Archive for the ‘ Nursing ’ Category

So for those who may or may not have read Mr. Grula’s latest attempt to convince the Pasadena Weekly reader’s that the California Nurses’ Association (CNA) should be given free reign at Huntington Memorial Hospital (HMH), by “just let the nurses vote” – what a disingenuous piece of tripe.

He begins by heralding that the LA region of the National Labor Relations Board (NLRB) has found “probable cause to believe the HMH has engaged in unfair labor practices against the nurses wanting to form a union”. That might be the case, but let me remind my readers that this is the same regional board of the NLRB that found that the threats made from the offices of the CNA against two Cedars’s nurses that opposed the union weren’t threats at all. However the DC NLRB (and final say on the matter) decided that threats made to one nurses children and another’s nurse’s pets were indeed threats and thus were enough to invalidate the vote – and to this day Cedar nurses remain union-free. In short, just because the regional branch feels there’s probably (i.e. a reasonable belief) cause it doesn’t mean that in the end it will be substantiated.

But what really galls me is this attempt by Grula to somehow equate union representation with the recently released “Leapfrog scores” published in a recent LA Times article — http://graphics.latimes.com/california-hospital-scores/. Granted HMH gets a rank of “C”, but so did 69 other hospitals, including such venerable institutions such as UCLA Medical Center, Loma Linda (which got a D believe it or not) and Stanford Hospital. Grula goes on, in his article to make it appear as though HMH is the only LA County hospital with such a low score – not true! He also goes on to pontificate that Kaiser (a CNA-represented hospital network) has a rank of “A”, which is true, but what he fails to disclose is many other CNA-represented hospitals that scored “C”, “D” and “F” grades– yes “F”.

So, Antelope Valley Hospital is the only LA County area hospital to receive a big fat F and is a CNA-represented hospital! California Hospital Medical Center, Citrus Valley Medical Center Inter-Community, Glendale Memorial Hospital, Good Samaritan Hospital, Henry Mayo Newhall Memorial, and UCLA Medical Center all receiving a C grade are all CNA-represented hospitals. So while HMH receiving a C-grade might provide fodder for Grula and the CNA to say that hospitals with unionized hospital staff get better grades from Leapfrog is a very weak assumption to make (I think they’re kind of leapfrogging to that assumption). It would appear that Grula is following in the footsteps of the CNA in not allowing the facts to get in his way.

The problem, in my opinion, lies with the CNA-campaign to gather enough valid RN signatures to call for a vote – and it would appear that they might be falling short of this goal. So now the CNA is trying to pressure HMH management into just giving the CNA the “keys to the kingdom” and allow a vote to go forward without showing via signed cards that a majority of HMH RNs want the union. The feedback that I’ve gotten from HMH nurses on the ground is that most have been rebuffing the CNA’s advances. So this will have to make the CNA representatives work all that much harder for the votes – oh boo hoo. The CNA likes to paint nurses that are pro-union as somehow being brave and self-determined all the while painting nurses that oppose the union as somehow misguided, naïve or shills for management. They accuse yours truly of interfering because I’m giving “aid and comfort” to those RNs standing up to the CNA union machine all the while the CNA applauds local politicians, church and community leaders who support the CNA. Their message if you support the CNA you are somehow brave and community minded, and if you don’t you’re weak minded and interfering; their logic boggles the mind.

The CNA tried this same tactic many years ago when they tried to get our state legislators to pass legislation that would bypass a vote entirely and simply allowing gathering enough signed cards to install a union. They testified that nurses were really too weak to “speak up for themselves” thus they needed this card check legislation. Union representatives even went so far as to tearfully testify that if only the nurses at that “Tenet hospital in Redding” had been unionized the RNs would have felt safe to come forward to blow the whistle on all the unnecessary cardiac surgery that was being performed. There was just one problem with that scenario. It was the nurses, themselves, that blew the whistle – the very non-unionized nurses that the union deemed to weak to speak for themselves. Meanwhile they never explained why the union represented nurses at UC Irvine never blew the whistle on the problems with the IVF program.

This is one of my fundamental issues with nursing unions, which is they all too often resort to mud slinging, fact mangling and sometimes out right lies to grow their ranks. Nursing is a profession and should be treated as such. All too often unions in their mad dash to unionize the RN workforce resort to tactics that leave a mark on our time honored profession. I say if they want to convince nurses to unionize do so with the facts, with well supported arguments and leave the bullying and threats out of it. And as I always say “if nurses are too weak and incapable to advocate for themselves (as the CNA purports) how can these same nurses advocate for their patient as they are require by The California Nursing Practice Act.

But back to the “C” grade awarded to HMH and many other hospitals. It’s important to keep in mind that there several different hospital safety “report cards” available. Leapfrog – www.hospitalsafetyscore.org- is but one of many that are recognized and used. You can also see how your local hospital stacks up by using the Joint Commission Quality Check – www.qualitycheck.org; CMS Hospital Compare – www.hospitalcompare.hhs.gov; and Consumer Reports Hospital Safety Ratings – www.consumerreports.org/health/doctors-hospitals/doctors-and-hospitals.htm to name a few.

In Grula’s opinion piece “Huntington Hospital is Ill” that ran in the November 6, 2014 edition of the Pasadena Weekly, he attempted to paint Huntington Hospital as some kind of sub-par hospital and it’s administration (calling out its CEO Steve Ralphs) as somehow cruel and uncaring of their nursing staff – all this, in my opinion, at the beck and call of the California Nurses Association (CNA).

Why? You may ask, because the CNA has been trying unsuccessfully, to date, to unionize the 1,100 RN workforce that ply their craft at Huntington Hospital. As expected, the CNA was up to its usual shenanigans, they held a rally where they claimed hundreds of supporters attended lining the length of Pasadena Avenue, when in reality somewhere about 80 – 100 people showed up, of which only a handful were actual Huntington RNs. Their theme for the rally, “restore quality patient care”.  As a RN and Pasadena resident it really irked me that the pro-CNA nurses at Huntington would allow the CNA to spread such a despicable message, because to restore something implies that something, in this case quality patient care, is missing which isn’t the case with Huntington Hospital. However, the CNA isn’t one to let the facts get in their way and neither it appears is Grula or the editors at the Pasadena Weekly.

