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Nursing and You

Volume 2, No. 1, Feb. 2000 - Nursing in Your Community

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Editorial: The New Century: Making Nursing Better for You

Recently, the governing Council of the College of Nurses of Ontario (CNO) passed new beginning practice standards for Registered Practical Nurses (RPNs) that are set to take effect in 2005. Late in 1998, it did the same for Registered Nurses, who will need bachelor’s degrees in nursing to enter the profession, also by 2005.

Together, these new "competencies" move nursing practice forward to meet the challenges of the 21st century; they are very important to CNO's mandate to protect the interests of the people receiving nursing care. They are intended to match changing client needs with the staff qualifications required to meet those needs.

Today nurses are caring for sicker clients, are responsible for greater workloads, and are expected to use more complex technology. The new RPN competencies represent the basic education, knowledge, skills and judgment of the beginning nurse working in this more challenging environment. They expand RPN practice by broadening skills, by supporting independent decision-making, and by strengthening the relationship with RNs and other health providers.

The College is now working with the provincial government and nursing educators to integrate the new expectations into the basic education curriculum for both RPNs and RNs.

While the future will see a significant change in the way nurses are educated, CNO is also working on initiatives that affect nurses practising today. In particular, we are continuing the development of the Quality Assurance Program, key to helping practising nurses keep competent and always growing in their knowledge and skills.

The bottom line for these changes, as in everything the College does, is to protect you, the client, as you come into contact with Ontario’s nurses. As explained on page four of this issue, your relationship with your nurse is fundamental to your health and well-being. The upgrading of nursing education can only improve the quality of that relationship.

Mary MacLeod, RN
Council President
College of Nurses of Ontario

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Nursing In Owen Sound

Owen Sound, on Lake Huron at the foot of the Bruce Peninsula, is a fairly typical mid-sized Ontario community. Although the town has a population of only 20,000, it is the main service centre for all of Grey and Bruce Counties, with a total population of over 150,000. As a result, over 900 nurses currently work in Owen Sound, in a diverse variety of roles.

The local site of the regional hospital, Grey-Bruce Regional Health Services, is quite large, employing almost 500 nurses. In addition, there are three nursing homes and four homes for the aged, two retirement homes, seven visiting nurse agencies, and many family practices or clinics. Georgian College has a Registered Practical Nurse education program, and there are several industries employing nurses, as well as the Health Unit and the Grey-Bruce Community Care Access Centre. Owen Sound nurses also work at the jail, a local laboratory, and many other social service or medical agencies.

Nurses have also been educated in Owen Sound for many, many years. The nursing school at General and Marine Hospital was founded in 1901, and continued to graduate Registered Nurses until a Regional School of Nursing was established in 1968. Georgian College took over the task of educating nurses soon thereafter; now, Registered Nurses complete their final semesters at Georgian’s Barrie campus.

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Empowering Students: A Life in Nursing Education

Registered Nurse Sandy Brewer, head of the Registered Practical Nurse (RPN) program at Georgian College in Owen Sound, started her teaching career only three years after graduation, instructing orderlies at Walkerton Hospital.

"The first day I taught, I knew it was what I wanted to do. I loved it." Now Sandy has been at Georgian College for over 20 years. First she taught courses in CPR, then got involved in the para-medic program. Finally, in 1978, the RPN program was begun, and Sandy was on the faculty from the start.

"I’ve taught everything over the years, but anatomy and physiology are my favourites," she says. In her 20 years, she’s taught about 600 graduates, and she meets them frequently as she travels in Grey and Bruce Counties.

The 12-month RPN course is usually completed in three consecutive semesters. Recent changes in the expectations for beginning RPNs, recommended by the College of Nurses of Ontario (CNO), the governing body for both RPNs and RNs (see Editorial, page two), may cause the course to be lengthened. Sandy was on the CNO planning group, and is also on the government body developing new program standards.

