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HomeMy WebLinkAbout1989-1890.Andrews et al.92-01-29 ON?'ARIO EMPLOY£,~ DE I.,4 COURONNE CROWN EMPLOYEES DE L'ONTA,RIO GRIEVANCE ' C,OMMISSlON DE SETTLEMENT REGLEMENT BOARD DES GRIEFS RUE I~t4.JNDA$ OUEST, BUREAU RIO0, TOROPITO [ONTARIO]. MSG IZB FAC,SiMtLE..'Tf~[..~COPtE : (4 ~6)~ 3R6-;'396 1890/89, 197/90, 202/90 IN THE HATTRR OF ]tN M?.BITRATZON Under THE CROWN F~PLOYEBB COLLECTIVE BARGAINZNG ACT Before THE GRIL'3FANCE 8ETTLEHE~ BO]tRD BETWEEN OPSEU (Andrews et al) G~ievor The Crown in Right of Ontario (Ministry of Health). _~ployer BEFORE: J. Samuels Vice-Chairperson $. Urbain Member D. Daugharty Member FOR ~ N. Coleman GRI~VOR Counsel Gowling, Strathy & Henderson Barristers & Solicitors FOR~q[B C. Zabek ~MPI~OYB~ Counsel Fraser & Beatt¥ Barristers & Solicitors HB~RING September 12, 25, 1990 December 17, 1990 December 3, 4, 17, 18, 1991 January 29, 1992 We began with about 57 grievances concerning the classification of the nurses who work in the twelve out-patient clinics of the Queen Street Mental Health Centre in Metropolitan Toronto. These grievances fell into three groups. Two of the groups of grievances were filed by nurses classified as Nurse 2 General, who claimed that they ought to be classified as Nurse 3 General. The other group of grievances was filed by nurses classified as Nurse 3 General, who claimed that they ought to be classified as Public Health Nurse 2. The twelve out-patient clinics of the Queen Street Mental Health Centre help patients with mental illnesses to function outside the hospital environment. The clinics are staffed by psychiatrists, social workers, psychologists, clerical employees, occupational therapists, recreationists, vocational rehabilitation counsellors, workshop irtstmctors, and nurses. These employees offer clinical and rehabilitation assistance. The clinical staff is coficemed with the treatment of the' mental illness itself. The 'rehabilitation staff is concerned with improving the patient's' ability to cope with the activities of daily living, such as finding a job and managing one's' finances. The grievors are the clinical nurses. They provide professional nursing service in the clinics and in the patients' homes. In order to facilitate the disposition of all of these grievances, in Phase 1, the parties agreed to present as an example the case for the Nurse 2 Generals at the Lakeshore Outpatient and Community Services Clinic. In late 1990, we heard evidence concerning the work of Ms. Cindy Arthurs, a Nurse 2 at Lakeshore, and we concluded, in an award released on January 14, 1991, that Ms. Arthurs was not properly classified as a Nurse 2 'General, and that she ought to be classified as a Nurse 3 General. This first award enabled the parties to settle all the grievances from the Nurse 2s-at the out-lying clinics. All of these nurses were reclassified as Nurse 3 General. Now we Will deal with Phase 2--the Nurse 2s at the three clinics .! located at the Queen Street Mental He~i~ Centre. These three clinics are Unit 1 Basement, Unit 2 Basement, and Unit 4-1 Day-care. At the urging of the Board, and with the admirable cooperation counsel and the parties, the evidence in this phase was introduced in the form of the three position specifications and an agreed statement 'of facts. These documents are found as appendices to this award, together with the class standards for Nurse 2 General and Nurse 3 General. Before turning tO all examination of the nursing positions, in the three out-patien~ clinics located right at the Queen Street Mental Health Centre, it would be useful to recall the basis for our earlier decision that Ms. Arthurs was not properly Classified as a Nurse 2 General. At pages 5 to 6, we said: 'Is Ms. Arthurs classified properly as a- Nurse 2 General? ...... · The. opening paragraph of this Standard describes a job which involves treatment of patients in a hospital or other institution. And the next two paragraphs give more detail concerning the types of duties which will be performed in this SJrlactured environment record and carry out physician's instructions, administer medications and injections, watch patients' symptoms and take appropriate action, assist in feeding and ward housekeeping, perform duties in an operating room. This is the kind of job which was involved in Gervais, 392/89 and Nichols et al, 778/89 to which we were referred by counsel for the Ministry. In these two cases, the grievors were ward nurses at the PenetanguiShene Mental Health Centre-Regional Division. This is not the kind of job performed by Ms. Arthurs. From the initial decision to admit the patient to the Lakeshore clinic, to the preparation of the treatment plan, to the carrying out of the required psychotherapy, Ms. Arthurs exercises a much greater degree .of-independent judgment and responsibility than is contemplated within the structured environment of a hospital ward. A patient is in the hospital because a physician said this is where the patient ought to be treated. On the other hand, at the clinic, for all intents and purposes, it is the admitting nurse who determines whether or not the patient should be admitted into the clinic. In a hospital, the physician is very much involved in the treatment administered to a patient, both in the planning of that treatment and in its giving. In an out-patient clinic like Lakeshore, the physician (psychiatrist) may have very little involvement with some patients--it is the nurse therapists who develop the entire treatment plan and administer it. At Lakeshore, for many patientS, the psychiatrist is there in the background, but is not involved at all as is a physician with a patient in a hospital. In our view, Ms. Arthurs is .not. properly classified as a Nurse 2 General. (emphasis in the original) The essential characteristics of Ms. Arthurs' position are found also in the positions of-the grievors who are staff nurses at the three clinics at the Queen Street Mental Health Centre. At these three clinics, as at Lakeshore, the trea_rrnent is largely decided upon and carr/ed out by the nurses, not by physicians or psychiatristS. The Nurse 2 General class standard deals with nurses who work in a hospital or other institution, where the patient is there as the patient of a particular physician (psychiathst), Where the patient's physician (psychiatrist) prescribes the primary treatment plan, and where the nurse's primary role is to carry out the physician's instructions. And this is not what the nurses do at the three clinics at the Queen Street Mental Health Centre. 