I make this bold statement, because in Grula’s piece he tries to convince his readers that somehow it makes sense to allow the Huntington nurses to unionize because 60% of California nurses already belong to unions. He bases these numbers on two statistics both provided by, you guessed it, the CNA. The first statistic he provides is that there are 200,000 RNs in California and that 120,000 are in unions. So when you use these figures its easy to see how one might conclude that about 60% of all California RNs are in unions, but there’s one small problem. What, pray tell, might that be? All it takes is a quick telephone call to the California Board of Registered Nursing (BRN) to learn that there are currently 398,134 actively licensed California RNs with another 16,025 holding an inactive license for a total of 414,159 California RNs. It’s that quick and easy. Not sure you can look it up on line at http://www.rn.ca.gov/about_us/stats.shtml or for the most up to date figures you can call the BRN at (916) 574-7699. So with more accurate figures the 60% of all nurses belonging to unions becomes more like 30% with the majority of California nurses (about 70%) choosing to remain union-free.

Gurla also tried to make a point of Huntington’s CEO Ralphs’ salary, but failed to note how much money the CNA will make yearly off the backs of the RNs in the way of dues if they are successful in unionizing the Huntington RN workforce. Think the number one followed by six zeroes and then some. His entire piece supports solely the goal of the CNA and the Huntington RNs that support the CNA, but fails to mention that the greatest opposition comes from within the very Huntington RN family – from members who don’t want the union to represent them as they feel they don’t need an additional layer between them and management. Of course, if Grula even mentioned that opposition was coming from Huntington nurses, themselves, then the CNA’s and his argument that it’s the “evil” management that’s fighting the CNA — falls to pieces and blows the “we’re poor weak nurses who can’t speak for ourselves so we need the CNA to fight our battles for us” theory out of the water.

So when Grula’s piece was published, wrong statistics and all, I submitted a letter to the editor to both correct the erroneous statistics and to provide my two cents on what’s happening at Huntington, which is that the CNA is facing resistance, not from hospital management but from the very nurses they are attempting to organize. Some of the nurses who didn’t want a union reached out to me and asked for advice and guidance, which I was happy to give them. Something the CNA hates, because they like to portray themselves as the protector of the hard working nurse who is somehow so downtrodden by management that they can’t stand on their on two feet. So when the very nurses they want to represent, fight them and spurn the CNA overtures, the leadership of the CNA becomes practically apoplectic.

After emailing my letter to the editor I followed it up with a phone call to the editor, Kevin, and had a nice chat with him and received a promise that he’d run my letter in the November 20th edition. So when November 20th rolled around I picked a copy of the Pasadena Weekly and found that my letter to the editor hadn’t been printed as promised. I called Kevin and imagine my surprise when he informed me that he gave my letter to Grula so he could “respond”. Why? Because somehow the statistics I provided from the BRN were an “opinion”, or as he so quaintly put it “my contention”. I’d say that the Pasadena Weekly editorial staff has egg on its face for failing to fact check Grula’s stats and now their trying to find a way to save face and to dig themselves out of this fiasco of Grula’s and their making.

So, I say to the Pasadena Weekly do the math, show some journalistic integrity, make the correction, print the letter, and let your readers know that it isn’t the management resisting the CNA, but many of the Huntington nurses themselves.

You can read Grula’s “hit piece” on Huntington Hospital here

Here we go again, the C.N.A. has spent their members’ hard earned money that they take in as dues to produce (CNA Flyer1) a high-gloss hit piece on yours truly. My oh my how I must frighten the C.N.A., this handicapped, little old lady from Pasadena.

So when I saw the piece that they’re passing out at Huntington Memorial Hospital I felt compelled to respond – since as so many nurses have come to learn from past experience, many members of the C.N.A. like to play fast and loose with not just the rules, but with the truth as well.

First – IStandWithHuntington (ISWH) are the Huntington Memorial Hospital nurses that feel that they don’t need the C.N.A. to represent them. The IStandWithHuntington blog is an alternative voice to the C.N.A. message/propaganda. Nurses whose opinions differ from those backed by the C.N.A. have the right to speak their mind and get their message out and they have chosen to do so – even though it means fending often scurrilous attacks from the C.N.A. “war machine”. They express their opinions, viewpoints and so forth on their blog.

Second – Did I help the ISWH nurses – darn tooting. I contributed to their cause by securing the IStandWithHuntington domain name and offered it to them for their use. They run and have full control over their blog. This isn’t illegal, the ISWH nurses have the right to freedom of speech, just as the C.N.A. members have and for the record Huntington Memorial Hospital hasn’t spent a dime in securing, purchasing or hosting this blog.

Third – The C.N.A. really does need to go back to school if they think I’m a professional union buster. Professional is defined as – a person engaged in a specified activity as one’s main paid occupation rather than as a pastime. I’m not paid to help nurses who want to get their union-free message out. Nurses call, write and email me when they want advice on how to get their message out, on how they can even the playing field and what not. I listen to them and if I think I can help I do what I can do, there’s a whole network of us who believe that nurses can effectively advocate for themselves, without union representation.

Fourth – They’re great about listing my administrative positions that I’ve held over the years, but conveniently leave out that I’m a RN and that I’ve spent more years at the beside as first a Pediatric nurse and then a PICU/NICU nurse than I have in administration. But then again if they did that they might actually provide folks with the impression that I’m a nurse and not some boogey man “union buster”, because nurse = good and union buster = evil, don’t you know.

Fifth – It’s no secret that I don’t support the RN-to-patient ratio, because I support the far superior patient acuity system. Title 22 and Joint Commission mandates an acuity-based system because nurses aren’t workers on an assembly line and patients aren’t widgets. I believe that nurses give the best care when patients are assessed based on the complexity of their illness, care needs and so forth and then matched to the nurse that has the skills, education and training to best meet those care needs – after all that’s why I became a nurse. And I think that’s why most of you became nurses, as well.

Ask yourselves this why does the C.N.A. feel the need to play so fast and loose with the truth, why do they resort to innuendoes, and cast aspersions? This is the union that says they want to represent you and yet they appear to show utter contempt of your fellow co-workers who chose to exercise their to freedom of speech and simply put their message out as well. The ISWH nurses have spent their hard earned money on their effort and whether you agree or not about joining or not joining a union the ISWH nurses are deserving of some modicum of respect. I think their blog has strived to keep their tone civil and information fact based. So just to be clear I’m not about union busting, as the C.N.A. likes to suggest, but I’m am about making sure that these nurses who want to have their message heard get the opportunity to be heard.

The C.N.A. loves the scorched earth technique in dealing with those who disagree with or oppose their viewpoint; do you? Do you want to be associated with a group that feels entitled to denigrate others in our profession because we don’t chose to follow their rhetoric? As nurses we are charged with advocating for our patients, so how can we be expected to advocate for our patients if we can’t even advocate for ourselves? I’m proud to be a RN. You’re welcome to call, write or email me.