"I’m not afraid of the new expectations," she says. "We’ve always taught our students to think critically, to question, to debate issues. Our students graduate feeling confident in their skills and their knowledge."

"We also teach a very ‘caring’ curriculum, with a lot of emphasis on the nature of the nurse-client relationship. Our students become well-rounded nurses."

Sandy is the only full-time faculty member in the program. Many of the other six teachers are currently working in clinical settings. "We look for nurses with degrees, who are patient, non-judgmental, with a sense of humour, and with a real passion for teaching," says Sandy. "It’s an art, and you really need the personality for it."

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Roles In The Hospital

Well over half of Owen Sound’s nurses work at the local site of Grey Bruce Health Services (GBHS), which administers six hospitals across the two counties. But if your perception of hospital nursing is largely based on television shows, you may be surprised at some of the unusual and interesting roles found within the hospital walls.

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Controlling Infection

Registered Nurse (RN) Anne Tobey is Infection Control Coordinator for GBHS’s Owen Sound site. She is responsible for preventing and controlling the spread of infection in an environment where a great variety of harmful organisms are always present.

Self-Regulation:

In her work with other nurses, Anne will refer to the Infection Control Guidelines published by the College of Nurses in 1996. This standard was developed in consultation with nurses like Anne.

"My job is largely an educational one," Anne says. "I consult with doctors and nurses in every part of the hospital to make sure the proper procedures are in place to stop infection at its source. This might involve things like protective clothing, storage systems, or methods of isolating patients, but the most basic tool is proper hand washing."

Anne also works extensively with other community agencies to control infection once a patient is discharged from hospital. For instance, she recently worked with the Community Care Access Centre’s volunteer drivers, educating them on how to keep themselves and their vehicles infection-free, not only for their own safety, but that of all their clients.

"We contact our world largely through touch," says Anne, "and that can be dangerous. Communicable diseases are very persistent; we have to do everything we can to discourage them."

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Leaving the Hospital

RN Mary Devlin calls herself the "options lady". As one of GBHS’s discharge planners, she works with clients and their families, when the time comes to leave the hospital, to help decide on the best place for continuing care – the home, long-term care, a retirement home, even a different kind of hospital.

Self-Regulation:

In order to help clients decide where to go from hospital, Mary must know other care facilities in the Grey-Bruce region well. If she has concerns about a facility’s support for quality nursing care, she might recommend the College’s voluntary Practice Setting Consultation Program.

"I get involved with clients at a very stressful time," Mary admits. "People are staying here for shorter time periods, going home sicker, not totally recovered from what brought them here in the first place. Our challenge is to make sure that whoever takes over their care – another institution, their family, maybe even themselves – has complete and up-to-date information on the client’s needs.

"There’s a lot of pressure to make health care seamless as clients go from one setting to another, and that’s very difficult to do."

Mary finds her job to be a very creative one. "What’s right for one client will not be right for the next. We all cope differently, and the situation we are moving our clients to must be the appropriate one for them and their care-givers. It’s what makes this job fascinating, but also very difficult and stressful."

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Helping New Mothers Cope

RN Brenda Scott has always worked with mothers and babies. Since graduating in 1973, she has worked in obstetrics, gynaecology, on the maternity ward in one way or another. And since 1993, she has been full-time lactation (breastfeeding) consultant for the Owen Sound hospital.

Self-Regulation:

Brenda deals with families almost as much as with mothers and babies. All are clients, as defined in the College’s Standard for the Therapeutic Nurse-Client Relationship.

We have 750 to 800 births a year in here," she says, "and 60% of those new moms and dads take pre-natal classes. I work with these couples for a couple of months before the birth, and for as long as a year afterward, making sure everything’s happening as it should. I get to know them pretty well."

Brenda, who has a degree in adult education in addition to her nursing preparation, says that with babies going home earlier, and with a large number of single moms with little family support, intensive education on what to expect is essential.

