Answering the Call

SECURE LINE Campbell River Public Health nurses (l-r) Crystal Mann, Carolyn Hutton, Joanne Hoffmann Funk and Stacey Chow were part of the team that used the professional responsibility process to replace outdated, inadequate flip phones with smart phones and improve patient care across Vancouver Island.

Campbell River public health nurse Carolyn Hutton recalls feeling spurred to act after missing a vulnerable young mom's call for help due to her outdated, cumbersome and unreliable flip phone.

"A client texted that she was thinking of harming her baby," says Hutton.

But the message didn't show up on Hutton's flip phone until a month after it was sent.

"I felt sick," she says. "It could have ended really badly."

The registered nurse was working for Island Health's Nurse-Family Partnership Program at the time, providing intensive support to young, vulnerable first-time mothers until their children reach two years of age.

Many young women in the program experience significant social or financial challenges such as lone parenting, low incomes, tenuous housing or homelessness, mental health issues or an incomplete high-school education.

Hutton visited clients on a weekly or bi-weekly basis to ensure they had a healthy pregnancy and to help the new moms prepare for childbirth. These meetings also allowed nurses to discuss nutrition, child development and to explore parenting skills and goal setting.

Hutton followed up immediately after receiving the alarming text.

"I called right away, but she was a bit confused because she'd sent it some time ago and I had visited several times since."

Luckily, the young mother had dealt with her feelings by relying on personal supports, but the scenario seriously concerned Hutton. She worried about how the situation could have ended, and how it affected her relationship with her client.

"Building trust and relationships with clients is a pillar of public health nursing," she explains. "She might have wondered why I didn't return the text, and think I didn't care."

The situation was a tipping point of frustration for Hutton.

She and her nursing colleagues in the Campbell River public health unit had been dissatisfied with their flip phones for years.

Given their age demographic, many young moms served by the public health nurses often don't have landlines and rely solely on their cell phones.

Hutton says clients tend to prefer texting to communicate with their nurses, often out of habit, but sometimes because they can't afford minutes on their phones.

But this practice posed confidentiality problems as the obsolete flip phones didn't have PIN-protected locking mechanisms and were shared between staff.

What's more, texting on the flip phones was clumsy and time consuming, so nurses couldn't respond quickly or in great length to clients' queries.

Hutton, at that time the local steward, decided to employ the professional responsibility process (PRP) to rectify a situation she felt was endangering patient safety and nurses' professional practice.

The PRP allows nurses and employers at a local level to engage in meaningful conversation about common goals and to improve patient care or professional practice in a collaborative manner. The process is designed to identify problems and resolve issues without involving blame.

Hutton took the first step in July 2016 by meeting with her manager to express her concerns. Her manager acknowledged the nurses' need for smartphones with data during their initial conversation. However, he requested that the team wait while he explored the possibility of securing the needed equipment.

"It had a huge impact – now all the public health units in Island Health can apply for smart phones."

- Carolyn Hutton

Months then passed, and Hutton hadn't seen any substantial results. So in July 2017, she re-engaged the PRP and again met with the manager to reiterate her concerns.

Hutton says he acknowledged that little progress had been made, but explained that there were challenges, as the cost of supplying cell phones to all of Vancouver Island's public health units was significant – in the hundreds of thousands of dollars. It would impact existing budgets, and possibly result in cuts to nursing staff casual hours.

"But I wasn't going to let it go," recalls Hutton.

She says her manger actually supported her moving the issue forward, agreeing it might be the best way to get the attention of Island Health's executive team.

Hutton asked co-workers if they'd help and a team of her colleagues soon responded to the call. "I got the ball rolling, but the others got involved and played their parts," said Hutton.  "I just kept the process moving forward."

In August 2017, the team outlined their written concerns on professional responsibility forms (PRFs), which were forwarded to the worksite Professional Responsibility Committee (PRC).

The PRC is comprised of two co-chairs representing the union and the employer, the nurse with the concern, the union steward, immediate supervisor and the excluded manager.

