The Nurse Unchained
One nurse’s unabashed opinion on all things nursing.

I’ve got a pretty good track record in getting letters to the editor published – if I say so myself.  Every now and then I send a letter that I think is particularly important, especially when it is correcting misinformation, doesn’t seem to make the “cut”.  When this happens I sometimes decide to post it on my blog, and this is what I’ve done with a copy of the letter to the editor that I sent in response to an Pasadena Star News editorial piece they published on the nursing education and nursing shortage challenge.  Though overall the article made a valiant attempt to present solutions, I also found at least one glaring error and many of the same old-same old problems and solutions that the nursing talking heads have been nattering about for almost as long as I’ve been a registered nurse.  However, the Pasadena Star News paper letter to the editor person felt that my response was too long to print and after he suggested that I might want to consider editing it down and “tightening” it up I should resend it, which I did.  Alas, neither letter has been published to date.  So below you’ll find both versions of my letter to the editor the first is the original followed by the much revised and edited down version of the second submission.

September 22, 2008

As someone who has written extensively on the issue of the nursing shortage and an outspoken advocate for nursing I have called on a “Flexner-like” study of our nation’s nursing programs.  In the early 1900s our Nation’s medical schools and the very structure of medicine received an overhaul of sorts in the form of a nation-wide study that is often referred to as the Flexner-study.  This study provided a framework from which all medical schools now design their program around which has allowed for a maximization of available “seats” in medical schools, the facilitation of transfers within and outside school systems all the while maintaining a high level of quality.  I think nursing, too, could benefit from a similar review.  This does not necessarily mean that I think nursing should be forced to adopt the same study tool, but perhaps nursing could use a top to bottom review from a core group of experts that could then provide recommendations on everything from what the entry-level of nursing should be to how we should structure the complete nursing career ladder, to how to design our nursing programs to maximize the available and often limited seats and so forth.

October 3, 2008

Many external factors impact our nursing education pipeline, some of which you noted in your article.  However your editorial failed to address issues such as the low student to instructor ratio which is mandated (in some cases as low as 8:1) which often makes colleges and universities hesitant to launch, expand or maintain nursing programs.  Many of our nursing schools have a high attrition rate; contributing factors are due in great part to poorly prepared students specifically in areas of science, math and yes English-language skills.  Nursing programs are also plagued by a great deal of “individuality” which often makes transferring from one nursing program to another problematic.  Not to mention that the average nursing school educator can make more money as a staff nurse. These are just a few of the issues that place a strain on our nursing pipeline, and while these problems are partially addressed, all too often they’re being addressed piece-meal with very little county, state or nation-wide coordination.

psn-room-for-nurses

This is an open letter from one RN who’s sick and tired of the American Nurses Association (ANA) getting away with propagating the myth that they represent the interests of 2.9 million RNs in this country!  Most RNs are not members of the ANA, and in a recently released Annual Report the ANA published that less than 11% of all eligible RNs in the country were members of the ANA or any other similar association/union.

Like so many organizations the ANA is a member organization and thus they can only speak for their members, and yet the ANA allows the media, pundits, elected officials and the public-at-large to believe that they represent the 2.9 million RNs, or the interest of 2.9 million RNs depending on which of their press releases your read.

Nursing is a profession that demands the highest of ethical practices from those who practice this time-honored profession; and in turn organizations that purport to represent nurses should be held to the same high standards, and when organizations such as the ANA promulgates misinformation about the number of RNs that are members they are perpetuating a deception on not only their members but the public as well.

Several years ago when the California Nurses Association (C.N.A.) tried to pass themselves off as the voice of the California RN, I was quick to illustrate in a letter to the editor that they represent just about one-third of California RNs (and most of those RNs were as much members by choice as by being forced to be members via a closed shop agreement).  I made clear that the C.N.A. was welcome to represent themselves as a voice or one of the voices of nursing in California, but unless they represented a majority of California RNs they could not be considered “the voice” of the California RN and to their credit to this day they only present themselves as “a voice”.   Now the ANA wants to pass itself off as the voice of the American RN and they do so in couched and carefully constructed sound bites to provide the illusion that all 2.9 million RNs are a united voice and the represented body for that voice is the ANA – how patriarchal and chauvinistic of them!

The most recent example of the ANA arrogance is their endorsement of Senator Barack Obama, and by claiming once again that the ANA represents the interests of the nation’s 2.9 million registered nurses.  The ANA needs to reissue their press release to accurately reflect the number of nurses that their organization actually represents, and stop perpetuating the lie that all 2.9 million RNs in this country have acquiesced their voice to this one organization.

This does not mean that the ANA hasn’t promoted programs that have benefited the nursing profession as a whole, but then again one could argue every nursing organization regardless of size, focus, or political persuasion has at some point or another promoted positive nursing change.  However this does not give the ANA or any other membership organization liberty to pretend to speak for all nurses!  ANA membership is not free, and to be a member of the ANA requires that you pay your dues, so until all 2.9 million (or majority) of RNs sign up as members of the ANA this RN will continue to speak out about the myth that the ANA represents the interests of 2.9 million RNs.

Answer me this who died and elected them our spokes-organization?

If you agree please add you name and your home state to this list and share it far and wide.

Geneviève M. Clavreul, RN, Ph.D. – California

If one were to believe the C.N.A. (based on the quote from their official spokesperson) that was written up in the August 12th issue of the Houston Chronicle (read the story here — http://www.chron.com/disp/story.mpl/business/5940099.html) an eight vote difference is a “majority” and thus an overwhelming endorsement for union representation and anyone that questions this vote is undemocratic. Contrary to the C.N.A. allegations, what the National Right to Work Foundation has (www.nrtw.org) done is file an unfair labor practice allegation against both the C.N.A. and Tenet (you can read the press release here – www.nrtw.org/print/3156). They allege is that the neutrality agreement that was signed between Tenet and the C.N.A. was the first “wrong” action in the C.N.A. attempt to gain a foothold in Texas. In addition, the nurses have alleged that this neutrality agreement was so one-sided it provided the Houston-area Tenet nurses no choice in which union the nurses could join, so in essence the C.N.A. was foisted on them. To make matters worse the so-called neutrality agreement also gagged the managers from speaking or answering questions raised by the nurses, leaving the nurses very little access to information that wasn’t either provided by the C.N.A. or vetted and approved by the C.N.A. – talk about a raw deal. Not to mention the agreement gave the C.N.A. access to the private home addresses and telephone numbers of the nurses without the nurses’ knowledge or permission. It’s also my understanding that a neutrality agreement is generally not introduced or signed until the prospective union can demonstrate that there’s an interest expressed by the nurses to be represented by that union, which I understand never happened in this case.