"I stay in touch, and in a community of this size, it’s fairly easy to do that. But I also help the moms stay in touch with each other. About 85% of new moms breastfeed now, so strong community links are important."

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Treating A Captive Audience

For 14 years RN Debbie Hicks has patrolled the gleaming cement corridors of the maximum-security Owen Sound Jail, always accompanied by a guard. She administers medications twice a day to the jail’s 40 or 50 inmates, tends to cuts and bruises (which can be severe after a fight), and then retreats to her tiny second-floor office, to go over files of incoming inmates, or prepare information for family physicians on those about to be released.

Self-Regulation:

Working largely on her own, Debbie doesn’t have access to the regular peer feedback often so helpful in keeping competent as a nurse. For her, the College’s Reflective Practice program is very important.

"Nursing in corrections is something you either love or hate, and obviously I’ve come to love it," she says. "I spent several years in long-term care, then in the hospital, but I find this more interesting. The independence, the variety appeal to me. And however tough they might have been outside, very few of these guys (usually over 90% of the inmates are male) have ever been tough with me."

There is also a lot of rough language, and a highly structured regimen which many other nurses might find difficult. Debbie must sign in and out, use keys as she travels throughout the building, and even lock herself in her office.

Debbie’s job is largely a nine-to-five, weekday one, but she will be called in for emergencies, or to do an assessment and case history on a new inmate.

Once a week, a physician will come in for two or three hours, and then Debbie will assist with examinations, prescriptions or rudimentary treatment. Inmates go outside for dental or hospital treatment, very closely watched at all times by a guard (who must also be present whenever Debbie has an inmate in her office).

"When I started, there weren’t a lot of training supports for correctional nurses," Debbie says. "But now we have an association, seminars, conferences. This is a unique area of nursing, and I’m glad I found it."

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Keeping The Workplace Healthy

In most Ontario communities of any size, there is some degree of industrial activity. If companies have more than about 250 employees, they are likely to employ an occupational health nurse in their human resources department.

Owen Sound has a number of long-established manufacturers. Trans-Continental Printing, with over 600 employees, is one of the largest single printing plants in Canada, while Edwards, with 900 employees, half in Owen Sound, is the country’s largest maker of fire alarms and other safety equipment.

Self-Regulation:

In large industrial settings, workers often have a wide variety of ethnic backgrounds. To care for this diversity of clients, Joanne or Betty can refer to the College’s Guide to Nurses for Providing Culturally Sensitive Care, published in 1999.

The nurse in charge of occupational health at Edwards is RPN Joanne Barber, who has been with the company for 26 years. Over at Trans-Continental is Betty Hendriks, an RN who worked in many other areas of nursing before joining the printing company three years ago.

"From a medical point of view, mostly what I do is first aid, over-the-counter medication, preliminary assessment, and arranging for transport to the hospital if necessary," says Joanne. "We get lacerations, back strain, and more and more repetitive strain injuries from the computers. But my more important job is preventing injuries and risks to health, making sure that the employees know how to stay well and work safely."

Betty agrees. There is a fitness gym for Trans-Continental employees, and part of her job is to counsel on its safeuse. In a printing plant, there are also issues such as hearing protection or the safe use of chemicals.

"Despite its size, this company has a family feel to it," says Betty. "In this kind of environment, it would be easy to get careless, and I help prevent that by reminding them of the hazards."

Occupational nurses also get involved in assessing whether an employee is fit to return to work, or in filling out workers’ compensation forms.

"My main message," says Joanne, "is that it’s okay to speak up if you feel your job is unhealthy. Basically, though, I think, people want to help themselves to be healthy. That gives us a great place to start."

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The Eyes And Ears Of Family Practice

Not all family practice physicians in Ontario employ their own nurse. In fact, evidence suggests the number not using nurses may be as high as 75%.

Self-Regulation:

In guiding patients over the phone, Darlene can refer to the College’s Telephone Nursing Practice Standards, published in 1999.

