Nursing Flashcards
(5) Job related actions to enhance position in medical labor force/achieve status of profession
1) shift to univeristy training
2) taking over physicians dirty work
3) use of managerial ideology
4) taking control of technology
5) unionizing
Occupation in crisis
Nurses
Impact of cutbacks on Doctors vs. Nurses
doctors have always been relatively privileged group - still had to work harder (reported increased stress) but incomes have remained high
Nurses have received the most pressure yet earn the same as national avg income
in 2012, average annual income of:
a) GPs
b) specialists
a) 180k
b) 350k
History of nursing begins with?
Florence Nightingale
Florence Nightingale
- background before Crimean war
born into relatively wealthy family in 1820
- strong-willed woman
- despite her familys strong objections to working as a nurse, she studied HC anyways
- became director of nursing home in England where she transformed it into an efficient little hospital
Nightingale effectively transformed nursing from… into…?
FROM occupation restricted to untrained nuns/charity workers INTO genuine occupation requiring vocational education
Nightingale is famous for her work in? (years?)
the Crimean War (1853-1856)
What was the nickname Nightingale earned in the Crimean war? For what reason?
Lady with the Lamp
- for her nightly rounds of checkin on patients with her lamp
When Nightingale and her group of nurses first arrived in Crimea, how were they recieved?
met with hostility from doctors there
(doctors were obsessed about maintaining control/a monopoly over HC)
How did Nightingale respond to the doctors hostility? (3 pts)
reassured them that nurses were not competition and were strictly there to obey the doctors orders & do women’s work (cooking & cleaning)
How did Nightingale make a difference by cooking & cleaning in the Crimean War (1853-1856)?
by taking over cooking & cleaning, she was able to introduce proper standards of nutrition & sanitation which was previously ignored by male doctors - mortality rates declined sharply
One famous case where Nightingale helped improve sanitation
persuaded military officers to go upstream & found dead horse spewing bacteria - convinced them to move it
Florence Nightingale -After Crimean War
took heavy toll on her, ill & bed-ridden most of her life
- became public heroine & used her fame to write about nursing, engage in political activism & organizational work that laid the foundation for modern nurse training
First Nursing School in Canada
St.Catharines
- established in 1874 in Ontario
- based on Nightingales model of nursing
Nursing - occupation for women
virtually only paid occupation for women
- therefore it was very attractive for those who wanted an education & career (middle-class women)
# of nursing schools in Canada in…
a) 1900
b) by 1909
c) by 1930
a) 20
b) 170
c) 220
The first 30 years of the 20th Century were known as the period that..
saw the greatest expansion in nursing
Impact of the Flexner Report on Nursing
following the recommendations of the Flexner report, the 1st university degree program in nursing was established in 1919 at UBC
1900s: # of nurses vs doctors
200 nurses compared to 5,000 doctors
1930: # of nurses vs doctors
30,000 nurses compared to 10,000
After 1930, what happened to the rate of growth of nursing?
declined
Despite the decline in the rate of growth of nursing after 1930, Throughout the 20th Century…
nursing maintained average annual increase of 50%
- compared to less than 10% for doctors
By 2006, How many registered nurses in Canada? What % were women?
320,000
94% women
Nurses made up __ of all HC providers becoming the…
2/3
single largest profession in Canada
In economic terms, the expansion of nursing allowed…
Canadian women to get back into labor market from which they had been virtually squeezed out of by late 19th century
Routes for Economic Independance for women in early 20th century? (2)
1) Inheritance
2) nursing
Despite being the only route to independance (apart from inheritance) for women, there were still drawbacks/limitations to nursing.
