Posts Tagged RNAO
With Ontario’s Nursing Week approaching, May 7 – 13, posters for the Ontario Nurse’s Association (ONA, our union) campaign on supporting nurses the same way pro-athletes are have been put up around Acme Regional.
The conversation often arises among my colleagues about how a baseball player can make over 20 million dollars a year where 3 or 4 nurses’ lifetime salaries combined will never compare to that. I often feel bitter when I think of those in the business world who receive all sorts of financial and personal incentives for their work. People who go on all expense paid trips because they have sold the most insurance (selling you safety nets in case you fall, but you likely won’t, however you have to have it…) for example that year, meanwhile in that same year I may have resuscitated a child, held the hand of a dying man during his last breath and treated a father of 4 for a heart attack among caring for other incredible people. I received my same pay as always and more importantly, do not expect an incentive. I don’t feel bitter that I’m not getting a trip, I feel bitter that in this society, a pro-athlete or businessman is more supported than nurses. On the other side of the coin, it makes me wonder what sort of nursing culture would be bred if nurses were provided incentives for life saving measures or actions/treatment/education. And what treatments or care would be deemed “more important” than others, garnering a higher incentive? In the emergency department health teaching is imperative; to prevent illness and disease so one could argue that is as important as treating the patient having a stroke. If incentives in nursing existed would the wrong sort of people be attracted to the nursing profession? Some say it’s a calling, the art of the practice; only certain people can and will do the job and do it well have you. It would be worrisome to think that an individual would only want to save a life or teach parents about how to appropriately treat fevers if it meant they would get a financial bonus.
And yet, despite all of this, I still struggle with the fact that people who sell the most cars, buy the most stock in a company, etc… are seemingly more valued and appreciated then those that save lives, give people more time on earth and genuinely (most of us at least) care about humanity. I have a hard time finding the balance in it all. Emergency nursing is in the “business of life saving” is it not? With more and more facilities receiving incentives for improved and rapid physician to patient initial assessment times, where does appreciation for the nurses fall in to all of this?
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.
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.]
[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.
*Nurse stereotyping at its best. The expert here also has an abiding interest in ghosts.
[UPDATE: some minor wording changes for clarity.]
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.
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?
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.]
Posted by torontoemerg in Before I Start Throwing Things, I'd Better Write This Down, What Nurses Really Want on Sunday 16 May 2010
In many ways the Registered Nurses Association of Ontario — RNAO — is the very model of a professional nursing association, pushing hard for good health care for Ontario, advocating for nurses, and promoting best practice and clinical excellence. It was the RNAO, which during the dire days of the Harris government in the 1990s, essentially saved the nursing profession in Ontario. In some ways I can’t speak highly enough of this organization, our organization.
I was checking out the RNAO website the other day, when I came across this:
The RNAO Centre for Professional Nursing Excellence and the International Affairs and Best Practice Guidelines team are pleased to bring you the Annual Best Practice Guidelines Summer Institute, a knowledge and energy-filled week-long educational experience. This institute offers an unsurpassed opportunity to learn from experts about clinical innovation, implementing best practice guidelines and championing clinical excellence.
Sounds exciting, I thought. Or at least relevant to my practice. Or this conference:
RECHARGE Your Workplace!
An opportunity to learn from the experts the key steps to creating healthy work places and evaluating the impact.
An exciting and dynamic education event.
A powerful forum for the exchange of knowledge and strategies about Healthy Work Environments through realistic case studies.
Now this was up my alley. A topic I feel strongly about, especially because of the relationship with patient outcomes. And it was far enough ahead I could actually get the time off without too much difficulty.
So I linked to the application form. I blinked. The conference fees for the “Healthy Work Environments Summer Institute” were:
RNAO Member: $2,270.00 + GST ($113.50) = $2,383.50 or $2270.00 + HST (13%) as of July 1, 2010 ($295.10) = $2,565.10
Non-Members: $3,180.00 + GST ($159.00) = $3,339.00 or$3,180.00 + HST (13%) as of July 1, 2010 ($413.40) = $3,593.40
The fees for the “Annual Best Practice Guidelines Summer Institute” were similar.