5 At the Queen S~ Mental Health CentJe, a patient is not admitted as the patient of a particular doctor, with a treatment plan prescribed by the doctor. Instead, p~tients are admitted by decision of the multidisciplinary team at the particular clinic (consisting of nurses, part-time psychiatrist, and other professionals), and then the patient is assigned to a member of the team, and that member prepares the treatment care plan, in consultation with the patient and the multidisciplinary team. Thus, when it is one of the grievo.rs who is assigned the patient, the grievor becomes the primary professional who is responsible for the patient's care. In the three clinics, the pm-time psychiatrist gives advice, sees the patient to complete the formal admission process, conducts a mental status examination and determines a diagnosis--but does not prescribe the treatment plan. The patient is not "the psychiatrist's patient", in the same sense that a patient in a hospital is a Particular physician's patient. The psychiatrist may see the patient only once every six months, when a formal progress report is completed. In the three clinics, when a patient' is assigned to a grievor, the patient becomes "the particular nurse's patient". The grievors have a significantly different responsibility from the positions covered by the Nurse 2 General chss standard, which deals with nurses who carry out the instructions of doctors' on hospital wards, or in some other structured institution. For this reason, we find that the grievors are not properly classified as Nurse 2 General. Would they be classified properly as Nurse 3 General? In Phase 1, in determining that Cindy Arthurs would be classified properly in this classification, we said (at pages 6-7): The first paragraph of this standard, like the Nurse 2 General standard, speaks of work in a 6 hospital or .other ihstitution. However, the second paragraph contemplates a broader ran. ge of operating environments. The last sentence of this second paragraph says that such employees may conduct clinics or provide outpatient, orthopaedic, or emergency care. This would fit Ms. Arthurs. The second sentence of the second paragraph speaks of overseeing treatment procedures. This is the heart of Ms. Arthurs' job. The first sentence of the second paragraph speaks of exercising "some independent judgment and initiative". One would expect that a qualified registered nurse would always be exercising a measure of "independent judgment and initiative" in carrying out nursing dudes. This reference in the standard must mean some higher level of judgment and initiative than would be the general rule in the performance of nursing duties. And, given the job we have described as Ms. Anhurs', we have no difficulty in concluding that she does exercise a greater degree of independent ju. dgment and initiative than is generally the case in the performance of nursing duties.. Indeed, when Ms. Anhurs first applied for the out-patient job-at the Centre, she was told by her supervisor that the job needed more experience than an in-patient job, that more skill and responsibility was involved. And Ms. Anhurs' testimony concerning the job bears this out. In our view, Ms. Arthurs would be classified appropriately as a Nurse 3 General (emphasis in the original) The evidence with respect to the grievors in Phase 2 shows that they are subject to a greater degree of supervision, and exercise somewhat less independent judgment and initiative, than we found to be the case for Ms. Arthurs. Firstly, it appears that there is more long-term treatment, involved with the patients in the three clinics at the Queen Street Mental Health Centre, than in the out-lying clinics, and as a consequence, there are fewer admission decisions to rbe made. At the thr~'i clinics, nearly all of the patients are chronically ill. Secondly, 'Ms. Arthurs spent part' of one day per week dealing with people coming in the door for help, and she made a fairly detailed initial assessment, which was committed to writing, and, if she thought that the person should be admitted, she made an appointment for the person t° see one of the clinicians, perhaps herself. This initial decision is taken to the next meeting of the multidiscipllnary team, and the preliminary admission decisions made by the admiring nurses are rarely overturned. In the clinics at Queen Street Mental Health Centre, the person who meets initially with an incoming patient completes a referral form, which goes to the multidisciplinary team. In Units 2-B and 4-1, th~ team then chooses two members, one of whom is usually the individual who took the referral, to carry out a patient assessment, and to bring a recommendation to the next team meeting. In Unit l-B, the person who takes the referral will do an initial assessment and bring it, with a recommendation Concerning admission, to the r/ext team meeting. It appears that the grievors have a somewhat leSser control over admission than did Cindy Arthurs. Thirdly, Cindy Arthurs had a much larger caseload than do the grievors, and this would have a bearing on. the relative mount of independent judgment exercised by them. Ms. Arthurs' caseload was roughly. 