hard road to travel
only gave limited form of independance
Although Nightingale herself was strong & independent, her teaching methods demanded…
strict obediance to male doctors
Argument about Nightingale’s teaching methods
some say she did a disservice to women
- but may have been the only way to be accepted & overcome the hostility of male doctors
Only way that nursing could be accepted by doctors was if…
they defined themselves as an AUXILLARY OCCUPATION to that of doctors (a supplementary occupation)
The general attitude about nursing by male doctors
women were still doing women’s work, just in a hospital setting
- which was acceptable to male docs at the time
Connection b/w Patriarchal relations that existed in Victorian family/society & HC
the patriarchal relations that existed in Victorian society/family (era: 1837-1901) were reproduced within the hospital
The Patriarchal (male-dominated gender) relations that existed in Victorian society/family were reproduced within hospital, creating…
a new gender division of labor in HC
Men providing cuts & chemicals (surgery & drugs) & women providing nutrition & sanitation was a reasonable division of labor. However, the problem was..
men ended up taking most of the money & power but the women did most of the work
- particularly nursing students
Early 20th Century - Nursing students
- treated like slave laborers
- work consisted of hard manual labor (washing floors/windows, changing beds, cooking)
- forced to work 12-16 hours/day in hospital WITHOUT pay
- only received training, room and board
When did Nursing students get paid?
How much compared to average male wage?
Only after they had graduated & recieved their Nursing Diploma
- only 1/2 of average male wage
Nursing students training consisted of..
mostly on-the-job training which consisted of working hard while being supervised by small permanent staff of grad nurses
- no time for actual study/theory
How long to finish a Nursing Degree in the early 20th century?
2-3 years
How did the hospitals benefit from nursing students in the early 20th century?
provided hospitals with rotating pool of cheap labor
After graduation, where would nurses work?
some worked as private nurses but increasings #s found jobs in hospitals
The explosive growth of nursing schools was greatly motivated by?
the desire of hospital administrators & doctors to have cheap labor
What effect did permanent nursing staff have on hospitals?
no more cheap labor
- less motivation for growth of nursing profession
How did nursing change hospitals in early 20th Century compared to 19th century?
19th century - hospitals were places people only went to die
20th - changed hospitals into hygienic centers of care & recovery which
changed public image of hospitals
Nursing made major contribution to… yet?
medical profession & doctors reputation yet still they were heavily exploited
paid virtually nothing for a lot of work
As the # of nurses rose, they begin to..
fight for their rights
Nurses realized the only way to get better wages & working conditions was through (2)?
self-organization & collective action
1908 - established?
Canadians Nurses established Canadian National Association of Trained Nurses (CNATN)
1924
reorganization CNATN and renamed as Canadian Nurses Assocation
Canadian Nurses Association - significance today
still remains main organization that represents nurses interests today
First goal of CNATN in 1908
establish provincial registries of qualified nurses -only these nurses could practice nursing
1910
began to set up registries & nurses became known as RNs
Through the process of registering nurses.. the nursing profession tried to…
gain monopoly on role of assistant caregiver but never been as successful as doctors in achieving a monopoly
By WW2 (1939-1945). organization of Nurses
organized enough to gain some concessions - gained 8 hour day
1950 - nurses income
nurses pay was 60% of avg national income
by 1980 - nurses income
risen to avg national income - mostly due to pressure from nurses
In addition to pushing for better wages & working conditions, Nurses also demanded?
real education and not just on-the-job training
1964 - Nursing
Hall report - Royal commission looking into HC delivered report that was critical of nursing education in Canada
The Hall Report of 1964 recommended what change to nursing?
seperation of nursing training from hospital demands for nursing services
(nursing education should be seperate from training)
How did the government respond to the Royal Commission’s recommendations of seperating nursing education from training?
in late 60s/early 70s → nursing education moved away from hospital schools into newly created diploma programs in universities
What aspects of Nursing were significantly improved after the government responded to the Royal Commissions recommendations?
skills & standards
What other change did the government make other than to nursing education?
changed immigration policy to attract more nurses
As a result of the change in Canadian immigration policy…
over 20,000 nurses immigrated to Canada - mostly from Britain
Britain’s NHS
Britain’s National Health Service/System (NHS) was more advanced & developed than Canada’s HC system
NHS - impact on Canadian HC
Canadian government deliberately tried to upgrade nursing standards & increase # of nurses
The government’s attempts to upgrade nursing standards & increase # of nurses by changing immigration laws was part of..
