10419 workload and capacity...

Workload Issues and Clinical Capacity Concerns

A Guide for NSNU Members

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Founded in 1976, the Nova Scotia Nurses’ Union (NSNU) represents over 6,500 Licensed Practical Nurses, Registered Nurses and Nurse Practitioners working in acute care hospitals, long term care facilities, and community care practices in Nova Scotia. As a professional trade union, the NSNU exclusively represents nurses, which is unique to labour unions in Nova Scotia.

The NSNU is affiliated with the Canadian Labour Congress (CLC) and is a member organization of the Canadian Federation of Nurses Unions (CFNU) which represents over 156,000 nurses and student nurses across Canada.

The NSNU negotiates Collective Agreements with employers and represents its members in workplace and labour relations issues. The NSNU strives to ensure that the voice of nurses on health care issues is represented and communicated to the public.

Nova Scotia Nurses’ Union © 2014

* A special thank-you to the Ontario Nurses’ Association for sharing its workloaddocumentation which has helped in the preparation of this guide.

* For style and simplicity, this document will use the pronoun ‘she’ to refer to allpeople generically.

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Table of Contents

NSNU: Vision, Mission, Values, Objectives .......................................1

Purpose of the Guide .........................................................................2

Workload / Clinical Capacity Concerns .............................................3

Workload Reporting Process .............................................................5

LONG TERM CARE AND COMMUNITY CARE NURSES

A. Informal Process ...................................................................... 5

B. The NSNU Clinical Capacity Report ........................................ 5

C. Labour Management Committees ............................................ 6

ACUTE CARE NURSES

A. Informal Process ...................................................................... 7

B. The NSNU Clinical Capacity Report ........................................ 7

C. Labour Management Committees ............................................ 8

D. Bringing Workload Issues to the CEO or Equivalent .................. 8

E. Independent Assessment Committees (IACs) ........................... 9

F. The Role of NSNU ................................................................. 10

APPENDIX A - Workload Language from Collective Agreements

i. COMMUNITY CARE (VON) .................................................. 11

ii. LONG TERM CARE ................................................................ 11

iii. ACUTE CARE ......................................................................... 11

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Table of Contents con’t

APPENDIX B - Clinical Capacity Report - Long Term Care ..............13

APPENDIX C - Clinical Capacity Report - Community Care ............15

APPENDIX D - Clinical Capacity Report - Acute Care .....................17

APPENDIX E - CCR Guidelines & Tips - Long Term Care Process .....20

APPENDIX F - CCR Guidelines & Tips - Community Care Process...21

APPENDIX G - CCR Guidelines & Tips - Acute Care Process ...........22

APPENDIX H - Clinical Capacity Concerns/Indicators .....................24

APPENDIX I - Workload Process Flow Chart - Acute Care ...............25

APPENDIX J - Tips for Meeting with the Labour ManagementCommittee ....................................................................................26

APPENDIX K - Documentation ........................................................28

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NSNU: Vision, Mission, Values, Objectives

Our VisionAs a Union, we have the courage to lead, confidence to challenge, commitment to care.

Our Mission The Nova Scotia Nurses’ Union advances the social, economic and work lives of nurses.

Our Values Integrity and Professionalism - We believe that fair representation must be guided at all times by the highest standards of integrity which in turn compels us to maintain a professional approach in all that we do. Accountability and Transparency - We believe we are ultimately accountable to our members and this is demonstrated through transparent decision-making processes and results reporting. Compassion and Caring - We believe we must consistently demonstrate compassion and caring for our nurses. Democracy - We believe democratic practices advance society, our members’ well-being, and our internal and external work as a union. Solidarity - We believe in the power of solidarity by harnessing collective power and common goals, ideals and values. Political Action - We believe maintaining a non-partisan stance enables us to be more effective in our political activity in advocating for positive public policy. Quality Health Care - As a union, we consistently reassert our fundamental support for the principles of the Canada Health Act that laid the foundation for a publicly funded health care system for Canadians.

Advocacy and Representation - We believe we must be guided by the principle of equity in our advocacy and representation activities.

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Our Objectives

• The advancement of the social, economic and general welfare of nurses andother allied personnel.

• The regulation of relations between nurses and other allied personnel andtheir employers and the negotiation of written contracts with employersimplementing progressively better conditions of employment.

• The promotion of effective communication.

• The promotion of the knowledge of nurses and other allied personnel in allthings related to their social and economic welfare through education andresearch.

• The promotion of unity within the nursing profession and other allied fieldsthrough cooperation with and support of other organizations.

• The promotion of political awareness amongst the membership.

• The promotion of the highest standards of health care.

• The promotion of the nursing profession.

Purpose of the Guide

The Guide to Workload Issues and Clinical Capacity Concerns has been prepared to assist NSNU members facing situations that make it difficult, if not impossible, to provide safe and quality patient//client/resident care within their scope of practice. Even if this does not describe your current work situation, this guide contains important information that every NSNU member should know and understand.

In this guide, you will find information on resolving clinical capacity concerns. It describes every step in the process, from recognizing a clinical capacity issue and filling out a Clinical Capacity Report (CCR), to bringing a clinical capacity issue to an Independent Assessment Committee (IAC).

