Persisting for Their Patients
DEDICATED TEAM Kelowna General Hospital post-anesthesia recovery unit nurses were some of the first BCNU members to use the improved professional responsibility process negotiated as part of the current Nurses' Bargaining Association contract. From left: Kathy Porritt, Louise Bernardin, full-time steward Tim Fitzimmons, Breanna Snow and Carmen Zachary.
A determined group of Kelowna nurses persevere for four years before securing much needed staffing and the re-hiring of a nurse educator on their unit
Talk to any acute care nurse working in BC today and they'll tell you about a range of staffing challenges they face on their units daily. Inadequate staff replacement coupled with chronic overcapacity means that nurses' practice conditions are in almost constant jeopardy.
For a team of nurses working in the post anesthesia care unit (PACU) at Kelowna General Hospital (KGH), the list of practice concerns was extensive, and their efforts to resolve many of them stretch back several years.
KGH is one of the largest hospitals in Western Canada with more than 700 beds. It offers high-level, specialty medical care including 24-hour emergency and trauma services, ambulatory and outpatient clinics, and diagnostic/paramedical services. In BC, it is the only hospital outside the Lower Mainland or Vancouver Island that performs angioplasty or cardiac surgery.
In 2013 some 30 nurses worked at KGH's post-anesthetic care unit. PACU nurses have extensive training in critical care and provide close monitoring of vital signs during surgical patients' immediate post-operative recovery. Nurses at this tertiary facility care for a variety of critically ill, complex patients from infants to adults. They work closely with the anesthesia department to ensure that patients leaving PACU are stable and comfortable before being transferred to the medical/surgical ward or an intensive care bed.
In March of that year, managers at the busy hospital began overnighting patients in the PACU because beds were no longer available in the facility's surgical recovery unit. It was an untenable situation that saw a group of PACU nurses turn to the Professional Responsibility Process (PRP) in an attempt to ensure their patients' safety.
The PRP is a way for nurses to safeguard their practice and protect their patients and residents. The multi-step process is part of the Nurses' Bargaining Association collective agreement. It outlines the steps that nurses and managers must follow when nurses feel their ability to meet professional standards is being threatened. This process is a critical tool for defending professional standards. When raising concerns, nurses have the opportunity to describe the events or circumstances that contributed to the concern. This can include policies and procedures, workload and staffing issues, and workplace communication.
Nurses start the process by having a conversation with their manager and if that doesn't result in action, they move to step two and fill out a professional responsibility form (PRF).
Kathy Porritt has worked on the PACU at KGH for the last 33 years. "There were many shifts that had workload issues with inadequate staff and unsafe patient scenarios," she says of conditions that she and her colleagues endured.
To make matters worse, their employer did not acknowledge emails outlining their concerns, and did not provide them with an opportunity to discuss the staffing situation. Porritt says she and her team started filing PRFs as a means to document practice conditions on the unit.
"If there had been only one individual championing this file, it would have been abandoned long before three years had elapsed."
The PRP is an important tool that can ensure safe patient care results in positive change for nurses, but the process is by no means a quick fix. For Porritt and team, the road to success was a long one with many obstacles along the way.
Under the PRP, after a PRF is filed, the worksite Professional Responsibility Committee (PRC) must hold a meeting within 14 days The PRC is composed of standing members (one appointed by the NBA and one by the employer) along with ad hoc members, such as the nurse or nurses with the concern, a PR rep or union steward, the immediate supervisor and the excluded manager. After the meeting, the PRC has 30 days to submit a final written report including action items and timelines.
Porritt and 16 other PACU members had filed some 40 PRFs by the time Porritt and three of her coworkers had their first meeting with the employer in November 2014, and this resulted in some important improvements.
"One of our accomplishments was creating staffing guidelines for overnight patients using data from the many PRFs we filed," says PACU nurse Louise Bernardin about the group's efforts. Bernardin, who has been nursing for over 29 years, says the group's PRFs also evidenced the need to secure additional staff for patients staying in the PACU as a result of the bed shortage elsewhere in the hospital.
While staffing guidelines were a good start, the team continued filing PRFs to address their staffing concerns. Subsequent PRC meetings resulted in the hiring of a care aide and a unit clerk, and the expedited the filling of vacant lines.
NEED FOR EDUCATION
Despite their progress on the staffing front, the group was nevertheless concerned about a larger patient-safety issue. The PACU lost its nurse educator in 2014 due to displacement.
The growing complexity of OR procedures and the addition of new equipment, makes a nurse educator integral to any PACU team. An educator ensures that students and new staff are oriented, and that nursing competencies are met. They also act as a liaison with other departments to facilitate the continuity of patient care.
But unlike their push for staffing guidelines, the group was unable to convince their employer to replace the nurse educator despite the PRFs that were filed, and were confronted with arguments about budgetary constraints. "At the beginning of 2016, we felt we had taken it as far as we could and we sat in limbo", recalls Porritt.