overall policy of Canada to establish Medicare by copying Britain’s NHS
Time period that saw considerable expansion in # of nurses
1960s & 1970s
The expansion in the # of nurses in 60s & 70s was accompanied by..
a growing division of labor
Nursing saw an increase in (3) things
1) specialization
2) fragmentation
3) hierarchization
Nursing began to generate its own __ ___
auxilliary occupations
(therapists, dieticians, orderlies, technicians)
specialization of nursing
some nurses took more education to upgrade their qualifications & specialize in one area of nursing
- realized pay only increased marginally
(still 3/4 of nurses are general duty nurses)
While there were some changes in nursing, more changes changes occured where?
at bottom of occupational ladder- auxiliary occupations
How did hospital administrator try to cut nurses wage bill after they had just gotten their wages increased?
replaced many nurses with registered nursing assistants (1970s)
- when RNAs got organized & pushed for higher wages, they were replaced with nursing attendants (1980s)
The replacement of nurses with registered nursing assistants & then nursings attendants demonstrates…
class struggle in action which is seen in any area of the economy
- cycle that is built into capitalism
Despite all these changes to the Nursing field, what remained constant? How?
Ongoing feminization of HC system
- by 1990s, 2/3 of HC system workers were nurses (90% women)
- nearly 80% of all HC workers = women
Despite the increasing proportion of women in the HC system..
women’s influence & power has not grown in proportion to their #s
in the late 80s/90s, how were hospital bills broken down?
into thirds
1/3 for doctors
1/3 for nurses
1/3 for administrative & support staff
Nursing expanded greatly in 60s & 70s, but in 80s & 90s, there was a major increase in..
administrative staff
(2) reasons for the major increase in administrative staff in hospitals
1) certain support services were removed from nursing & subcontracted to private companies
2) growth & change in kind of hospital administrators
80s → certain support services removed from nursing
hotel services (cooking, cleaning, laundry, catering) were no longer nurses responsibility & hospitals subcontracted these to private companies
What was the beginning of privatization of HC
subcontracting private companies for hotel services
Growth & change in in kind of hospital administrators
in 5 years (1981-86), # of HC administrators grew by over 2/3s
- hospitals began to hire administrators outside of HC field-
mostly managers from private sector who had an education in management & not HC
Before the 80s, who were hospital administrators?
mostly doctors or other HC workers that had climbed administrative ladder internally
by 1993.. HC administrators characteristics
1/3 of HC administrators had NO HC experience
- mostly men
- business degree/experience in management
Changes in control/influence due to the new kind of hospital administrators
doctors lost control of hospitals
- womens influence decline
How did these new hospital administrators view their job & how did this affect working in the hospital?
saw their job as the same kind they had in private sector
- pressure workers work as hard as possible
Why did most of pressure from hospital administrators fall on nurses?
doctors were still seen as relatively privileged group, middle-class professionals who deserved to not be pushed as hard
Managerial structure emerged in hospitals
private administrators > doctors > nurses & auxiliaries
To the hospital administrators, nurses were seen as..
the working class of the HC system which management has always pushed to work harder
How did Hospital administrators push nurses to work harder??
through the process of deskilling
deskilling
breaking down jobs into simple tasks so highly paid experts can be replaced with less-skilled cheaper workers
(2) advantages of deskilling for management
1) increased control over workforce
2) saves $$ by decreased wage bill
Deskilling - first noted in academic terms by..
Chares Babbage in early 19th Century
→ known as Babbage Principle
Other terms for deskilling
late 19th century → Fordism (Henry Ford)
early 20th→ Taylorism (named after Frederick Taylor who invented time & motion studies & scientific management)
late 20th→ Mcdonaldization
Terms for Deskilling within the field of HC
Managerial Ideology
Case-mix grouping
Total Quality Management (TQM)
Why should TQM be called Totalitarian Quality Management? (as opposed to total quality management)
because it introduces total control over nurses work
totalitarian (def’n) - system of government that is centralized, dictatorial & requires complete subservience to the state.