By Genevieve M. Clavreul, RN, Ph.D.

Working Nurse Magazine

I know that for a lot of nurses, talking about politics is about as appealing as going to the dentist. However, legislation and policy decisions can shape the way we practice at every level, sometimes dramatically. That’s why it’s important for nurses to pay close attention to proposed laws or new regulations affecting our profession.

Let’s take a look at some current healthcare-related measures and what they could mean to you.

Opioid Restrictions

If you or any of your patients suffer chronic pain and have a liver condition that contraindicates acetaminophen (the active ingredient in Tylenol), you should be very alarmed by S.2134 and H.R.4241.

These bills, prompted by the recent fear-mongering about prescription opioid abuse, would ban Zohydro ER, the only FDA-approved opioid that doesn’t contain acetaminophen. The legislation would also prohibit the FDA from re-approving Zohydro “unless it is formulated to prevent abuse.”

Aside from its impact on chronic pain sufferers, this attempt by some members of Congress to usurp the function of the FDA would set a frightening precedent. If Congress can summarily ban a drug that’s already passed the FDA’s approval process, what’s to prevent legislators from banning other approved drugs, like contraceptives, in hopes of scoring political points? I shudder at the potential consequences.

Safe Staffing Ratios

There’s brighter news in the area of nurse staffing requirements. As most of us know, California has had mandatory nurse-patient staffing ratios for the past decade and Congress is now considering national requirements.

The federal Registered Nurse Safe Staffing Act (H.R.1821 and S.2353), which would apply to all Medicare-participating hospitals, is quite different from California’s rules, which mandate specific ratios for each type of unit. Instead, the proposed federal law would require each hospital to establish a committee — at least 55 percent of which must be RNs providing direct patient care — that will create staffing plans based on patient acuity, staff experience and other factors.

Longtime readers know that I’m very critical of California’s “one size fits all” approach to staffing ratios. I strongly believe that an acuity-based system makes more sense, allowing managers to match nurses to patients based on the nurse’s skills and training rather than arbitrary legislative dictates. The federal law would also give nurses a greater voice in those decisions.

Unfortunately, these bills wouldn’t change California’s current requirements. If this law passes, Medicare hospitals in our state would still need to organize the required committees and create staffing plans, but those plans would have to comply with existing state laws.

Lab Result Reporting

Till now, patients have always been told, “The doctor will call you when your test results come back.” However, in February, the Center for Medicare and Medicaid Services amended the Clinical Laboratory Improvement Amendments of 1988 (CLIA) to give patients the right to request test results directly from the laboratory. All entities subject to HIPAA must comply with the regulation by October 6.

It will be interesting to see how the new rule will affect the patient-provider relationship. Will patients be better informed or will they be panic-stricken after trying to interpret their test results based on Internet searches? Will patients even be informed of the new rule? (I know my and my daughter’s providers have yet to say anything about it.)

If your facility’s lab is subject to CLIA, have you been educated about the new regulation? How do you feel it’s working so far? Drop me a line and let me know.

MRSA and Worker’s Comp

If you’re unlucky enough to contract a methicillin-resistant Staphylococcus aureus (MRSA) skin infection while working in patient care, a proposed state law (AB 2616) would make it easier for you to file a workers’ compensation claim. The bill, which is supported by the  California Nurses Association and National Nurses United, passed both houses of the Legislature in August and now awaits the governor’s signature.

AB 2616 states that MRSA skin infections contracted while providing direct patient care will now be presumed to be work-related unless there’s specific evidence to the contrary. That means if you file an MRSA-related claim, the burden of proof will no longer be on you, which is good news.

Workplace Violence

Workplace violence is an ongoing concern for nurses and other healthcare workers. There’s been some progress since Napa State Hospital psychiatric technician Donna Gross was strangled to death by a patient in 2010, but nursing organizations and unions have been calling for more.

SB 1299, which went to the governor’s office on August 28, is intended to light a fire under the state Occupational Safety and Health Standards Board and push state hospitals to take action. The bill would require acute care and acute psychiatric hospitals to establish plans to prevent workplace violence in both inpatient and outpatient settings.

The plans must include training and education for workers, procedures for investigating incidents, and policies for documenting and reporting incidents to the Division of Occupational Safety and Health, which would be required to post anonymized reports online starting in 2017.

Quicker Licensure

Too many new RNs have passed the NCLEX, graduated from nursing school and started applying for work — only to wait and wait for the BRN to issue their licenses. A bill in the Assembly, AB 2165, seeks to address that problem by giving professional licensing boards a 45-day deadline to issue licenses to candidates who’ve completed all the requirements.

The 45-day clock wouldn’t start ticking until you have completed all the application requirements, so this law wouldn’t help if you had missing paperwork or problems with your background check. The point is to keep qualified applicants from being held up by bureaucratic backlog.

Using our Power

This list is by no means comprehensive. New measures come up all the time, including ones that aren’t specific to nursing, but may still affect our work.

The good news is that we don’t have to sit back and watch idly. With almost 400,000 active RNs in California alone, we have more political power than many of us realize. However, for us to use that power, we have to be aware of what’s going on and willing to get involved. We can’t afford to let politics be a spectator sport.

 

How to Stay Informed

If you want to find out more about these bills and others like them, check out the following links:

•  The Library of Congress THOMAS database allows you to look up information about federal bills.

•  GovTrack.us  is another option for keeping track of happenings in Washington. It requires registration.

•  The Official California Legislative Information webpage includes information on current state laws and proposed legislation.

•  LegTrack is another search engine for state measures. It requires registration.

•  Ballotpedia is “an interactive almanac of U.S. politics,” including neutral descriptions of federal and state measures.

•  The Board of Registered Nursing (BRN) website often provides useful information on pending legislation. The BRN’s legislative committee examines all measures and decides whether the board should support, oppose or watch each measure.

•  Professional organizations and unions such as the American Nurses Association, California and the California Nurses Association/National Nurses Organizing Committee also monitor relevant legislation, although these organizations’ information may be available only to members.

Some professional organizations also organize “lobby days,” which are a great opportunity for nurses to learn about important current issues and the political process in general.

Working Nurse Magazine – Issue

Nurses Answering the Call

Hurricanes, floods and earthquakes are no match for heroic nurses

By Genevieve M. Clavreul, RN, Ph.D.Working Nurse Magazine

Nurses across the country have long been at the forefront of disaster response, whether the crisis is an earthquake, hurricane or tsunami, a flood or some manmade tragedy. When disaster strikes, nurses respond at the drop of a hat, often putting their own lives on hold to offer their services and compassion to those in need.

