Nurses and Nurse Practitioners of BC
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It’s Time to Talk about CDMR, by Paddy Rodney, RN

For quite some time we have been hearing about Island Health’s[1. Formerly Vancouver Island Health Authority] Care Delivery Model Redesign (CDMR)[2. CDMR is the acronym for Island Health’s Patient Care Model – similar models may be employed in other health authorities under different names], a patient care model that, according to Island Health:

… not only improves patient care, it enhances the work environment for nursing staff by supporting nurses to work in collaborative teams. The Patient Care Model is based on nurses utilizing the full scope of their high level of training, knowledge and practice, and gives them a key role in health care planning and assessment."[3. http://www.viha.ca/NR/rdonlyres/63276A4E-5CD2-4755-892E-0E420089B75F/0/BoardQAMay2013.pdf]

While the intent behind the CDMR model is admirable, ARNBC has become increasingly concerned by the first-hand stories we have heard from point-of-care nurses working under CDMR.  These nurses have indicated that they are struggling with several aspects of the CDMR program, and that staff and patients are suffering as a result.

Specifically, nurses have told us that under this model, their patient loads have increased to the point where they do not believe that they are able to deliver the safe, competent, compassionate and ethical care that their profession mandates. For example, nurses have told us that one RN may be responsible for managing the care of 10 or more acutely ill patients with inadequate professional nursing support because unregulated care aides have replaced so many RN and LPN positions.

Point-of-care nurses report that it is almost impossible to deliver an appropriate level of patient care when overseeing the needs of so many acutely ill patients.We have also heard that there are nurses in management positions who are navigating conflict and uncertainty as these changes unfold.

In other words, rather than helping nurses and other health providers to provide better patient care, what we are hearing is that this new CDMR model is causing nurses undue stress and may be putting patients at risk.

On February 27, 2014, ARNBC was pleased to participate on the panel of MLA Andrew Weaver’s Town Hall on CDMR along with nursing colleagues from the BCNU and the University of Victoria.  We heard more first-hand stories from nurses as well as members of the public who are concerned about the impact CDMR is having on their communities. Along with our other nursing colleagues, we believe that it is time to speak up in support of good patient care and a healthcare system that values the health and well-being of its employees.

The Need for Evidence

As time has gone on, we have become increasingly concerned about the lack of evidence and outcome data that has been released by the Health Authority that either supports or refutes CDMR.  At the Town Hall Meeting we heard that despite requests from nursing groups and at least one FOI (freedom of information) request, the nursing community in B.C. continues to have no official data to work with when analyzing the impact of CDMR on nurses and on patients.  The only information we have to assess the situation is anecdotal stories from nurses who have been directly impacted.

It’s important that provincial research on CDMR be made publicly available so that nursing organizations, nurse researchers and others can thoughtfully and carefully analyze the impact of the program on nurses and other staff, as well as patients and their families. Through better transparency about the planning and evaluation of CDMR, nurses in B.C. would be in a stronger position to collaborate and support Island Health in their goals to improve patient care and enhance the work environment for nursing staff.  The well-being of nurses is linked to the well-being of the patients and families they serve.[4. Rodney, P., Buckley, B., Street, A., Serrano, E., & Martin, L.A. (2013). The moral climate of nursing practice: Inquiry and action. In Storch, J., Rodney, P., & Starzomski, R. (Eds.) Toward a moral horizon: Nursing ethics for leadership and practice (2nd ed.; pp. 188-214 ). Toronto: Pearson-Prentice Hall]

There are currently warnings emerging from the United Kingdom about what can happen if we get nurse staffing and care delivery models wrong. A recent report from the United Kingdom discussed a series of public inquiries revealing serious breaches of duty on the part of the Mid Staffordshire NHS Foundation Trust.[5. Francis, R. (2013). Letter to the Secretary of State. In The Mid Staffordshire NHS Foundation Trust Public Inquiry, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: Executive summary (pp. 3-5). London: The Stationery Office]