What were nurses told that TQM do?
provide greater autonomy
make jobs easier by improving job effeciency
help to assess staff needs - hopefully to decrease workload of nurses
What did TQM actually do?
breaks down nursing into specific jobs & assigning specific amounts of time for each task (based on polls asking nurses how much time they needed for each)
- allowed administration to cut amount of time allowed for each job to force nurses to work harder/faster & save money by not hiring more nurses
Origin of TQM relating to the negative consequences of TQM
TQM was taken from factory work where assembly lines can be standardized to improve efficiency
- However, people are not machines & HC cannot be standarized because it wouldnt account for personal differences
How does the standardization of HC by TQM affect nursing care how?
left nurses without enough time so that they were constantly falling behind on tasks - made decision making difficult b/c they had less time to make possibly life-or-death choices
Quality of Care given by nurses after TQM introduced
of mistakes increased
of people harmed increased
- because they did not have enough time
TQM’s attempt to standardize HC had negative effects on…
the patients & the nurses
Study by Canadian Institute for Health Information (2004)
- main finding
over 5 million CDNs reported they or member of their family had been harmed by medical errors in hospital
Study by Canadian Institute for Health Information (2004)
- statistics given (5)
- 1 in 9 reported receiving incorrect meds/dosage
- 1/9 adults & 1/11 children contracted infection in hospital
- 1/81 newborns suffered birth trauma
- 1/~1000 seniors suffer hip fracture
- 1/~7000 reported having foreign object left inside them after procedure
TQM treats nurses as if they were?
interchangeable components on assembly line
How has TQM resulted in a lack of continuity of HC?
different nurses do different jobs on same patient → unable to learn patients overall health situation so nurses can’t treat patients like individual with individual needs
TQM is the ultimate extension of?
& denial of?
extension of male mechanical model
& denial of traditional holistic female approach to HC
TQM turned the continuous process of care into?
series of compartmentalized cures that were about seeing to a patients minimum needs
TQM also eliminated what side of HC?
subjective side of HC - part of nurses work called emotional labor
Explain how private sector administrators view HC & how that is reflected in their management.
administrators deal with balance sheets, numbers & money
- the comfort that nurses provided is invisible & seen as a waste of time that must be eliminated to increase speed**, **efficiency** & **decrease cost
How does TQM treat
a) nurses
b) patients
a) as if they were uneducated unskilled labourers who have to be told what/how/when to do things
b) treats patients in a standardized manner
In Sociological Terms, professionals want control over their own __ __
labor process
TQM has greatly increased level of ___ that nurses experience from their jobs
alienation
How has TQM affected quality of care given by nurses?
How has this affected hospital in last 30 years?
has forced them to do their jobs badly bc they do not have enough time or resources
- health, sanitation & nutrition levels declined over last 30 years
In general, how has TQM affected nurses?
- cause nurses to blame themselves/other nurses
- increases levels of stress
- physical** stress of **overwork
- psychological stress of not being able to do jobs properly*
- rise in work-related injuries & illnesses for nurses
By the late 1990s, as a result of TQM, nursing has become known as..
the sickest profession in Canada
Nursing - Sickest Profession in Canada - Example
1997 - sick leave average
CDN = 1 week
nurses = just over 3 weeks
Nurse Burnout
in 1990s, as a result of TQM - many nurses quit because they couldn’t take the pressure
Why is the phenomenon known as Nurse Burnout only happening in the later 20th Century?
in the late 19th/early 20th Century, nursing was really the only acceptable & paid job for women
- now, women have many other options
2000 - Canadian Nurses Association study found..