Tales of Heroism

In 2001, nurses answered the call when terrorists flew two hijacked Boeing 767s into the Twin Towers of the World Trade Center in Manhattan. Some of the first nurses on the scene were sent to the Jacob K. Javits Convention Center, which had been converted into a makeshift 40-bed emergency hospital. At first, nurses could do little more than pour bottled water over the eyes of rescue workers.

Even when more supplies did arrive courtesy of the American Red Cross, the nurses had to cope with limited resources and nurse-patient ratios of more than 5,000 to 1.

After Hurricane Katrina in 2005, volunteer nurses streamed into the Gulf Coast, many taking unpaid leave and using vacation hours to help survivors in some of the hardest-hit areas of Louisiana, Mississippi and Texas. In response to the devastation, the California Nurses Association (CNA) formed the Registered Nurse Response Network (RNRN) to serve as a “clearinghouse” for RNs responding to disasters. The RNRN reports that some 300 nurses traveled to Gulf communities to offer aid and nursing assistance after Katrina.

Even nurses who were unable to make the trip found ways to help. One nurse answered phones at her local Red Cross. After watching television coverage of the disaster, another nurse volunteered to work in the temporary pediatric clinic that had been set up at the Houston Astrodome, treating and comforting children suffering from cuts, bruises, hunger, dehydration, disorientation and exhaustion.

Local nurses, too, put their personal needs on hold to provide much-needed assistance in the wake of Katrina. At the partially flooded Memorial Medical Center in New Orleans, where as many as 2,000 people and 200 patients were trapped without power or running water in stifling heat, nurses struggled for days to provide continuity of care and then navigated darkened stairwells and manually operated Ambu bags to transport patients to the helipad for evacuation.

International Efforts

The disasters to which American nurses have responded have not been limited to the borders of our country. In 2010, U.S. civilian nurses joined their military colleagues aboard the amphibious assault ship USS Iwo Jima for Operation Continuing Promise 2010, a four-month humanitarian deployment. Nurses provided medical assistance to Haitians after Hurricane Tomas, treating a total of 4,054 patients onboard and ashore (as well as more than 1,200 veterinary patients). As part of that operation, nurses went on to participate in seven other missions in Latin America and the Caribbean.

In 2013, Typhoon Haiyan struck the Philippines, killing more than 6,000 people and leaving almost 30,000 injured. Medical and nursing teams from hospitals and nursing associations through the U.S. raised relief funds, donated food and clothing and assembled healthcare teams to aid in disaster relief.

One team saw more than 250 patients a day, many of whom had suffered injuries that became potentially life-threatening due to the harsh conditions and delays in obtaining treatment. In addition to treating physical injuries, the healthcare teams also assisted survivors with mental health issues like anxiety, insomnia and overwhelming grief in the wake of this horrific event.

An Ethical Obligation

When a crisis strikes, people look to nurses and other medically trained professionals for information and guidance as well as care, which makes it all the more important that we learn basic disaster preparedness skills.

An article in the Australian Nursing Journal estimates that each nurse who is helpless in the face of a disaster may leave 50 or more patients in the lurch. That’s why Joanne Langan, RN, Ph.D., CNE, coauthor of the 2004 book Preparing Nurses for Disaster Management, argues that every nurse has an ethical obligation to be prepared for disasters.

Responding to a disaster doesn’t have to mean jumping on a plane at a moment’s notice. Relief efforts often need volunteers to help organize and coordinate the first responders, a role in which a nurse’s training and experience can be invaluable. Of course, nurses can also get involved by donating food, clothing, medical supplies or money to aid the victims of the disaster.

Many hospitals have established on-site disaster response teams, but nurses should also consider joining an outside organization involved in relief efforts. It’s a great way to learn more about disaster response and find opportunities to help. Below are a few places to start:

I think what nurses bring to crisis response is best summed up by a remark made by Marirose Bernard, MN, APRN, CNA-BC, then a nurse supervisor at Memorial Medical Center in New Orleans. When a reporter asked why Bernard and her colleagues didn’t leave the devastated hospital, Bernard responded, “I would never have thought of that. We were there; we were there to take care of our patients. Because we’re nurses, and that’s what nurses do.”

So, to all my fellow nurses: Keep doing what you do and have a Happy Nurses Week!

Here’s my latest article in Working Nurse Magazine —

One of nurses’ most important and underappreciated duties is advocating for our patients. While much of that advocacy takes place at the bedside, we are also in a unique position to address the larger issues that affect the practice of nursing and medicine.

The latest issue that demands our attention is the controversy over prescription opioids and the efforts of the Medical Board of California to crack down on these dangerous but necessary medications.

THE PERILS OF STATISTICS

If you listen to the fearless pundits of the Fourth Estate, deaths related to prescription drugs are a national crisis. According to the Centers for Disease Control and Prevention, 38,329 Americans died of drug overdoses in 2010 and about 60 percent of those deaths involved prescription medications, many of them opioids.

Back in 2012, the Los Angeles Times ran a four-part investigative report on the human cost of opioid abuse and the role of some physicians in overprescribing painkillers. The story reported that between 2006 and 2011, there were 3,733 deaths related to opioid use in just four Southern California counties: Los Angeles, Orange, San Diego and Ventura. That story and others like it have put pressure on the Medical Board of California to respond to the growing “epidemic.”

I put the word “epidemic” in quotes because the outcry is somewhat out of proportion to the reality. As alarming as the number of opioid-related deaths sounds in isolation, the L.A. Times report failed to contextualize that statistic in terms of the combined population of those four counties (16.9 million as of July 2011), the population of California as a whole (37.7 million) or the number of deaths due to other causes during the same period. For example, according to the California Highway Patrol, car crashes killed 18,416 Californians between 2006 and 2011: almost five times the death toll of the headline-grabbing opioid menace.

PSE AND THE METH EPIDEMIC

I don’t mean to diminish the significance of those deaths or suggest that there isn’t a problem, but it’s important not to let alarmism triumph over common sense. While the number of collision-related deaths may indicate a need for better traffic safety, no one is seriously suggesting closing our freeways or restricting how far commuters are allowed to drive!

Unfortunately, when it comes to drugs, such overreaction is the rule rather than the exception. For instance, many of us are familiar with the federal Combat Methamphetamine Epidemic Act of 2005 (CMEA), which sought to stem the rise of methamphetamine abuse by restricting the sale of products containing the nasal decongestant pseudoephedrine (PSE).