60 patients, whereas the grievors on Unit 1-B have a range of 25- 28 patients, on Unit 2-B and 4-I the caseload is 10 to 15. Ms. Arthurs must develop many more treatment plans than do the grievors in Phase 2. Fourthly, the grievors in Phase 2 appear to be subje6t to somewhat more supervision, than is Cindy Arthurs.. Ms. Arthurs receives virtually no direction from her head nurse. There is no regular contact with. the head nurse concerning the caseload or Ms. Arthurs' day-to-day work. The head nurse does an annual performance-evaluation of Ms. Arthurs. In Unit 4-1, the head nurse conducts random spot checks of patient files to ensure that the treatment care plans are being formulated in accordance with the Ontario College of Nurses Standards of Nursing Practice, to make certain that p/'ogress reports are being completed on a regular basis, and to ensure that the progress reports reHect what is contained in the treatment care plan. For all of the three units at the Queen Street Mental Health Centre, the Nursing Quality Assurance Department conducts a.random audit of three flies per month to ensure that patient records are being prepared and completed in accordance with the Ontario College of Nurses Standards of Nursing Practice, as well as with the Patient Care Standards and policies and procedures established at the Centre. In all three units, the head nurse does an annual performa~, ce evaluation of the nurses. Fifthly, because of their physical location, the three units have ready · access to the Centre's resources~emergency teams, internal security force, medical staff and all medical services. This' means that the environment generally is somewhat less independent in the three units than is the case for the out-lying Clinics. Taking all of this into consideration, it may be possible to fit the Phase 2 grievors too into the Nurse 3 General. standard, but we have concluded that the better remedy is to order the Ministry to develop an appropriate class standard for them. Indeed, we will go further to suggest that it is necessary to develop a new class series to cover psychiatric nurses who work in clinics such as the ones we have learned about in this case. The Nurse General series is designed, to cover nurses who are not the primary professional care givers--it covers nurses who work in situations where a doctor orders the primary treatment. Whereas, in the clinics with which we have been concerned here, the nurses have the primary responsibility for developing the treatment plans for the patients. A patient does not come to one of these clinics to be the patient of a particular doctor, with the nurses performing a number of the elements of treatment, as directed by the doctor. A~t these clihics, the patients become the responsibility of a p~rticular nurse, and the nurse is in charge of the treatment plan and its implementation. The class series and standards ought to reflect this fundamental reality. · Once an appropriate class series and standards are developed, it will probably be best to reclass.ify all the psychiatric nurses, including those whose grievances were before us originally, and who have already been reclassified to Nurse 3 General. We will reserve our jurisdiction to determine whether the grievors are properly classified in the new classification developed by the Ministry. The grievors sb,.ould be reclassified as of 20 days before each grievance, and should be compensated for any monies which ought to have been paid and were not paid because of the improper classification, with interest at 10% per annum bn any sum from the date it ought to have been paid to the date it is paid. We will reserge our jurisdiction to deal with the other grievances mentioned ~it the outset of this award, which have not yet been disposed of. Done at London, Ontario, this ~c~ day o ,1~?1' _ ~. %. S~muels, Vice-Chairperson S. Urbain, Member D. 6aughany, ~ dl~ of p~ess~on~2 fl~( ~uc~.~ ~or ~c~encs ~ ~c~o ~os~c~s ~d ~n ~[~rie~ o~ p~cA~ schools ~d ~ci~ions. ~e~r hour~ &~ usua2Ly ~C~L~ be~ee~ my of ~tl ~n3ecc~o~s U a~chor~:~,.obc~ p&c~e~cs~ con(~e~cl ~ feeder' ~d ~ housekeeper, iss~c paclenc~ v~ ~e~r ~e~sofl~ needs ~d ca~. ~co~ ~t~eflrs' cond~ciofls ~d repe~ ~ ~c~denc~ ~u~er~o~ ~ey m7 acc~p~y pack,cs Co ~cL~ creamenc~ or o~ ~r~sfers ~s t~u~ ~ p~v~de ~fo~c~ ~d co~se~ Co ~aC~encs~ relaC ryes ~S authorize. ~n ~dGLc~on, ~ese mployee~ ~T '~o ~e ~ge~enc~ for preTar~c~on, sce~c~on ~ ~ss~g of ~g~c~ ~d operac~g p~c~es aha pr~de p~ or ~sc~cive n~s~g c~ of ~aciencs. Ia ~e postc~onl. ~ere ~ESE ~ployees ~y be oa .~en~ fo~ ho~ as ceq~r~, pr~c~p~ 4uc~es of ~oyees ~ ~ c~us ~y be of f~rsc a~4, cL~c~. ~ ~fL~ ca~ ~der d~c~on of & f~2 or ~uc~e$ ~c c~eck ~e vO~ Of ~ubo~ace ~c&ff oe ~e s~e sh~fc.. on factors ~ch as ~he ho~s o~ ~u~, the ~ze ~d ~e ~o~c cf active nursLng ~eq~ m the ~scrAc~ve ~c, chey'i~'~spens~b~e co a su~e~sml n~se for ~ or pa~ of chi n~ ~ 9ersona~ c~ ~ ~ a~scraciYe ~c u &ssL~ ~e7 ~Y. on occu~o~, r~eve b-~s Ln[ n~ses $~mmar'7 Specl~c&cion CLA~ ~nployees ~a positions allocaced to ~is class p~vi~e professto.~ $upe~is~oa of ~e n~s~g ~d person~ c~ of such po~c~on~ ~hese ~plo~es sch~e dvcAes. ~e.