The NSNU is committed to providing the resources and education necessary to help members effectively use this process to address workload concerns.

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Workload / Clinical Capacity Concerns

Over the past several years, nurses in Nova Scotia and across the country have become increasingly concerned with issues around their workload. When faced with workload issues, including heightened patient/client/resident acuity and fluctuating staffing levels, it is very difficult to provide safe, ethical and quality nursing care.

Licensed Practical Nurses, Registered Nurses and Nurse Practitioners each have an independent practice and are accountable for their own decisions and actions. The College of Licensed Practical Nurses of Nova Scotia (CLPNNS) and the College of Registered Nurses of Nova Scotia (CRNNS) have Standards of Practice that registrants are expected to meet. If nurses cannot meet these standards due to a shortage of staff, lack of education and training, inappropriate assignments, elevated acuity and complexity of patient/client/resident care and so on, it is up to individual nurses to report these concerns to the employer and attempt to resolve them.

All NSNU collective agreements recognize the joint employer/employee responsibility to provide safe quality care according to the professional standards set out by the licensing bodies (colleges). They contain language such as the following:

“All parties to the Agreement share a responsibility and accountability to provide quality and safe health care in Nova Scotia; to maintain professional nursing practice standards; and to promote healthy workplaces so that the people of Nova Scotia are well and effectively served.”

Every nurse is required by their professional standards to report professional practice concerns to the employer and attempt to resolve them. Nurses often face workload assignments that are excessive, at times to the point where it is impossible to provide the quality of care required of them. The response to nurses’ concerns has too often been, “do the best that you can” or simply “there’s no more staff”.

In 2013, the NSNU and employers agreed on a new procedure to address workload concerns. The new procedure recognizes that nurses need a means whereby they can exercise their professional judgment in assessing their workload and have any concerns addressed.

The new procedure is designed to address Clinical Capacity Concerns which can take several forms.

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A workload issue occurs when a nurse, in her professional judgment, is concerned that due to insufficient staffing on a specific shift, or insufficient levels of training, equipment and so on, she is unable to complete or adequately perform all of her assigned tasks within the hours of the shift. The insufficient staffing could result in compromised patient/client/resident care (e.g. medications not given on time, treatments not done). For example, if a community care nurse is required to cover half the case load of another nurse who has called in sick, she is unlikely to be able to provide adequate care for all of her clients. Similarly, if the ER is above capacity and nurses are treating patients in hallways or other areas, it is very difficult to provide appropriate care. A competency concern relates to the adequacy of the scope of practice or employment of health care workers to the care they are asked to provide. For example, an RN or LPN may be concerned if an employer hires an unregulated care provider to feed patients in the Intensive Care Unit (ICU). The nurse may believe that the unregulated care provider does not have adequate training or an adequate level of competency to determine whether a patient is swallowing properly. According to CRNNS and CLPNNS, the RN or LPN has a responsibility to provide either direct or indirect supervision of this care provider (CRNNS/CLPNNS, Assignment and Delegation Guidelines for Registered Nurses and Licensed Practical Nurses, 2012). The RN or LPN in this situation must intervene to ensure patient safety and inform the employer of this competency issue. Failure to report could be considered professional misconduct by the relevant licensing body.

A procedure or policy concern relates to the appropriateness of the employer’s procedures and policies with respect to safe patient care. For example, if an employer announced that within the next two months, the licensed nursing staff on the night shift in a large nursing home will be reduced to one, LPNs and RNs in the facility might be concerned that this change will compromise resident safety. The nurses might make recommendations concerning this policy, realizing that CLPNNS and CRNNS standards require them to provide feedback on policies and procedures that affect resident care. To take another example, if an employer decided that RNs in the ER will begin suturing, without providing the necessary education and training, the nurses would be rightly concerned with upholding their professional standards and the quality of patient care. In this case, there is a concern with both the employer’s policy and the competency of the nurses who have not received the appropriate training.

In short, clinical capacity concerns include any situation that creates an unsafe or unprofessional practice setting, including inadequate or inappropriate staff or skill mix, excessive non-nursing duties or lack of support staff, excessive workload, employer practice or policy that is detrimental to patient/client/resident care and/or safety, new patients/clients/residents with inadequate staff, staff not given adequate orientation and/or mentorship in area assigned, and a lack of adequate equipment or supplies. A checklist of Clinical Capacity Concerns/Indicators can be found in Appendix H.

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Workload Reporting Process

The experience of other provinces has proven that an effective workload reporting process can result in an increase in licensed and support staff, changes in policy and procedures, additional equipment and many other workplace improvements. The NSNU will use reports from nurses to track trends and nursing concerns, assist in lobbying the colleges regarding the need to develop new standards or change existing ones, and to help NSNU’s negotiator and Provincial Negotiating Committee in identifying professional issues that need to be addressed in bargaining.

What follows is an explanation and brief overview of the various stages of the workload reporting process.