But at RN Darlene Turner’s clinic in downtown Owen Sound, each of the four physicians has his own nurse, and Darlene has been working there for over 14 years. Recently, she did a major housecleaning of her doctor’s files, and of the 1,700 patients on record, she only failed to put a face to five of them.

"Because of my training and experience," she says, "I can provide an extra set of eyes and ears in this practice. Although I don’t get as much time with the patients as I’d like, especially in areas like health promotion or post-treatment counselling, I still get to know many of them very well. And the doctor and I really work as a team. We regularly sit down to discuss challenging cases."

"I spent my time in the hospital, the nursing home, even as a private duty nurse," Darlene recalls. "Besides the shift work, I didn’t like the short-term nature of the relationships I had with my clients there. Here, I have the opportunity to watch them grow up, to really get to know their needs. And because they know me so well, they’ll sometimes feel able to confide in me. Last year, I was able to refer an abused woman to a shelter after she told me about her situation. I’m not sure what would have happened if I hadn’t been here."

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Perceptions About Nursing

Most residents of Owen Sound were surprised when we told them over 900 nurses live and work in their community. These were a few of their comments when we asked them their perceptions and expectations of nurses, and what they knew about how the profession was regulated.

"I know nurses are well-educated. But it’s more than that, I think. They have to be sympathetic and compassionate. For some reason we expect more from them than from other people in health care."

"Nurses seem overworked these days. There’s not enough of them to do everything they’re expected to do."

"I know nurses are closely regulated — I’m not sure who by — but I wonder if the regulators really get out into the communities and see the conditions the nurses work in."

"I think we expect nurses to care for us. Not just treat our wounds and give us our pills, but really care for us. The doctors treat us, but the nurses are expected to make us whole again."

"You read about people complaining about doctors, maybe even dentists. But I don’t think I’ve ever read about people complaining about nurses."

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Did You Know?

  • That there are about 140,000 nurses in Ontario?
  • That like 20 other health professions, nurses are regulated under provincial legislation to protect the public interest?
  • That nurses play a major role in regulating their profession?
  • That there are detailed standards governing everything from how a nurse conducts her practice, to the ethics of her profession, to her relationship with her clients?
  • That when you have concerns about a nurse’s conduct or competence, you can have that concern investigated by nursing’s regulatory body?

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How Nurses Regulate Themselves – The College Of Nurses Of Ontario

Despite their diverse roles, the nurses of Owen Sound have three things in common – their professionalism, their membership in the College of Nurses of Ontario (CNO), and their obligation to follow the practice standards whiich are established by the College.

CNO is the regulatory body for nursing in this province (contrary to its name, it is not an educational institution). No one can practise as a nurse in Ontario or use the titles "nurse", "registered nurse", or "registered practical nurse" without a valid certificate of registration from the College. There are similar Colleges for many types of health care provider in the province.

The College of Nurses has about 140,000 members across Ontario. We have about 106,00 registered nurses (RNs) in the general class and over 33,000 registered practical nurses.

All of Ontario’s health regulatory Colleges have similar responsibilities, as set out in the Regulated Health Professions Act (1993). We must:

  • decide what education and other qualifications are necessary to become a member;
  • establish the standards of practice with which all our members must comply;
  • administer quality assurance programs in which members are required to participate to help maintain their competence; and
  • provide a complaint and investigative process for people who feel the standards have not been met.

CNO is governed by a 39-member Council, 21 of whom are nurses elected by their peers from across Ontario (14 RNs and 7 RPNs). The other 18 members of Council are appointed by the provincial government, and are members of the public.

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Self-Regulation

The College of Nurses’ mission is to protect the public’s right to quality nursing services by providing leadership to the nursing profession in self-regulation. What does this really mean?