~he requ~ co exe~Ase ~e ~dep~c ~c ~d ~iciaclve, rev~ c~a, p~par~ re~s, ~c~ reco~s, gfls~ ~ucpicAeflt orchop&~c, or merjea~ c~. ,~ ' Position SpeciF tion &'Class Aliocatlon-CSC 615C (Refer to back of form for comp~tion instru~ns) OfllsrJo Orate ~v~ Pr~lous ~iel nun~i~ff New ~r~l F~ ~C u~ only ~EGISTE~ED NURSE, Uni~ I Basemen~ New New ~im,~y ow~ Institutional Health Health Mental ~alth~l~ies I Oueen S=reet Nental Health Centre ~00~ 0ueen $==eet West, Toronto I 695~I No. of P~ Pr~ ~p I~t~i~ to: I~btl Su~iW'I title ' $u~i~r'l ~dt~On No. of~4t~l / No. of~ 4 - L - Head Nurse 0..5-9771-60 Re~r=ing ~o ~e Head Nurse an4 in collaboration with the multidisctplinary team, =he Registered' Nurse coordinates a.client case load ~o rehabilita~e and maintain adults, with ~n=al illness and psycho-social dysfunction, in ~he co~uni=y a~ their highest level func%ion. ~. Coordinates · c~enC case Xoa~ b~: - screening ~efe~als E=om inpa~ien~ units and con, icy agencies co de~ermine clien:'s'.eligibill=y for a~sSion as outlined by a~ission criteria; - eliciting, evaluating and d~en=lng f~om =he client, ~he f~ily and =he inpa~ien~ record ail relevant infor~ion such as psychiatric end medical history, ~dica=ion requiremen=s, cockily sup~r~s and empZ~men~ =o assess client for a~ission and .=rea=~n~ rec~nda=ions; - formula=inS, in consul=a~ion wi~h =he client and ~e mul=idisciplinary ~e~, a reh~ili=a=ion trench= plan which may include ~ica~ioa ~in~enance, social ac:ivi=ies and vocationaZ skii!s; - moni=orin~ and assessin~ client's response =o =~ea~n~ plan through interview, ho~ visits and/o~ f~ily and co.unity feedback; 70% - al~e=ing, in consultation with the client, ~he mu~tidisciplin~y ~e~ and/or the psychiatrist, ~he ==eat~nt plan as r~uired by in=erview and observational outcome; - identifying an~ contacting ne~ed health .and social su~rt services such as medical. welfare and housing ~o assis~ ~he cllen= gain access; - co.unica=inS wi~h client's social and co~ity'ne=works such as f~ily, friends, landlords, physicians, employers and ~lice ~o ensure co~uni:y sup~r~ and consistency; - conducting ~Zien~ support and skill groups .~o promote Social development; - intervening, in clien~ crisis to ensure adequate resources are access~ =o sup~=~ or resolve the crisis,, i.e., ~dica~ion or hospi=aliza=ion. 2. Undertakes res~nsibilities consistent with professional - administering medication to c~inic clients either orally or parenterally, as prescribed, =o ensure therapeutic levels are maintained; - preparing overnight and weekend medication packages to ensure meO~ ':~on programs as requ£re~; - moni=.cing monthly prescription requi~=men=s w~=h physician and ensuring accurate ~ranscripC£on and communication is ma£ntained; - monitoring vital'signs~, recommending required blood work, and . providing kwellada treatments as dictated by client need; - assessing and counse~l£ng c~ents regarding =he£r hygiene and nutritional needs. 3. Participates in Program A~ministration by: - developing, assessing and altering, in con~unc=£on wi~h ~.he Head Nurse and ~he mul~idisciplinary team, clinic programs and - preparing and presenting inservice sessions to multidlsciplinar¥ =eam~ - participating in progra~ research as identified or required. 4. Performs other duties as assigned: $% - relieves Head Nurse as required - as assigned. Registered as a nurse in Onta:io~ thorOugh knowledge of general and psychiatric nursing =heo~y and practice ~o ~nclude kn~ledqe of psychiatric illnesses, disorders and beh~v~ours~ knowledge of relevant drugs and s~de effec=sl k~ledge of relevant medical conditions and e~r~en~ p=ocedu=es~ ~n~e=v~e~ing, counselling, and docu~n~a~on skLlls~ kn~ledge o~ hospi=a% and clinic ~licy and =elevan~ acrs s~h as Hen~al Heal~ ~=, .Hea~ Disciplines Ac=, p~lic H~~ Ac=, and ~e Occupa=ional Heal~ and Safe~y. ~urse 2, General 50052 SP-06 O1 I O1 ~ 90 a. Employees.provide nursing care co ea~ien=s in an Ontario Hosplcal. Perform a ua=ie=y of pcoEessionaZ nursing au=les under direction of supervising nurse, i.e., s. administer medica=ien, watch fog patients~ symp=oms or =eac=ions= assis= patients w~ch che~= ~rsona~ needs~ provide info~a~ion and counsel co pa=iencs~ relatives. c. ~e~==ing co a Eead ~urse, ~he lnc~nCs adminis=e= medicacioa co Clinic cliencs~ eliclc ~nformacion~ formulate, moniCo= and alce=, in consultation wi=h the muZCi-discipZinary team (includes physician), a CreaCmen~ are accessed; co~icace ~ich clients~ social and co,unity'networks which include relatives. S~ltUrl of Oatl  I Position Specili~; on & Class Auocarlon-u~u (Refer to back o! form lot completion instructions) 'Ontario For CSC REGISTERED NURSE, Unit 2 Sasement~ ~inistry O~ili~ Institutional Health Health Mental Eealth FaciLities Oueen Scree~ Mellta~ ~:~b C~ntre 19~10ueen Street west, Torontn I - - Head Nurse 0 5-9 7 71- 6'2 I' Reporting to the Head Nurse an4 in co[laboration with the psychiatrist and multidi~ciplinary team, the Registere~ Nurse coordinates a client case load :o ~ehabilitate an~ maintain adults, with menta[ illness an~ psycho-social dysfunction, In the co,unity at their highest level of ~. Coordinates a ~[ient case lea4 - screening referrals from inpatient units an4 co,unity agencies to determine client's · eligibility for a~issi~ as outline4 by admissign criteria; - eliciting, evaluating and documenting ~rom the client, the family and the 'inpatient record all relevan[ info=ma=ton such as psychiatri¢ and medical history, medication requirements, su~==s an~ em~loymen= =o assess clien= ~or ~=ogram..admission and treatmen~ reco~enda~ions t - formulating, in consultation with ~he client and the mutt[disciplinary ~eam, rehabilitation ~rea[~n~ ~[an which may include m~ica[ion maintenance, social activities an4 vocational skillst - moni[orin~ an~ assessin~ 'client's res~nse to trea:~n~ plan through interview, 50% home visits and/or f~ily and co.unity feedback; - altering, in consultation ~[~h ~he qlien~, the multidisci~ltnary te~ and/or ~he psychiatrist, the ~=ea~n~ ~p[an as required by ~terview and observational outcomes; - iden~ifyin~ an~ con~ac~i9~ needed health an4 social supp0r~ se=vices such as welfare and housing [o assist the clien~ ~ain -, communica~ing with client's social an~ co.unity networks such as family, friends, landlords, physicians, employers and police ~o ensure co.unity support a~ consistency; - conductin~ ~a:ien~ sup~r~ and skill grou~s :o promote social development; - intervening in client crisis to ensure adequate ~esourees are accessed ~o or resolve ~he crisis, i.e., medication or hospi~aliza~ion. 2. Undertakes res~nsibilities consistent with ~rofessional t~ainin~ by: - administerin~ medication ~o clinic clients either orally or parenterally, as ~rescribed, to ensure therapeutic levels are maintained; -. preparin~ overnight and weekend medication packages ~o ensure medication compliance; - monitoring' medication Compliance and alterin~ individual medication 35% programs as required; - mort! ring vital s£gns; re~o~mendin~ quired blood work; and providing kwellada treatments as dictated by cl£ent need: - assessing and counselling clients regarding their hygiene and nutritional needs. 