When nurses muzzle their own

We are Registered Nurses from Saskatchewan, Ontario and Quebec who take our profession, our reputation and our image extremely seriously. We have read with great interest and concern the complete decision[1] rendered by the Saskatchewan Registered Nurses Association (SRNA) on October 18, 2016 following a complaint filed against Registered Nurse Carolyn Strom, in the wake of a post she made on Facebook regarding the care received by her grandfather. We were also alarmed by the update on the SRNA’s decision according to which a penalty nearing $30,000 had been suggested as a way to punish Ms. Strom for publicly criticizing her profession.

The SRNA discipline committee came to the conclusion that Ms. Strom was guilty of professional misconduct and was in breach of several provisions of the Canadian Nurses Association Code of Ethics by posting a comment on Facebook where she suggested that “some staff provided subpar care” to her grandfather. Among other things, the decision indicates that, as a professional, Ms. Strom should have used appropriate communication channels to convey concerns; that she harmed the reputation and image of nursing; that she harmed the reputation of nursing staff at the facility where her grandfather was cared for; and that she undermined public confidence in the staff.

We agree that nurses, like any other professional, must be held to a high standard of professional conduct. However, before a nurse is ‘trialed’ as part of a disciplinary hearing, one should first consider the grounds that underlie the complaint, and should be particularly cautious when retribution seems to be the driving factor of the claims being made. In this particular case, it is surprising that the Macklin health facility, where Ms. Strom’s grandfather received cared, suggested that a staff member (a nurse) file a complaint with SRNA against Ms. Strom, rather than connect with Ms. Strom to understand what, in her grandfather’s care, led her to conclude that “some staff” (with no mention that this was, indeed, nursing staff) provided “subpar care” or “was not up to speed” in palliative care. It is alarming that the facility’s apparent priority was to retaliate against Ms. Strom for speaking against a situation that clearly troubled her deeply. While staff (nursing or otherwise) at the facility could, understandably, be upset over the Facebook post, there is no mention in the committee’s decision or in any other account that anyone from Macklin or the SRNA discipline committee actually examined a family member’s concerns.

It is essential to remember that it is part of one’s professional (and institutional) obligation to acknowledge shortcomings in care and address potential gaps. It is deeply concerning that Macklin and its staff did not follow through on this obligation and that the SRNA appears to condone the direction that nursing staff chose to deal with the situation. In any other circumstances, the subjective experience of a patient or a loved one would have led to a reflective consideration on ways to improve patient care. The SRNA decision suggests that Ms. Strom’s experience and concerns as a family member was denied due to her status as a registered nurse. Yet the Canadian Nurses Association Code of ethics[2] clearly states that nurses and health care facilities have an obligation toward patients and their loved ones during care but also after patients pass away:

When a person receiving care is terminally ill or dying, nurses foster comfort, alleviate suffering, advocate for adequate relief of discomfort and pain and support a dignified and peaceful death. This includes support for the family during and following the death, and care of the person’s body after death (p. 14).

We believe that, had Ms. Strom not been a registered nurse, her concerns would have been handled differently. However, the fact she was a registered nurse made her an easy target, a point we shall return to shortly.

Furthermore, both the complaint and the decision against Ms. Strom do not engage consistently with the division between the personal and the professional domain. Ms. Strom made observations about a patient’s care as a family member, a private citizen. She briefly identified as a registered nurse in her post, not to speak ill of the facility and its (unidentified) staff but to advocate for change. This too is consistent with the CNA code of ethics2, which clearly suggests that nurses can do so as private individuals. The CNA code of ethics also emphasizes the role that must be played by various organizations (including the SRNA) in this regard:

Nurses as individuals and as members of groups advocate for practice settings that maximize the quality of health outcomes for persons receiving care, the health and well-being of nurses, organizational performance and societal outcomes (Registered Nurses’ Association of Ontario [RNAO], 2006). Such practice environments have the organizational structures and resources necessary to ensure safety, support and respect for all persons in the work setting. Other health-care providers, organizations and policy-makers at regional, provincial/territorial, national and international levels strongly influence ethical practice (p. 5).