LONG TERM CARE AND COMMUNITY CARE NURSES

A. Informal Process

At the beginning of every shift, and throughout the shift as changes occur, nurses assess the acuity and status of their client/resident assignments. If a nurse believes that adequate and safe client/resident care cannot be provided due to the nurse’s workload or related matters, she brings this to the attention of her immediate supervisor, or where appropriate, the supervisor’s designate. At this point the supervisor or designate may call in more staff or make other arrangements to address the nurse’s clinical capacity concerns. Whenever possible, it is best if issues can be resolved at this level.

B. The NSNU Clinical Capacity Report

If the matter is not resolved to the nurse’s satisfaction, she may file a written report called a Clinical Capacity Report (CCR, Appendix B / Appendix C). This should be submitted to the nurse’s manager identifying the concern.

The completed form should be distributed to all relevant parties, as indicated on the form. Tips for filling out the form can be found in Appendix E / Appendix F of this document.

Completing CCR forms is an important means for nurses to improve working conditions. They provide a mechanism to:

• identify situations that impact a nurse’s ability to provide safe and qualityclient/resident care

• make recommendations to improve the quality of client/resident care

• motivate the employer to make the necessary changes

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• prove that licensed staff (LPNs, RNs, and NPs) have met their professionalstandards

• prove that licensed staff informed the employer of unsafe client/resident careconcerns

C. Labour Management Committees

When the response to the CCR form is unsatisfactory, the matter is forwarded to the Labour Management Committee for review. As per NSNU collective agreements, this committee generally meets several times per year to discuss workload concerns and other issues. For the VON, there are local union management committees as well as a provincial committee that meets twice per year. For nurses in long-term care, the composition of this committee will depend on the particular employer. Further details are available in collective agreements.

At the Labour Management Committee meeting, both the employer’s side and the union’s side may speak to the clinical capacity issue being discussed. The employer may be prepared to offer suggestions to solve the complaint, or the two sides may devise a solution together. If a solution is offered, the union should not accept it immediately, but rather wait to respond to it within a day or two. This will give the members involved an opportunity to discuss the employer’s offer among themselves, and to consult with the bargaining unit executive. If a resolution is eventually reached it should be documented to the satisfaction of both sides.

During this period, ongoing documentation of clinical capacity concerns is necessary. Moving issues forward will require members to make the decision to compile formal written proof, demonstrating the clinical capacity issue and identifying recommendations to resolve the complaint. This:

• provides documented evidence of professional responsibility and workloadconcerns

• helps determine recommendations necessary to resolve the problemsidentified in the workload complaint

• helps keep the Bargaining Unit President and the Labour RelationsRepresentative (LRR) informed of developments in relation to the complaint

If there is no resolution at this level, the union may be able to pursue other avenues for addressing the issue, including Occupational Health and Safety standards and the grievance process.

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ACUTE CARE NURSES

A. Informal Process

At the beginning of every shift, and throughout the shift as changes occur, nurses assess the acuity and status of their patient assignments. If a nurse believes that adequate and safe patient care cannot be provided due to the nurse’s workload or related matters, she brings this to the attention of her immediate supervisor, or where appropriate, the supervisor’s designate. At this point the supervisor or designate may call in more staff or make other arrangements to address the nurse’s workload concerns. Whenever possible, it is best if workload issues can be resolved at this level.

B. The NSNU Clinical Capacity Report

If the matter is not resolved to the nurse’s satisfaction, she may file a written report called a Clinical Capacity Report (CCR, Appendix D). This should be submitted to the nurse’s manager within 72 hours of identifying the workload concern. Tips for filling out the form can be found in Appendix G of this document.

Once a manager has received a CCR, she must meet with the nurse to discuss the matter within five (5) working days. This meeting may take place in person, or by telephone or video conference. Furthermore, the manager must provide a written response (Clinical Capacity Follow-up Report) to the Nurse within ten (10) working days of receiving the CCR.

The completed form and the manager’s response should be distributed to the relevant parties, as indicated on the form.

The CCR is a negotiated provision of the collective agreements and there should be no fear of reprisals against a member for exercising her rights under the collective agreement.

Completing CCR forms is an important means for nurses to improve working conditions. They provide a mechanism to:

• identify situations that impact a nurse’s ability to provide safe quality patientcare

• make recommendations to improve the quality of patient care

• motivate the employer to make the necessary changes

• prove that licensed staff (LPNs, RNs, and NPs) have met their professionalstandards

• prove that licensed staff informed the employer of unsafe patient care concerns

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C. Labour Management Committees

When the response to the CCR form is unsatisfactory, the matter is forwarded to the Bargaining Unit Grievance and Labour Management Committee (BUGLM) for review. As per NSNU collective agreements, there is one such committee per district health authority which meets between six and ten times per year to discuss workload concerns and other issues. Further details are available in the collective agreement.

At the BUGLM meeting, both the employer’s side and the union’s side may speak to the clinical capacity issue being discussed. The employer may be prepared to offer suggestions to solve the complaint, or the two sides may devise a solution together. If a solution is offered, the union should not accept it immediately, but rather wait to respond to it within a day or two. This will give the members involved an opportunity to discuss the employer’s offer among themselves, and to consult with the bargaining unit executive. BUGLM must provide a written response to the nurse within 10 working days of the meeting. If a resolution is eventually reached it should be documented to the satisfaction of both sides.