3. Participates in Program ~dminis~ration by: - developing, assessing and al=e~ing, in conjunction with the Head Nurse and the multidisciplinary team, clinic programs 10% and initiatives to ensure client needs are - preparing and presenting inservice sessions to mul~idisciplinary team; - participating in program research as iden~ified or required. 4. Performs o=her duties as assigned~ 5% - relieves Head .Nurse as required - as assigned. 4. Skillsandknowled~ ~equitedt~p~tmj~bitfu~w~rking~vet(~nd;~t~man~to~y~nt~i~r~i¢K¢K~i~)~ii~b~ ~egiste=ed as a nurse in Ontario; thorough knowledge of general and psych£a~ic nursing theory and prac=ice to include knowledge of psychiatric illnesses, disorders and behaviours; knowledge of relevant drugs and side effects= knowledge of relevant medical cond£tions and ~ emergency procedures; £nterviewJ~g, counselling, and documentation skllls~ knowledge of ' hospital and clinic policy and procedure~ knowledge of co=mun£ty resources; knowledge of relevant acts such as Mental Health Act, Health Disciplines Act, Public Hospitals' Act, .and the' Occupational Health and ~afe~y. 5, $ignltuft lrr. mtClleta Su~4~o~ Date' Ministry Olficial Date Ty~e Su~is~'s n~e Ty~ 01fici~'s n~e ~ title ~urse 2, Ge.e=al 50052 SP-06 hive cJalsi[ied this go,lion in ~ord~Cl with the Civil $trv~e Commission CllstilKili~ Stand.ds lot the foll0~ reiS0h: · ~. ~mp~yees p~ov~de nucs~ng c~ze to patients ~n ~n 0nCac~o Per,Dcm a variety o~ proEess~onal nursing duties unde~ d~re~ion of supervising nurse, i.e., B. personal needs~ provide informa=ion and counsel =o pa=ien=s' Re,or=lng ~O a Head Nurse, =he incumbents adminis=er medica=ion =o clinic clien~s~ c. in~orma=ion~ formula=e, monitor and alter, in'consul=a=ion wE~h the ~ul=i-disciplinary team (includes ~hysician), a =rea=men= plan~ intervene Eh'clEan= crisis ~o ensure adequa=e are accessed~ co~unicace wi=h clients' social and co~uni~ networks which include relatives.  ' / Po$1tiorl 3pecJ~ 1lion Ck (.,llls$ ~JIOCauun.,,,h~ (Refer to bb.... Of form loc completion insb'dct~ns) - ,~('ltat'iO Dire malived Prwiaus ~l~tll numbe~ New t~,t~ aum~et Fe~ C~C u# onl~ REGISTERED NURSE, UniC 4-1 Day Care J 05-9771-65 Sch. H~I. Wo~ X (R.P.T. Porn. Only} jCll~ ich.J SeMmJ Warn ~nm ~ em e, mini. il ejeim~Me.) COde{iii JF ~nc~onel cocle · I ,,,? [,,.o --o --.o ,.o I I!t . P~fJlillCJi"l lille J PPolilJon C~,Cll Cliff title IA(I New ! New New Ministry Oivili~n Institutional Health Heal=~ Men=al Health Fa~.~es ..~ Oueen ~treet Mental Heai=h Centre 1001 Queen Street west, T~ronto ~ 69501 Ne.~f ~jfi~ / N~,of gl~ 3 - [ - Hea4 Nurse 05-9771-66 Re~r=ing ~o the Mea~ Nurse and in colla~ration with =he mul:i-~ls~iplinary team, the Regis:ired Nurse coordinates a client case load %o reh~ilitate an~ ~in=ain aduI=s, w~h men~al illness and psycho-social dysfun=~ion, In =he co~nl~y a= their highest level of ~unction. 1. C~=dina=es a client case load ~: - screening referrals from in~=ien= units and co~ity aqencies ~o determine client's elig~lli=y for a~ssion as assigned by Head N~se; = elic'i~ing, evaluating and d~nting from ~he client, ~e f~ly. and chi inpatient =ecord all relevan~ lnfor~iOn such as psychia~ic ~d m~ical biscom, medication require~nCs, sup~rts and emplo~nt Co assess client for progr~ a~ission and Crea~enC recomenda=ions~ - fo~ula=ing, in consul~ation wi~h =he clien~ and Chi multi-disciplinary a reh~ilication ~rea~ent plan which ~y include ~dica=ion main~enance, s~ial 70% ac=iviCies and voca~ional skills; - monitoring and assessing c~len~'s res~nse =o =remOunt plan through interview, home visits and/O= f~ily and co.unity fee~ack; - 'al=icing, in consultation wi~h ~he client, the mul~i-disciplina~ =e~ and/or Chi psychiatrist, =he trea~nc p~an as r~uired by interview and observational ouCco~s; - - identifying and con=ac=lng needed health and social sup~=C services such as medical, welfare and housing to assist =he client gain-access; - co~unicaCing with cilen~'s social and co.unity nec~rks such as family, friends, landlords, physicians, employers and ~lice to ensue co.unity super= and consistent; - conducting patient sup~rC a~ skill groups =o ~=omote social develop~nc; - intervening in client crisis co ensure adequate resources are accessed co or resolve the crisis. Under=akes respons£bil£t£es consis=efi= wi=h professional training by: - administering medication to clinic clients either orally or parenterally, as prescribed, to ensure therapeutic levels are maintained; - preparing overnight and weekend medication packages to ensure medication compliance; - monitoring medication compliance and altering individual 20% . maLnta. - monitoring vital signs; recommending required blood work; and providing kwellada treatments as dictated by client need; assessing and counselling clients regarding their hygiene and nutritional needs; - providing supervision, suppor~ and guidance to Registered Nursing Assistants who carry a client case load of 15-16 clients; - responding to emergency codes as required in designated area of the hospital; - checking emergency equipment and supplies on a ~egular basis to ensure equipment reliability and adequate updated quantity of supplies; - supervising nursing students as assigned. 