A difficult dilemma
I recently faced a dilemma. A difficult one. One where both choices were undesirable but which needed action nonetheless. This isn’t unfamiliar ground for a leader. Leaders face large and small dilemmas on a regular basis. But I will admit to being unprepared for the hornets’ nest that opened up a few weeks ago after I took a very public stand on a very important issue: RPN employment in tertiary, quaternary, and cancer care hospitals as well as their employment in large community hospitals.
Some history….On the first day of Nursing Week, 2016, RPNAO could not have been more blindsided. Our colleagues at RNAO released a document, Mind the Safety Gap, a document described as intended to reclaim the role of the RN. Within that document were eight recommendations including three that caused concern at RPNAO. Most concerning for us was the recommendation that the Ministry of Health and Long Term Care legislate an all RN workforce in acute care effective within 2 years for tertiary, quaternary and cancer centres, and within 5 years for all large community hospitals. This recommendation has appeared in several documents since that week, and so we were not surprised when it appeared in RNAO’s election platform in February 2018 which stated that the political parties “require that all new nursing hires in tertiary, quaternary and cancer care hospitals be RNs”, clearly an action that would eliminate RPNs from those hospitals by attrition. In other words, this proposed government policy would see thousands of practical nursing positions leave these hospitals, as the positions vacated by RPNs would no longer be permitted to be filled by an RPN.
The vast majority of these RPN roles are not new. Indeed many have been in place for 50+ years. There is no doubt that more acute hospital populations will and should have a higher ratio of RNs to RPNs. Certainly, the professional practice approach to nursing that looks at the patients’ needs to decide category of care provider (or discipline of care provider) needed is always the approach embraced by RPNAO in our work and will, if applied correctly, lead to the right nurse for the right patient at the right time. But we cannot forget that the large tertiary centres are also community hospitals for those who live nearby, and will have patients who reflect those realities.
Recently my daughter gave birth to a beautiful, healthy baby in St Mike’s hospital in Toronto. Their experience was uncomplicated and a completely normal mom and perfect baby returned home after the normal length of stay. Did they go to St Mike’s because of St Mike’s ability to handle complicated births? Of course not. They went to St Mike’s because they lived a few blocks away. Around the province, RPNs are working in highly effective roles in post-partum units, including in tertiary hospitals, every day. Why would we eliminate these roles because of the size or category of the hospital? This is but one example of how tertiary centres are community hospitals for the people who live in the communities where they are located.
Until recently, we have dealt with these recommendations, and others that were concerning for us, through meetings with key individuals in healthcare and government and by sharing compelling history of both the long term contribution of RPNs in hospitals and the existence of roles even in tertiary centres that do not fit the idea that all patients within those hospitals are tertiary in their needs.
This election platform was the point, for me, when it seemed time to take a much more public stand. I sent out a series of tweets condemning the continued suggestion that no role exists in these hospitals for RPNs in the future, and identifying other concerns I had with their document in general. And that is when the aforementioned hornets’ nest was stirred and we were all left dealing with the fallout.
Nurses responded to us. Nurses of every description and category. The vast majority expressed gratitude that RPNAO had taken a stand. Nursing leaders called and emailed and said thank you; they said such things as: “I lead at one of those hospitals and I don’t want to lose my RPNs who are excellent nurses”.
But there were also responses that were angry. RNs who felt RPNs have no place in hospitals. One individual said maybe a role as assistant to an RN. Some RNs (and a handful of RPNs) expressed concern that by standing up so very publically for the role of RPNs in those hospitals, we had caused further rifts between nursing categories and I would have been best to leave well enough alone. Most disappointing was the degree to which a few nurses from each category said unkind and hurtful things about each other. And heartbreakingly for me, a tweet from a leader at RNAO suggesting that I had put spin on their document in a false way, a statement that I challenge. This tweet calling my integrity into question was retweeted by 46 people, including some international tweeters, making me wonder if they were retweeting without fully considering the context or the implications of throwing their support behind such recommendations.
I had a great facilitator during my studies at Royal Roads University. He once told us that if we find ourselves in the centre of a mess, we will have played a part. That might not be obvious to us right away as we look at the factors that lead to the problem in the first place but that is just our frail need to believe ourselves to be right. Every good leader will spend time reviewing their actions to learn and to build on the results. This is especially important when facing a dilemma or difficult decision about how to proceed.
I have done this and can say that I really believe that the public defense of the work of RPNs working within those hospitals was the right thing to do. But I also recognize that the rebuilding of this profession so hurt by divisiveness will require a great deal of collaboration among RPN, RN, and NP associations who DO have an understanding and intrinsic valuing of the work of RPNs in all sectors. Let the healing and growth of this profession of nursing start today.
Category: Messages from the Chief Executive OfficerDate: Thursday, March 29, 2018