Sunday, June 27, 2010

Q & A

The following is a message I received via Facebook. Identifying information has been removed.

I work at one of the Twin Cities Hospitals. Yes, I voted to strike. If I posted the question I am going to ask you on the MNA page I would get my head bitten off.....Out of 12,000 eligible nurse votes, less than 9,000 voted, something like 8700.Out of those 8700 (less than 75% of the nurses) 87% voted to strike. That is only 63% of Twin Cities nurses voting to strike. How is that overwhelming?!

My Answer:

If this was a survey, you would say you had a voluntary sample of 8700 out of a population of 12000 (roughly 73%). Although the Office of Management and Budget requires a sample size of >80% for surveys to be used for government policy-making, >70% response is considered adequate for most academic purposes, and reasonably reflective of the studied population. 63% of the population is still significant, beyond any margin of error, and would be a filibuster-proof majority in the US Senate. Using the same math, you can also say that 9.5% of the MNA nurses voted against the strike. In that 3300 members didn't vote, the actual support of the strike could be anywhere from 63% to 90.5%. We'll never know.
However, this was not a survey; it was a vote. That is, it's a way for us to contribute to a decision-making process, to directly instruct our bargaining teams in what we want them to do. Thus, only those who participate matter. A 73% turn-out for any election is well above the norm, although more would have been better.
I, also, despair that someone with a sincere question or declines to see things in black and white is ridiiculed, viewed with suspicion, or both. It may be the way things are in situations like this, but that doesn't mean I have to like it or support it.

Perhaps it's time to set aside the torches and pitchforks, and at least for now, call off the witch hunt. Such scourges against those lacking "ideological purity" always do more harm than good.

Thursday, June 24, 2010

Living My License

Early this week, nurses voted to allow their negotiating teams to call an open-ended strike if they deem necessary, and I voted with them. You may well wonder why I consider this necessary. In short, this vote was the natural consequence of living my license.
Because I am licensed by the State of Minnesota and not by Abbott Northwester Hospital or Allina Health Systems, I have an independent responsibility to my patients. Because I am a licensed professional, I also have a responsibility to my profession. And just because I’m a grown-up, I have responsibilities to myself. Living my license involves all three spheres of responsibility, and it’s at the heart of these contentious negotiations.
That nurses have an independent responsibility to our patients is most clearly evident in the operating room. In addition to the surgeon and the anesthetist, there are two additional critical roles, the “scrub” and the “circulator.” The scrub may be, but seldom is, a nurse; he or she passes instruments as called for by the surgeon, and keeps track of needles, blades, sponges, and other items on the tray. The circulator is always a nurse, and is the interface between the sterile surgical field and the non-sterile world. The circulator also watches everything: he or she can stop the surgery because the sponge count is off or sterile technique is broken or any number of other reason. This might annoy the surgeon, but that doesn’t matter. The circulator is there to protect the patient, not the surgeon’s ego.
The major sticking point in our contract negotiations is around staffing levels. How many nurses does it take to care for this many patients, and who gets to decide? While facilities in the Twin Cities staff better than many places in the country (I know, I’ve been there), it still may not be enough. Patients are sicker, and the components of safe patient care are continually becoming more numerous and more complex. When I, as a charge nurse, call for more nurses than our staffing scheme allows, it is for concerns of safety, not so we can catch up on our online shopping and not to torpedo the hospital’s bottom line.
This also reflects my responsibility to my profession. Administrators do not, and cannot, know what it takes to provide care to patients on a day-to-day, shift-to-shift, hour to hour basis. They aren’t there. I am. We are. It has been so thoroughly demonstrated that the closer the decision making gets to the point of service, the better the decisions, it’s practically a law of nature. Part of our professional duty is to determine how our services will be provided. Determining the number of nurses needed to take care of patients is an important part of that professional control.
We are individually and collectively responsible for ourselves. Assuring the solvency of our pension fund and the stability of our health insurance is in our personal best interests. We understand that neither of these are inexpensive propositions, and will negotiate on them because it’s also in our best interests to have solvent and stable workplaces. However, it’s our responsibility to look out for ourselves, rather than hoping someone else will.
Living our license can be tough work. Holding a picket sign in the rain washes away romantic illusions, leaving the unyielding realities of our responsibilities. Standing up to a temperamental physician can be nerve-wracking, but critical. We are independently responsible to our patients. We are responsible to our profession. We are responsible to ourselves. It is out of these responsibilities that we make our voices heard and presence known, early this week and in these days that follow. It is ironic how much our employers depend on us to live our licenses and take these responsibilities seriously, even with the resulting expense and inconvenience they find so encumbering. We take these responsibilities seriously because we understand who and what we are. We are professional nurses. Allina isn’t health care; Abbott Northwestern Hospital isn’t health care. We are health care. I am health care.