3. Participates in PFogram Administration by: - developing, assessing and altering, in conjunction with =he Head Nurse and the multidisciplinary team, clinic programs and 5% initiatives to ensure client needs are met; - .preparing and presenting inservice sessions to multidi$ciplinary team as requested; - participating in program research initiatives as identified or required. 4. Performs other duties as assigned: - relieves Head Nurse as required 5% - as assigned. ~egis~ered as a nurse in On~io; ~ho~ough kn~led~e of ~ene~al and psychia~ic nursing ~heory and practice to include ~Xedge of psychia~ric illnesses, disorders ~d behaviours; knowledge of =elevan~ drugs and side effects; knowledge of relevan~ ~dica~ ~ondi=ions and e~rqency procures; in2e~iewing, co~se11~g,: a~ d~n=a~ion s~ills; kn~ledge of hospital and clinic ~1i~ and procedure; knowledge of co,unity resources; knowledge of relevant acts such as ~n~al Health Ac~,. Health Disciplines Ac=, P~lic Hospitals Act, the ~cu~a~ional Heal~ and Safety. M~th Y~ Oiy Month TV~ S~'s ~e Ty~ Officld's ~ e~ til~ Catherine Sa,toe 4oyce Rainvilie, Assistan~ Administrator, Nursin~ *.~mp~oyees p~ov~de ~u~s~n~ c~e,~o pa~en~s ~n an On~ar~o /9 I r I ~0 John ~ibyc: GSB Nos. 189/89, 197/90, 202/90 IN THE MATTER OF AN ARBITRATION Under THE CROWN EMPLOYEES COLLECTIVE BARGAINING ACT Before THE GRIEVANCE SETTLEMENT BOARD BETWEEN: OPSEU (Andrews et al) Grievors .THE CROWN IN RIGHT OF ONTARIO (Ministry of Health) Employer A~l~h'h'~' STAT~.MF-NT OF FACTS 1. The Grievors are registered nurses employed by the Ministry of Health at the three outpatient clinics [hereinafter "daycare units"] located at Queen Street Mental Health C~ntre [hereinafter "QSMHC"] and 'are classified as Nurse 2 Generals. The daycare units axe known as Unit I-B, Unit 2-B and Unit 4-1. Units l- B and Units 2-B are located in the basement of Towers 1 and 2 of QSMHC and Unit 4-1 is located on the ground floor of Tower 4 of QSMHC. All three towers contain inpatient wards. -2- 2. The three daycare units offer substantially the same programs. Individual programs include supportive counselling, psychotherapy, fami.Iy counselling, remotivation therapy, sexuality, and assessment for vocational therapy. Group programs offered include psychotherapy, remotivation therapy, family counselling, life appreciation, stress management, weekend planning, life skills, cooking, current events and recreational therapy. 3. All of the daycare units oper~"te daily Monday to Friday from 8:00 a.m. to 4:30 p.m. Urfit 4-1 also offers an evening program ~wice a week from 4:30 p.m. to 9:00 p.m. The staff for the evening program consists of one registered nurse and one psychiatric nursing assistant. In addition, a psychiatrist is on call, a Nursing Coordinator is on duty, and the various emergency teams are available at QSMHC, should they he needed. 4. The staff of Unit 2-B includes one head nurse and ~, registered nurses. As well, there is a multidisciplinary team which is made up of one part-time psychiatrist (three hours per day), one full-time psychometrist, one occupational therapist and the nursing staff. A part-time general practitioner is also available when needed from inpatient care. 5. The~staff of Unit 1-B consists of one head nurse, one ward clerk and four registered nurses. The multidisciplinary team includes one part~'time psychiatrist (three hours per day), one full- time psychologist, one social worker, one recreational therapist and the nursing staff. A.part-time general practitioner is also available when needed from inpatient care. 6. Unit 4-I has a staff consisting of one head nurse, one ward clerk, ·three registered nurses and three psychiatric nursing assistants.. Members of the multidiscipli~ary team are: one part-time psychiatrist, one full-time psyehometrist, one full-time psychiatric resident, one occupational therapist,'"' one. social worker and the nursing staff. A pan-time general practitioner is also available when needed from inpatient care. 7. The majority of the patients who are admitted to the daycare programs, approximately 80%, originate from the in-patient wards in the t°Wers in ,which the dayeare units are located'. The. other 20%' of the patients are made 'up of referrals from Other institutions which include other hospitals, community organizations, family members· as well as self-referrals. Individuals who are referred from other hospitals" may be. seen by a psychiatrist, of QSMHC before being assessed for admission, into the daycare units. The majority of the patients who originate from sources external .to · QSMHC are, in fact, referred by the Admitting Department of QSMHC to Unit 1-B. As well, most of these individuals have been previously admitted into the dayeare units and who, because of the chronic nature of their illness, are re-admitted. 8. Because nearly ail of the patients are chronically ill, they tend to remain in the program for an extended period of time. As a result, the turnover of patients in the daycare units is relatively low. As the number of patients in the .dayeare programs is limited, and because of the iow turnover, each unit may have a waiting list for .admission into some of its programs. 9. In all of the daycare units, a referral is usually made by telephone~ In most circumstances, either the head nurse, a registered nurse, or a psychiatric nursing assistant if the referral comes to Unit 4-1, will answer that phone. At that time, a referral form is completed. The individual taking 'the call determines whether the referral meets the established criteria of the program. If not, recommendations may be made to the referral source a~ that time, or after assessment, as to other services which Would be more appropriate to meet that particular client's specific needs. Nurses may. follow up patients to' outside agencies for some patients originating from external sources. 