Wednesday, April 23, 2008

Nurses alleged that nurses attack them!

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)

Wednesday, April 9, 2008

The Myth of the Magnet Hospital

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.

Sunday, November 25, 2007

Endangering the patient . . .

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 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!

Wednesday, October 31, 2007


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
➢ 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.

Sunday, October 14, 2007

When newspapers fail, are they even aware of it?

In mid-September I opened my copy of the Los Angeles Times and as I read through the various sections my roving eye stopped at an article picked up from the San Diego Union-Tribune entitled “Outsourcing education”. The article heralds a bold new idea that the California Labor and Workforce Development Agency had worked out to “solve” California’s persistent nursing shortage. The solution they would send upwards to 40 students who had completed their pre-nursing education to attend nursing school at a college in Guadalajara, Mexico. The twist to this brainchild the team at the California Labor and Workforce Development Agency is that the students would have to be English/Spanish bilingual and willing to spend upwards to two years working in a “needy” hospital. It appears this program will cost somewhere in the neighborhood of $20,000 US dollars, not to mention the cost of the team that will be organized to support these students to ensure they acclimate to the new system, and cultural environment.

I attended the California Board of Registered Nursing (BRN) when this notion was presented. What was suppose to be a simple 10 – 15 minute presentation turned out to be nearly an one hour+ dog and pony show, complete with The Honorable Rosario Marin, Secretary of California’s State and Consumer Services Agency and a honcho from the university in Guadalajara. When the members of the BRN expressed concern at what appeared to be an quick start time, they presented the plan with the intent to kick-off the program in January, the members of the BRN were presented with a “your approval is not necessary, since they will be educated outside the US and will enter the California system as a foreign-educated nurse”. When I expressed my concerns at the meeting Stacy Leach form the California Labor and Workforce Development Agency approached me and announced that she had been meaning to contact me, and as of the writing of this post I’m still waiting to hear from her, but then again I’m not surprised at another bureaucrat making empty promises.

Now I’m no investigative journalist but I can tell when something doesn’t seem like it make sense and this entire plan reeks of old fashion patronization. Questions like why will this program cost nearly $20,000 which is the cost of a community college nursing program (hint the current currency conversion rate is 1 USD to 10 Mexican Pesos), why is the program only available to Spanish/English speakers and does this violate equal access laws especially since it appears that the program will be receiving taxpayer dollars, if we can do this why aren’t we investing these dollars in our local community college nursing programs, and if this program is so much on the “up and up” why sneak it through the back door – they presented the program as a fait accompli, etc. One would think that the San Diego Union-Tribune reporters would be the ones asking these questions, but they appeared to be more concerned about regurgitating the press release then asking the really hard questions. And the newspaper owners, editorial boards, reporters, etc., wonder why they continue to lose subscribers.

So when I read the article I sent the following letter to the editor, and since it appears they chose not to run it I am taking this opportunity to post it on my blog.

In closing I fervently believe that we need to muster all resources and ideas to alleviate our nursing shortage (both in the educational and work pipeline). However, first and foremost we need to look at ways of supporting home-grown solutions, as these are the only ones that will have the most long-term and long-reaching affect and effect.


September 19, 2007

Letters to the Editor
San Diego Union-Tribune
PO Box 120191
San Diego, CA 92112-0191

Re: “Outsourcing education”

Dear Editor:

As a RN with over 35 years of experience I can’t begin to say how this plan gives me a great deal of concern. What are they thinking?

The plan to pay for almost 40 Spanish/English speaking Californians to attend nursing school in Guadalajara, I believe it is short-sighted and poorly thought out.

First, would such a program if being supported through taxpayer dollars violate our provision of equal access? This could be a problem since the program is not, contrary to the article open to bilingual nursing school students, its only available those who speak Spanish and English.

Second, will the courses in Guadalajara be in English, or will they be conducted in Spanish; and if the later will those graduates be required to take the required English proficiency exams required of nurses educated in foreign countries?

Third, the cost of the program seems high even by California standards. If memory serves the amount quoted in the paper is at the high end of our A.D.N. program so why does this program appear to cost the same dollar to peso?

Four, why not invest these dollars into our local community and community college economy. Why do we continually not blink an eye to outsource when for nearly the same investment we can begin to grow our own nursing pipeline?

In short this is an idea whose time has not come.

Geneviève M. Clavreul, RN, Ph.D.

Monday, September 10, 2007

SEIU cries "foul" over outsing by nurses

The nurses of St. John's Mercy Medical Center were offered a choice, stick with their union, the SEIU, join a different union, the UFCW, or dump them both and become free of union representation. A total of 1.036 nurses voted for neither, 685 voted to stay with the SEIU and two voted to join the UFWC. With a vote spread of nearly 349 between those wanting to seperate from the union versus to remain with the union -- the union cries "unfair practices".