That’s some serious change. Even if I’m an RNAO member, nearly $2,400 for a five day conference would carry some serious thought: it’s $480 a day exclusive of incidentals. It’s three mortgage payments, two weeks at a Cuban all-inclusive (with air fare) or financing for a medical mission trip to South America. To put it in perspective, to certify in Trauma Nursing (TNCC*), which directly affects my patient care and ultimately, patient outcomes, costs around $420, including textbook. And that’s over two days. If you are a new grad, or raising a family, or even furthering your education, $2400 is a pretty significant chunk of your annual income.
I’m guessing the demographic profile of attendees would be older and not younger, academic and managerial rather than front line, and wealthy (or institutionally well-funded) instead of middle middle-class. In short, the average, bedside RN is effectively barred from attending these events, not officially or as a matter of policy, but practically as a matter of money. Who can afford it?
I can’t. I don’t have a sugar-daddy, institutional or otherwise.
A clue: in the application form, there is a space for “title”, i.e. what is your exalted place in your institution’s food chain. Implication: if you have no title but Registered Nurse, don’t bother coming.**
For an organization dedicated to “[r]especting human dignity. . . a community committed to diversity, inclusivity, democracy and voluntarism,” is this right?
Granted, there are resources available to offset this extraordinary cost. The provincially-funded Nurse Education Initiative will reimburse $1500 of eligible program costs. But the process is labyrinthine and slow, the financing isn’t guaranteed, and in any case, who can afford to carry $1500 for three months while the application is decided?
I am an RNAO member, and I am concerned. My first problem is relatively minor: for years, the RNAO fought and still fights the widespread (if mainly unfair perception) that it’s an elitist society for management and academics — the ones who can say shit, as a colleague on mine once said, but would never touch it. I’m guessing that if you ask bedside nurses who are not members of the RNAO why they are not members, a fairly large percentage of them will state it’s “not for me” or “they don’t care about front line nurses.” Hard to argue the point when in fact that appears to be the case.
More seriously, there is a problem with ethics and accountability. To put it plainly, I appear to be financing conferences, through my RNAO fees, which apart from their entirely hypothetical benefit to the profession, I am effectively barred from attending because of their high cost and the cumbersome reimbursement process. Even if these conferences are self-financing (which I would hope), RNAO resources, which I pay for, are being expended in terms of organization, advertising and so forth. Bluntly, why should RNAO members enable our nursing leadership to hang out in Hockley Valley for five days when we ourselves are for all intents and purposes excluded?
Lastly, and most aggravatingly, these conference actually seem to be hugely useful. The point is not that I am against conferences of this sort, but RNAO should make them entirely more accessible to all nurses. If RNAO is serious about empowering nurses at the bedside, and making them the strongest possible advocates for the profession and their patients, it needs to give front line nurses the serious tools to do so. Because with few exceptions, we are not going to get this sort of leadership from our managers, and academia ultimately can’t do this work for us. We really need to know about best practice and how to build a safe workplace. We need to learn the language and gain the skills. The front line is the nexus of change in the nursing profession. The future of nursing is located here.
I don’t think, of course, any of this is deliberate on the part of RNAO. I think it rather bespeaks a sort of institutional carelessness, lack of mindfulness and isolation. But ultimately, excluding nurses from gaining these skills because of financial reasons is ultimately counter-productive and estranges the front line from the leadership. Twenty-five year-old nurses two or three years from graduation should be populating these conferences, not fifty-seven year-old managers near the end of their careers.
*TNCC = Trauma Nursing Core Course
**I spent some moments thinking up titles to grant myself. Such as “Vice President of Charge Nursey Affairs” or “Anonymous Blogger Extraordinaire.”
Sort of screwing the pooch today, which means I’ve picked at about five different posts for your ongoing amusement, but got bored with all of them and finished none. Instead, some bits and pieces bouncing around my draft pile. Consider it my version of the clip episode.
1. The Truth About Nursing, a web site that monitors how the media portrays nursing, released its Best and Worst Media Portrayal of Nurses of the Decade.