10. In Units 2-B and 4-1, the individual who cqmpleted the referral form will present the information to the mulfidisciplinary team at the mult'idisciplinary team meeting. The team will choose two members, one of which is usually the individual who took the -5- referral, to carry out a patient assessment. An appointment is then made and the two members conduct the 'assessment. 11. At the next meeting of the 'multidisciplinary team, the results of the assessment are presented to the team by the "assessors". The assessors recommend to the team whether or not the client should be admitted. The team discusses the client and a decision is made with respect to admission. If a decision is made to admit the client, the team decides to which member the client should be assigned. In most cases, the client is assigned to the individual who originally obtained the referral, unless their ease load is too .great. However, should another member of the team be better. qualified to meet the needs of that client, the 'client will be assigned to that individual. The client would then be seen by the psychiatrist who would complete the formal admission procedure. At that time or shortly thereafter, the psychiatrist would do a mental status examination of the' patient and determine a diagnosis. 12. With respect to Unit l-B, the individual closest to the telephone would take the referral call and complete the referral form. That. individual would make an appointment to assess the- client. At the meeting of the multidisciplinary team, information would be presented concerning the new referral, the findings of the assessment, and a recommendation would be offered as to admission. The team would discuss the referral and then decide whether or not admission was appropriate. Once the decision is made to admit the client, that client is assigned by the team to the case load of a member decided upon by the team. As in paragraph I1 above, in most cases the client is assigned' to the individual who conducted the assessment, unless that individual's case load is full or the patient's needs would be better met by another member. Dr. Krstich, the attending psychiatrist of Unit l-B, would then see the patient, conduct a mental status examination and determine a diagnosis. 12a. If during the course of patient treatment or during the admission proces's a psychiatrist determines that a patient is inappropriate, for admission into the program, the patient wilt not be admitted or will be discharged. 13. In ail of the units, for those patients who have been admitted into the program on prior occasions, the practice is to assign that patient to the same individual to whom the patient was assigned previously. 14. Each time a client is admitted into the program, a treatment care plan must be prepared. The plan is prepared 'by the member who has 'that client in his or her case load in consultation with the client and the multidisciplinary team. The treatment plan may include supportive counselling, psychotherapy, medication, group therapy, vocational assessment, psychometric testing, family -7 or couple counselling, community supports and rehabilitation programs. Some of the treatments, such as psychometric testing or medication, require sanction by a physician. Other treatments such as vocational assessment, family and couple counselling, and psychotherapy, if requiring the intervention of a specialist, the case coordinator will refer the patient to the appropriate specialist such as', respectively, vocational counsellor, social worker, or a professional specifically trained in psychotherapy. 15. The number of times the attending psychiatrist sees a patient after admission is dependent upon the nature of the patient's illness.'~ However, at a minimum, the psychiatrist is required to see a patient at least once every .six months, as 'a formal progress report is to be completed at that time. Although psychiatrists are only required to complete progress reports for patients to whom they preset/be medication, Dr. Krstich does see patients for whom she does not prescribe medication. However, these patients are few in number as nearly all of the patients admitted into the daycare units require medication. 'The case load coordinator may recommend or the client request more frequent appointments with the psychiau'ist. 16. The number of patients which a Nurse 2 General has in his or her .case load varies. In Unit l-B, there is a range of 25 to 28 patients, in Unit 2-B' there is a range of I0 to 15 patients and in Unit 4-1, there is a range of 10 to I5 patients. -8- 17. In Unit I'-B and Unit 2-B, the multidisciplinary team meets at regularly scheduled meetings three times a week. One meeting is devoted to patients' progress and present condition, another to business matters and the. third is educational in nature. More meetings of the team may be scheduled if required. 18. In Unit ~-1, the multidisciplinary team meets four times per week. One. meeting concerns business matters ~nd the remaining three are devoted to patients' progress and present condition. Again, additional meetings of the team. may be scheduled if necessary. 19. In each of the daycafe units, ,a head nurse also 'wo~'ks, carries his or her own case Icad of patients and performs certain administration and supervisory functions. The head nurse ia supervised by a Nursing Coordinator, whose office is located in the same tower as the daycare unit. The Nursing Coordinator, on occasion, makes visits to the daycare units. The Nursing Coordinator is supervised by the Assistant Administrator, Nursing Services, who is also located at QSMHC. 