It means nurses regulating themselves to ensure high standards of nursing practice. Almost all of our budget comes from annual registration fees, paid by practising nurses. Our governing Council has a majority of nurses. Most of our professional staff are also nurses.

But the term "self-regulation" also means that all of our members are responsible for practising in accordance with the standards of the profession, and for keeping themselves current and competent throughout their nursing careers.

The College provides leadership to the profession by establishing standards of practice that all nurses are expected to follow. In addition, we help nurses maintain their competence throughout their careers through our Quality Assurance (QA) Program.

One element of QA is Reflective Practice, whereby with the assistance of colleagues, employers, and through self-assessment, a nurse can identify the strengths of her practice and put together a learning plan to address areas that need development. Participation in Reflective Practice is required by law for all nurses practising in Ontario.

Another element of our QA program is voluntary, and focuses on the places where nurses work (what we call practice settings). The Practice Setting Consultation Program involves both employers and nurses in a joint effort to identify elements of the workplace which support quality nursing care, and those which could use improvement.

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Resolving Concerns About A Nurse

From time to time, concerns may arise about a nurse’s conduct or competence. A key element of the College of Nurses’ responsibility is to investigate all written or verbal complaints received about a nurse, from patients, employers, fellow nurses or members of the public. The following is based on a recent complaint investigation.

Mr. A suffered an Alzheimer’s type mental condition. As behavioural difficulties worsened, his family was no longer able to care for him in the home. He was placed in a nursing home, but after a number of aggressive outbursts, was transferred to a psychiatric hospital. About 10 months later he was transferred to an acute care hospital for treatment of a large bedsore he developed while at the psychiatric hospital. Mr. A died several days later.

His daughter, Ms. A, expressed several concerns relating to these areas of nursing care at the psychiatric hospital:

  • appropriate communication between the health care team and family;
  • obtaining appropriate health care consent, and recognizing when the client is not competent to give consent; and
  • the nurse’s role as a client advocate.

Ms. A wanted to make a difference at the hospital. She was interested in the College’s Participative Resolution Program (PRP) as a way to improve nursing practice there.

The PRP option encourages the parties to a complaint – the patient and/or his family, the nurse, the College and sometimes the facility involved – to actively work together to resolve the concerns that have been raised.

In Ms. A’s case, a College practice consultant reviewed the complaint and the health record in detail, and identified learning opportunities for the hospital’s nursing staff. A workshop was held, focusing on the following areas: communication; the nurses’ advocacy role; and the Health Care Consent Act. The nurses were active participants in identifying solutions to some of the issues identified in the complaint.

Ms. A was pleased – she felt this resolution addressed all of the points of concern to her – but she was also a bit sad that it was happening too late for her father. She was encouraged that other families would benefit from the initiative.

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Reflections: Expectations and Outcomes of a Nursing Client

Except for having his appendix out about 30 years ago, 85-year-old Murray Cleland of Flesherton, Ontario (about 20 miles southeast of Owen Sound) has stayed pretty healthy.

Born and raised in Meaford on Georgian Bay, Mr. Cleland inherited the wheelbarrow factory founded by his grandfather. He sold it in the mid-1950s and moved to the hobby farm near Flesherton which has been his home ever since.

Only about six weeks before we spoke with him, Mr. Cleland suddenly had a serious problem which resulted in encounters with a great many nurses – a fall which broke his hip.

"It was the silliest thing," he recalls. "I’d put a piece of pie down on a pile of papers, and I saw it start to slip. I reached back to save it, and down I went. It took me 12 hours, blacking out every now and then along the way, to crawl to a telephone and call for an ambulance."

Mr. Cleland was rushed to Markdale Hospital, x-rayed, then sent to Owen Sound, where a "lucky break" (maybe not the right word, he admits) allowed him to be operated on that very night. After a week recovering on the surgical floor, he developed pneumonia and was transferred to the medical unit. Another week and he was sent to the hospital’s rehabilitation centre, where he made good progress.