One nurse expert stated that problems were “fuelled by the hospital management being driven by the achievement of targets – set centrally by the Department of Health – that were paper-based indicators of ‘quality care’ and ‘success’. These were inextricably linked to financial imperatives, which created a culture where, if the numbers look right, then it was assumed that the hospital was providing quality care."[6. Hayter, M. (2013). The UK Francis report: The key messages for nursing. Journal of Advanced Nursing, Vol. 69, No. 8, pages e1-e3, August 2013.  Article first published online: 1 Jul 2013 DOI: 10.111/jan.12206]

In addition, a recent article published in The Lancet clearly identifies the significant problems that can arise when staffing mix decisions are not carefully thought out.[7. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study, February 26, 2014]

ARNBC’s Priorities for Staff Mix/Models of Care

Our main priorities as the professional association that represents B.C. Registered Nurses and Nurse Practitioners are to:

1)      Ensure that the health of British Columbians is the first and foremost priority of all decision-makers and stakeholders as we work through the complexities of staff mix and care delivery models.

2)      Ensure appropriate, evidence-informed decisions are being made about staff mix and care delivery models on the basis of planning and outcome data that are publicly accessible and peer reviewed.

3)      Compel government and health authorities to collaborate with nurses around staff mix and care delivery models, and be transparent and accountable for the decisions they make.

4)      Promote registered nurses to be supported in every aspect of their professional work and have a safe place to share their concerns.

Fortunately, there are some good national guidelines that can help. In February 2010, the CNA established the Staff Mix: Regulated Nurses and Unregulated Care Providers Working Group.  This pan-Canadian group was comprised of RNs, licensed practical nurses (LPNs), registered psychiatric nurses (RPNs), unregulated care providers (UCPs) and a research consultant. The working group defined staff mix decision-making as the act of determining the mix of the different categories of health-care personnel employed for the provision of direct client care. The work resulted in the publication of the Staff Mix Framework which provides direct care nurses and nurse managers with excellent direction and identified five guiding principles that were agreed upon by all participants:

  • Decisions concerning staff mix respond to clients’ health-care needs and enable the delivery of safe, competent, ethical, quality, evidence-informed care in the context of professional standards and staff competencies.
  • Decision-making regarding staff mix is guided by nursing-care delivery models based on the best evidence related to (a) client, staff and organizational factors influencing quality care and work environments, and (b) client, staff and organizational outcomes.
  • Staff mix decision-making is supported by the organizational structure, mission and vision and by all levels of leadership in the organization.
  • Direct care nursing staff and nursing management are engaged in decision-making about the staff mix.
  • Information and knowledge management systems support effective staff mix decision-making.

Next Steps for ARNBC and How You Can Help

While we have been monitoring the situation in Island Health and listening to the concerns of nurses, ARNBC has become increasingly aware that tensions and stress are rising.  We have written about staff mix previously in our blog and with an issue statement, but we are increasingly concerned about the lack of availability of outcome data and related information around CDMR.

In the absence of actual evidence, we can only base our analysis of CDMR on the anecdotal evidence we hear from nurses.

Some components of the CDMR program are good for the healthcare system, good for patients and good for nurses and other team members.  As a professional nursing association, ARNBC will work with Island Health and with nurses to have an honest, frank discussion about the program, the outcomes, the stories and the data – and we would hope this discussion could help Island Health to make changes and improvements to CDMR -- changes that would be a win-win for everyone.

ARNBC will undertake further policy work to explore, analyse and make recommendations around Staff Mix and CDMR.  We anticipate that this work will further refine ARNBC’s position on staff mix and care delivery models, and will provide a number of recommendations for next steps that can be taken in British Columbia.