Something tells me that if the roles were reversed the C.N.A. would have been screaming “bloody murder” and Congressman Henry “I’ve never met a congressional hearing I didn’t like” Waxman would have been chairing hearings on such outlandish behavior. So the nurses have had to rely on themselves and a network of management/union-savvy nurses from around the country to get answers and information to then share among themselves. But then again we are talking about the world according to the union, so we shouldn’t expect things to appear logical. I feel confident in making such a bold statement because a couple of months back a Fresno-area hospital rejected the C.N.A. for the second time by a 125 vote margin, and guess what the C.N.A. has contested the outcome. How come the C.N.A. cries undemocratic to question a neutrality agreement that results in an eight-vote margin win for the union, but when another hospital’s nurses vote to stay union-free this is worthy of being contested by the C.N.A., which that claims that all it wants to do is let the nurses have a voice?

I guess it just another example of a union talking the talk but not walking the walk – why am I not surprised.

For the past year or so the National Nurses Organizing Committee (N.N.O.C.), a spin-off of the California Nurses Association (C.N.A.) has been aggressively trying to recruit and add nurses from across the country to their union.  At present N.N.O.C. has Texas-area nurses in their sights and they are currently in Houston (under a neutrality agreement) trying to recruit nurses from three Tenet-owned, Houston-area hospitals; the three hospitals are: Cy-Fair, Houston-Northwest, and Park-Plaza.

When I learned of the N.N.O.C. activities in these hospitals I reached out to some of my contacts in Houston as well as at least one of the nurses who had been identified as leading a nurse-driven opposition to the unionization attempt.  Several conversations and emails later my daughters and I found ourselves taking a short trip to Houston and meeting with the various nurses from all three hospitals.  Even though I had received a great deal of background information from these nurses prior to arriving in Houston the sheer scope of the nurses’ abandonment and betrayal by their employer only became clear after I read the Tenet/C.N.A.-N.N.O.C. neutrality agreement and listened to the personal stories of the RNs that I met during my stay.

I thought how odd that a neutrality agreement would be signed even before the union presented any authorization cards showing that there was an interest from the nurses to call for a vote.  Neutrality agreements are often controversial, but in short a well-written one (i.e. one that favors the union at the expense of employer rights) can make unionizing efforts much easier for the union and its representative.  The Tenet/C.N.A.-N.N.O.C. agreement is heavily weighted in favor of the union, even going so far as requiring that the hospital have any of its opposition information which was to be neutral-language based preapproved by the C.N.A./N.N.O.C before it could be distributed; and the part that I thought even more interesting was the part where the hospital would provide the union with the names of “eligible” RNs personal contact information.  The nurses didn’t even know their private, confidential contact information had been provided to this third party until nurses began receiving calls at home from union representatives; it was only after numerous complaints from nurses that the nurses were given an opportunity to opt-out but of course by then the union already had the complete list.  One nurse shared that she discovered her contact information had been released to the union, without her knowledge, when union representatives contacted her at home and used her given name not the “nickname” that she normally goes by even at work.

The nurses that strongly opposed the union quickly formed two ad-hoc groups, UB-144 and Informed RN (http://informedrn.googlepages.com/) to reach out and provide an alternative source of information then the one being provided by C.N.A./N.N.O.C.   Though one cannot necessarily blame the C.N.A./N.N.O.C. for drafting a contract that favors them and their cause so heavily, I wonder why the administration at Tenet was so willing to pretty much just roll over and take it.  The first rule of contract negotiation is to make the tough demands up front and then negotiate, negotiate, negotiate.  But there is little give and take in this agreement since it binds Tenet in such a way they have pretty much left the nurses that want non-union information out in the cold with no support from any Tenet official.  However, these nurses showing a great deal of initiative have reached out and garnered answers and support from other nurses in Texas and across this nation – because of the little known fact that nursing unions and most of the main-stream media fail to clarify is that nursing unions do not represent the voice of nurses, since most nurses (either 89% or 80% depending on which statistic you pick) choose to speak with their own voice – not a union voice.

However, what concerns this nurse and citizen most is what, in my opinion, is a very undemocratic and almost draconian tact that the C.N.A./N.N.O.C has demanded of the three Tenet hospitals.  For example C.N.A./N.N.O.C. can and does get meeting space at all three of these hospital – this is fair; but when Tenet-nurses wanted to get their “we are professionals and don’t need a union to represent us” message out the C.N.A./N.N.O.C. demanded that the hospital refuse a room to these nurses.  Even though these nurses were doing everything on their own time and dime and the only thing they asked for was the same courtesy that C.N.A./N.N.O.C. had demanded – a room to meet in.  The C.N.A./N.N.O.C. demanded and got a confidential employee list with the private home contact information of all the eligible RNs; when the nurses of Informed RN asked for the same courtesy they were denied access to the list.  So next time when the C.N.A./N.N.O.C. (or any union for that matter) pontificates about democracy and rages against special interest groups – remember the above example because if C.N.A./N.N.O.C. was all about informing and empowering nurses then they wouldn’t fear a grass-action group such as Informed RN.  But of course the C.N.A./N.N.O.C. does fear such groups because groups such as Informed RN are all about empowering RNs to be informed and to take action on what they know – all without having to pay dues to the union machine.  To me how C.N.A./N.N.O.C. has dealt with the Houston RNs, coupled with the language that they crafted for a California Assembly Bill 1201 (thankfully killed in committee) shows what their union leadership really think of nurses.

