Quality Practice Environments : Quality Care

Pediatric Critical Care Columnist · Feb 21, 2004

I think you'll learn very quickly that most facilities pay lip-service to these principles, but make very little effort to see them through. Staffing is often barely adequate for safe care. Extra bodies are considered a waste of money and are either just not scheduled, or are shuffled off to another area where workload is already unsafe. Nursing leaders are more or less figureheads who are expected to maintain management's corporate design. Control over practice is expected, but control over worklife is not usually forthcoming. Professional development is something all managers will say they support, but try getting time off for a workshop or conference, or funding to travel to a symposium. (Where I work the only people who qualify for funding assistance are those selected to act as preceptors, a group of about ten people out of a staff of more than a hundred.) As for organizational support, the Provincial Health Authorities of Alberta are trying very hard to push nursing back to the 50's where nurses had no control, no say and no choice. BC has already achieved that goal.

I have indeed left a practice environment I did not feel was one I could improve by any action of my own. After that experience I decided that if I could not do it alone, I'd enlist help, as much help as I needed to get things done. It worked in my last job, to a degree. Now I'm taking on my new environment. My advice to you is that if you find your practice environment is not as it should be, figure out how to make it so, and ask your coworkers to help. Most will refuse, but some will be on your side.

vislandnurse · Feb 21, 2004

janfrn

Thanks for the reply and your perspective on what your experience has been regarding quality practice environments, as well as the advice on how to attempt to change things when environments are not what they should be. You mentioned that nurse leaders and managers are either figure heads or concerned about the bottom line and that many colleagues do not want to be a part of change. Why do you think this is? Is it burn out? Is it that they don't feel that nurses have the power to change conditions because of the continuous oppression of those in the profession? I am curious, because we all have standards and the code of ethics to live up to, and nurses are caring, so what's the deal? I have only done clinical placements in a few facilities and already see differences in the practice environments. I envision the type of environment that I want to work in. I feel that because I am older entering the profession, I don't want to spend any time working in a facility that does not allow me to practice as I have been taught - to provide excellent patient care in accordance with the standards of practice. I am willing to be a catalyst for change when I begin my practice (idealistic student thinking?). Are there types of facilites or areas of specialty practice where this is easier to accomplish? One last statement / question: the RNABC has set up a system where you can consult a nursing practice consultant when your practice environment is not what it should be. Is there a similar system or avenue to get assistance from your professional body in Alberta? Thanks for your input, it is greatly appreciated.

JMP · Feb 21, 2004

Quality practice enviroments are out there- but the same hospital can have one quality practice enviroment in one area and then have a less than great practice enviroment across the hall- literally in the same building.. I know I have been in both a good quality enviroment and a less than great enviroment at the same time.

Quality practice enviroments are not just managers responsiblities. Change can take place at the staff nurse level- but you have to be prepared to take time to build your credibility and practice skills at the bedside for a bit before you can jump in and expect to bring about change.

Always persue education, pay special attention to issues in your enviroment, such as horizontal violence, which can be so devastating to the nursing profession..... and it is often felt at the staff nurse to staff nurse level.

Once you have some work experience, consider continuing your education. I am in Ontario and BSN is now entry to practice, so leaders of the future, will require masters level education to affect further change in education, leadership and management.

While you are the beside, soak up everything, take note of best practice guidelines in your facility and always remember PROFESSIONAL PRACTICE.......is more than knowing how to put in a NG tube- or apply a dressing. Professional practice means mentoring, pursuing educational opportunites, taking the incentive to make change happen.... good luck.

JMP

Pediatric Critical Care Columnist · Feb 21, 2004

Let's see if I can do this without being too cranky...

A lot of what makes a quality practice environment comes down to autonomy and feeling valued for the work you do. If a person has some control over their worklife and working conditions, they feel valued and have no difficulty meeting both internal and external standards of care. An environment such as this fosters high morale among its members and perpetuates itself. When a person is not given the ability to make decisions or choices about his worklife or practice, or credit for a job well done, it is dehumanizing and demoralizing. Morale, once lost, is hard to regain. (Just ask the members of the Broken Hearts Club at Winnipeg Children's Hospital. ) As JMP said, there are vast differences between units within the same facility. You can pick out the environments that provide staff with the tools to maintain a quality work environment by looking at the job postings. If there are always no vacancies on a unit, that's a big clue, and vice versa.