If a practice issue cannot be resolved by the PRC, it can be referred to step three of the PRP, and can take one of two paths: practice concerns not directly related to staffing are dealt with by the senior review committee (SRC) – a health authority-wide body with union
and employer reps. The SRC has 60 days to issue its recommendations. But if the practice concern requires the hiring of additional staff to address, it is referred to the health authority's Nurse Relations Committee (NRC). This new committee was established under the terms of the Nurses' Bargaining Association 2014-2019 collective agreement that was ratified in May 2016. The NRC is composed of union representatives and employers who meet bi-weekly. Committee members have decision-making authority to work collaboratively but, unlike the SRC, this committee is not bound to make recommendations within a set timeframe. The PACU team's PR issue was referred to the NRC.
At the beginning of this year, PRC employer reps suggested creating a half-time temporary educator position that would be reviewed in six months. But the union's NRC rep did not agree to the proposed terms of a part-time educator, arguing that tertiary care requires highly specialized equipment and expertise, and that it is was unreasonable for the PACU team to be simultaneously learning electronic charting while conducting orientation for student nurses. The union also noted that PACU nurses working in nearby Vernon Jubilee Hospital shared a full-time educator with their operating room staff.
"It was what we had prior to losing our half-time educator in 2014," says Porritt of the employer's proposal, "but we also had a smaller staff complement and less acuity in the department back then."
A 2015 building renovation also underscored the need for a nurse educator. That year the OR was moved to a new and larger building that resulted in the PACU being divided by a medication room and two nursing stations. Patient acuity also increased with the additional patient numbers – but nurses saw no increase in staff following the changes.
Porritt recalls feeling that managers had not heard or recognized staff efforts to champion a full-time educator, and says that she and her colleagues were deflated and emotionally drained at that point in the process.
"This team did their homework and they worked so well together. However, they encountered every imaginable circumstance that continued to defer their file," says BCNU Okanagan-Similkameen region chair Rhonda Croft.
Because the issue still remained unresolved, the group's request for an educator could now be referred to the Nursing Staffing Secretariat (NSS), which is responsible for establishing data and reporting requirements for compliance with the protocol MOUs negotiated by BCNU and HEABC in 2014 and requires employers to provide adequate staffing levels for safe patient care. The NSS is also part of the new, two-pronged approach to resolving professional practice issues, and builds on previous ground-breaking contract language that now sees even more improvements to Article 59 (the Professional Responsibility Clause) of the NBA provincial contract.
The Kelowna PACU team was one of the first groups to consider advancing their concerns to this level, and they continued to develop a very clear case that demonstrated the PACU nurses were unable to meet their practice standards for licensing without an educator for clinical support and education. They also argued that they were continually denied access to educational resources normally available to PACU staff working in other tertiary centres. And the fact that the nurses did not have time to mentor the sheer volume of students at the hospital also formed part of their rationale for a full-time educator.
However, likely as a result of these nurses' dogged advocacy, Interior Health chose to make a decision before an NSS meeting could take place, and instead made an announcement at an NRC meeting informing the union that it would be able to fund a full-time educator. The PACU team was more than relieved when they received a joint letter from the union and the employer this June informing them that Interior Health had finally listened to their calls.
"The PACU nurse team who pushed for these changes have to be commended for their incredible determination to achieve results."
Carmen Zachary has worked on the PACU at KGH for the past eight years. "As nurses, we must be very persistent about the issue and never give up if we believe there's need for improvement," says the 36-year nurse. "We work at the ground level and see the needs first." She credits Porritt for acting as the group's secretary. "She took very specific notes on what transpired, kept everything transparent for us and we owe her a huge amount of gratitude."
PACU nurse Breanna Snow agrees. "I thought when we first embarked on this, it would take a year. I never anticipated it being this lengthy a process. Kathy was the driving force that kept us together."
Tim Fitzimmons was working as BCNU's full-time steward at KGH when the PACU nurses began their efforts. He says that patients will be the primary beneficiaries. "After years of effort, patient care will benefit from safer staffing levels and adequate support for existing and new staff."
Bernardin notes that this PRP shows how improvements can be made if nurses stick together and work toward a goal. "This was successful because of our team," she says. "We have much work to do on maintaining our competencies, but at least it has been identified and work will continue," she adds. "Morale has also improved just by having our needs identified and reaching success through this long process."
"Every professional responsibility process will have multiple varying factors that will impact the route to ensuring safe patient care," says Croft. "The PACU nurse team who pushed for these changes has to be commended for their incredible determination to achieve results."
Porritt says she was kept on track by working with a dedicated and passionate group of individuals whose goals were to provide optimum patient care and to improve their working environment. "If there had been only one individual championing this file, it would have been abandoned long before three years had elapsed," she says. "I think that the recurring theme for any PRP is the need for patience and persistence." •
UPDATE (Dec 2017)