Meanwhile, I hear that these buttons (see below) are so popular that Informed RN can hardly make enough to meet with the demands.  Way to go Informed RN!

A short while ago I was invited by some nurses from Houston, Texas to pay them a visit. Since my daughters and I had been discussing taking a short vacation for some time the invitation provided us with an opportunity to take a road trip to Texas. I let the nurses in Houston know that I’d be happy to pay them a visit and chat with them about their experiences with the California Nurses Association/National Nurses Organizing Committee. Which is why after just a few days in Houston, my daughters and I found us in Austin having lunch at the Sheraton Hotel and under the watchful eye of C.N.A./N.N.O.C. officials. We had personal business to attend to in Austin, and since the C.N.A./N.N.O.C. has planned a strategy session with HCA nurses to discuss “unionizing” I thought it would be a perfect opportunity for me to observe them in action, so to speak.
As I walked down the hallway between the conference rooms and the restaurant where my daughters waited for me, a C.NA. representative recognized me and quickly left the meeting room so he could follow me. And follow me he did, stopping short of the restaurant entrance where he then stood for 10 – 15 minutes, in plain sight, observing us as we ordered our meal and while he busily spoke to someone on his cell or text messaged. A little while later he motioned for someone to join him and appear to direct him to continue the vigil while he went back upstairs. After finishing our lunch we made plans to complete our errand and found it most amusing to see that we were still being “watched”; oh to have such power.
Which brings me to my point of hubris. Why the officials of the C.N.A./N.N.O.C. would think that I would plan to disrupt their activities or meetings is interesting – but of course they would think this is how people behave since they think nothing of disrupting a meeting, stalking or harassing those they perceive as “threats” or even raiding other unions – so of course they would believe this behavior to be the norm and thus everyone else would exhibit the same deplorable behavior. Which is why they made a point of observing and stalking my daughters and I while we were having our lunch and then made sure we were “observed” during our entire stay at the hotel. If they had only come up and introduced themselves perhaps they would have learned my intent and thus not wasted their time on looking the fool.
Nonetheless when I shared this experience with my fellow nurses from Texas and California everyone had a good laugh at the actions of the C.N.A. and commented on how this made for a memorable experience for this Texas road-trip. Of course one would think that the C.N.A./N.N.O.C. exercise in hubris would end there, but have no fear the day after my return I received an email from an N.N.O.C. nurse from Tennessee. Nurse Chapman chose to send me an email regarding a very popular article I wrote, “To Unionize or Not to Unionize, that is the Question?” Apparently he was under the impression that he was my editor or significant other because he attempted to “deconstruct” my article throwing around such words as nurses need strong union representation (just see what such strong unionization has wrought the nurses of Great Britain, Australia and Canada), research and studies have shown. . . without providing a single citation for his conclusions, and my favorite “I request that you change the title of your article. . ”. Of course my response to him was NO, I would not change the title of my article, as I like it very much the way it is now. I also reminded him that this article, as all my articles and blog postings reflect my opinion and experience and thus not subject to his approval. Of course he chose to ignore the underpinnings of all my articles which that my readers should always do their due diligence, which by the tone and context of his letter I think he preferred that nurses just remain as sheep and that they should follow his piped piper. “N.N.O.C.”.
Oh the hubris of the C.N.A. and their operatives to think that they can intimidate nurses so easily, and me in particular.

Nursing unions are quick to praise RNs when they vote to bring in a union and often characterize these nurses and their actions to join a union as brave or groundbreaking. However when RNs chose to deny a union foothold into their ranks suddenly these same RNs are now somehow victims of intimidation by the “evil” hospital administration, or somehow too weak to resist the management propaganda and thus hoodwinked into voting against unionization.

Case in point, the recent failure of the C.N.A. to organize the RNs at St. Agnes Medical Center in Fresno, California. The S.E.I.U. put out a “call for union unity” and used this recent loss (452 voted no while 327 voted yes with a margin of 125), which was the second failed attempt to unionize the St. Agnes RNs by the C.N.A. In the S.E.I.U. press release they clearly argued that the RNs were somehow manipulated by the hospital management and thus somehow incapable of making a decision of their own volition. Meanwhile, the S.E.I.U. conveniently failed to acknowledge the St. Agnes coalition of RNs “Our Voice-Our Choice” that lead an independent grassroots efforts to provide the “other-side” of the discussion to the RNs. This action was completely independent and to my knowledge unfunded by the management or administration of St. Agnes. So I find it rather ironic that a union that claims it’s all about empowering RNs to speak up for themselves would fail to acknowledge that these RNs did just that – oh I know it must not count if it’s not a union-led effort.

Too bad that nursing unions often show themselves to be no better than the hospital management that they label unresponsive to RNs wants and desires. In the case of St. Agnes the no vote appears rather decisive, but instead of giving kudos to the RNs for expressing themselves and exercising their collective will the C.N.A. has decided to fight the outcome of the vote and the S.E.I.U. chooses to characterize St. Agnes RNs as some kind of dupe to the hospital administration. In my opinion if the nursing unions were all about empowering the nurses, they should be celebrating that the St. Agnes nurses came together and that they made their will so clearly known, but then again it only counts when RNs chose to unionize versus affiliate as professionals. Why else do you think 85% of all RNs in the USA continue to choose to eschew the nursing unions, and over the past several decades or so nursing unions have basically been playing a zero sum game when it comes to membership?

In short, if we are expected to celebrate when RNs chose to vote in a union, we should equally celebrate when they chose to “self-represent” and be union-free. Otherwise, if we are to believe the union propaganda that RNs are somehow so feeble-minded that they fall under the “mind-control” of hospital administration or allow themselves to be so easily frightened and intimidated then you have to ask yourself do you want such a weak and feeble-minded RN caring for your loved-one, caring for your patient, or working on your team. For far too long nursing unions have denigrated RNs that resist their siren lure; it’s time that they show the same respect for RNs that chose to remain union-free as those who chose union membership.

Dateline Dearborn, Michigan – Nurses alleged that nurses attack them!