In the meanwhile, we invite nurses who have concerns about CDMR to share your stories anonymously in the comments section of this blog (you will be prompted to share your name and email address – please don’t hesitate to make up a name and email address if you are concerned about sharing your information).  Or you can email us at aburton@www.nnpbc.com.  Lastly, you can make an anonymous phone call to our Communications Director, Andrea Burton, by calling 604.730.7402. We believe that hearing your stories and impressions of what is happening under CDMR will contribute to ARNBC being better able to support quality health care delivery in British Columbia.

It is time to talk more openly about CDMR, and to take a balanced, thoughtful approach to finding the middle ground between the goals of health authorities and the needs of patients and healthcare providers.

paddyABOUT PADDY RODNEY

Paddy Rodney, RN, is a nurse educator with a specialty in ethics. Paddy is currently an Associate Professor at the UBC School of Nursing and is affiliated with the UBC Centre for Applied Ethics and the Canadian Bioethics Society. Over the last 25 years, she has lectured and consulted on nursing ethics for nursing associations and unions.  Paddy is on the ARNBC Board.

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18 thoughts on “It’s Time to Talk about CDMR, by Paddy Rodney, RN”

  1. Thank you both for bringing forward this important issue. I've heard a lot of concern coming from both nurses and community members within Island Health.

    While I fully understand an attempt to ensure that we are being efficient with healthcare dollars - this can never be done when safe client care is put at risk.

    I'm really glad that nurses are speaking up to ensure quality care!

  2. As a community nurse, a substantial part of what I do is teach and inform patients in order to help improve their health outcomes. This requires time and knowledge. To replace the RN's affects the quality of patient care, by expecting a part of the health care team to possess the expertise which they clearly do not have. I value every member of the health care team, but it is unfair and irresponsible to put them in a role they are not prepared for.

    Currently, our community intake RN's have been replaced by LPNs at Victoria Health Unit and our RN Case Managers are being replaced by LPNs. (specifically at Saanich Penninsula Health Unit). In a candid conversation with one of our casual Case Managers who works at several sites, she admits that they "fudge" their assessments, because the 26 page form (the RAI) does not fully capture the "client's actual health experience" or reflect the reality of their situation. Although there are areas for individual comment by the nurse, these are not taken into consideration. Apparently only the "numbers" matter when determining which services a client qualifies for. Her further comment was "any dummy can fill out a form"--it doesn't mean that the true situation is reflected. LPN's are being taught as Case Managers to "fill out the forms". How does that ensure quality care for our vulnerable and trusting clients?

    My concern is that we are quickly being forced to chose between our professional standards and acquiescing to an employer so that we can keep our jobs. Not a satisfying choice, in my opinion.

  3. We can't talk. We are THREATENED if we talk to the media, to our patients, to politicians about what we are seeing and experiencing in Island Health.

    We are afraid to have meetings on site because we are pretty sure that the walls have ears and that there is almost always someone listening in.

    We are told that our jobs are in jeopardy if we complain, if we say anything bad about CDMR, if we try to advocate on behalf of our patients who are suffering.

    We are being bullied by the health authority, government and the people we work for and we cannot provide the kind of care our patients need.

    I work at NRGH. I wish I didn't.

    1. Hi Anonymous

      Thank you so much for your reply, and for sharing what you are experiencing. All information we can gather will help us to ask the right questions of the right people, and begin to understand how to move forward. We are here to listen and support and seek change and we will continue to consider ways to ensure your voice and concerns are heard in a safe way.

      We want to reassure all nurses that your comments here can be 100% anonymous. Use any name (Petunia, Tired - anything you want) and enter a fake email address like nowhere@nowhere.com. That will ensure your complete anonymity. Or you can phone us at 604.370.7402 if you're more comfortable speaking to someone live.

      Anonymous, be good to yourself. We'll keep you posted on what we are doing as things continue to evolve.

