You gain strength, courage and confidence by experience in which you really stop to look fear in the face.

-Eleanor Roosevelt

On April 5^th, I volunteered to represent CNA at the Atlantic Ballet “Ghosts of Violence” event in Calgary. CNA was one of the primary sponsors. The performance focused on identification, behaviors and prevention of violence against women. 50% of all proceeds were directed to various women’s shelters and services in Calgary. My role was to represent CNA at a booth with information about the event, CNA and our profession. Other booths were manned by experts focused on prevention of violence and services in Calgary for women experiencing violence.

Today I write about this topic because of some very thought-provoking discussions I had with some experts in the field of intimate partner violence and workplace violence at the event. They expressed genuine concern about the work RNs do and how research indicates that professional nurses are more likely than any other health provider to encounter workplace violence (emotional and physical) and high rates of intimate partner violence and how the two intersect. I was directed to a classic article by Anderson (2002) that spoke about the correlation between past victimization and future abuse and our profession. Anderson writes that the effects of the exposure to previous abuse in a nurse’s personal life plays itself out in the workplace with decreased productivity, increased numbers of work injuries and absences. She indicated that those that experienced past violence and abuse were at higher risk for workplace violence; specifically higher rates of emotional types of horizontal violence (e.g. criticism, insults, intimidation). One expert told me that she meets with RNs seeking help to address violence and that the numbers are very high and on the rise. She also indicated that RNs do not often feel comfortable seeking support through employee assistance programs and prefer to seek help from sources outside the usual system or in the community.

As you know ‘bullying in the workplace’ was the topic for the guest speaker at our AGM in 2012.  CARNA Regional Coordinators do presentations on horizontal violence and there is a webinar on this topic on our web site.

I want to have a conversation about ‘violence against nurses’ and to get a sense of how serious you think the issue is and if you agree with what the research and the experts suggest.

So what can be done to identify those at risk and to intervene?

As Eleanor Roosevelt said it is time to look fear in the face and address this issue in the interest of the health and well-being of our profession and the public we serve.

Anderson, C. (March, 2002). Past Victim, Future Victim. Nursing Management. p. 27-30.

Once again we are experiencing turbulent times in Alberta. Discussions at many leadership tables and in the media focus on budget cuts, the resources needed to meet patient needs, and the gap between the two.  I hear your concerns about decisions that may affect patient safety, such as replacing registered nurse positions with other types of health-care providers.

As registered nurses, we have a professional responsibility to advocate for work environments that support the delivery of safe, compassionate, competent and ethical care. One of the ethical responsibilities of nurses included in our Code of Ethics (2008) is to “advocate for persons in their care if they believe that the health of those persons is being compromised by factors beyond their control, including the decision-making of others (p. 11).”

Advocacy is defined on the CNA website as:

…engaging others, exercising voice and mobilizing evidence to influence policy and practice. It means speaking out against inequity and inequality. It involves participating directly and indirectly in political processes and acknowledges the important roles of evidence, power and politics in advancing policy options (CNA, 2013)

Registered nurses’ concerns about patient safety, excessive workloads, fatigue and staffing issues and the impact on outcomes are well-documented. The essential elements required to deliver safe quality care include staffing decisions based on client health needs and not on financial pressures, improving work environments to foster open communication within teams, providing nurses with more control over resources and leadership at decision-making tables.

As the largest group of health professionals in Alberta, our unique knowledge and skills are crucial to the delivery of quality care and influencing effective change. We must continue to draw the attention of decision-makers to solutions based on evidence.

How can we advocate for change in our current work environments or programs?

How can we work together as a profession and on teams to ensure that the changes in the future are ‘on-track’ and make sense of a complex and constantly evolving system?

What are your solutions at the individual, organization and system levels and what have you seen that is working well?

I look forward to your ideas, stories and our conversation on this important topic.

“Every accomplishment starts with the decision to try”.
-Gail Devers, three-time Olympic Champion in track and field.

As your President, I have thought about and used this quote many times when I consider my world and what I can accomplish in this role. It is not “if” for me but “when”. It is not about having a dream for the future, it is about living the dream. I have the honour and privilege to live my dream every day.

Have you ever considered becoming the next president of CARNA? Maybe it was when you were feeling positive about your profession, your leadership, your performance on a project or your achievement of a goal. To be president requires a passion for our profession, a desire to lead, to learn and to grow. Skills include not only your ability to be the ‘Chairman of the Board’ but to be that ‘watchful eye’ and that strong ‘listening ear’ when registered nurses, the public and our key stakeholders raise issues, ask questions, identify our strengths as a profession and sometimes our weaknesses. Communication skills are the key to your success combined with an ability to respond to unforeseen circumstances with flexibility and new found energy, to smile when that may not be what you are feeling and to challenge the status quo on behalf of our profession, patient safety and quality care and services and our role in self-regulation. You do not require a PhD or published research to be president however; you should have proven skills as a leader, a change agent and a facilitator. I encourage everyone to give this role some consideration if you feel you have what it takes; if you have a dream.