Yes, you read correctly, the nurses and other members of the California Nurses Association/National Nurses Organizing Committee (C.N.A./N.N.O.C.) alleged that during their convention in Dearborn that members of the Service Employee International Union (S.E.I.U.), a rival nursing union, barged into their event and began to harass and attack their members. C.N.A./N.N.O.C representatives have alleged that at least one woman was injured during this altercation and had to be treated at a local hospital for her injuries.

When I read this report in my e-mail and later in my local newspaper I thought what a sad, sad day for the nursing profession; and a sense of déjà vu came over me. Since several years ago I was very nearly “that” woman who had to be taken to the hospital after being accosted by a male RN who was a C.N.A. member.

During a special election that had been called by our Governor the C.N.A., S.E.I.U. took issue with a request from the Governor to delay the implementation of phase two of the California mandated nurse/patient ratio law, asking that a review and report of the impact of phase one first; this request seemed reasonable to me since many hospitals were claiming the law had been at the heart of a series of hospital closure and the nurses were arguing that it had “solved” our state’s nursing shortage. A review of what phase one had or had not done seemed reasonable however some chose to interpret that to mean a rollback of the law. So the C.N.A. started its now famous campaign where it dogged the Governor and many other elected officials to various events throughout the state holding loud and boisterous demonstrations and even interrupting the “non-political” annual Governor’s Conference on Women. Historically this conference has placed a focus on women and women issues with little to no political agenda, a rare venue where divergent groups could gather for an open exchange of ideas – no more because since that day the conference has become like so many public meetings have become susceptible to “hijacking” by one group or another for its own political agenda.

I was with a group of nurses who decided that we had had enough with members of the C.N.A. disrupting events through-out our state and when the C.N.A. decided to hold their post-election night event at the same venue as ours we decided to take our signs and hold a low-key, peaceful demonstration outside their room; since of course what’s good for the goose is good for the gander – no? As we stood outside the door of their event with our signs; members of the C.N.A. came out to demand that we leave, when that failed they tried to drown us out and when that didn’t work they tried kicking my cane out from under me so I’d fall.

So, while I found it very distressing that nurses would resort to physically assaulting one another (as if they don’t experience this type of bullying enough in the workplace) I found it rather ironic that Rose Ann DeMoro would yell “foul” when treated to some of the same tactics she and some members of the C.N.A./N.N.O.C. was infamous for – talk about the pot calling the kettle black. This recent event also helps highlight what happens when people are intentionally “radicalized”, allowed to funnel all their frustration (both real and imagined) into a perceived “foe”, and then let lose to vent. The past several years have seen the C.N.A./N.N.O.C. aggressively recruiting for new nurse members throughout the country. In many of these recruitment activities there have been accusations made that the C.N.A./N.N.O.C. has engaged in union raiding, the use of State Board of Nursing mailing lists to recruit (this is usually prohibited), and even the attempt to recruit under the guise of emergency response, etc.

There is little doubt that the C.N.A./N.N.O.C. has developed a reputation for “bare-knuckle” fighting and not being shy at calling out those that they perceive are hampering their agenda. Most organization members would welcome such aggressive “protection”, however sometimes when a group behaves in a way that is very much outside the societal norm and don’t face consequences then the groundwork is laid for the potential of even more outrageous behavior in the future and where does the line get drawn?

Time for disclosure, for those who may be unaware of my personal bias let me make it clear I am not one who supports or promotes the idea of unions for nurses. I am however a firm believer that nurses should seek out, participate and join professional associations, but NOT unions. Strikes and the behavior exhibited by the rival nursing unions in Michigan are a good example of what happens when nurses adopt the no-holds barred mentality of unions.

Another thing that has concerned me about the recent confrontations in Michigan is the silence from organizations that claim to be professional nursing associations and advocacy groups on the alleged nurse on nurse violence that was reported to have occurred in Dearborn, MI. You’d think that they would at least issued a statement denouncing such unprofessional, let alone poor human behavior. Of course, I’m sure that if this had been an episode of E.R. or House maybe we’d have received a denouncement.

I’m also concerned at the fall-out from this violent encounter, since the S.E.I.U. and C.N.A./N.N.O.C. confrontation over the stalled unionization in Ohio I have received numerous mailers from the S.E.I.U. about the transgression; and now with the events in Dearborn one wonder if there will be an intervention or will things continue to escalate? However, Ms. DeMoro shouldn’t be allowed to cry wolf about the S.E.I.U. members “stalking” C.N.A./N.N.O.C. members since it has been my experience that the C.N.A./N.N.O.C. has engaged in this behavior, usually meant to coerce uncooperative nurses at hospitals targeted by the C.N.A./N.N.O.C. for union organizing. Don’t believe me just read the testimony of nurses from Cedars-Sinai hospital that describe what they experienced at the hands of C.N.A. representatives when they opposed unionization; as well as the documented threats made to some nurses’ families. This does not mean I believe such behavior is justifiable or acceptable but it is interesting that when C.N.A./N.N.O.C. members experience such hostility it is suddenly not so palatable. Maybe this might be a significant emotional event for both groups to step back and take a look at what has happened and what is happening and maybe alter the collision course they are both on. Of course there are some observers who also see this as an opportunity to expose the darker side of nursing unions, and it very well maybe but the question remaining is will the media report and investigate, or will they take their usual role of union sympathizer and sweep it under the rug?
Meanwhile, this morning a brief news article revealed that a court official had lifted the temporary restraining order that had been granted to the C.N.A./N.N.O.C. against the S.E.I.U. The court official ruled that the restraining order was “not supported” by the evidence filed by the C.N.A./N.N.O.C. (source Los Angeles Times, April 23, 2008)

Recently, I spoke with a reporter from one of our Western States.  She had reached out to the members of our health care journalist list asking for feedback on the Magnet Hospital program.  As a columnist I shared with her both my personal and professional opinion (note to readers a columnist is entitled to an opinion, while a reporter is charged with reporting the facts).  As our conversation drew to a close the reporter commented that she was somewhat surprised when this particular hospital became a Magnet hospital, since in their community it is considered the worst of the two hospitals their town has to offer.  My point exactly, I told her that is why among nurses the significance of “Magnet” status can be and continues to be so hotly debated.  Why do nurses seem to be so divided on this issue?  You’d think that nurses would rally around the Magnet program, but in reality many nurses view the Magnet Hosptial designation with suspicion and trepidation, while others welcome it with open arms and sing its praises.  Why?