  4. Having worked my way up from RCA to LPN to RN I get the difference in scope and depth of understanding the health challenges of patients. I am often responsible for 10 to 12 patients, with a LPN, and RCA helper. If my partners are experienced and skilled at their jobs I can make through a 12 hour shift without wanting to run away, but unfortunately that is not always the situation I find myself in. I find it impossible to be completely up to date on assessments, meds given, family concerns addressed in a timely manner, Doctors questions, and most importantly any changes in a patient's presentation for 10 or more patients. It is frustrating and scary to nurse in such an atmosphere!

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  6. Thank you for taking the time to spread the word about CDMR, both to nurses and to members of the public through events such as Andrew Weaver’s Town Hall.

    The BC Nurses’ Union has been actively engaged in raising awareness about the risks of implementing a model of care that replaces regulated nurses with other care providers for many months. In fact, it was BCNU who filed the FOI request you mention in your blog as we, too share your concern that evidence is sorely lacking.

    We’ve gathered thousands of signatures on petitions that have been presented to Island Health. We’ve held rallies which received extensive media coverage. We’ve held BP clinics. We’ve placed print ads, bus shelter ads and billboard ads based on the award-winning BCNU ad promoted widely by author, Suzanne Gordon who is a tireless advocate for nurses and the knowledge and skills they bring to the bedside. The concept is that a seemingly mundane act of a nurse speaking to a patient about jello actually reflects a complex set of assessments a nurse performs when interacting with a patient.

    We also encourage members to use their collective agreement language when relevant, for example by filing Professional Responsibility Forms when safe care is compromised. We are preparing for similar care models that replace regulated nurses with other unregulated providers to spread throughout the province and encourage nurses to watch for information from BCNU about actions we can all take to advocate for safe staffing.

    1. Christine, many thanks for making visible here the work that the BCNU has been doing re CDMR.

      The International Congress of Nurses (ICN) talks about the importance of 3 pillars of action for the protection and advancement of nursing, health, and health care--union action, professional association action, and regulatory action. I think that our challenges in BC regarding staff mix really emphasize the importance of all 3 pillars....

      Best wishes from Paddy

  7. CDMR
    I'd like to know what people consider a "team approach" to front-line nursing. When an RN has a 50-80 % workload increase of acutely ill patients and the Care Aids can do nothing else but personal care, toilet and assist with mobilization,... how does that constitute team nursing. We've lost ALL of our LPN's, and now have 2RN's to share 1 care aid amongst 12 - 16 sick patients. Stop trying to run an acute ward like a long term care facility!

  8. People deserve better

    As a previous RCA and RN for many years, I am afraid for the safety of patients. It's hard enough for most people to remember 10 people's names let alone their diagnosis, past medical history, allergies, code status, care plan, tests ordered, test results...etc.
    Sure, RCA's are a nice extension to the health care team because they can help get someone to the toilet or assist with bathing...etc, but when your elderly mother is writhing in pain for hours waiting for a shot of morphine because the nurses are run off their feet where is the justice in that?
    Sure the RCA's may assess the patients for changes, but if there isn't a regulated health provider available to respond then what's the use?
    I feel very deeply for the senior citizens of Vancouver Island. For those of you who have paid into the healthcare system your whole lives, you deserve better! For the patients and their families who want answers about their loved ones, but can't get them because the Dr. is too busy, the nurse is run off her feet and and the RCA has no clue about complex pathophysiology, pharmaceuticals, diagnosis and treatment....although (scary enough) some of them think that they do.
    If you take a 12 hour nursing shift, subtract 1.5 hours of break time (30 min lunch & dinner, and 2 15 min coffee breaks) you have 10.5 hours for 10 patients. Doesn't look so bad does it? Oh, wait! We need to subtract the time it takes to read through and update each patient's care plan, check the Dr.s orders, review the diagnostic and lab results and the time it takes for charting...etc. If you allow even just 30 minutes per patient, for 10 patients that's 5 hours! So now you're down to 5.5 hours for 10 patients....if there isn't a crisis like a cardiac arrest, significant haemorrhage...etc. In which case you could be nursing 1:1 with a patient. Don't forget to subtract the amount of time patients families interrupt you in the hall with their questions, subtract time for discharge planning and coordinating and subtract time for checking and dispensing medications and it looks like the patients may be lucky to get 15 minutes of a nurses time in a 12 hour shift. What part of that sounds like better care? All in all, this is a recipe for nurses cutting corners, high stress environments, employee burnout, bullying by employers, increased patient risk, increased employee sick time and increased incidence of adverse events.