During this period, ongoing documentation of professional responsibility concerns is necessary. Moving issues forward will require members to make the decision to compile formal written proof, demonstrating the clinical capacity issue and identifying recommendations to resolve the complaint. This:

• provides documented evidence of professional responsibility workload concerns

• helps determine recommendations necessary to resolve the problems identified in the workload complaint

• helps keep the Bargaining Unit President and the LRR informed of any developments in relation to the complaint

D. Bringing Workload Issues to the CEO or Equivalent

Where the Union side of BUGLM, in consultation with the nurse, believes the matter is not satisfactorily resolved by the BUGLM committee, they shall forward a report with recommendations to the Employer’s senior management team. The CEO or her designate must respond in writing to this report as quickly as possible.

Alternatively, if the BUGLM has received more than 10 CCRs related to separate incidents from one unit in one month, the matter will automatically be referred to the CEO or her designate for a response.

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E. Independent Assessment Committees (IACs)

If the Union side of BUGLM believes the response of the CEO (or designate) is not satisfactory, the matter is then referred to an Independent Assessment Committee (IAC) comprised of equal members from the employer and the union. Committee members will schedule a meeting as soon as possible. The members of the IAC will typically be different than the parties involved in the dispute. Ordinarily, we anticipate that there will be two members from each side, unless the parties agree to more.

Prior to the meeting, both sides will be provided with the relevant documentation including the CCR and the manager’s response, the response by BUGLM and the response of the CEO. Furthermore, either side may request relevant information from the other prior to the actual dates of the committee meeting. This could include background information on the hospital (e.g. its size and location), a description of the unit, floor, ward involved, a floor plan, job descriptions, an outline of the patient classification system (if there is one), hospital policies, relevant collective agreement language and any other material which could help the committee in its determinations.

The Process of the Committee MeetingThe committee process will be developed in conjunction with each employer (DHA). In a typical meeting, both sides present a submission and take turns answering questions on it. The meeting is semi-formal and not bound to any particular format, nor subject to the rules of an arbitration hearing. The IAC deals with issues and objections as they are brought forward.

After the presentations, the IAC meets to discuss the evidence and the presentations and to make a preliminary determination of its recommendations. The committee will meet and review the CCR report along with the responses given at each stage of the process. They will make recommendations to the employer and/or the Union on how to remedy the situation giving rise to the clinical capacity complaint.

The committee may make whatever recommendations it sees fit. They are bound by neither the union’s recommended solutions nor those of the employer. They may make recommendations that neither party had initially considered.

After appropriate recommendations are determined by the committee, one side shall offer to draft the report and then share it with the other side. The report will contain the position of each side as well as the recommendations that are agreed upon. The report will be finalized once both parties agree.

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F. The Role of NSNU

The staff and leadership of the NSNU are committed to ensuring that the workload reporting process is understood by the membership and used effectively to address workplace concerns. In particular, the NSNU commits to the following:

• prepare resource material and provide support to the membership on theworkload reporting system

• assist and support the members to continue to complete the CCRs, compilenecessary information and refine recommendations as needed

• ensure the recommendations reflect the solution(s) to the problems identifiedby members

• gather evidence to support member concerns, including data from the nursingcolleges and various nursing/health care associations

• help ensure timelines for the issue are met (as per the collective agreement)

• act as liaison between member and management in setting up meetings etc

NSNU’s website contains several resources to assist you in addressing clinical capacity issues, and these resources are being updated regularly. Resources include:

• downloadable copy of the CCR form

• PowerPoint tutorial on filling out CCR forms and on the entire workloadreporting process

• IAC Reports (as they come out)

• relevant documents from the College of Licensed Practical Nurses and theCollege of Registered Nurses

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APPENDIX A Workload Language from Collective Agreements

i. COMMUNITY CARE (VON)

18.09 Workload

(a) A Nurse who believes that adequate and safe care of clients cannot beprovided because of that Nurse’s workload, shall bring the matter to theattention of the Nurse Manager or other designate of the Employer.

(b) Failing resolution of the complaint, the Nurse may then refer the matterin writing to the Union Management Consultation Committee as set outin Article 24.05.

(c) The Union Management Consultation Committee shall meet as soon aspossible to hear and attempt to resolve the complaint to the satisfactionof both Parties as indicated in Article 24.06 and 24.07.

ii. LONG TERM CARE

XX.00 Workload(a) A Nurse who believes that adequate and safe care of residents cannot be

provided because of that Nurse’s workload, shall bring the matter to theattention of the immediate Supervisor. If the matter is not satisfactorilyresolved, the Nurse may file a written report (Clinical Capacity Form)which is attached at Appendix “D” [of the collective agreement] whichshall be submitted to the Employer.

(b) Failing resolution of the issue, the Nurse may refer the matter to theUnion Management Consultation Committee as set out in Article 28.

iii. ACUTE CARE

17.00(a) The Employer agrees to make every effort to maintain or improve safe

standards of patient care.

(b) Nurses assess acuity and status of their patient assignments.