The Magnet Hospital designation has been promoted as the “gold” standard for a hospital’s nursing staff much like achieving Joint Commission  (formally JCAHO) is considered the proverbial “Good Housekeeping Seal of Approval” for hospitals.  The American Nurses Credentialing Center (ANCC) (a sub-organization of the American Nurses Association [ANA]) created the Magnet Recognition Program.  The objectives are simple and make for a persuasive argument for seeking such recognition.  These objectives are:

? Recognize nursing services that use the Scope and Standards for Nurse Administrators (ANA, 2003) to build programs of nursing excellence for the delivery of nursing care to patients
? Promote quality in a milieu that supports professional nursing practice
? Provide a vehicle for the dissemination of successful nursing practices and strategies among health care organizations using the services of registered professional nurses
? Promote positive patient outcome

As my children are fond of saying, it doesn’t take a rocket scientist to realize that the above objectives are not only admirable but objectives that all nursing teams, whether at a hospital, clinic, or doctor’s office, should want to achieve.  The question that one must ask is whether or not this program is achieving the goals that they promote, or is it yet another program that is run and defined by paperwork, achieving a “magic” number, and generating revenue for an outside organization?

Nurses are very much divided when it comes to the value of a hospital seeking Magnet Hospital designation.  In the Los Angeles and Orange County area there are only four and three hospitals, respectfully, that have been granted “Magnet” status. One in LA has a chronic nursing shortage, a second made the local news and not in a good way for problems that can be laid at the feet of the nursing staff.  Hospitals trumpet far and wide when they receive their “Magnet” designation, and to my knowledge only one hospital, UC Davis Medical Center, has ever had its designation removed.  After a recent and well publicized medication error occurred at a local area hospital a journalist posted a question to our mailing list asking what if anything happens to the Magnet status that had been awarded in such as case, or after a hospital received State sanctions or fines?  Did the ANCC place the hospital in probation, did they reassess, did they publicize when a hospital looses its Magnet recognition?  I found the response provided by another list member who is also involved with the ANCC rather shocking, but indicative of why so many of my fellow nurses take the vaunted “Magnet” designation with such a grain of salt.  Her response was that the ANCC did nothing in such cases and that it was up to the hospital to “inform” the public.  Such a passive position, in my opinion, only reaffirms the suspicion of many nurses that the Magnet designation is just one more scheme to generate funds to an outside agency and to see how many hoops they can make the nursing staff go through to please some “nameless” accrediting body.  My readers may find this statement overly harsh, but as a registered nurse who prides herself as a professional and who has never worked in a “Magnet” designated hospital but who has had the privilege to work in many stellar hospitals during her career it offends me when a credentialing agency promotes a “seal of approval”, setting one hospital above another and then when one of their “meets a higher” standard hospital fails to maintain this goal does nothing to place that institution in a probationary status, require review before reaffirming the “seal of approval” or outright revocation of the “seal of approval”.  This type of behavior only provides more reasons for nurses to be suspicious of the validity of such a program.

Does this mean that such a “seal of approval” should be designed or furthered?  Hardly, nurses share the common desire of other professionals to have the organization they work for be recognized for outstanding performance, and having a specific segment (such as nursing) singled out even furthers a feeling of pride in one’s institution, team and self.  Unfortunately, like with so many “seals of approval” they are more often than not a paper tiger.  I know that many supporters of the Magnet recognition program often express frustration and bewilderment when nurses, such as myself, show a profound lack of acceptance and respect for this program and its lofty goals.  However, I believe that the skepticism is justified and warranted based on our experience either working in such institutions, knowing the overall character/skills of the nursing staff at some of these organizations, and in some cases having been a patient or knowing someone who has been cared for by the nursing staff at these “Magnet” designated hospitals.  A common complaint that I hear from nurses that have both experienced the evaluation process or worked within a Magnet hospital is that once the Magnet recognition is received by the hospital the staff, administration and hospital often pretty much fall back into their old routines and thus making the positive changes set forth by the Magnet program moot in many cases.  Many nurses often express the same opinion and frustration with the Joint Commission process.

I know that supporters of the Magnet recognition program will often cite published research that support the assertion that hospitals with Magnet recognition are “better” at attracting and keeping quality nurses and that this then translates to better patient outcomes.  Without a doubt reading such articles, and I read the many that come across my desk, one has to also balance such studies with the bias (and we all have them) that the researchers, their funders, and yes the publications may have and how this may affect the outcomes.  One way to deduce the potential for bias is to know the author of the paper and their institutions, another is to request the study tool that was designed and utilized.  This does not mean that such studies are inherently flawed, on the contrary they may be well designed but by educating yourself on what the assumptions were in designing the study that lead to the published outcomes can help you understand how the conclusions were derived.  My son, an actor/independent film-maker, likes to remind me that even documentaries have an inherent bias, because the moment the director chooses which angle to shoot from, where to plant the camera, or which scenes to cut or not cut the documentary becomes biased.

Could a program such as Magnet recognition serve as a marker of distinction, without a doubt?  However, I think the program as it is currently used, and implemented has many flaws that the ANCC continues to turn a blind eye to and the most serious flaw is what to do when a hospital’s nursing staff turns out to be less than the exceptional model set forth in the goals of the Magnet Recognition program.  Nurses who participate in the evaluation and accreditation process need to be able to attach a value to the entire program, and one way to achieve this is for the ANCC to also publicize when a hospital that has been designated a Magnet fails to maintain the highest expectations of the organization and the credentialing program.  For example when UC Davis lost its Magnet recognition designation the local newspaper reported that the ANCC had taken this action in part because of the unionization of the hospital (when UC Davis had initially received the designation it was non-union), and had responded to calls from the nursing team that had contacted the ANCC independently.  The logic was that if the nurses felt the need to seek union representation that this must mean that the nursing structure was not fulfilling the fundamental goals set forth by the Magnet program, and thus they decided to remove the Magnet recognition, which to this day UC Davis has failed to recapture (though they may have chosen to reapply).  The union argued that the removal was arbitrary and unwarranted, and on the one hand they have a point since the fact that it was the nurses working as a team chose to contact the ANCC does somewhat validate some of the core principals of the Magnet recognition program.