Despite the Code of Ethics acknowledging registered nurses as individuals, the SRNA’s decision ultimately focused solely on Ms. Strom’s identity and title as a registered nurse. There are several issues with this. One is that it is unreasonable to expect nurses to restrict their private lives to their professional identity. Another is that the SRNA decision suggests that a person who discloses their nurse designation cannot speak ill of nursing or other nurses or professionals, because it would be “unprofessional”. The deduction then is that in order to openly critique care, care providers or care facilities, nurses must first shed their nursing identity, and speak as private citizens, which nullifies the CNA standard described above. Furthermore, while the committee also claims being in favour of nursing advocacy, it does not address how the decision effectively severely restricts what a nurse can actually say as a nurse. Unfortunately, subpar care does exist, including in end-of-life care, and it is a serious issue for which change needs to be advocated. But if nurses who are in the best position to speak up about deficient care cannot do so because their critique might be interpreted as “upsetting” or “hurtful”, the SRNA decision effectively limits nurses’ ability to speak (which is protected by the Canadian Charter of Rights and Freedom); it limits their advocacy; and it harms their credibility and professional standing.

The SRNA decision stresses the fact that, as a professional, Ms. Strom should have obtained all the facts before posting her comment on Facebook. The decision implies that information is available and accessible to whoever seeks it. However this is far from true. For starters, while nurses employed by a facility could appear as a straightforward first step for any patient or family member with a concern, they are obligated to sign non-disclosure agreements which limit what they may discuss with patients and families. Indeed, when requesting information, petitioners are often told information cannot be disclosed due to privacy concerns. Moreover, accessing one’s own medical chart (or the chart of a loved one) can take weeks, even months. Documents can be purged from the file at the discretion of the facility, unbeknownst to the petitioner. Tedious procedures may make some documents available, but with many portions redacted, obscuring one’s understanding of a situation or the identification of persons who may be accountable (the SRNA’s decision letter, which bears several redacted portions, is an example of this). Finally, nurses continue to be poorly represented in meaningful and influential leadership and executive positions in healthcare. Information traveling in these circles is key to understanding what occurs in a given facility. However nurses cannot access information such as a unit’s or a facility’s staffing decisions (e.g. when an absent nurse is replaced with a lesser qualified individual or is not replaced at all), budget, bed count, staff ratios, and statistics about incident reports, workplace injuries, and nursing overtime, to name just a few―information that could help a person better understand the context of a challenging situation. This reality is not addressed in any way in the SRNA’s deliberation and decision. It is also important to point out that the nurses who filed a complaint against Ms. Strom did not, themselves, seek all the facts before reporting her. They did not engage with her to uncover what, in her grandfather’s care, or in the facility’s handling of her concerns, led to her Facebook comment.

It is astonishing that, while both parties involved in this complaint are nurses (the complainants and the person under disciplinary review), they are not held to the same standard in terms of their professional obligation to seek all the facts before forming an opinion and acting on it. SRNA is also guilty of this, by accepting unsubstantiated information as legitimate facts, including suggestions that Ms. Strom was not a ‘very engaged visitor’, which suggests that she should not enjoy a high measure of legitimacy as a speaker in her grandfather’s care.

Furthermore, within Saskatchewan, the SRNA self declares that it functions as both a regulator and an association, accountable for protecting the public interest and promoting professional interest.  In the case of the Strom hearing, there are larger questions: on whose behalf was the SRNA acting? What was in need of protection and from whom?  How do these considerations tie to safeguarding the public interest? While the SRNA holds that Ms. Strom acted unprofessionally, with much attention to the fact that she identified herself as a registered nurse, there is little attention given to the issue of nursing care, promoting patient safety or quality practice environments.  Rather sole attention was given to one nurse’s status and use of social media.

The SRNA decision also stresses the fact that, as a professional, Ms. Strom should have gone up the proper channels to address her concerns. The assumption here is that Ms. Strom could have done so without any negative impact to her or to her grandfather. Yet it is well known that patients and loved ones are often reluctant to speak up about problems in care provision because they fear being labeled as “problem patients” or “difficult families”, or they fear receiving less care. Furthermore, as professionals, many nurses have experienced firsthand the consequences of relaying concerns upward or critiquing decisions made by higher ranking individuals. Many of these have been discussed in the media and the scientific literature[3][4][5][6][7][8][9]. Because of this, some nurses will come forward but only under the condition of anonymity, as was seen again recently in the case of obstetric nurses working at the Ste-Justine Hospital in Montreal[10]. As a result, while it is reasonable to expect nurses to abide by their professional standards of practice and their code of ethics, it is equally reasonable to expect nursing regulatory colleges such as the SRNA to support nurses in health care environments where upholding these high standards becomes more and more difficult.

