Professional Accountability

Nurses demand concerns about care and safety be taken seriously

Nurses face a unique dilemma.

On the one hand they have a professional and ethical responsibility to protect the interest of patients. On the other hand, they are expected to obey directives from employers, even where such directives may compromise patient safety.

The only RN on night shift in a small hospital may become overwhelmed by new admissions, or critically ill patients who suddenly become unstable and need her full attention. She knows she needs another RN to provide safe care to her patients. She phones her supervisor to ask permission to call in a colleague to help. Her supervisor says, "No, we're over budget, you will just have to cope."

If she obeys her supervisor, thereby failing to maintain professional standards, she risks discipline from her professional association as well as legal liability for any harm arising to the patient. If she disobeys her supervisor, and calls a colleague in to assist, she may be disciplined by her employer, including suspension or dismissal.

Nurses who joined unions were seeking much more than protection against unjust dismissal, unworkable schedules, or inadequate salaries or benefits. Nurses also expect their unions to help solve this dilemma- responsibility without authority.

In Alberta "professional responsibility" was a major issue in contract negotiations

The right to exercise some control over the safe care of patients has, since the time of Florence Nightingale, been a central concern of nurses. Nurses have always acted as advocates for their patients, striving to get them the care and resources they need to be well. This theme in the profession carried directly over into their collective bargaining when nurses unionized.

Heather Smith:   "That's were I actually began, started to become active in the union, was through professional responsibility. I didn't see myself as a union activist. A patient advocate, yes. You were always very clear on that, but that's how I came in was through wanting to advocate, wanting to get the staffing for the patients on my medical unit."

In Alberta,   the right to "professional responsibility" was one of the major issues behind one of the few provincial strikes by United Nurses of Alberta nurses.   And it was one of the issues, right from the beginning for UNA. As President Heather Smith points out,   "The key issue, the primary issue in initial bargaining was wages. They were atrociously poor. The other issue that came up was the ability to advocate, to have a say and we called that professional responsibility, the professional responsibility committee."

Helen Krizan: The professional responsibility clause, is one of the only clauses in our contract that lets us have access to the hospital board. In a hospital it's really important to nursing. Maybe we're short staffed, maybe there's something in the institution that's not safe. You keep working, but you can file a form that says this is what happened, this is what we think should change. So it's asking for action on things that you are concerned about.

Mike Mearns: The Professional Responsibility Committee was very high on the agenda, because nurses believed that they knew what was good nursing, and they wanted to use their collective bargaining capital to ensure they had a say on how the patients were nursed.

In negotiations in 1980 both the wages and the professional responsibility came to a head.

Trudy Richardson who worked as UNA's education officer for many years remembers it clearly. "So bad were the wages that UNA's ingoing proposal was for a wage increase of 33.3% and the employer offered at 29% wage increase, but they refused a professional responsibility committee.   They said the question of professional responsibility didn't lie with the nurses that was management's responsibility and nurses should just do what they were told and not question the professional judgment of the employer regarding nursing."   

The stand off led to a strike. The nurses were quickly ordered back to work, but despite the fact they had been offered a nearly 30% wage increase, the nurses refused to drop their demands for professional authority.

Finally the courts were about to become involved and at the last minute negotiations continued.   Trudy Richardson remembers: "They just bargained right through that weekend, hour after hour after hour.   There were two huge impediments: one was the question of wages and at some point early in that marathon the employer agreed to I think it was 39.8% which was 10% higher than their last offer and more than the nurses had initially asked for.   So obviously they knew these nurses were serious and it also indicated how badly paid they had been. A 40% wage increase like that doesn't happen often.   But what held up the talks, the second huge thing was a professional responsibility committee.   They were more insulted by the nurses' demand for a say in the quality of health care that was being delivered than they were about whatever the money was and it was only into the very, very early morning of the Sunday night Monday morning that they finally agreed to the professional responsibility committee."

Margaret Brick : The union has been the only way I've been able to see where I can fight for my patients.

The nurses had successfully negotiated a mechanism to raise their professional concerns about their patients' care and safety. The new contract laid out the process for the professional responsibility committee or PRC. Nurses always have the right to bring up concerns to the joint nurse-employer committee and have it addressed. If the nurses are not satisfied with solutions that are reached, they can take their concerns directly to the governing board of the Health Region or employer. Over the years nurses have filed hundreds and hundreds of PRC complaints and made many, many presentations to the Boards of Directors.

Lee McNiven: We can do it successfully through our collective agreement, through our professional responsibility committee, right within our worksite, within our nursing unit where we work. The care can be upgraded and other issues related to patient care can be talked about. Those things that we don't think we have any impact onto, ie. that there is no linen cart that's going to arrive on the nursing unit and midnight, and you're out of linen. What do you do about that?

Nurses use their contract rights to protect patients

Inadequate nurse staffing is the safety concern that nurses raise far more frequently than any other.   At Alberta Hospital Edmonton, for example, nurses took the following complaint right through the Capital Health Board of Directors

Nurses, when unavailable due to vacation, illness or other reasons, are being replaced by psychiatric aides, or in some cases, not being replaced at all, resulting in inadequate nursing care.   This is an ongoing problem.   It is happening for both predictable absences such as vacation leave, and for unpredictable absences, such as illness.   Levels of permanent nursing staff are insufficient to provide accessible, sustainable, and consistent quality nursing care.

Cynthia Perkins: And, in fact, in our emergency department over the last six years, we have had so many professional responsibility concerns there that they have increased the staffing by probably eight FTEs because the manager there was very receptive, and he used these PRCs as ammunition to his manager to increase the staffing.   So it really worked in some cases, and so I really encourage people to do that.   It's the only way that we're ever going to get safe staffing levels.

Judith Russell: The first PRC submitted at the Charles Camsell caused a hurricane at level five. I wrote a PRC citing a Dopamine drip on a medical unit, down the hall, unmonitored, as unsafe. Management classified this as high treason. Waiting for the axe to fall, we stood our ground and came out with all our heads intact and the patient included in the winnings.