17.01(a) A Nurse who believes that adequate and safe care of patients cannot

be provided because of that Nurse’s workload, shall bring the matter

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to the attention of the immediate Supervisor, or where appropriate, the Supervisor’s Designate. If the matter is not satisfactorily resolved, the Nurse may file a written report (Clinical Capacity Report) which is attached at Appendix “F” [of the collective agreement] which shall be submitted to the Nurse’s Manager within 72 hours of the Nurse identifying the concern.

(b) The Manager will meet with the Nurse to discuss the matter within five (5) working days of receiving the Clinical Capacity Report. The Manager will provide a written response (Clinical Capacity Follow-up Report) to the Nurse within ten (10) working days of receiving the Nurse’s Report.

(c) After full completion, the form shall be distributed to the listed parties.

(d) Failing resolution of the complaint by the Manager, the Nurse may then refer the matter to the Bargaining Unit Grievance and Labour Management Committee as set out in Article 28.

(e) The Bargaining Unit Grievance and Labour Management Committee shall meet as soon as possible to hear and attempt to resolve the complaint to the satisfaction of both Parties. The BUGLM shall provide a written response to the Nurse within ten (10) working days of the meeting.

(f) Where the matter is not satisfactorily resolved under (c) above, or the BUGLM has received more than ten (10) Clinical Capacity Reports related to separate incidents from a unit in one month, a report with a recommendation shall be forwarded by the Bargaining Unit Grievance and Labour Management Committee to the Employer’s senior management team. The CEO/designate shall provide a written response as quickly as possible.

(g) If the response of the CEO/Designate is not satisfactory to the BUGLM, the matter shall be referred to an Independent Assessment Committee (IAC) comprised of equal members from the Employer and the Union.

The IAC will review the matter and make recommendations to the Employer, copied to the Union.

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APPENDIX B Clinical Capacity Report - Long Term Care

EMPLOYER NAME: ___________________________________________________

FACILITY: ___________________________________________________________

(1) NAME: _______________Date of Occurrence: (YYYY/MM/DD)__________

UNIT: ________________SHIFT/TIME OF OCCURRENCE: ______________

(2) STAFFING (NUMBERS) SCHEDULED THIS SHIFT:

RNs ______________ __________________

______________ __________________

______________ __________________

LPNs

OTHER

(3) Number of residents on unit: ______________________________________

(4) Describe situation affecting safe and adequate care of residents: ________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

(5) Detail actions you took in response to the workload situation to address

resident needs: _________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_____________________________ ______________________________ Date: (YYYY/MM/DD) & Time of Submission Signature

Original to Employer; cc: NSNU Labour Relations Representative, Nurse

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GUIDELINES FOR USE

(1) A Nurse who believes that adequate and safe care of residents cannot beprovided because of that Nurse’s workload, shall bring the matter to theattention of the immediate Supervisor. If the matter is not satisfactorilyresolved, the Nurse may file a written report (Clinical Capacity Form) whichshall be submitted to the Employer.

(2) Briefly outline:

(a) the work situation; and(b) identify specific problem(s). If the form does not provide sufficient

space, please add further information on a separate sheet.

(3) DO NOT identify any names of individuals involved in the incident described;use Dr. X or client/resident A.

(4) Clinical Capacity Reports are not intended to replace any incident reportform or other internal documentation required under Employer Policies.

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APPENDIX C Clinical Capacity Report - Community Care

EMPLOYER NAME: ___________________________________________________

SITE: _______________________________________________________________




RNs ______________ __________________

______________ __________________

______________ __________________

LPNs

OTHER

(3) Number of clients on unit: ________________________________________

(4) Describe situation affecting safe and adequate care of clients: __________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________


client needs: ___________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_____________________________ ______________________________Date: (YYYY/MM/DD) & Time of Submission Signature


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GUIDELINES FOR USE

(1) A Nurse who believes that adequate and safe care of clients cannot be provided because of that Nurse’s workload, shall bring the matter to the attention of the immediate Supervisor. If the matter is not satisfactorily resolved, the Nurse may file a written report (Clinical Capacity Form) which shall be submitted to the Employer.




(3) DO NOT identify any names of individuals involved in the incident described; use Dr. X or client/resident A.

(4) Clinical Capacity Reports are not intended to replace any incident report form or other internal documentation required under Employer Policies.

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APPENDIX D Clinical Capacity Report - Acute Care

EMPLOYER NAME: ___________________________________________________

FACILITY: ___________________________________________________________




RNs

LPNs

OTHER

______________ __________________

______________ __________________

______________ __________________

Number of patients in isolation: ____________________________________

(3) Number of patients on unit: _______________________________________

(4) Describe workload situation, including acuity of patients: ______________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________


patient needs ___________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

(6) Name of Manager/Supervisor/Designate Contacted:

_______________________________________________________________

Time Contacted: ____________________________ ____________________

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(7) Describe action/response given by Manager/Supervisor/Designate: ______

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

(8) Describe your response: __________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

(9) What other options might have been considered: _____________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_____________________________ ______________________________ Date: (YYYY/MM/DD) & Time of Submission Signature


GUIDELINES FOR USE

(1) A Nurse who believes that adequate and safe care of patients cannot be provided because of that Nurse’s workload should bring the matter to the attention of the immediate Supervisor, or where appropriate, the Supervisor’s Designate. Where the issue has not been satisfactorily resolved, the Nurse may complete this form.