~ 1/3 nurse graduates left canadian nursing within 5 years of graduating
- 20% quit altogether
- 10% went to USA to work in private sector (paid more)
What decade saw a sharp decline in the # of applicants & graduates of nursing schools?
1990s
Nurses graduated in Canada in 1999 vs. 2000
1999: ~9000
2000: <5000
How did Nurses try to fight back against the increasing stress put on them? (3)
in late 1980s, Nurses Union proclaimed TQM was endangering patients life through pressure putting on nurses
- Provincial Nurses Unions took a stand on SAFETY TO PRACTICE issues
- went on strike
First Wave of Nursing Strikes
bc they were being completely ignored, wave of nursing strikes swept across Canada in late 80s/early 90s
late 80s/early 90s - Nursing Strikes
1988- SK & AB
1989 - BC & Quebec
1991 - Manitoba (longest strike)
What was the result of the Nursing strikes?
a professional responsibility clause was added to nurses contracts that established channels for nurses to express their grievances
2nd wave of nursing strikes - when?
late 90s/early 2000s - every province in Canada
1999- SK
How did SK government respond to SK nurses going on strike
NDP gov met nurses w/ great hostility despite being party of the working class
- ready to enact back to work legislation
- used courts to threaten unions with fines & leaders with prison time
Throughout the 2000s, nurses have been ___, ___ & ____
overstressed
over-supervised
over-worked
2003 Statistics - Nurses Overtime
CDN nurses worked over a quarter million overtime hours in a week
- equivalent to work of 7,000 full-time jobs a year
2005 - Study on Ontario Nurses - findings
58% of nurses & 66% of junior nurses experiencing symptoms of nurse burnout
- 1 in 3 nurses under 30 plan to quit
- 1 in 3 over 50 plan to retire early
2005 Study on Ontario Nurses
- Symptoms of nurse-burnout (5)
- reasons for symptoms of nurse-burnout? (3)
- depression, emotional/physical exhaustion, physical illness & growing cynicism of job*
1) work overload
2) lack of fairness in workplace
3) lack of empowerment (increasing supervision & not in control)
- depression, emotional/physical exhaustion, physical illness & growing cynicism of job*
How does TQM put more pressure on nurses to quit?
their job involves making life-or-death decisions
- mistakes increasing b/c of lack of resources/time/people
- worries nurses b/c patient life & health is compromised
How has SK addressed this issue of nurse burnout?
In 2012, Premier Brad Wall announced that SK will once again lead way for Canada in improving HC (just like TD did) → 1st province to introduce LEAN Management
LEAN Management in SK
in 2012, SK government signed 4 year contract with Seattle-based company John Black & Associates
- pay 40 million over 4 years to teach LEAN management techniques in over 1,000 HC facilities
Origin of LEAN
Japan
Sensei (meaning)
one who has gone this way before
- voice of experience
- teacher
How did the public view LEAN?
initially well until 2014
- was criticized for 40 million $ price tag
- Cam Broten of NDP called lean a “cult”
How has SK Premier defended Lean & its 40 million dollar cost?
says that LEAN management has already more than paid for itself
- by eliminating waste & improving efficiency, has saved:
- 35 million in blood services
- 16 million in design of new hospitals in Saskatoon & Moosejaw
- millions more in 100s of small savings in HC facilities all across province
How was lean created?
Toyota automobile corp.
- the term was coined by American Analyst John Krafcik who wrote article about Toyota in 1988
- introduced idea of LEAN to the west
Toyota - History
founded in 1930s as small family business
-has since grown to be the 5th largest corporation
The Toyota Way - History & Basis
based its production on assembly line techniques pioneered by Henry Ford In USA
- concerned with efficiency & elimination of waste by standardized & simplified production process
- an extension of Fordism & based on Taylorism (time & motion studies)
- Flow System -production should flow smoothly - no bottle necks or unused resources
- aka Just in Time system - each person finished their part of job just in time for next person to take over
- dont need lots of backup inventory (save $$)
The Toyota Way Philosphy
(6) points
- culture
- philosophy
- emphasizes
- decision-making
-
- establishing culture where everyone is committed to always looking to improve process
- managerial philosophy
- emphasizes teamwork & mutual respect between management & employees
- decisions reached by consensus
- regular meetings to look for ways to do things better
- work as team, come to think of as team
How does the Toyota Way differ from standard manager-worker relationships
management regularly consults workers & gets feedback
- workers are involved in decision-making process & their opinions are respected
- makes them feel like it is their company so they want to be more efficient & finds ways to do job better
What does Toyota literature say is the primary reason behind their time-saving techniques?