I look forward to your conversation about the role on this blog or a conversation with me in person via either e-mail president@nurses.ab.ca or via telephone at (780) 909-7058. I answer every e-mail and if I do not answer the telephone right away I will call you back. The deadline to run for president-elect is fast approaching (April 1, 2013) and now is the time to ‘step to the plate’ with your decision to try.

For more information on running for president-elect and to obtain a nomination form, click here. 

Does this sound at all familiar to you? I recognize that the role of the registered nurse or nurse practitioner in all settings can be stressful and challenging and quite often exhausting. I also recognize that sometimes it is nice to share a joke or to laugh together at work; this collegiality and sharing is so important on a team. My concern is that if we do not portray professional behavior towards our patients/clients, towards each other or in own practice how do we expect to gain and maintain the respect of the public, our leaders, our colleagues and the government as we advocate for the value of our role on the team and to the future of the health system?

In the CNA Code of Ethics we must remember that:

“Nurses are accountable for their actions and answerable for their practice” (p.18)

“Nurses clearly and accurately represent themselves with respect to their name title and role (p. 19).

“Nurses share their knowledge and provide feedback, mentorship and guidance, for the professional development of nursing students, novice nurses and other health-care team members (p.19) 

Let’s talk about this. What can we do to change behaviors and/or build and support a positive work environment? Do you think there is a link between professionalism in the workplace and RN retention? I look forward to your thoughts on this important topic.

Albert Camus
French Algerian author

In some of my recent conversations with RNs and NPs I have heard many concerns about the current level of support for the education of our students in various clinical settings. Concerns ranged from the lack of interest by RNs and NPs to be a preceptor to students, the lack of support and encouragement for students in the clinical settings and the lack of support for the RNs and NPs themselves when they do assume the important role of clinical preceptor. Some have even described bullying behaviors towards students. Students, as we all recognize, are the future of our profession and need our kindness, our support and our experience to learn and grow. It is our chance to role model the work we do and provide a visible example of professional excellence in practice. Being a preceptor can be both rewarding as a professional and a learning experience for both the preceptor and the students. Nursing education is rapidly advancing in Alberta with new technologies and innovations; keeping pace with our evolving health system. So why are we not stepping forward to preceptor students and take them ‘under our wing’ to guide and mentor our future colleagues and learn more about their exciting world as a student?

Let’s have a conversation about this. What challenges are you facing and what support do you as registered nurses and nurse practitioners need to assume this role?  What could we do as professionals and leaders to improve the work environment for our students and for you as preceptor? I know there are a number of sides to this issue and look forward to hearing your views.

It is our time. The ‘buzz’ in health care today is all about primary health care, health promotion, prevention of illness and injury. RNs and NPs have the knowledge and expertise to be an entry point and leader in a health system shifting from an illness model to keeping people well.  The National Expert Commission (NEC),[i] has challenged all of us, RNs and NPs, to use our knowledge and expertise to promote, sustain and lead the way to better health, better care and better value in healthcare delivery for all Canadians. The report indicates that models of care delivery “should be centred on what individuals and families need, should treat the individual as a whole person…, and should ensure that all professionals, including nurses, work to their full scope of practice” (NEC, 2012, p. 7).

To start this discussion I will talk about ‘full scope of practice’ and our current state. Some research on nursing scope of practice[ii]^,[iii],[iv] has revealed that we need to identify a compelling vision for nursing that differentiates the distinct roles of NPs, RNs, and Licensed Practical Nurses (LPNs) in care delivery.  We recognize that RNs/NPs are currently not working to the full extent of our knowledge and skill in many settings. There continues to be an over-emphasis on the management of disease and illness at a time when we should be focusing on identification of risk factors (i.e. individual, population), health needs and ensuring long-term quality outcomes. We know that educational preparation differences do not always determine how employers utilize nursing staff. There can be significant role overlap and duplication, resulting in tensions between RNs, LPNs and other team members in the workplace. It is vital that nurse managers consider the potential impact on patient or client outcomes by replacing one type of provider with another when dealing with staffing shortages or patient assignment difficulties.

There is no question that the patient or client with complex challenges (e.g. the critically ill & injured, seniors, clients with complex community services needs) require and deserve access to our expertise and our care. That is not disputable however, often our practice is limited to a heavy focus on the performance of bio-medical tasks and activities without consideration that others can work with us to fulfill these tasks and/or free us up to focus our expertise on the ‘complex’. If we want to achieve the vision for our profession and healthcare that is reflected in the NEC report we need a lasting shared vision among decision-makers, educators, regulators, policy-makers and RNs/NPs ourselves.  We know that the shift from illness models to wellness will not be easy and simply will not happen without our leadership and commitment.