(3) DO NOT identify names of individuals involved in the incident described; use Dr. X or client/resident A.

(4) Clinical Capacity Reports are not intended to replace any incident report form or other internal documentation required under Employer Policies.

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CLINICAL CAPACITY FOLLOW-UP REPORT – ACUTE CARE

REPLY OF THE MANAGER

Date of Reply: _______________ (2) Completed by: _______________________

SITE: _______________________________________________________________

(1) Describe findings: _________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Describe action/response: _____________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Recommendations: ___________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

_____________________________ ______________________________Date: (YY/MM/DD) Signature

Copies to: Nurse; NSNU Labour Relations Representative; Employer

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APPENDIX E CCR Guidelines & Tips - Long Term Care Process

In the interest of safe patient care and safe nursing practice, the parties agreed to a process to address Nurses’ concerns:

• Nurses assess acuity and status of their resident assignments on an ongoingbasis

• a Nurse who believes that adequate and safe care of residents cannot beprovided because of that Nurse’s workload, shall bring the matter to theattention of the immediate Supervisor

• if the matter is not satisfactorily resolved, the Nurse may file a written report(Clinical Capacity Form) which shall be submitted to the Employer

• failing resolution of the issue, the Nurse may refer the matter to the UnionManagement Consultation Committee

The following is a brief guide to completing the form:

• Staffing: be as specific as possible. Include level of experience; skill set mixand familiarity with the unit.

• Number of residents on the unit: be specific; census could change throughoutthe shift.

• Describe the situation affecting safe and adequate care of residents: clearlyarticulate the issues that impacted or could have impacted delivery of saferesident care. Be factual and specific. Maintain confidentiality. Do notphotocopy any Employer or resident records. Issues could include but arenot limited to: resident acuity/complexity, census, incomplete or deferredresident care, staffing levels (including non-nursing staff), skill set/experiencemix, equipment, supplies, non-nursing functions, environment, outbreak,missed breaks and admissions.

• Detail the actions you took in response to the workload situation to addressresident needs: clearly articulate your response to the situation, includingdetailed account of communications with supervisors/management. (Howdid you manage the situation at the time? How did you prioritize care?)

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APPENDIX F CCR Guidelines & Tips - Community Care Process

In the interest of safe client care and safe nursing practice, the parties agreed to a process to address Nurses’ concerns:

• Nurses assess acuity and status of their client assignments on an ongoingbasis

• a Nurse who believes that adequate and safe care of clients cannot be provided because of that Nurse’s workload, shall bring the matter to the attention of theNurse manager or designate

• if the matter is not satisfactorily resolved, the Nurse may file a written report(Clinical Capacity Form) which shall be submitted to the Union ManagementConsultation Committee

• the Union Management Consultation Committee shall meet as soon aspossible to resolve the complaint to the satisfaction of both Parties


• �Staffing: be as specific as possible. Include level of experience; skill set mixand familiarity with the area.

• Number of clients assigned: be specific; census could change throughout theshift.

• Describe the situation affecting safe and adequate care of clients: clearlyarticulate the issues that impacted or could have impacted delivery ofsafe client care. Be factual and specific. Maintain confidentiality. Do notphotocopy any Employer or client records. Issues could include but are notlimited to: client acuity/complexity, census, incomplete or deferred clientcare, staffing levels (including non-nursing staff), skill set/experience mix,equipment, supplies, non-nursing functions, environment, outbreak, missedbreaks and admissions.

• Detail the actions you took in response to the workload situation to addressclient needs: clearly articulate your response to the situation, includingdetailed account of communications with supervisors/management. (Howdid you manage the situation at the time? How did you prioritize care?)

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APPENDIX G CCR Guidelines & Tips - Acute Care Process

In the interest of safe patient care and safe nursing practice, the parties agreed in Article 17 of the Acute Care Collective Agreement to a process to address Nurses’ concerns:

• Nurses assess acuity and status of their patient assignments on an ongoingbasis

• a Nurse has 72 hours to file a CCR to the Nurse Manager after first bringingthe matter to the attention of the Supervisor or designate

• the Manager will meet with the Nurse to discuss the matter within 5 workingdays of receiving the CCR and provide a written response to the Nurse within10 working days

• failing resolution of the complaint by the Manager, the Nurse may thenrefer the matter to the Bargaining Unit Grievance and Labour ManagementCommittee (BUGLM)

• the BUGLM shall provide a written response to the Nurse within 10 workingdays of the meeting

• where the matter is not satisfactorily resolved or the BUGLM has receivedmore than 10 CCRs related to separate incidents from a unit in one month,a report with a recommendation shall be forwarded by the BUGLM to theEmployer’s senior management team. The CEO/designate shall provide awritten response as quickly as possible

• if the response of the CEO/Designate is not satisfactory to the BUGLM, thematter shall be referred to an Independent Assessment Committee (IAC)comprised of equal members from the Employer and the Union

• the IAC will review the matter and make recommendations to the Employer,copied to the Union


• �Staffing: be as specific as possible. Include level of experience; skill set mixand familiarity with the unit.