  9. Pingback: New Care Delivery Model Redesign (CDMR) | nursekellyblog

  10. I am an RN and work within a team that consists of an RN, an LPN and a Care-aide. We care for 9-11 acute patients together. I understand the concerns that many people are expressing, but for the majority of my shifts, when I am a part of a good team, it is a wonderful feeling to have the right person doing the right job. As an RN, I find the distinction between the RN and LPN, a little hazy at times but having RCA's is a gift.
    I have worked on units where I was the only one caring for five acute patients and I have to be honest: they were lucky to get a washcloth thrown at them from the door, as I did not have time to care for their basic needs in addition to their acute issues. Most patients had Foley's and had to be on anti-thombolytics due to lack of mobility.
    Where I work now, one Care-aide working in a team of two between two 'pods' of twenty patients are run off their feet trying to meet the basic cleaning, toileting and feeding needs of our patients. I am so grateful for the RCA's and wish this conversation could start to go in the direction of staffing the appropriate amount of RN's, LPN's and RCA's at any given time based on the patient load and acuity rather than this being a discussion about taking RN's away from the bedside. I do not, as an RN need to toilet and change a patient six or seven times in a shift to know that they are having skin breakdown. I need to plan and organize a change in their care to eliminate or minimize the issue. This requires time and planning that I cannot do if I am helping to coax a patient to eat or doing yet another complete bed change.
    I think perhaps NRGH did not staff appropriately when they made the change. It is not CDMR that is the problem. It is the cutbacks in general. It is not replacing sick calls, or float nurses or providing support over weekends when pharmacy and lab are not available. There are places on the Island that are quietly using this model with a modicum of success and satisfaction for patients and staff.
    Please stop maligning care-aides and recognize them as the valuable and integral team members that they are and start talking about the real issue: budget mismanagement and the fact that there is NOT a nursing shortage but a hiring shortage.

  11. Short and Sweet.

    One sided comments is great for media and public fear. Thank You. I Have worked in Acute care for the Past 11 years as a HCA. I remember In 2008 when LPNS were Not classified as Nurses In the eyes Of a RN.
    My original plan was to become an RN, then LIfe took Hold and I became a parent, then by the time school became a option BCNU introduced Biase, Harrasment, Bullying Tactics to me and My fellow collegues as HCAs. A attitude I did not know was accepted as a Nurse in This Proffession.
    I understand CDMR has put a strain on Nurses, But to continually BLAME HCAs and claiming WE are the UNSAFE ones? Are we the ones handing out meds? doing Bandages? IVs?
    I am tired Of having to walk into my Place of work to see signs, Billboards, stickers, Pins, clothing, flyers, Petitions. Stating I'm UNSAFE.... Then to go home and see on media and news, or personal computer websites that again I am Unsafe doing a job I love.
    Is it not truly ther nurses who are unsafe? As per above comments, too many acute patients to provide safe care for? This has nothing to do with me and The 13-17 Patients I provide all ADLS for.

    Im not too sure how RNs would feel if we as HCAs started to call them out on their MED errors we witness daily, Or all the Personal conversations that occur while we HCAs are busy answering call bells for MED request, Or bed alarms while They discover through personal conversation How their vacation was. Or the fact that when we ask for a nurse to come check on a Patient they Bluntly Ignore us as if we are dense causing us to have to Go above their Heads to team leads who then Have to call the Medical situation to the said nurse. WE as HCAs on the floor Watch everything Nurses do... Even More now due to this Harrasment we expierience on a daily basis.
    LPNS had the same attiude based On their Skills, And fought to be apart of the team... Funny how Memory tends to misplace that whole UNSAFE debate in 2007, and they now can try and reflect HCAs who DO no Medical, as the unsafe ones Now.