PSE is not a prescription drug in most states, but the CMEA limited how much PSE a customer could buy at one time, mandated behind-the-counter placement in stores, required photo identification for purchase and forced sellers to maintain logbooks of sales and customer information. Those measures have had little impact on the meth epidemic. At a conference this February, DEA Office of Diversion Control Deputy Assistant Administrator Joseph Rannazzisi admitted that “NEITHER of these systems [tracking or rescheduling PSE] will have ANY impact on methamphetamine availability in the United States.” [emphasis in the original]. In short, these restrictions  have not curbed the meth supply, but have added a considerable bookkeeping burden for retailers while inconveniencing millions of cold and allergy sufferers.

The effects of the state medical board’s response to the outrage over opioid-related deaths may be far worse. Some of the suggestions I heard at a recent meeting of the board’s Prescribing Task Force left me wanting to tear out my hair in frustration.
the role of alcohol

California’s medical community has good reason to be embarrassed by the L.A. Times expose, which linked a substantial number of overdose deaths in Southern California to a surprisingly small number of doctors.

The story also raised serious questions about the medical board’s effectiveness in responding to complaints about excessive or reckless prescriptions. The board seldom suspends a doctor’s prescribing authority even if he or she is being actively investigated or has already been disciplined for reckless prescribing.

Given all that, you might expect that the Prescribing Task Force’s focus would be on improving the medical board’s oversight of its own members. Instead, I listened to hour after hour of experts proposing new restrictions on patients. The suggestions ranged from requiring patients to sign a contract with their physician prior to receiving prescription opioids to forcing all patients to submit to pill counts and random urine tests. Such measures would be tantamount to treating patients like criminals!

There were more sensible proposals calling for greater patient education, but overall, I was dismayed by the lack of clear-headed perspective on the issues involved. For example, one expert pontificated at length about the evils of opioid abuse without once mentioning the role of alcohol in many painkiller overdose cases. When I asked him about it, he replied that he would touch on that point at the end of his presentation, suggesting that he considered alcohol a trivial footnote rather than a significant contributing factor in many overdose deaths.

PUTTING PATIENTS LAST?

As a nurse and as one of the estimated 100 million Americans living with some degree of chronic pain, I am well aware of both the power and the dangers of opioid painkillers. There’s no argument that opioids carry a high potential for abuse and can kill if misused.

However, I’ve also witnessed the consequences of overzealous protocols that prevent patients from getting needed medication. If you suffer chronic pain, draconian limits on how much painkiller you’re allowed do not protect you; they just reduce your ability to function and increase the chances that you’ll find some other way to self-medicate — possibly with lethal consequences.

Tools like pill counting or contracts may be appropriate in certain cases, but imposing such restrictions on all patients would only have a chilling effect on the provider-patient relationship. If our approach to patients defaults to suspicion and mistrust, we only discourage our patients from communicating openly with us about issues like abuse and addiction.
comprehensive approach

So, what should be done? A better solution would include all of the following:

  • Improved education for patients about the dangers and proper use of opioids, including the risk of adverse interactions with alcohol or other drugs.
  • Better educating physicians and their healthcare teams about the signs of opioid abuse, including how to recognize potential risk factors like addictive personalities.
  • Fully implementing a real-time prescription drug monitoring program that can flag suspected prescription shoppers and physicians who may be recklessly prescribing opioids or running “pill mills.” California’s CURES (Controlled Substance Utilization Review and Evaluation System) could be but currently isn’t used for that purpose due to a lack of resources and interest.
  • More effective sanctions for doctors whose prescription history suggests a pattern of reckless or inappropriate prescribing.
  • Finding and funding alternative treatments for chronic pain and conditions that cause it. If you remove the source of the pain, you also remove the need to treat it with opioids.

Obviously, many of these are long-term solutions. In the short term, it’s important that nurses get involved in the debate. The Prescribing Task Force’s next meeting is in May. (See www.mbc.ca.gov for a schedule.) The meetings are open to the public and I urge readers to attend and participate.

This is an issue that directly affects many of us, our loved ones and our patients. We should not sit idly by while the medical community devises quick-fix solutions that may ultimately do more harm than good.

Genevieve Clavreul’s earlier article on this topic, “The Great Opioid Debate of 2012,” was published in WN127, Sept. 3, 2012.

_____

Scott Glover and Lisa Girion, “Dying for Relief: A Times Investigation,” Los Angeles Times:

Part 1 (“Legal Drugs, Deadly Outcomes,” 11 Nov. 2012)

Part 2 (“Reckless Prescribing, Lost Lives,” 9 Dec. 2012)

Part 3 (“Rogue Pharmacists Feed Addiction,” 20 Dec. 2012)

Part 4 (“Unused Tool Could Help State Flag Deadly Doctors,” 30 Dec. 2012)

_____

CDC, “Drug Overdose in the United States: Fact Sheet,” last updated 10 February 2014. The fact sheet says 60 percent of 2010 overdose deaths were pharmaceuticals, of which 75 percent involved opioids and 30 percent involved benzodiazepines.

Physicians for Responsible Opioid Prescribing, “Cautious, Evidence-Based Opioid Prescribing.”

The American Academy of Pain Management, cites 100 million chronic pain sufferers in America, per Institute of Medicine Report, “Relieving Pain in America.”

Transforming Prevention, Care, Education and Research (Washington, D.C.: The National Academies Press, 2011.

What to expect and when you need a lawyer

By Genevieve M. Clavreul, RN, Ph.D.

The mere mention of an investigation by the California Board of Registered Nursing (BRN) can strike fear into the heart of any nurse, and for good reason. A BRN investigation can turn your life upside down and even end your career.

With that in mind, I thought it would be worthwhile to explain what you can expect if you become the target of such an investigation.
by the numbers. Nurses can take some comfort in knowing that only a small percentage of RNs wind up in the BRN’s investigative sights each year.

Look at the Numbers

According to the BRN, there were 392,458 actively licensed RNs in California in September 2013. During the 2013 fiscal year (July 2012 through June 2013), the BRN’s Complaint Intake office recorded a total of 8,330 new cases, of which 7,714 were assigned for investigation.

The majority of last year’s new investigations — more than two-thirds — were initiated because the BRN learned that a nurse had been arrested for or convicted of a felony or misdemeanor related to his or her nursing duties or qualifications. The most common offense was driving under the influence (DUI).

Only 2,876 BRN complaints were filed by consumers in fiscal 2013 and 508 of those complaints were closed without an investigation. That means only about 0.6 percent of California RNs — one in every 163 nurses — faced a BRN investigation last year due to a consumer complaint.