Where I work, conditions have deteriorated in the 17 months I've been here, and I'm finding myself looking at my decision to take this job, and realizing that I'm stuck, having spent far too much money and effort moving and settling in a new city. I have very little control over my worklife, from minor things, such as always getting the assignments nobody else wants and having to take my break at the very end of the shift, to major, like having my schedule changed without consultation and not getting my vacation granted when I've followed the proper, convoluted method of making such a request, instead going onto a list for last-minute vacation, granted on a shift-to-shift basis dependent on workload. Do I feel valued and respected? Not a bit.

In some ways I feel sorry for middle management, because they're really caught between a rock and hard place. They know that what's going on isn't good for the unit, but are powerless to do anything much about it. They get their instruction from a faceless higher power who has no understanding of what it is that nurses do, or how things really work on an inpatient unit. Anything they try to do to mitigate the decisions from on high falls short. No one can serve two masters so they choose the ones holding the money.

Lower-level management is maybe even more powerless, since any decisions they make can be overridden by anyone on a rung above. The team-leaders are the ones who understand the issues facing a unit best, but have the least ability to effect change. Staff meetings are held in our unit q other month; they are unpaid, thus are poorly attended and accomplish very little. A notice is posted a couple of weeks before the meeting date asking for people to write down their concerns, sign their names and be prepared to address these at the meeting. (Very few items are ever written on these notices, for obvious reasons.) They are held over the supper hour, in the staff break room. The only people generally who attend are those staff who are in the room having their suppers. (They call that a break?) I have attended two meetings, several things dear to my heart were discussed, a plan was made to deal with them, and NOTHING changed. This is at the heart of the reason why most of my coworkers are unwilling to get involved in a battle to improve our environment. They've seen time and again that nothing changes. :chair: In collaboration with some of my coworkers who aren't afraid of the fallout, I am currently drafting what I call my List of Burning Questions with No Really Good Answers about working conditions in our unit, and will present it to management when I've polished it up. There can't be any answers if no one asks the question.

Nurses, although we represent the largest group of health care providers, are very low on the totem pole when it comes to respect from above. A quality environment depends on mutual respect and appreciation for each party's role in getting the job done. The Alberta Association of Registered Nurses does provide practice consultation services as you described, vislandnurse. However, they have publicly stated that they will not become involved in any organized attempts to improve working conditions or support the nurses working for such change. What's a nurse to think when our regulatory body isn't even willing to help?

Okay, I fell better now... :stone maybe.

vislandnurse · Feb 21, 2004

Wow...I am speechless (it takes a lot to make me speechless). What can I say, except that I have gained increased appreciation for the courses in our BScN Program that teach about professional practice, and how to have a voice in nursing and have it be heard. BScN preparation is now required for entry to practice in BC, and perhaps with more of us learning to use our voices we can collectively be heard as a voice for change...Perhaps more idealistic student thinking, but I do not know many in my class that will be willing to put aside what we have learned regarding our standards of practice and code of ethics, regardless of where the 'squeeze' is coming from. In saying this I do not mean to imply that those working in the profession today have willingly or easily put these aside, but if you give up working for change and settle for less than quality care, in effect you do. If we become apathetic we let ourselves down as well as those we care for, by not providing what we know we should be. This cannot be satisfying and fulfilling work which I trust most of us thought nursing would be. I know that this is easy for me to say now, as I work as an unpaid student, and don't have other obligations hanging over me related to my work. :balloons: I admire nurses like you that are willing to challenge the status quo and work for change. Keep speaking up...as the squeeky wheel will eventually get the grease. After all, how will government and management cope with the nursing shortage if nurses are leaving out the back door of the profession as quickly as they train new ones to come in through the front. Eventually, they will have to acknowledge that if environments are not such that nurses can live up to their obligations and feel good about what they do every day, the crisis related to human resources in the profession will continue to escalate. :) I would be happy to work along side you, and others like you. :) Thanks for the alert...hopefully over the next two years I will continue to learn what I need in order to not only survive but thrive (optomistically) in a profession facing so many challenges.