    I would like to thank the BCNU and their commitment to make Us HCAs feel like we are Unwelcome in Our work place and to be belittled daily, And to allow Public to have fear on a change that have Let HCAs take the sole blame for. CDMR is not the fault of HCAs, If Nurses feel they are overwhelmed Dont put the Blame ON HCAs, Blame the CDMR, To Blame us for Their short Commings Shows how proffesional they are in Handling Their mistakes and Blaming others to cover them.

    1. Oh dear. I would not want to work with you. You sound like one of those HCAs that thinks they are a nurse. I'm so tired of care aids asking me what dose of medication I'm giving, interrupting me at my med cart to ask inappropriate questions unrelated to their job (distracting me while I'm preparing meds, hence in the increase in med errors). There are good HCAs, but unfortunately many are lazy and would rather spend time watching the nurses deal with medical emergencies instead of getting on with their own work. Where I work the HCAs are calling in sick and then picking up overtime. It's not cost effective, and it's not good patient care.
      And you need to stop using capital letters in the middle of sentences.

  12. Thanks to all for your ongoing contributions. I fully agree with the important points that have been made about fully valuing ALL members of the nursing team--PCAs, LPNs, RPNs and RNs.

  13. We have now been nursing under the model of "CDMR" at NRGH for almost 20 months. We have seen some improvements to staffing levels that were most horrific but we are far from safely nursing. Can you please update us on what ARNBC is currently doing to address nurses concerns about delivering safe patient care?

    1. Jaycille, thanks for your question. One of the main areas of focus for the ARNBC to respond to workplace challenges such as CDMR has been to promote the uptake of the CNA et al (2012) staff mix guidelines (the links to which are in the blog above). I also participated as an ARNBC Board member in the political panel on CDMR in March 2014 reported on in the blog above. This panel was, I believe, a good example of constructive BCNU and ARNBC collaboration. At the ARNBC we made this blog expressing our concerns about CDMR widely available in nursing and political circles.

      In our ARNBC AGM in 2014, where a representative from the Ministry of Health was present, there was a brief discussion of how we as an ARNBC could help the Ministry to prevent the kinds of quality of care erosions that have occurred in the UK because of reduced RN staffing (see also the links in the blog above re the UK situation, as well as the new article noted in my most recent blog (https://www.nnpbc.com/blog/a-call-to-cease-hostilities-by-paddy-rodney/ ).

      More recently, our ARNBC staff has continued to gather information on CDMR and other related workplace concerns through our Network Leads program (http://www.arnbc.ca/networks/network-leads/index.php). We are currently ramping up our nursing policy office, and the quality of nursing workplaces is one of our policy priorities. To this end, we have made the quality of nursing workplaces the focus in one of our recent regional policy forums (http://www.arnbc.ca/events/regionalforums/index.php), and our AGM this May (http://www.arnbc.ca/agm/) will be accompanied by a provincial forum on nursing workplace issues.

      I also wanted to note that as an ARNBC Board member and an academic whose focus is on ethics and nursing workplaces, I have been involved in several activities to follow up on CDMR in partnership with the BCNU:

      - Visiting Nanaimo (twice) to meet with nursing staff and BCNU stewards.
      - Two BCNU stewards, myself and Debra McPherson presented on the ethical challenges of CDMR at the Canadian Bioethics Society in May, 2014.
      - I am engaged in ongoing related research on the quality of nurses' workplaces with the BCNU.

      It has been clear to me that the BCNU has provided an outstanding leadership role in responding to CDMR. It has also been my observation that adding our ARNBC voice to the BCNU's (for example, by advocating for the uptake of the CNA staff mix guidelines) has been a constructive and powerful combination.

      Thanks again and best wishes from Paddy

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