Finally, Mr. Cleland went to Central Place, a retirement home where he expects to be until spring. There, we caught up to him and asked him about the nurses he’d met – what he expected and what he discovered.

"One day a nurse was shifting me in the bed and discovered a bedsore on my heel. She said she’d take care of it right away, and the way she bandaged it, she was so careful and deft and expert at it. It’s a small thing, but I wouldn’t have expected such skill and care. It really left an impression."

"I guess I’ve seen 50 nurses in the last few weeks. They’ve been very likeable, but very professional."

"For a while, I was using a ‘commode’, but one day the nurse insisted on helping me to the bathroom. The nurses don’t always go along with what is easiest for you, but with what will make you better."

"You expect nurses to be friendly, but above all you depend on them. They need to give you a feeling of safety."

"I think whatever system produced these nurses, whoever told them what they needed to know and how to do what they do, I think that system’s doing a good job."

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The Nurse And The Client: What You Should Expect

How should a nurse relate to a client? What does a client have a right to expect (or not to expect) from a nurse? We use the term "client" rather than "patient" to signify that the person receiving nursing care is in fact a customer with rights that must always be respected.

For example, the client need not always be sick or injured. The client may be a patient’s family. In the case of a public health nurse, the client may be a school, or a whole community. In the case of a teacher like Sandy Brewer (see page one), the client is a nursing student. For a nurse manager, the clients are other nurses.

Whoever the clients are, however, the principles guiding their relationship with the nurse are the same. Those principles can be found in the College of Nurses’ Standard for the Therapeutic Nurse-Client Relationship, a practice guide which all Ontario nurses are expected to know and follow. Below are some excerpts.

Aspects of the Nurse-Client Relationship
The authority of the nurse’s position in the health care system, her or his specialized knowledge, influence with other health care providers or the client’s family, and access to privileged information – all these factors put the nurse in a position of power. The nurse must use this power in a caring manner to ensure the client’s vulnerable position is not taken advantage of.

The client expects the nurse to possess knowledge and skill and to demonstrate caring attitudes and behaviours, and so entrusts his or her care to the nurse. If trust is breached, it is very difficult to re-establish.

Respect for the dignity and worth of the client is crucial to an effective relationship. The nurse needs to know and understand the culture and other aspects of the client’s individuality, and to take these into account when providing service.

By virtue of the kinds of activities nurses perform for and with clients, there is intimacy in the relationship, with personal and private closeness on many levels. The nurse must be careful to ensure this intimacy does not jeopardize the therapeutic (healing) nature of the relationship.

Warning Signs
There are a number of warning signs that may indicate a nurse is in danger of crossing the appropriate boundaries of the nurse-client relationship. These may involve treating a client differently from others: spending extra time with the client, dressing differently with that client, spending off duty time with that client, or keeping secrets with the client apart from the rest of the health team.

Abuse of Clients
The abuse of clients breaches the trust and respect in the nurse-client relationship, and is never acceptable. Verbal, physical, emotional and sexual abuse are prohibited by regulations under the Nursing Act, 1991. Client neglect or financial abuse are also named. As part of its mission to protect the public, the College of Nurses takes very seriously the issue of abuse of patients, by nurses or by any other care provider.

The College has a comprehensive educational program, entitled One is One Too Many, aimed at raising awareness among Ontario nurses of abusive behaviour. The program focuses on helping nurses to recognize warning signs, and on their obligation to speak out and take action against abuse.

If you have questions or concerns about the conduct of a nurse, please contact the College of Nurses of Ontario.

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Contact Us

For further information about any aspect of nursing regulation in Ontario, including how to express a concern about a nurse's conduct or practice, please contact:

College of Nurses of Ontario
101 Davenport Road
Toronto, Ontario, M5R 3P1
cno@cnomail.org
Telephone: 416-928-0900 or Toll Free 1-800-387-5526
Fax: 416-928-9841

 

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