, the detective told her to leave when she kept repeating that she would never hurt a child. [Emphasis mine.]

Let me return to Gina Proudman for a moment, who wrote about her experience for the Registered Nurses Association of Ontario:

[I] am the nurse who had that charge against her withdrawn on November 9,1999. I had held a dying baby, who had no one there to hold him, and he died in my arms. I was naïve. When the police wanted me to answer a few questions, I said of course, I had nothing to hide. For that same reason, I did not take a lawyer with me.

Needless to say, that was a serious error in judgement. That particular piece of naiveté resulted in a charge of second degree murder, complete with a nine-day period of time spent in a segregated cell.

*****     *****     *****

What did I do wrong? My first, and biggest, mistake, was not getting a lawyer immediately. When the situation was presented to me by management, I knew it was serious, but I felt that since I was not guilty of anything, I did not need a lawyer. I felt that obtaining one would make me appear guilty (a view that was reinforced by the police when I made mention of possibly bringing an attorney). Wrong. If anyone needs a lawyer, it is an innocent person. You need someone to discuss with you whether or not you will give a statement to police, and if you will, what the content of that statement will be.

Do not give a statement without having discussed it with a lawyer first. The innocent can be easily manipulated because of a desire to clear their name. There is a strong belief that the police and people in authority really are seeking the truth. As I discovered, this is not always the case, and one has to protect oneself immediately. [Emphasis mine.]

You see the common theme. We trust too much. The lawyer of Sharon Ochoa-Reyes is fairly clear the hospital is trying to scapegoat the nurses for avoiding, and then covering up a known problem with a medical device, in order to escape their own liability. Did the hospital act in bad faith towards its nurses? From my particular perch, it looks like it. Here lies a lesson for all nurses: ultimately, your employer will only ever act in its own interest. And ditto for regulatory bodies and the police.

Nurses are sometimes deceived by the perception of commonality, that employers and the rest always have our best interests — our professional lives or even the care and safety of our patients — at heart. It isn’t true, and all nurses need to develop a high degree of skepticism and critical evaluation to navigate a minefield of competing and conflicting goals and agendas. It’s important to remember why nurses are frequently thrown to the wolves: we’re relatively small fish in the hospital food chain, we tend act passively, even when accused of negligence and malfeasance, and we are too deferent to authority. When bitten we tend not to bite back. We scarcely even bark. This must change, and I think it is changing as nurses clearly and forcefully advocate for their profession and for themselves.

However, to some degree we can also take practical measures to protect ourselves. Clear, accurate and timely documentation and charting is essential (and obvious) for nurses to protect themselves, and is something none of ever give priority to. But we never think to take notes, even immediately afterwards, when meeting with a manager or some other administrator, or documenting for our own records concerns about practice or equipment. Membership in a professional organization is essential, especially if like the RNAO they offer a degree of legal advice. Don’t hesitate to enlist your union to back you, or if the police or a regulatory body comes to investigate, a lawyer. In short, nurses must always aggressively defend themselves, because in the end, no one else will.

[Many thanks to the ever diligent Vernon Dutton (TwitterFlickr) for pointing out the Nevada cases to me. His take can be found here.]


*Nurse stereotyping at its best. The expert here also has an abiding interest in ghosts.

[UPDATE: some minor wording changes for clarity.]

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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.


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.]

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