Are you ready to champion change? Where do we start? What are the barriers that we must overcome to achieve success? I look forward to our conversation.

On November 2nd, the Honorable David Rodney, Associate Minister of Wellness, hosted the second annual Action on Wellness forum in Calgary. Representatives from various sectors including health, police services, social services, education, public coalitions on a variety of topics and many others were invited to attend. We participated in a discussion and provided feedback on the first draft of the Alberta Wellness Framework and Strategy. I was pleased to see that the framework was a holistic primary health care vision addressing the social determinants of health, evidence-based decisions, cultural sensitivity, community input and community capacity building across sectors. The objectives included promoting physical activity, good nutrition, good mental health, a tobacco free Alberta, freedom from alcohol, drug and other substance abuse and injury prevention linked to multiple indicators of success.

I know that achieving wellness and health promotion is an integral part of your work every day, I would love to hear your ideas on wellness and what you believe should be the primary targets and strategies moving forward in Alberta. I hope to meet with Mr. Rodney very soon and will bring your ideas forward. Here are the questions we were asked at the forum:

• What are the most important collective actions we can take over the next two years towards achieving wellness in Alberta?
• What could our role(s) be in this work?

I look forward to your comments.

November is Family Violence Prevention Month in Alberta. It is a time to talk openly and honestly about this serious issue in society and take action. I attended a recent presentation at a Calgary/West CARNA event on domestic violence. The speakers talked about the fact that one in five Canadians report some form of abuse in their past or current relationships, with almost one half reporting multiple incidents of abuse and victimization (Statistics Canada, 2011).

An article on this important topic appeared in Alberta RN in Summer 2012 to raise awareness and educate nurses. The article indicated that the challenge is not the disclosure by a patient or client but the discomfort nurses have  with asking about domestic violence and their lack of understanding regarding it. The CNA Code of Ethics states that it is our ethical responsibility to “work to prevent and minimize all forms of violence by anticipating and assessing the risk of violent situations” (page 9). We know that domestic violence impacts lives forever. Screening for abuse and taking action can be life saving and life changing.

 Let’s talk about this issue. As registered nurses and nurse practitioners why do we choose so often to avoid asking the questions and screening for abuse? Why is it not a regular part of our practice in all settings? I look forward to your comments and the community conversation on this important topic.

What are the barriers to fulfilling your role as a ‘moral agent’ in your work setting? I look forward to a community conversation on this important topic.

If you want to reach CARNA’s confidential practice consultation service to discuss specific moral or ethical issues, please call 1-800-252-9392 and ask for a practice consultant or email practice@nurses.ab.ca.

Over the past three months, I have toured a number of seniors’ care centres and talked to RNs working with this often frail population. There are a number of common themes that have arisen. RNs working in these settings are doing the very best they can to try to provide quality care and services for seniors. They have implemented several creative strategies to address the needs identified including, for example, the introduction of visits by a dental hygienist to one site to ensure quality dental care and to reduce the need to travel for these services. Creative efforts, however, are often thwarted by day-to-day challenges of inadequate or inappropriate staff mix ratios, limited or lack of funding, lack of support for RN leadership and expertise at the sites, little to no support to address seniors’ mental health issues, placement of frail seniors in Assisted Living when they require 24/7 long term care, lack of adherence to required standards of care to meet the needs of residents and the creation of new rules for staff to reduce costs. One rule identified was that all residents are limited to one bath/week without recognition of individual health-care needs. The media and others have promoted the belief that seniors do not have complex care needs and are ‘bed blockers’ in acute care and must be discharged as quickly as possible to improve access to beds and reduce emergency wait times. Actions to address these issues include rapid placement of seniors into settings not based on individual needs but on availability of beds and home care workloads that far exceed capacity for safe, quality care.

So what are the answers to these issues? I can suggest three. One is to ensure that there are sufficient numbers of registered nurses working in all settings where they can address the needs of seniors. They need to be available to perform regular assessments in order to identify subtle health changes and address the complex issues and social determinants of health on site and therefore prevent emergency admissions. The second is to fund nurse practitioners to work in long term care settings in partnership with the registered nurses so that residents’ primary care needs can be addressed quickly and effectively. Third is to focus energy and resources on seniors’ health promotion, illness and injury prevention and chronic disease management led by RNs and NPs in all settings.

What messages would you suggest that I share with the Minister of Health and others related to improvement of seniors care or promotion of health and wellness for seniors in Alberta? I look forward to your ideas and your experiences.