The nurses presented their case to the PRC that October and got a supportive response. The committee agreed unanimously that the public health nurses needed smartphones.

Under the PRP, the PRC has 30 days following a meeting to submit a final written report that covers action items and timelines.

According to Hutton, the high cost of cell phones meant the issue could not be resolved or decided at the local level. So, it advanced to the Senior Review Committee (SRC), the third step of the PRP. The SRC is a health authority-level body with BCNU and employer representatives that's designed to address nurses' concerns not directly related to staffing or workload.

At this stage, Hutton recalls experiencing a hiccup and delay due to confusion about how to make submissions to the SRC. The additional paperwork that resulted also had to be completed around the group members' busy schedules.

However, the process got back on track after a January 2018 follow-up call from BCNU Pacific Rim region professional responsibility advocate Sharon Fulton.

"Sharon was fantastic because we didn't know how to pull it off," remarks Hutton. "If you've never done it before, all the acronyms and forms can be overwhelming. But we did it, and she was integral to getting us through it."

The group finally got their submissions into the SRC in March 2018 and a meeting took place the following June.

Lactation consultant Joanne Hoffmann Funk is one of the Campbell River public health nurses who shared her concerns about inadequate flip phones.

Funk, like Hutton, has also experienced a situation that raised grave concerns about urgent quality of care and patient confidentiality.

She remembers being tasked to do a home visit of an infant being monitored by Victoria General Hospital's cardiology clinic.

When she arrived, the baby was having difficulty nursing and its breathing was very laboured. The mother called the baby's cardiologist, who asked that they take a video of the infant and send it to him before taking the child to emergency and being transferred to Victoria. But the mother didn't have a smartphone and Funk's work-issue flip phone wasn't capable of recording video.

It was a frustrating and worrying moment.

"In order for that baby to have timely care I used my personal cell phone," says Funk, noting the situation breached confidentiality guidelines. "I deleted it as fast as possible, but I made the judgment [that taking the video] was critical. That video made a difference to baby's well-being."

Funk and Hutton's stories, along with other scenarios presented by their public health co-workers, convinced the SRC, and in August 2018 both BCNU and Island Health SRC representatives recommended the provision of smartphones.

"I thought it was a complaint, but it proved to be a solution."

- Joanne Hoffmann Funk

Later that month, 10 new iPhones arrived in Hutton and Funk's office.

"The Campbell River nurses' need for smartphones is an excellent example of the kind of practice issue the PRP is designed to address," says BCNU executive councillor Rhonda Croft.

"The PRP is built on trust and common goals and enables nurses and the employer to engage in meaningful conversations around opportunities for improvement, and while the most effective approach to resolution should be at the local level whenever possible, it's sometimes necessary to advance concerns to the SRC."

Croft notes that the PRP is currently under review as part of the terms of the new Nurses' Bargaining Association collective agreement. She says the goal is a PRP that addresses professional practice  problems, and that will see staffing-related issues addressed using the NBA contract's new direct patient care staffing language and workload assessment process (see sidebar: New PR Process to Focus on Practice Issues).

Island Health chief nursing officer and SRC rep Dawn Nedzelski agrees that the PRP is an effective way for nurses to address practice concerns that arise in the course of their work. "The PRP provides the opportunity for meaningful discussions to understand where we can make improvements for nurses, their colleagues and ultimately the patients we serve," she says.

All told, the process took two years but Hutton feels the time and energy was worth it, benefitting more than just the public health nurses in Campbell River.

"It had a huge impact," she says. "Now all the public health units in Island Health can apply for smart phones."

Hutton encourages members who are thinking about using the PRP to access BCNU resources and reach out to their stewards and regional professional responsibility advocates.

Funk agrees, and reminds nurses not to think about the professional responsibility process as adversarial in nature.

"I thought it was a complaint," she says. "But it proved to be a solution." •

UPDATE (Apr 2019)