A reasonable person could understand if the vote to decertify was close, but when the majority says no then shoudn't the union respect what the workers' want, isn't that what the union purport to support -- what workers' want? This nurse says respect what these professionals want, respect their opinon and more importantly respect their vote!

Below is a copy of the letter to the editor which I submitted in response to the article the ran on the SEIU's sour grapes attitude. The link to the original article can be found at the end of the letter.


August 23, 2007

Letters to the Editor
St. Louis Post-Dispatch
900 North Tucker Blvd.
St. Louis, MO 63101

Re: “Union says hospital used access to influence nurses”
Dear Editor:

Can we say “sour grapes”? After losing the “decertification vote” by 349 the union cries “undue influence”, why? Because in their myopic view of the world no one in their right mind would reject the benevolent protection of the union power structure, and nurses surely could not think they could – speak with their own voice. As to Wright’s complaint about the letter from the Sister’s of Mercy to vote with the hospital, how is this any different from the full page newspaper ads this same union is taking out in my home town beseeching the community to “stand by the nurses” in their attempt to unionize at a local hospital. Oh, I know the difference these full page ads are paid for by union dues and displaying the signatures of local, state and federal politicians and powerbrokers are meant to influence the community into browbeating those opposing joining a union into joining one. Also, it should have been apparent to the union that they were most likely on the losing side of this vote when only 1/5 of the nurses chose to join them under the open shop agreement – this was not a resounding endorsement, or maybe the St. John’s nurses were aware of the SEIU’s role in the King/Harbor Hospital debacle and didn’t think they wanted that “type” of representation.

Whatever, the reason, this nurse says kudos to the nurses of St. John’s for making their voices heard. I think what every one should take notice in this vote is the turnout and the disparity between the ayes and nays, because contrary to the unions plaintive assertions this speaks volumes about what the nurses wanted!

Geneviève M. Clavreul, RN, Ph.D.

The link to the original article can be found here:

Monday, August 20, 2007

For whom the bell tolls, it tolls for thee – King/Harbor Hospital

By now the closure of King/Harbor Hospital’s Emergency Room after the failed “make or break” CMS inspection has made the rounds of the newspapers, radio talk shows and various news outlets. I was one of the many King/Drew Medical Center supporters who both fought for and knew that the hospital could be “fixed” if the correct steps were taken. However, as the months passed and endless reports were issued I quickly concluded that under the current “save the hospital” plan being implemented that failure was the only possible scenario.

My knowledge and expertise was based on over 35 years as a nurse at the bedside, in nursing/hospital management and as a nursing educator. The County hired two different consulting firms, one that was billed as a consulting firm (The Camden Group) with nursing expertise and the other (Navigant) billed as being skilled at hospital turn-arounds. A little due diligence and research on my part provided me with information that contradicted the PR being spewed by Dr. Garthwaite, (head of Department of Health Services at the time). However, the Board didn’t have to rely on my word or even my proof, they only had to read the reports from the CMS and even the local paper to discern that the so-called nursing consultants were not making the grade. Under Camden’s watch we had the stunning failure of surgical instruments not being counted at the end of surgeries. Not long afterwards CMS issued their now infamous memo, which forced the County to enter into an agreement to pay for a management firm to oversee the day-to-day hospital operations. This MOU gave us Navigant Consulting and their 1000+ problems of KDMC report. It was about this same time that Garthwaite made his recommendation to close the trauma center, explaining that this would help “decompress” the hospital’s other service areas and thereby assuring a greater chance to pass the much needed CMS inspection. No one should forget that the Los Angeles County District Attorney found that the Board of Supervisors had violated the Brown Act by holding a closed-door session prior to announcing the decision to close the Trauma Center; however he never released the tapes of that session and I believe that this is still being litigated.

Navigant took over the day-to-day operations with a guarantee of a full time staff and promises that they were the “right” folks to do the job. And it was long afterward that we discovered that full time attention meant something more like Tuesday through Thursday; and forget have a Chief Nursing Officer (CNO) on 24 hour call since their CNO flew back to spend her weekends in her home in one of the Carolinas. She was later replaced with a CNO who lived much closer only requiring her to travel to New Mexico for her weekends. After at least one contract extension and a couple of financial augmentations Navigant finally concluded their overhaul of King/Drew with the placement of Ms. Antoinette Epps-Smith as the hospital’s Chief Executive Officer. There was a small opportunity for the County to rid itself of Navigant and replace them with another firm. Supervisor Antonovich managed to get the Board to consider FTI Cambio, unfortunately Ms. Epps sang the praises of Navigant (I wonder why) and we continued on with a firm that had been with us through several failed JCAHO and CMS inspections.