We also find it very concerning that the SRNA discipline committee used examples of other professionals acting in an unprofessional manner to justify its decision, especially those that involved criminal charges. The committee appears to treat cases where criminal acts took place as appropriate benchmarks for a situation where no criminal activity occurred.

We do not believe that Ms. Strom harmed the standing of the nursing profession in any way. Ms. Strom acted as an advocate for patients, which is entirely in keeping with her, the SRNA’s and the CNA’s professional standards, values and ethics.

What really harms the reputation and the standing of a profession is the sustained cuts, restructuring and so-called optimization processes that are not supported in any way in the scientific literature, yet continue to be applied in health care settings to the detriment of quality nursing care as well as patient (and nurses’) health, safety and dignity. What harms the reputation and standing of a profession is a decision against a professional that seeks to make a public example of her.

Nurses who bear witness to poor care should be able to speak up without fear of reprisal, retribution or slandering. If nursing professional organizations appear as though they are impeding nurses’ advocacy, it will harm the credibility of, and the public’s trust in, the nursing profession. Finally, if the SRNA decision has the power to set a precedent, but one that rests on an apparently vindictive complaint, restrictive interpretation of the Canadian Charter of Rights and Freedom, and a questionable comparison with criminal cases, this also harms the reputation and the standing of the nursing profession. Many members of the public and the media have expressed outrage over SRNA’s decision. If SRNA is sincerely committed to protecting the public as well as the public image of nursing, it should listen.

We urge SRNA to re-examine the investigative process and the grounds on which its decision rests, and reverse its decision regarding the case of Registered Nurse Carolyn Strom. The decision, and the proposed penalty, can hardly be construed as anything but retaliation against Ms. Strom, and will further discourage nurses from speaking up when healthcare issues arise. As a result, given SRNA’s stance that its members are not allowed to critique their profession, we are not comfortable signing our names at the bottom of this letter because we do not trust that nursing regulatory colleges such as the SRNA sincerely support nurses’ right and duty to advocate for patient care.

Editor’s note: For more critical analyses of this case, please read the opinion piece published by graduate nursing students and the op-ed published by André Picard in The Globe and Mail. To sign the online petition, click here.

[1] SRNA Decision  of the Disciplinary Committee (Oct 18, 2016). http://www.srna.org/images/stories/RN_Competence/Comp_Assurance_Hearings/SRNA_Discipline_Decision_Strom_Redacted_Oct_27_2016.pdf

[2] Canadian Nurses Association Code of Ethics (2008). https://www.cna-aiic.ca/~/media/cna/files/en/codeofethics.pdf

[3] Fletcher, J.J., Sorrell, J. & Cipriano Silva, M. (1998). Whistleblowing As a Failure of Organizational Ethics. Online Journal of Nursing Issues, 3(3). Available online http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol31998/No3Dec1998/Whistleblowing.html

[4] http://www.cbc.ca/news/canada/sudbury/north-bay-nurse-fired-violence-1.3429850

[5] http://www.oregonlive.com/portland/index.ssf/2015/09/jury_awards_3_million_to_legac.html

[6] http://news.nationalpost.com/news/canada/chief-nurse-fired-for-exposing-safety-maladies-ontario-association-says

[7] http://www.nationalnursesunited.org/press/entry/white-house-invites-nurse-fired-for-speaking-out-at-huntington-hospital/

[8] http://www.nationalnursesunited.org/press/entry/giant-hospital-chain-fires-nurse-leaders-at-forefront-of-fight-for-safe-car/

[9] Cleary, SR. & Doyle, KE. (2016). Whistleblowing Need not Occur if Internal Voices Are Heard: From Deaf Effect to Hearer Courage: Comment on “Cultures of Silence and Cultures of Voice: The Role of Whistleblowing in Healthcare Organisations”. International Journal of Health Policy and Management, 5(1), 59-61.

[10] http://www.cbc.ca/news/canada/montreal/sainte-justine-hospital-nurses-overworked-1.3839535

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