I see the potential of the Magnet program, however in its current incarnation I also think that it is far too often a “soft” tool and has too much of a subjective appearance, much like so many of the other “this is a great hospital” programs available today.  Programs with the lofty goals, such as the Magnet Recognition, really need to also have some teeth, so that once the recognition is achieved the hospital and nursing administration and nursing team know that they cannot allow any falling back into the way it was or else they risk loosing this very unique and rare designation.  As the near-tragic Heparin overdose occurrences at Cedars-Sinai Hospital in December of last year, a quick search of the ANCC website shows that Cedars still retains its Magnet designation.  One would think that the near fatal overdosing of three infants, the admission of the break down in procedure by the hospital administration, the findings from the State that Cedars failed to implement its own policy, hefty fine, and the admission of the nurses that they did not read the information on the vial would warrant at least a probationary status or a re-evaluation.    One may think this rationale overly harsh, I think not.  If we are to accept that Magnet Recognition is the epitome of what the nursing profession can and should aspire to, that hospitals that pay large sums of money to go through such a recognition process and meeting the set goals in order to recognized as an institution that has enshrined these ideals and put them into practice; then in turn when such an institution fails to uphold or continue to meet this standard there should be serious repercussions.

Otherwise examples such as these leave nurses with the feeling that Magnet Recognition is more myth then reality – and it doesn’t have to be that way.

Earlier this month a medication error was reported at Cedars-Sinai Hospital. The television show “TMZ” (The Thirty Mile Zone) first broke the news of this error, since it involved the children of a celebrity. The error, as it was reported, involved the unintentional overdosing of three infants (though other sources have reported that the incident may have involved up to 13 infants) with a Heparin overdose. Two of the infants that were affected by this medication error are the twin infants of Dennis Quaid and wife Kimberly Buffington.

As of today, Nov. 25, 2007, there seems to be several conflicting stories, so I’ll start with the initial report. TMZ broke the news with the following general information; three infants received inadvertent overdoses of Heparin, used to flush IV lines. They reported that two separate doses of 10,000 u were administered: the first was on Saturday and the second 10,000 u was on Sunday; and that the error was caught when the nurses noticed that the infants were beginning to “bleed-out”. The drug Protamine, the anti-dote to the Heparin overdose, was administered and the children were in Neonatal intensive care (NICU). Cedars later issued a press release that characterized the incident as an error that occurred due to a technician inadvertently placing the high concentration 10,000 u vial of Heparin (usually used in adults only) in the unit’s pharmacy stock, the nurse accustomed to only one dosage type (the lower concentration vial of 10 u) being available grabbed the high concentration vial and administered the incorrect amount, the nurses realized an error had occurred, ran the test to confirm their suspicions and then administered the anti-dote, Protamine. The hospital admitted that the error occurred in part because the nurse did not follow hospital protocols and procedures and that the State of California Department of Health and Human Services was investigating the incident. It has also been reported that the infants were in stable condition and had suffered no ill effects.

In my opinion the most interesting coverage about this unfortunate, but preventable, error came courtesy of the Los Angeles Times. Their coverage appears to me to be an almost “kid glove” handling of this very serious medication error and breech of nursing practice. Let’s not forget that Cedars is suppose to be a “Best of the Best Hospital” and a Magnet Hospital and the list of so-called “excellent” hospital awards goes on, so for such a medication error to occur should have news agencies asking the tough questions. Instead, news agencies seem to be happy to regurgitate the Cedars press release and to “downplay” the incident by spinning it as medications errors in hospitals are not uncommon. When a similar incident occurred at the now defunct King/Drew Medical Center several years ago the LA Times, rightly so, reported heavily on the hospital’s failure to safeguard their patients from medication errors; but they seem unwilling to use the same journalistic scrutiny on Cedars during this incident. The first Los Angeles Times’ article, which ran the day after the story broke on TMZ seemed to be mostly a regurgitation of the information provided by the Quaid/Buffington family, TMZ and the Cedars-Sinai Hospital authorized press release with no real new information provided. The second story, which ran the next day, in the Los Angeles Times tried to convince its readers that hospital drug errors were not uncommon; and if we believe this then we should be very concerned about the state of nursing and medicine in our Nation’s hospitals. What the Los Angeles Times failed to mention or question was how could such a medication error and failure of basic nursing practice occur in a hospital that proudly displays its US News America’s Best Hospital 2007 award and that it has been awarded the American Nurses Credentialing Center’s (ANCC) Magnet Excellence in Nursing status. Cedars even proudly displays this statement from the ANCC on its website “The ANCC found that Cedars-Sinai’s nursing services “represent the highest standards in the nation and internationally.” I would have to say that the recent Heparin overdose incident puts this label into question. But then again most RNs think that both Joint Commission and Magnet status are “jokes” and more often representative of how well hospitals prepare and present their documentation and how they “play” to their surveyors then an actual representation as to the quality of care and the nursing staff.

As a RN with over 35 year of experience at both the bedside and in nursing management and education I find the nursing error at Cedars frightening, but not completely surprising. Why, because I am very familiar with this particular hospital and the caliber of its nursing staff. And though there are many good nurses at Cedars, I also know that the nursing staff as a whole has not always been at the peak of their game (also using many registry and traveler RNs). The past several years have seen at least two, ugly, but failed unionization attempts of the nursing staff. These attempts have taken their toll on the staff and have left many nurses feeling angry and betrayed by one or the other side. I know that at least one unit, which once had a very stable staff, has experienced a great deal of turn-over recently, and this turn-over has left the remaining staff feeling unsupported by nursing management, and in many cases feeling demoralized and burnt-out.