• Number of patients on the unit: be specific; census could change though outthe shift.

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• Describe the workload situation, including acuity of patients: clearlyarticulate the issues that impacted or could have impacted delivery ofsafe patient care. Be factual and specific. Maintain confidentiality. Do notphotocopy any Employer or patient records. Issues could include but are notlimited to: patient acuity/complexity, census, incomplete or deferred patientcare, staffing levels(including non-nursing staff), skill set/experience mix,equipment, supplies, non-nursing functions, environment, outbreak, missedbreaks and admissions.

• Detail the actions you took in response to the workload situation to addresspatient needs: clearly articulate your response to the situation, includingdetailed account of communications with supervisors/management. (Howdid you manage the situation at the time? How did you prioritize care?)

• Describe action/response given by Manager/Supervisor/Designate: bespecific. Document direction given and/or discussion re: situation.

• What other options might have been considered: the options outlined heremay lay the foundation for recommendations in further follow up to theClinical Capacity Report. Be specific and creative. Identify resources thatwould have alleviated the situation.

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APPENDIX H Clinical Capacity Concerns/Indicators

The checklist below is presented as an aid to help nurses recall the various factors affecting their workload.

Workload/clinical capacity concern

STEP 1Advise immediate Supervisor/Designate

STEP 2Nurse files CCR

Supervisor responds verbally and in writing

Supervisor takes stepsWorkload Issue Resolved

STEP 3Matter considered by BUGLM which issues response

BUGLM response satisfactoryWorkload Issue Resolved

STEP 4Matter forwarded to DHA CEO for response

CEO response satisfactoryWorkload Issue Resolved

Supervisor does not/cannot take satisfactory steps

Manager does not/cannot take satisfactory steps

BUGLM response not satisfactory

STEP 5Matter forwarded to IAC

CEO response not satisfactory

Supervisor takes stepsWorkload Issue Resolved

STAFFING EQUIPMENT & SUPPLIES COMMUNICATION

q RN Staff q Faultyq Lack of Leadership &

Support

q LPN Staffq Training on New

Equipmentq Policies & Procedures

q CCA Staff q Insufficient/Lack ofq Charting/Documentation

System

q Physician Staff q Maintenanceq Availability of nursing

management on call

q Other Staff q Not Appropriate q Other

q Policies & Procedures q Other

q Baseline ENVIRONMENT

q Contingency staffingNON-NURSING FUNCTIONS

q Patient/Client/ResidentTransfers

q Occupancy q Answering Telephone q Cleanliness of Area

q Break ReliefqHo

Maintenance/usekeeping

q Construction/Renovation

q Scheduling q Visitor Inquiries q Fire Alarm

q Sick calls q Calling in Staff q Noise Level

q Vacations/leaves q Otherq Power, Plumbing &

Heating

q Staff Not Replaced q Physical Layout

q WorkloadEDUCATION/ORIENTATION

q Placement of Patient/Client/ResidentInappropriate

q Patient/Client/ResidentAcuity & Complexity

q Access to ReferenceMaterial

q Safety for Patient/Client/Resident and Staff

q Agency Staff q Agency Staff q Care Fragmentation

q Model of Careq Novice nurse

orientationq Influenza or other

Outbreak

q Skill Mixq Job Duties/

Responsibilitiesq Compliance Issues

q Staff training/education q Casual Nurses q Other

q Continuity of care q Other

q Other

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APPENDIX I Workload Process Flow Chart - Acute Care

Workload/clinical capacity concern

STEP 1 Advise immediate Supervisor/Designate

STEP 2 Nurse files CCR

Supervisor responds verbally and in writing

Supervisor takes steps Workload Issue Resolved

STEP 3 Matter considered by BUGLM which issues response

BUGLM response satisfactory Workload Issue Resolved

STEP 4 Matter forwarded to DHA CEO for response

CEO response satisfactory Workload Issue Resolved

Supervisor does not/cannot take satisfactory steps

Manager does not/cannot take satisfactory steps

BUGLM response not satisfactory

STEP 5 Matter forwarded to IAC

CEO response not satisfactory

Supervisor takes steps Workload Issue Resolved

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APPENDIX J Tips for Meeting with the Labour Management Committee

(Adapted from the Ontario Nurses’ Association)

Provide Rationale for each of your recommendations: ask yourself:HOW WILL I SELL THESE RECOMMENDATIONS TO THE EMPLOYER?

What is the Outcome if

Workload issues are not resolved:

• Liability to all parties, law suits, costs• Increased sick leave• Burnout, turnover• Poor morale• Public relations problems• Labour relations problems• Waste

Workload issues are resolved:

• Increased production• Cost effectiveness• Less waste• Improved public relations• Improved morale• Increased funding/grants/etc.• Decreased liability-law suits

Useful Tips

• Meet in advance to prepare who will introduce the committee members and the issues. Choose someone to speak on an issue who is knowledgeable and consider involving the nurses who filed the CCR

• Be familiar with your collective agreement workload language.