Wanna guess, dear colleagues, which shows get it in the tender parts?
1. Grey’s Anatomy — created by Shonda Rhimes, ABC, 2005-2009.
This hugely popular drama pretended that nurses play no significant role in hospitals, as the heroic surgeons who dominated performed many critical tasks that nurses do in real life. But the show also included direct attacks on nursing, and presented nurses as bitter or fawning losers.
2. House — created by David Shore, Fox, 2004-2009.
This hit hospital show ignored nurses completely–except when it showed them as mute, anonymous lackeys to the smart physicians who provided all the important care, and when the brilliant Greg House attacked the nurses as annoying fools who were just there to clean up the mess.
3. Private Practice — created by Shonda Rhimes, ABC, 2007-2009.
The show began by mocking clueless nurse Dell Parker–who worked as a receptionist at an L.A. health practice–for his midwifery studies. Although Dell eventually appeared to become a nurse midwife, he showed little expertise compared to the brilliant physicians who dominated.
What’s even worse are the clearly clueless nurses who defend these shows being “entertaining” and that the “public really knows the difference.” Sometimes we are our own worst enemies.
TORONTO, January 21, 2010 – Members of the public will not be well served if the provincial government pursues a plan to allow physician assistants (PAs) to work in hospitals, family health teams, community health centres, and family physician offices.
The board of directors of the Registered Nurses’ Association of Ontario (RNAO) has unanimously endorsed a position statement, which raises serious questions about the level of education and regulatory oversight physician assistants have and how these could jeopardize patients.
The role was adopted by the Ministry of Health and Long-Term Care in 2006. A number of pilot projects are currently underway in selected Ontario communities. Physician assistants are not regulated health professionals and can only work under the direct supervision of their assigned physician. They can conduct physical examinations, interpret test results, diagnose and treat illnesses, write prescriptions and assist during surgery.
Wendy Fucile, President of RNAO, says the association is alarmed about the inadequate educational requirements to become a physician assistant. “They only need two years in an undergraduate program to be admitted into a PA education program and their course of study doesn’t have to be in a scientific or health-care related field. The candidate could have studied history or engineering to be accepted.” Fucile also takes issue with the program itself saying the requirement to spend one year in the classroom and one year in a general clinical setting is insufficient.
RNAO’s Executive Director Doris Grinspun says if the Ministry of Health and Long-Term Care is interested in improving access to care and improving clinical outcomes in a cost-effective way, it should be educating and hiring more registered nurses and nurse practitioners instead of creating a new type of health-care worker that is unregulated. “Patients in Ontario can rely on the fact that RNs and NPs are highly educated, skilled professionals. That’s why nurses enjoy the highest level of trust among members of the public.”
Part of this is a territoriality issue. But the reason I find this annoying is that for 30 years or more the RNAO has been pushing for and focussed on the credentialization of nurse practitioners, who represent a tiny fraction of Ontario’s nurses. The rest of us, as far as expanding our scope of practice goes, have been failed by our leadership. Hence the perceived need for physician assistants.
3. Amid all the horror and tragedy in Haiti, spare a thought and a prayer, if you’re so inclined, for Yvonne Martin, a nurse on medical mission, who’s among the known Canadian dead:
The sons of an Ontario nurse who was killed in the Haiti earthquake hours after setting foot in the impoverished country say their mother was a generous person who just wanted to help others find their way.
Yvonne Martin was the first Canadian to be confirmed dead in the devastated region. Her body was found Wednesday, the day after the shelter she was staying in collapsed under the pressure of the tremor.
Luke and Terry Martin said their mother had a special affinity for Haiti. This was her fourth time in the country on a Christian mission.
“She was growing her love for Haiti, this was her retirement plan, to fundraise, learn Haitian Creole and go back,” Luke Martin told CTV’s Canada AM Friday in an interview from Kitchener, Ont.
Yvonne Martin, a resident of Elmira, Ont. travelled to Haiti with World Partners — the missions’ agency of the Evangelical Missionary Church of Canada.
In paradisum deducant te Angeli.