When CMS came for its next inspection the failure was so great as to caused the County to promise to down size and reorganize the hospital, placing it under the “umbrella”
of its sister hospital Harbor-UCLA. In the real world Ms. Epps would have tender her resignation or the DHS would have asked for her resignation, but of course this is Los Angeles County where people get promotions, praises, and raises when they fail. So Ms. Epps received a standing ovation from the community she failed and praises from the Board of Supervisors. It was about this point in time when Chernof and Epps became successful in clamping an almost complete lockdown on information about all things King/Harbor. Employees (nurses, physicians and staff alike) seemed fearful of sharing any information with anyone – but that didn’t stop the failures from occurring.

The most notable was the death of Ms. Rodriguez, a woman who had sought help from the hospital instead found an unresponsive and uncaring staff. Even after being left to writhe on the ER floor for 45 minutes, and it has been reported that numerous staff, including at least one RN, ignored her cries of pain that is until the hospital safety police came to arrest her, her boyfriend agreed when an officer informed him that she would get care at the County USC jail ward – imagine his desperation that allowing her to be arrested on the promise that it could possibly get her the medical care that King/Harbor personnel were unwilling or unable to give her. Unfortunately this intervention came too late. As she was being wheeled out to the patrol car she collapsed and all attempts to rescuitate her failed.

Shortly afterwards the State of California Department of Health and Human Services issued a notice that the state planned to revoke the hospital’s license. And this was followed by the failure of King/Harbor to pass the last critical CMS inspection and the loss of 200 million dollars in crucial federal dollars. The County immediately closed the ER and is in the process of closing the hospital leaving an urgent care clinic in the footprint of this once 200+-bed hospital.

Do the citizens of South Central need a hospital with an Emergency Room, without a doubt! Do I believe King/Drew Medical Center could have been brought up to minimum national standards, you betcha! There are those who blame the Board and indeed they deserve their share of blame for the failure – these failures occurred at several critical junctures and in my opinion they were:

1. Not firing the Camden Group when it was apparent they were being unsuccessful and once they “completed the job” and it was discovered that the work product appeared less than exemplar the County never sought legal remedy.
2. Not firing Dr. Garthwaite for his gross misunderstanding of the problem, which led to the mandated MOU agreement with CMS, which of course saddled us with Navigant.
3. Not replacing Navigant with Cambio or another firm when the opportunity presented itself.
4. The hiring of Ms. Epps, who was advertised as having presented an excellent resume did not appear to have ever been solely responsible for such a momentous task.
5. Not firing Ms. Epps when King/Drew failed its first “make or break” CMS inspection, which then caused for the drastic downsizing and reorganization of King/Drew and it being renamed King/Harbor.

You may wonder why such measures, because the failures that we saw at King/Harbor were never new ones but the repetition of many of the same ones that caused the original jeopardy. The consultants and DHS staff alleged that much of the King/Harbor staff appeared unwilling to accept change and there were even vague allegations of “sabotage” such as employees being given new policy to adhere to only to pretend that they had never received such policies. But most importantly the incident involving Ms. Rodriguez illustrates a staff so demoralized and demotivated that they were unable to respond to someone writhing in pain on the floor right before their eyes. When a staff reaches this point there is little that can be done to reinvigorate it and often the only remedy is closure.

So what does the future hold for beleaguered King/Harbor Hospital? Well, if we are to believe the Board of Supervisors they plan to find a private firm that will assume the operations of the hospital. It won’t be an easy task to find a private firm to assume the operations of this hospital, if we are fortunate enough to find such a firm then, I believe, to ensure the greatest possibility of success the County will, no must, relinquish a great deal of authority thus allowing the private firm a wide latitude of autonomy to make the necessary changes that will not only restore the hospital’s federal funding, but also stave off the loss of the hospital’s licensure to the State. And it’s not just the County that has to be willing to give up some control, all stakeholders are going to have to give up some of their “interests” (something that never really happened the last time around) and allow the firm to do what must be done. This of course is all dependent on the premise that the private firm is competent in its function and that they have a strong commitment to providing service to the community of South Central and by extension all of Los Angeles.

Just for added background on August 2, 2004 I submitted a civilian complaint to the Los Angeles County Civil Grand Jury, vis a vis the board of Supervisors lack of appropriate knowledge to oversee the health care of Los Angeles County and ask that they recommend a health care authority. The civil grand jury investigated and recommended the creation of a health authority. It would appear that, as usual, the Supervisors decided to let things be as is and now we know where that course has led. See grand civil 2004 findings and recommendations.

And for those who believe that CMS was overly harsh in its critique or evaluation of King/Harbor I encourage you to read the complete CMS report, which can be found at and select CMS Report, or you can download the report directly at Read the report and then draw you own conclusions . . .