• Involve your Labour Relations Representative (LRR)

• Prepare and present your action plan to the employer at the meeting. This way you can provide rationale for your recommendations and have dialogue on each issue making sure the employer understands what it is you want and why

• State why you are meeting “We are bringing our issues to you as per article ____ of the collective agreement (or refer to CLPNNS/CRNNS professional standards). There have been a number of workload issues brought to the unit manager’s attention and the nurses on the unit believe that the issues have not been resolved to their satisfaction. We are here today to discuss and attempt to resolve the issues.”

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• State the facts clearly using examples and dates of incidents whenever possible (use real incidents of unsafe issues/lack of quality patient/client/resident care)

• Focus on patient/client/resident care and safety first then relate it to nurses and how it affects professional standards

• Focus on legal and public relation liabilities to the employer if safety and quality patient care is not improved

• Refer to the facility mission statement to support your recommendations

• Use college standards to make your argument (remember a Nurse is a patient advocate)

• Set time lines for when you want a response to your issues (don’t leave the meeting without this)

• Be assertive but not aggressive. Remain professional and dignified

• Set follow up meeting dates as necessary before leaving the meeting

• Following the meeting assign a committee member to update the action plan and track the time lines for responses and to follow up

• When you receive the employer response and it isn’t exactly what you recommended ask yourself, “Will it improve the workload and therefore patient/client/resident care and safety? Can you work with it? Are there other ideas or improvements you can recommend to their suggestions?”

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APPENDIX K Documentation

(Adapted from the Ontario Nurses’ Association)

Documentation is written proof of facts and events. Documentation is necessary whenever the union decides to propose changes to the workplace. This is true whether dealing with negotiations, grievances, health and safety issues, or with concerns that are brought before the Labour Management Committee.

Recommendations for change must be based on an accurate assessment of current practices and a demonstration, through facts, that the employer’s current practice requires revision.

What should nurses include when gathering documentation about a concern? This depends on the type of concern, but some principles apply in all cases. Generally, documentation should include the answers to these questions:

WHAT is the problem? WHERE did it happen? WHEN did it happen? WHO is involved? WHY did it happen? and HOW does it impact the patient/client/resident? What was missed, delayed or incomplete?

After gathering this information in writing from the members involved, the union is in a position to answer the last question, which is: “What do the members WANT the employer to do to rectify the problem or address the concern?” For example, at the Labour Management Committee, everything from employee parking to patient/client/resident care equipment to workload may be discussed. In each case, documentation that demonstrates the nature and extent of the problem must be gathered to support a recommendation for change.

Suppose that in your workplace nurses have a problem with a workload assignment that is too heavy to ensure proper patient/resident/client care. This is a matter that the Labour Management Committee may address. What should members write down about their workload to prove their concern is valid? At the end of each shift, each member should record the following:

• Her direct patient/resident/client care assignment, including for each:- Diagnosis.- Treatments/medication/monitoring required.- Any other information about the care received, which affects the

length of time needed for care, such as age, mental/emotional state and attitude, etc.

• Other duties performed during the shift which, depending upon the workplace, may include:

- Care planning - Housekeeping- Dietary - Portering

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- Paperwork - Meetings- In-service - Supervision of other staff- Referral forms - Answering the telephone- Travel time - Orientation

In other words, include anything that takes time. Also include duties that would have been performed had time permitted, and duties that were delayed or incomplete.

Identify also the professional nursing standards that have been compromised or not met. This may include but is not limited to, your professional standards of accountability, leadership, knowledge applications, medication administration, documentation, infection prevention and control, and practice guidelines. Also identify employer policies and protocols that may not be being met.

Specific standard statements may include an inability to meet the professional standard of accountability by:

• Not being able to provide/facilitate/advocate or promote the best possible care for clients because you are rushed, hurried, unable to complete assessments, due to an inappropriate staffing levels leading to delays in nursing interventions.

Inability to meet the standard of knowledge application, which may include:

• Being unable to identify, or recognize abnormal or unexpected patient/client/resident responses and taking action appropriately.

• Manage multiple nursing interventions simultaneously related to overall workload.

Other standard statements may include medication administration – the inability to administer medications timely, or medication errors or omissions. Documentation may be affected because it is incomplete or there is missed documentation. Infection Prevention and Control may be affected because you are unable to take all measures necessary to prevent transmission of infection and lack proper education and time or access to Personal Protective Equipment (PPE).

For each shift, record the number of staff, including all categories of staff: RNs, LPNs, clerical staff, and unregulated care providers such as porters, orderlies and aides. Also record whether the staff is oriented/familiar with the job they are doing during that particular shift.

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When noting support staff, remember to mention how much of their time is available. Is this staff assigned to one area or is their time shared? Also record for each shift the request(s) made for additional staff. To whom was each request directed? What was the response?

* Remember: Never use patients’ names in documentation. Assign each patient a number to protect confidentiality.

At all times during documentation, keep in mind:

• Accuracy is extremely important. The more accurate the documentation, the more credible your argument for change.

• Only accepted health care terminology should be used. Do not use terms that are exclusive to your work setting. Someone unfamiliar with your area may not understand your particular jargon. For the same reason, use acronyms only when you are absolutely sure they will be understood.

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10419 workload and capacity...

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