JMP · Feb 22, 2004

Janfrn is right on the money on this- autonomy is lacking in many enviroments in nursing. SHe is also right that you can't get answers if you don't ask questins.... I work in two very different areas right now ( ICU and dialysis ) and the differences are astounding...... to say the least. They are across the hall from each other- but worlds away from each other on many other levels.

I have my reasons for doing the split right now- but, many days I come home disheartned and full of despair........ since many things I normally do in one area- not allowed in another........ I won't go into details-- but believe me, the differences are astounding.

Respect for work well done is key----having input is key----- autonomy is key-- and all of these things are hard to undersand until you are in practice. I know that this sounds like I am saying something negative...... but all I can tell you, work at least two years........ and try at least two different nursing areas......... and then things will become clearer......they have for me. However, postitive change can happen, and I am on the road to that change right now-----I just don't always like the view.

Chow JMP

vislandnurse · Feb 22, 2004

janfrn and JMP

Thank you both for your words of wisdom. Receiving honest appraisals of the reality of the practice setting helps me to be realistic as I prepare for my entry into practice. Really, the concepts of respect and appreciation, input and autonomy are not that difficult to understand as these concepts are important to all persons that desire to be valued in whatever role they occupy - within and outside of nursing or health care. Your words help me to reflect on the challenges and possibilites for change. I take heart from your words, because they allow me to see that NURSES DO CARE and that change will come when nurses like you and others refuse to settle. :)

gwenith, BSN, RN · Feb 22, 2004

Okay - for a start yes you are being a little idealistic in outlook. A lot of nurses who are putting up with less than ideal do so because of various factors not the least of which is workplace bullying.

You come out with stars in your eyes and within months you are unsure of how to breathe correctly because EVERTYHING you have done is questioned, you feel as though every move is scrutinised twice, thrice over and your self esteem has been stripped. I have seen confident and competant RNs reduced to where they are so unsure of themselves that the threat of losing thier liscence does not have to be made - these RNs are now living in fear that they are not good enough to keep practicing.

It can happen to you.

Back, though to your original question. At present I work in an "Evidence Based Practice" hospital and find that the QA cycle that they have is excellent. Anyone can and does speak up and we can and do kick around ideas for improvement. This makes everyone feel valued.

Don't forget too, that many of the respondents on this BB are North American and many work in "for profit" organisations. This makes a difference to QA and how it is implemented.

vislandnurse · Feb 22, 2004

Please excuse my ignorance, :uhoh3: but could someone please explain what a QA cycle is?

Pediatric Critical Care Columnist · Feb 22, 2004

Don't forget too, that many of the respondents on this BB are North American and many work in "for profit" organisations. This makes a difference to QA and how it is implemented.

Alberta is not a "for profit health care" province... yet. But boy does King Ralph want to see it become one. He is all for deregulation and letting someone else foot the bill. In the ten years he has been premier of Alberta, he has slashed government budgets to the bone, forced departments to change the definition of their clientele in order to exclude more people from services and deregulated all utilities. These measures were supposed to save us all money, but really have resulted in the opposite. Electricity and natural gas are now costing individuals and businesses alike as much as double what it would in a regulated system. Auto insurance is often as much as triple or quadruple what other provinces pay. Highway maintenance has been privatized and the carnage due to poor road conditions is unbelievable. Education is being starved, with elementary school classes containing up to forty children. And then there's health care. He loves Alberta's annual prestigious first place in MacLean's magazine's Health Care Review, and is bending over backwards to bring as many high-profile programs (such as the vaunted under-construction Alberta Heart Institute) into play as possible, but won't pay the bills these things create. I could go on for days. I won't. I already have a headache!

gwenith, BSN, RN · Feb 22, 2004

QA = Quality Assurance Cycle our whole focus is not just reaching a goal but of continous reappraisal of where we are at in relation to "best practice" Some places call it Quality improvement cycles some just best practice - lots of names for essentially the same thing.