these time-saving techniques are by-products of the positive attitude, teamwork, mutual respect & culture of improving workforce
Why is the Toyota Way unsuccessful for many companies over the longterm?
most managers dont think/dont want to think this way - they beleive that managers should give orders & workers should obey (top-down manner)
- rather than set up meetings, they hire Sensei’s to tell workers what to do which makes workers angry, decreases morale & makes workers less engaged
(5) Job-related actions
Top-down manner of LEAN in HC
techniques implemented without consulting workers
- nurses are expected to learn japanese terminology on top of their job
- alienates workforce
The top-down arrogance eliminates chances of?
from the beginning, eliminates chances of creating a teamwork attitude & gaining workforce support
Why is the experiment of introducing LEAN into HC inevitably going to lead to problems ?
LEAN was invented in factory setting to provide goods not services
Problems with LEAN in HC Setting (3)
1) standardization
2) Flow/Just in Time
3) Eliminating Unused Inventory
1) Standardization
LEAN works by standardization → can’t standardize people → need customized/individualized care
2) Flow/Just in Time
in factory setting, production slowed/temporarily halted - may lose $$ but overall system still making money In HC → If one person doesn’t do their job on time - endangers peoples lives
3) Eliminating Unused Inventory
in factories, production & supply needs are fairly predictable - can just order supplies if needed In HC → needs are not predictable & goods needed right away or patients can die
April 2014 - SK Survey
50% of nurses said quantity & quality of supplies available have declined since LEAN - vital equipment missing & meds unavailable
The Governments real motivation behind LEAN
to save money
What evidence backs up the idea that the Government only introduced LEAN to save money and not improve HC?
**Nurses Survey (April 2014) **
before LEAN, prov. gov. increase HC budget by 7-10% but now after LEAN → only 3-4% annual increase
- July 2014 Report
July 2014 - Report
published by independent assessor of HC system
Conclusions?
Wall gov. has neglected HC facilities
- need to spend 2.2 billion $ just to provide essential repairs to existing HC buildings that are falling apart
- 87% of HC facilities rated poor-fair
LEAN implentation timeline
2012 - contract signed
2013 - introduced at start of this year
Tracy Zambory
President of SK Union of Nurses
Change in SUN’s opinion of LEAN
2013: LEAN leading to “many commendable changes”
Within 1 year (early 2014): already became obvious that only purpose of changes was “budgetary savings” & these changes had “little impact on direct care at bedside & patient outcomes”
- does not fit into safe nursing practice
Positive Change of LEAN (4)
1) inventory management
2) waste reduction
3) saving $$
4) undo certain steps of TQM - sped up delivery of HC
SUN Survey
Found HC has sped up form before LEAN (2012) to after LEAN (2013)
- also increase in critical incidents faster not safer
What is the only way that LEAN could work in HC?
If LEAN was really done Toyota Way
- regular meetings & consultations b/w docs, nurses & hosp admin - IF so → give front-line HC workers more input & reduce input of admin
LEAN done the SK Party Way
not about improving HC
- about saving prov. gov. $$ & increasing power & control over front-line HC workers
What can LEAN not do?
- deliver on its promises of better HC
- gain support of nurses
LEAN as a fad
enthusiasm has waned, eventually will fade away when next fad comes along
Cycle of HC Fads
TQM, LEAN… - always about reducing costs & increasing control