First Steps

Let’s imagine that worse comes to worse and someone files a complaint against you. The BRN’s first step is to review the complaint to determine if it falls within the board’s jurisdiction. If not, the complainant may be referred to a more appropriate agency, but the case is considered closed as far as the BRN is concerned.

If the complaint does fall within the board’s purview, the next step is to determine if there is reason to refer you to the Diversion Program. This is a voluntary, confidential program for nurses struggling with mental illness or problems with drugs or alcohol. Obviously, that isn’t relevant in many cases and even if it is, the BRN may not offer you the option. Also, you can’t practice while you’re enrolled, so while the program might let you keep your license, you will probably lose your job.

If you aren’t offered that option or you decline, the board assigns the complaint for further investigation. Depending on the nature of the allegations, a complaint might be investigated by BRN staff, the Division of Investigation of the California Department of Consumer Affairs (of which the BRN is a part) or an outside investigator.
harsh questioning

Make no mistake — a BRN investigation can become a nerve-wracking examination of your professional and private life that makes a TSA strip search look like a friendly pat on the back.

Adding to the stress is the fact that investigators aren’t obliged to tell you exactly what they’re after or even the full details of the complaint. You won’t usually know who the complainant is or what they said, which can leave you scrambling to defend yourself without really understanding what kind of trouble you’re in.

BRN investigations are considered administrative actions, not criminal investigations, so many of the legal tidbits you’ve gleaned from watching TV dramas like “Law and Order” don’t apply here. Nevertheless, there are two rules that do apply: You have the right to remain silent and anything you say is likely to be used against you!

Call Your Lawyer

You are allowed legal counsel when speaking to the BRN investigators, and if you’re facing an investigation, hiring an attorney may be a wise move. Unfortunately, it can also be expensive. Many malpractice insurance policies don’t protect you in the event of a board complaint or will impose caps on how much the insurer will pay to assist in your defense. Still, if the investigation results in a formal accusation, your entire nursing career may be on the line, so the cost might well be worth it.

If you don’t know how to find a lawyer with expertise in this area of law, the American Association of Nurse Attorneys (www.taana.org) may be able to help. This is an association comprised of RNs who are also attorneys, many of whom have experience representing nurses in cases like these and understand both the legal and professional issues involved.

The Formal Investigation

An investigation is just that: examining the evidence related to a complaint to determine if it has any substance. Not all investigations result in an accusation, much less disciplinary action. Sometimes, investigators conclude that the allegations were false or at least that there is insufficient evidence to substantiate them. In other instances, the board might decide the allegations are substantiated, but opt to let you go with a citation and a fine.

If you’re not so fortunate, the board’s next step is to issue a formal accusation that you have violated the Nursing Practice Act. This accusation is public record and anyone can look it up on BreEZe or the BRN website. In most cases, the accusation will be followed by an administrative hearing, which is like a trial.

If you haven’t already hired a lawyer by this point, you should seriously consider doing so. Administrative hearings have their own terminology, rules and procedures; a simple misunderstanding could be career-ending. If you don’t promptly file a notice of defense after receiving the accusation — in which case the board will assume you’re forfeiting your right to a hearing — or if the board rules against you, you may be kissing your license goodbye. Depending on the allegations, you might even face criminal charges.

Keeping the BRN Fair

We like to think that the BRN represents nurses’ interests, so ending up on the receiving end of the board’s suspicion can feel like a betrayal. However, we should keep in mind that the BRN is not in the business of protecting RNs — it’s in the business of protecting the public from RNs!

If the BRN has reason to believe a nurse has stepped out of line, the public and our elected officials have every right to demand that the board act swiftly and firmly to investigate and correct the situation.

That doesn’t mean that nurses have to stand by helplessly or be railroaded. By educating ourselves on the BRN’s policies and disciplinary procedures, we can exert our influence to ensure that the board acts fairly and justly. BRN meetings, including the meetings of the Diversion/Discipline Committee, are open to the public and allow for public comment on any issue relevant to the committee’s business, even if the item isn’t on the agenda.  (You can find a schedule of meetings here.)

Another option, and one I always recommend for nurses, is to get involved with the legislative process. Remember, the BRN’s function is to enforce state law and regulations. If you feel those rules are unjust, it only makes sense to address your complaints to the lawmakers with the power to change them — or consider running for office yourself.

 

As nurses, we’re familiar with eight-, 12- and even 24-hour shifts, but our profession has developed another unpleasant permutation that not all of us have yet encountered: split-shift floating.

Split-shift floating means that a nurse starts his or her shift in one unit and then at some point during the shift is moved to a different unit. Shift-splitting is most often done with registry or traveling nurses, although it occasionally happens to staff nurses as well.

Thankfully, shift-splitting is relatively rare, but it can be a sign that something is seriously wrong with the way a hospital manages its nursing staff.

Why It Happens
I know that a lot of readers have strong prejudices against registry nurses, but there’s no denying that they are a fact of life in many hospitals. In a perfect world, there would be no need for registry nurses, but in a perfect world, no staff nurse would ever call in sick, have to leave in mid-shift due to an emergency or quit at an inopportune time. Unfortunately, in the real world, those things happen all the time and when they do, many hospitals turn to registry nurses (also called travel nurses or just “travelers”) to pick up the slack, particularly in states like California that mandate minimum nurse/patient ratios

Registry nurses typically work through a staffing agency that contracts with the hospital to provide temporary nursing services. Because hospitals aren’t usually in a strong bargaining position in these negotiations, travel nurses are often hired on “pay or play” contracts, meaning the hospital is obliged to pay for a predetermined number of hours or shifts regardless of how many hours the traveler actually works.

That’s why when the patient census drops, staff nurses sometimes find themselves sent home while the registry nurse stays — the hospital is on the hook for the traveler’s time whether he or she is working or not! For the same reason, travelers may sometimes find themselves shifted from one unit to another during a single shift to make up nursing shortages in different areas of the hospital.

Where It Goes Wrong
Floating nurses from unit to unit on different shifts is not itself a bad thing and there are occasions where shift-splitting is unavoidable, albeit far from ideal. However, if they become commonplace,  “Houston, we have a problem.”

Splitting shifts can have very negative consequences for the hospital and patients as well as the nurses. Having to change units during a shift can lead to a whole assortment of errors ranging from incomplete charting to missed or late medication. Worse, if something does go wrong, other nurses may have to step in to fix it, taking time away from their other duties and potentially compounding the bigger problem.