As recently as four weeks ago, a neighbor and nurse, was admitted at Cedars for surgery and when she returned she spoke of a very poorly run nursing staff and a care-environment that was anything but caring. What gave her great concern was the lack of English exhibited by the nurses in the clinical setting. She said during her entire stay that she very seldom heard a word of English spoken in her presence (she is an English speaker) and she was concerned that if their English was so poor that they had to communicate to one another in their common “native” language then how well did they comprehend orders that were given in both verbally and in writing in English.

However, as a RN, what concerns me greatly is the failure of the nurse to follow the most basic of nursing protocols and that is to always check the medication (and that means reading the label). We work in a field that is not only high-stress but prone to human error and it is for this reason we are taught to rely on our eyes to verify such things as: is it the right medication, the right dosage, etc. The excuse given that “the nurse was unaccustomed to more than one type of heparin vial” is a poor one.

This past April I covered the issue of medication errors for my column From the Floor, which is published every three weeks in Working Nurse Magazine. My article can be found by following this link http://www.solutionsoutsidethebox.net/articles___studies. In this article I spoke of a medication error that cost a young mother her life and left her newborn an orphan and how medication errors occur and what nursing and hospitals can do to minimize and reduce situations that give rise to errors of this magnitude. There is a current trend in nursing and medicine to practice what has been labeled “blameless medication errors” the premise of this method is that if we do not “blame the nurse” for a error then the nurse will be more forthcoming when an error occurs thus allowing the error to be addressed and a correction plan implemented. However, the downside to “blameless medication error” reporting is that there may very well be an incident in which protocols and practices have been violated in such a way that blame should be assigned, as in the case of outright negligence.

What concerns me about the Heparin incident at Cedars is that 1.) This is not the first time this type of error has occurred, 2.) There was an FDA warning issued about the possibilities of such incidents, 3.) No one double-checked the vial to ensure it was the right medication or dose, 4.) The conflicting reports that first there were two overdoses versus just the one, 5.) First reports provided different facts as to how the overdose was caught, 6.) Reports seem to vary greatly as to how many infants were actually given the Heparin overdose and 7.) The report that there have been no ill-affects, when any NICU nurse or physician knows that it could be weeks to months before we learn if the children who received the overdoses will suffer from any negative sequelae.

Yes, this was indeed a culmination of a series of human errors, however as nurses one of our jobs is to serve as the patient advocate, which sometimes translates into the last line of defense. In the end there should have been two nurses whose job it was to ensure that the patient received the correct medication and dosage. The nurse whose job was to administer the medication should have had another nurse check the order, the vial for appropriate drug and dosage (it was never stated if another nurse had check the dosage and drug). This failure to practice what is a most basic of nursing skills has caused several infant lives to be endangered, families to be traumatized; and for the nurses and the staff involved this may very well be a career ending event. Let’s hope that this time we learn the lesson so that no other infant is placed in this type of preventable medical jeopardy – again!

The nurses at Pomona Valley Hospital, who are represented by Service Employee International Union (SEIU) staged a brief strike recently; they struck on the pretext that they were striking for patient safety, first and foremost. Meanwhile, the nurses in Northern California held a two-day strike earlier in October also echoed this same sentiment. However, as often occurs when individuals feel the need to draw the proverbial line in the sand, the loftiest of intentions can have unplanned consequences and sometimes those consequences can be negative. For example shortly after the nursing strike at Pomona Valley Hospital I received calls from RNs expressing their concern at some of the behavior they had observed exhibited by the individuals (purported nurses) on the picket line. What they described was an action that the picketing individuals made by pointing their finger at their eye and then pointing that same finger at nurses that had made the decision to report to work, and of course “cross the picket-line”. The nurses with whom I spoke with interpreted this gesture to mean, “we are watching you and we know who you are!” – an overt act of hostility.

Shortly after the Pomona Valley Hospital strike made headlines, the California Nurses Association, C.N.A., gave notice of the intent of nurses at numerous Sutter Hospitals to stage a two-day strike. On the first day of the strike the Contra Costa Times newspaper reported at least two incidences, which gave me cause for concern. The first was the action of some of the picketers that caused the road in front of one of the Sutter hospitals to become blocked thus making it difficult for patients, visitors and employees alike to access the hospital; and the second was a 911 call to the local police that a member of a group of 30 picketers had shined a spotlight in the eyes of a bus driver, temporarily blinding the driver as he tried to drive a busload of replacement nurses into the hospital parking lot.

Of course a reasonable person might correctly conclude that such incidents, as described above, are in all likelihood the exception rather then the rule during a strike – or are they?

Strikes can and do evoke very strong feelings among the strikers and their supporters and the non-strikers and their supporters. It is precisely because both sides have felt that they have been “backed into a corner” that these feelings and emotions can and often do erupt in such a way as to cause someone who might normally never engage in unacceptable, dangerous or violent behavior to do so, and under the auspice of a strike some individuals feel as though they have been given “permission” by society to act out in ways that they might not normally engage in – a mob mentality so to speak. However, it is just this perceived license that can make for a situation that leaves behind feelings of betrayal among nursing cohorts, hospital employees and even members of the community.

Strikes are not something that nurses salivate over in anticipation of holding, in reality strikes are an activity that many pro-union nurses see as a kind of “final solution” to what they often perceive as an impasse in negotiations, usually over contract terms, and rarely occur outside the parameters of these negotiations. There are formalized rules and protocols that surround calling a strike vote, and usually include providing a strike notice thus allowing the targeted hospital time to plan and prepare to have adequate replacement nurse staffing. Nurses and the public-at-large are unaccustomed to nursing strikes but when they do occur hospitals and nurses both take a hunker down and see it through attitude. The past several months have seen at least two separate nursing unions call a strike, each lasting only a couple of days and thus placing minimal strain on the services the hospitals can provide to the communities they serve. Over twenty years ago the nurses at a local Los Angeles-area hospital went on strike and besides the hospital having to reduce its beds by half, they also lost significant dollars a day for the duration of the strike. Strikes, if held long enough can and do cause extensive economic harm, and it is no different when nurses or other first responders strike, except there can also be unintended harm done to the community they serve. As a one visitor to a Sutter Health hospital during the recent strike was quoted as saying in the Contra Costa Times after their access to the hospital was temporarily blocked by one of the picketers who walked out in the middle of the road and tried to stop them from entering. “They lost some sympathy from us.”