Tuesday, June 15, 2010


One change management theory posits that change is accomplished by "unfreezing" current ways of doing things, rearranging to a different configuration, then "refreezing" the changes into place.
As the Minnesota Nurses' Association and a number of Twin Cities hospital systems square off during contract negotiations and another likely strike, things are seriously unfrozen. Normally, the change process is carried out carefully and intentionally. Well, not this one. Change is coming, and no one really seems to know either what we're transitioning from or transitioning to. Neither side is articulating a vision for high-quality and sustainable health care.
MNA demands from employers concessions that run afoul of a particular from Matt Miller's The Tyranny of Dead Ideas. Specifically, "My company should take care of me." Much of the health care and all the pensions provided for MNA nurses are funded by the employer. The costs of these benefits, according to the employer, are becoming unsustainable. Perhaps they are. Even if they aren't, perhaps it's time to remove these benefits from the employer's pervue: they will no longer have to fuss with it and we will no longer feel blackmailed into staying someplace we'd rather not be.
The employer, on the other hand, fails to understand something that must be grasped with utter clarity: hospital nurses are not just the "face of health care" within their facility, they are health care. Whatever the proposal, from changes in the supply chain to staffing patterns, the first question must be, "What impact will this have on the nurses' effectiveness?" If other questions are being asked instead, too often it's because the effect on nursing care is already understood to be negative. Ditto if anyone but nurses are called upon to answer the question.
Nurses need a financially viable venue in which to practice. Hospitals need a dedicated, professional, and effective nursing staff. Both need to provide for the other in ways that are sustainable and make it more likely to get what they need from the other party. That neither side really seems to know what that looks like leaves everyone feeling like they're living a poster.
Right now, everything is in flux, in chaos, unfrozen. Anything is possible. Of course, "anything" includes utter disaster. It also includes the possibility of extraordinary adventure and even extraordinary success, a success that meets everyone's needs and exceeds everyone's expectations.
Does either side realize this, and is either side willing to reach for this, work for this, and convince the other side that it's possible?
I hope so.

Friday, June 11, 2010

The Rest of the Equation

The statement "nurses eat their young" has been so often repeated it has become axiomatic. "Lateral" or "horizontal" violence is a very real issue in professional nursing (among other occupations), it has been heavily researched, and various interventions and corrective actions have been initiated with varying levels of success.
There are "zero tolerance policies;" there are defense strategies for new nurses to use to protect themselves. But are we missing half the equation?
Lateral (or horizontal) violence describes how members of an oppressed culture, unable to strike back at their oppressors, instead take out their anger and frustration on the more vulnerable members of their own group. In the nursing profession, this is usually new hires and those newly graduated from nursing school. The consequences of lateral violence are dire: new nurses are often driven out of a particular work environment and perhaps out of the profession altogether. As the current nursing shortage is likely to only worsen, this has grave implications for the accessibility and quality of health care.
As grave as the problem of lateral violence is, all the interventions are directed at the behaviors: how to defend against the behaviors, how to identify and punish perpetrators. Certainly, lateral violence is reprehensible, unacceptable, and professionally self-sabotaging. But what about the other side of the equation?
As lateral violence is endemic to oppressed cultures, shouldn't the issue of oppression be addressed? How might lateral violence be affected if there were other, more benevolent, more productive opportunities to wield power?
Certainly, there are many aspects of professional nursing practice that are non-negotiable: patients require care, competencies must be maintained, and standards must be met. However, it does not necessarily follow that in order to do everything that must be done, every step must be prescribed and every process delineated, with every deviation or innovation at least suspect if not outright punishable.
Nurses, by training and by licence, are independently accountable to the patient and are expected to exercise professional judgement and critical thinking. We are taught to negotiate with patients to develop a plan of care that best meets their needs. However, we are seldom extended the same courtesy.
Work schedules and shift availability is on a take-it-or-work-elsewhere basis, patients are assigned, seldom selected by the nurse. These sorts of problems are hardly unique to nursing, and professions that experience similar working conditions also have similar problems with lateral violence.
For nursing to be a profession, we must be responsible to our patients, our profession, society, and ourselves. As professionals, we have the right to negotiate how we meet each of those responsibilities. Every professional knows that these responsibilities often conflict, and the give-and-take among them is a part of professional reality.
Participating in this negotiation, both collectively as a profession and individually as a professional is the other side of the equation that must be addressed for effective control and eventual eradication of lateral violence. All the interventions addressing behaviors associated with lateral violence must continue to be addressed, but it's past time that addressed the rest of the equation.