Behind the Eight-Ball
To illustrate the disruptive nature of shift-splitting, here’s a recent night in the life of a travel nurse named Charlene, who has given me permission to share her story with you.

Charlene was scheduled to spend the first half of her eight-hour shift, from 19:00 to 23:00, in Unit A and the remainder of the shift in Unit B. Here’s a small sampling of her duties during her four hours in Unit A: One patient presented with glucose of over 400 with no order for a sliding scale, had a wound V.A.C. to address ulcers on one foot and needed a leg ulcer dressing change at hours of sleep.

Charlene managed to track down the physician and get an order to administer a stat dose of 15 units of NovoLog while caring for three other patients, one of whom presented with a persistent fever and prompted Charlene to seek a doctor’s order for straight catherization for urine culture and sensitivity.

Charlene managed to accomplish and document all these tasks and at 23:05 was ready to brief the nurse assigned to relieve her. Five minutes later, while giving that report, she got a call from the assistant nurse manager of Unit B demanding to know why she wasn’t there yet!

This is a common dilemma for nurses working a split shift: If they don’t take the time to make a full report to their relief, patients’ continuity of care is likely to suffer, but taking that time almost certainly means being late to the next unit and being chewed out by the manager there. Charlene aptly describes the whole situation as being “behind the eight-ball.”

Dirty Curtains
Obviously, this is not good or sound nursing practice. Unfortunately, nurses in that position don’t have much recourse. When Charlene spoke up, she was given a dressing down and warned, “When you’re in someone’s home, you don’t tell them that their curtains are dirty.” A travel nurse who complains too much about a hospital’s practices is likely to be rewarded with a “do not send” note in her agency file.

Staff nurses may not fare any better. How many of us have been (or seen colleagues) reprimanded or otherwise punished for pointing out an unsound or unsafe practice? Such punishments send a message to the rest of the team that they should keep their mouths shut or share a similar fate.

A Better Way
During my various tenures as a director of nursing, one of the first things I always tried to put in place was an in-house pool of floater nurses. This pool wasn’t simply plucked arbitrarily out of the nursing staff; it was a group of talented and adventurous nurses who had been carefully recruited and, most importantly, had volunteered for this unique and challenging assignment.

Building those pools took work (each nurse had to be a generalist with the right personality and the ability and desire to take on a diverse and ever-changing array of duties), but it allowed our leadership to respond to each unit’s day-to-day staffing needs with nurses who were up to the task — without needing to rely on travelers or shift-splitting.

The point is not that hospitals should  never float nurses between units or hire registry nurses, but it is vital that the nursing chain of command not allow short-term solutions to become routine practice. Responding to an occasional emergency is one thing, but regular shift-splitting or constantly relying on travelers rather than addressing ongoing staffing issues will just mean higher costs and more mistakes.

It’s also crucial for nurse managers to create a climate where the staff is not afraid to offer constructive criticism. At the same time, nurses must have the courage to speak up when they see an unsafe situation and not throw each other under the bus just to make it through the workday.

If more nurses made it clear that we as a profession won’t stand for unsafe nursing practices like shift-splitting (and won’t stand for colleagues being capriciously or unfairly punished for a valid complaint), it will make our hospitals safer, saner environments for nurses and patients alike.

 

~Geneviève M. Clavreul, RN, PhD

From The Floor

Working Nurse Magazine

Adventures in Patient Land

My latest column is out —

What Makes a Great Nurse?

There’s more to nursing than experience alone

By Genevieve M. Clavreul, RN, Ph.D.

In recent years, there’s been a lot of talk in the nursing world about education: advanced degrees, certifications and training in the latest technologies. However, this nurse has long believed that all the certifications and degrees in the world are no substitute for good basic nursing skills, including attention to detail, listening and, most important of all, a deep and abiding compassion for all the patients under your care.

I recently received a dramatic reminder of this point when my eldest daughter Patricia was unexpectedly hospitalized. Her experience left me simultaneously impressed and frightened about the state of nursing in the Golden State. (Before I begin this tale, I should note that Patricia has given her consent to my sharing her story with my readers, but I’ve redacted the names and certain details to protect the innocent — and the guilty.)

Unexpected Surgery

Patricia’s hospital “adventure” began with an emergency trip to her primary care physician. Patricia had seen the doctor earlier in the week about a persistent rash and swelling in her feet. Blood tests revealed that her hemoglobin count had dropped to 8.0; since 12.0 to 15.5 is considered the normal range for women, such low levels were serious enough to merit immediate hospitalization.

After Patricia was admitted, her hemoglobin count continued to fall even after she received several full pints of blood. A CAT scan eventually revealed a large abscess that had displaced her right kidney from its normal position to the front of her abdomen. As if this weren’t bad news enough, the scan showed that the kidney was basically a shriveled mass and no longer functioning.

To make a long and painful story short, Patricia underwent a six-hour surgery to remove the abscess and the nonfunctional kidney, after which she was intubated for several days. She also ended up in isolation after a nasal swab came back positive for MRSA. As of this writing, she’s still in the hospital, but her white blood cell count is back to normal, most of the tubes have been removed and she is once again allowed solid food. She’s looking forward to going home.

The whole spectrum

 

The quality of nursing care my daughter received throughout this ordeal ranged from superb to truly lousy. Here are just a few examples from both ends of the spectrum:

Good: One of the day nurses was consistently attentive and thoughtful, making a point of always speaking to Patricia each and every time he needed to perform any action that affected her, from taking her blood sugar (like me, Patricia is diabetic) to more invasive procedures like checking her two No. 19 BLAKE drains. It was a small gesture that made a big difference.

Extraordinary: When Patricia received her diagnosis and was told that her kidney needed to be removed, she was understandably overwhelmed and began to cry and fret. One of the nurses, aware of the situation, disappeared down the hallway for a moment and returned with a harpist who offered to play several songs for Patricia to help her relax.

Bad: After Patricia was moved from the ICU to a regular room, the nurse who received her made it clear that she considered Patricia a burden. When my daughter complained of feeling warm and flushed after starting a new, more powerful antibiotic, the nurse could barely find the time to answer a call light and refused to take my daughter’s temperature again until asked to do so by the charge nurse. Appallingly enough, the recalcitrant nurse was mentoring a student nurse at the time. So much for modeling good nursing practice!