Strikes also can cause a rift to develop between those who chose to strike and those who chose not to strike, especially when those who cross the picket line are union nurses, or when a unit is ethically divided over the strike thus leaving some walking the line while others cross it. It’s easy in these circumstances to feel the desire to demonize the ones who crossed the picket line to report to work, and they are often pelted with catcalls, invectives, and name calling such as scab, by the picketers. Those who are pro-union are often supportive of such behavior, and from their perspective it makes sense. They are taking an extreme position, holding the strike; and in order for the strike to have a full effect the “line must hold”. So for every staff and replacement RN that crosses the line and reports to work it either weakens or appears to weaken this hard line stance and the fear of the strike failing can become a reality. The other argument that is used to support the strikers is that when the union succeeds and its contract conditions are met in whole or part then all the RNs benefit, including those who didn’t walk the picket line. This behavior often leaves the RNs that honored and walked the picket line feeling “betrayed” that they didn’t receive the full support of their fellow RNs, many of whom they may view as friends not just co-workers. Of course these feelings are very much within the norm and should come to no surprise to anyone with even a modicum of understanding of human behavior.

The challenge for a nursing strike, especially when the premise is that of patient safety, quality of care or other similar concerns is that the action of the nurses on strike can become an issue of ethics and a reality check as to the underlying “real” cause of the strike. This is not to say that when patient health and safety or quality of care is an issue then it might be reasonable that a union after feeling that it has exhausted all other avenues to remedy the issue may present a case to their RN members that a strike is the “wake up call” that is needed. However, this can create a scenario where the RNs create an environment that puts the very patients they are advocating for in jeopardy, thus rendering their reason for striking moot. Let me present the following example: many years ago a local nursing union called a strike at a nearby Los Angeles-area hospital, their nursing membership agreed with the call for a strike and then planned a five-day strike in order to bring attention to numerous issues, but two issues were singled out. They were patient safety and short staffing. I was doing a research project at this hospital prior to the strike vote and when approached with the opportunity to work during the strike I thought that this would provide me with the proverbial bird’s eye view of what a strike environment was like in a hospital. I had never worked a strike before, and this was the only strike I ever worked but it opened my eyes to the fact that some RNs exhibit the same take no prisoner attitude that strikers of other ilk have been known to exhibit. The most memorable experience was showing up to work the first day of the strike to discover that many of the RNs that had ended the shift before and were now walking the picket line with signs espousing the need for patient safety and quality of care had locked the replacement and staff nurses out of many of the monitors required to perform much needed tests on the critically ill patients in the NICU and had hidden the manuals to many of the other equipment. So it would appear to me that some RNs thought nothing of placing patients lives at risk in order to prove their point of the need for patient safety. I guess my greatest disappointment was learning that no-one from the nursing union seemed to be concerned that patients’ lives were put at risk, not because of a lack of nursing care or even incompetent nursing care but that a few overly zealous RNs thought that by making the replacement RNs lives ”difficult” they could advance their issues. Sad but true.

Does this mean I believe that RNs shouldn’t be allowed to strike? No, it is their right under our law, however on a personal level I would never strike. What saddens me is that RNs, especially when there are extreme feelings on both sides (both pro and con) about unions that this sometimes leads these individuals to engage in unprofessional and just plain bad behavior. When RN’s strike and that strike becomes “angry” with all the negative emotional baggage that comes with such a strike then situations occur that can cause irrevocable harm to the hospital, to the patients, to the community and to the RNs themselves. A RN strike is not like a grocery worker or entertainment industry strike. When the grocery workers strike you can choose to change your shopping patterns, as many of us did during the last one; and in a protracted strike lasting many months that may cause for a shortage of some food items you may loose a little weight as you consume fewer calories. During an entertainment strike you may not see any new movies or have a leaner selection of TV shows but you can always watch re-runs, DVDs or even shift activities to compensate for a lack of TV/movie programming. However, during a nursing strike, especially when the strike may take place at the one hospital in the community it may have the unintended consequence of placing a community at risk.

Things to remember when you’ve drawn that line in the sand:
? Remember that as a nurse we take an oath to advocate and care for our patients, don’t let your actions put them in
jeopardy,
? Remember to follow the rules and codes of conduct of the hospital if you decide to cross the picket line and report
for duty,
? Remember to follow the rules and codes of conduct set by your union for the strike action,
? Remember to avoid the temptation to make “your point” through vandalism, malicious action, etc.,
? Remember just as your reasons for striking are valid and should be respected, so are the reasons for those RNs
who chose, for whatever reason, not to strike,
? Even though the purpose of the strike is to “make the hospital aware”, try not to engage in activities or behavior
that intentionally creates the very problems related to safety you say you are striking about,
? Since it bears repeating, remember if you can feel so passionate about your position that you walk the picket line
to express your devotion to your patients, those RNs who chose to cross the picket line are also expressing their
passion and commitment to their patients by staying at the bedside,
? Remember it’s suppose to be about the patients,
? And finally, remember every strike has consequences – good and bad.

What I ask that pro-union RNs to consider when undertaking a strike is that they comport themselves in such a way as not to endanger their patients, their patients’ families and friends or even the replacement RNs that have been called in to provide care. Keep in mind that when the issues that brings you to the final solution of calling and holding a strike is patient centered then you should not create an environment that jeopardizes the health and well-being of the very patients’ whose safety you have gone on strike to protect. As professionals we must never lower our level of care and concern for the wellbeing of our patients and by extension our community by engaging in unprofessional behavior that places those patients at an even greater risk.