Worse: Since Patricia has very fragile veins, her doctors decided she needed a peripherally inserted central catheter (PICC) line to continue her antibiotics. The nurse who was sent to insert the PICC line insisted that I leave the room during the procedure because she needed a sterile field, but seemed oblivious to the gnats flitting about her so-called “sterile field.”
To my dismay, she then proceeded to pick up items that had fallen on the floor and put them back on the top of her cart without cleaning them first. I finally ordered her out of the room and requested a different PICC nurse.

Some of the nurses were very nice, but seemed worryingly inept. For instance, when I asked one young nursing graduate what dosage of morphine she was about to give Patricia, the nurse had to leave the room and reread the order before she could answer — hardly a reassuring sign. So much for making sure you’re giving the patient the right meds!

Some of the nurses shaped up noticeably after they learned I was an RN myself and thus was keeping an extra-sharp eye on them. It was good to know they were paying attention, but it suggested that they had grown a little slack and lazy when they didn’t think they were being “graded.”

Even the best nurses on the hospital’s staff had their off moments. One RN, an excellent nurse by most standards, had the bad habit of picking up the trash can lid each time he disposed of something and then continuing with his patient care. This didn’t make him a bad nurse, but it was a bad habit that could have negative consequences for patients.

What really counts

It struck me during Patricia’s hospitalization that there wasn’t an obvious correlation between the nurses’ levels of experience and the quality of care they provided. There were seasoned nurses who acted like they were going through the motions and veterans who still behaved as if each patient was as unique and important as the first patients they cared for when they begun their careers 20 years ago. There were new nurses who seemed out of their depth, but some of the finest nurses we encountered had only been RNs for a few years.

There were also patient care assistants (PCA) who provided care as good as or better than the RNs they supported. One PCA was so attentive and conscientious that I was heartened to learn she had just received her RN license that night. It gave me hope for the future of nursing.

What made the difference was not so much each nurse’s experience or level of training, but his or her personal commitment to patients and determination to practice to the best of his or her ability. Simply put, some of the nurses cared for my daughter as if she were their own loved one and others did not. Speaking as both a nurse and as a worried mother, it wasn’t hard to tell the difference and it had a meaningful impact on my daughter’s experience.

upholding the principles

I know there’s no such thing as a perfect hospital and even the best healthcare professionals make mistakes or have bad days — we’re only human, after all. I also don’t wish to downplay the importance of education and the judgment that comes with experience. However, it’s important for us to remember that education and experience are not a panacea. Teachers and mentors can tell us over and over again about the importance of compassion and patient advocacy, but it’s up to us to uphold those principles at every stage of our careers.

We must never forget that we often see patients at their most vulnerable and those patients’ families and friends are counting on us to help restore their loved one to health. Our profession demands that we challenge ourselves to always provide the best care we can and not allow ourselves to compromise patient outcomes with bad habits or a poor attitude. When that happens, it tarnishes us all.

The AFL-CIO just released an announcement that heralds the following: “Catholic Bishops, Health Providers, Unions cooperate to support workers’ rights”. The headline and the subsequent list can easily leave the reader believing that employer, workers and union organizers have agreed to a set of very good and positive principals. However, you’d be wrong because according to the AFL-CIO blog post that details this accord “the new guidelines cover seven principals for employers when workers seek a union”, the operative word here is employers. In short, the guidelines only apply to employers, not to the employee in favor or opposed to unions, or the union organizers themselves. And though this is not quite as egregious of an agreement as the odious Tenet/C.N.A. (an affiliate of the AFL-CIO) neutrality agreement, which handed over the personal information of registered nurses (without the knowledge of those same RNs) at C.N.A.-targeted hospitals it’s still nonetheless a one-sided accord.

The seven principals for employers when workers seek a union:

Respect;

Access to information;

Truthful communication;

Pressure-free environment;

Expeditious process;

Honoring employee decisions; and

Meaningful enforcement of these principals

How can I tell? because of the term employers in the sentence, and not phrases such as all parties, everyone, all concerned and so forth. So once again unions have found a way to stack the deck. What’s truly sad is that the guidelines suggested above are well meaning, but without them being applied to all, and I mean all parties (that would include employee both in opposition to and in favor of union representation and the union organizers) this then leaves the door open for union and their supporters to engage in bad behavior without fear of repercussions (this would also go for the employees who are in opposition to union representation).

Additionally several of the phrases are subjective rather than objective. For example, how are we defining truthful communication, pressure-free environment and meaningful enforcement? I ask this since one person’s pressure could be another person directly asked question. Truthful communication? What does that mean? For example in a recent flyer put out by the C.N.A., an AFL-CIO affiliate, numerous duplicate signatures, unidentified employee signatures, terminated employee signatures, and signatures of people in favor of decertification were found on a “petition” to encourage Cy-Fair nurses to vote against decertification. When a C.N.A. representative was asked why such a flyer was even being distributed the response was oh well it was a printing error; but to many individuals including myself this flyer was less than truthful, but apparently to the C.N.A. there was nothing “untruthful” about it.

So though the accord that seems to have been reached, I think it’s once step above an Election Procedures Agreement (EPA). If unions and employers were all about supporting the workers then these guidelines should’ve used more objective language and should’ve been written to include ALL parties. All too often unions accuse non-union nurses as being surrogates for management thus putting into question the motives of these nurses; and pro-nursing union nurses are often found exhibiting less then positive adult like behavior. The union gets the option of pointing the finger of blame to the first and ignoring the bad acts of the later; while employers do the same in reverse – meanwhile it’s the nurses themselves that suffer in the end. Or you have experiences such as the nurses in Houston and Philadelphia where hospital management was so cowed by the EPA that they decided to not respond to any questions that nurse had that remotely referenced the union, and barred any message by pro-union messages going so far as to give the union a glass covered bulletin board, but no such favor to the “No to the union” nurses. Is this fair? Does it fall in line with the above AFL-CIO guidelines?

You may wonder why I even decided to address the AFL-CIO accord with the Catholic Bishops et al; simple the link was sent to be by someone identifying himself or herself as:

hello

2227638@gmail.com

70.136.177.33         

Submitted on 2009/07/09 at 3:24am

I’d like to know your thoughts on this:

http://blog.aflcio.org/2009/06/22/catholic-bishops-health-providers-unions-cooperate-to-support-workers%E2%80%99-rights/

I found the query trapped in my spam folder since both the name and email appeared suspicious to my spamblocker. I did a quick whois search and found that it had been sent from the servers at the California Nurses Association (see copy of search here). I wonder what ulterior motive the C.N.A. had in sending me this link to their affiliated organization? Are they contemplating adopting a similar, somewhat more restrained approach to their well know aggressive organizing? Well who’s to know the real reason, but respond I have with my opinion.