20. The head nurse of each daycare unit conducts annual formal performance evaluations of the registered nurses. -9- 21. In Unit 4-1, the head nurse conducts random spot checks of patient files. The purpose of this is to ensure that the treatment care plans are being formulated in accordance with the Ontario C6Ilege of Nurses Standards of Nursing Practice, to make certain that · Progress reports are. being completed on a regular basis, and to ensure that the progress repons reflect what is contained in the treatment care plan. 22. For all of the daycare units, t~he Nursing Quality' Assurance Department conducts a random audit of three files, per month of' patient files from' each daycare unit. Again, the purpose of .,this is' to ensure that patiant records 'are bei, ng prepared and completed in accordance 'with the Ontario College of Nurses Standards of Nursing Practice, as well as with the Patient Care Standards and policies and' procedures established at QSMHC. If a discrepancy is found, a report is sent to both the head nurse of the unit as well as the Nursing Coordinator. The two meet to discuss .the problem and to determine how it will be remedied. The responsibility then rests on the head nurse to rectify the situation. 23. The programs offered by the daycare units are reviewed by the multidisciplinary team and' revised. Often, 'retrea. ts' external to QSMHC are scheduled for this purpose. 24. The staff and patients at the daycare units at QSMHC have ready access to and utilize QSMHC's resources. For instance, if a crisis situation occurs, there are different emergency teams available: Code I II for a medical emergency, Code 99 for a psychiatric emergency and Code Red if there is a fire. In addition, there is an internal security force which can be called in the event that a patient becomes uncontrollable or for the eviction of an unwanted visitor. The dayc'are units have complete access to further QSMHC resources such as the various sports facilities, the staff library and the patient library as do the other community clinics. In 'addition, the full medical staff of QSMHC and all medical services are available to the daycare units. · 25. Subject to any modifications noted above, the position specifications accurately describe the duties and responsibilities of' the grievers. Seventy (70) percent of thc duties re: client caseload, balance is split between 4/2 and #3 in the job specification. 25a. .The grievors have the same responsibility for nursing students as does Wendy Bcaton. (See paragraphs 45 and 4/L) USAGE WITNESS: WENDY BEATON 26. Wendy Beaton is a registered nurse employed by the Ministry 'of Health at the Community Mental Health Services Unit [hereinafter "CMHS Unit"] of Whitby Psychiatric Hospital and is cIassified as a Nurse 3 General. The CMHS Unit provides outpatient care for patients suffering from psychiatric illnesses. The CMHS Unit is made up of one outpatient clinic located at Whitby Psychiatric Hospital and six other satellite outpatient clinics in different locations in Ontario which include: Lindsay, Port Perry,. Uxbridge, Ajax, BowmanvilIe .and Whitby.. All of the outpatient units operate daily, Monday to Friday, from 8:00 'a.m. to 4:00 p.m. 27. Wendy Beaton works three full days at the clinic located at Whitby Psychiatric Hospital and one full day and two half days at one satellite clinic. 28. The staff of the CMHS Unit is comprised of eight Registered Nurses, one CIinic Coordinator, three full-time Psychiatrists, two part-time PsYchiatrists, two PsYchologisis, and three Social Workers. This Staff is responsible for providing care to. all of the patients at all of the clinics which make up the CMHS Unit. 29. The -staff make up a number of different multidisciplinary teams. Generally, there is one team for each satellite unit as well as two main teams for the unit located at Whitby Psychiatric Hospital. The multidisciplinary teams meet once a week to discuss patient referrals and patient care. 30. The multidisciplinary team in which Wendy Beaton is a member consists of one Psychiatrist, two Nurses, one Social Worker, and one Psychologist. 31. The patients who are admitted to the CMH$ Unit originate from a wide va_yi.'ety of-sources which include: referrals from the inpatient wards, of Whitby Psycfiiatric Hospital, referrals from different community organizations, referrals from the police, referrals from family doctors, referrals from family, as well as self- referrals. Some patients are chronically ill, others are not. Some patients are in the program on a short-term basis and others on a long-term basis. Some patients have been admitted into the program before and are re-admitted. Generally,' the turnover of patients is quite high. There is no fixed number of patients for admission into the CMHS Unit 32. Patient referrals are usually made by telephone. A secretary would take down all referral information and prepare a list of referrals. She will then give this list to three nurses, one of which is Wendy Beaten, who meet twice a week to review the list and determine which clients are eligible for admission into the CMH$ Unit. If the patient is found to be ineligible for admission into the CMH$ Unit, the patient will be referred to another agency. Often, the intake nurses would contact the agency for the patient and arrange appointments, If the patient is eligible for admission, an assessment of the client would then be arranged. 7 33. Assessments arc conducted by the nurses and are usually conducted alone. However, if it is apparent 'that the client may have a serious mental condition, a psychiatr{$t may accompany the nurse for assessment.- 34. The individual who conducted the assessment would report' his or her' findings to the multidisciplinary team at its next meeting, and make a recommendation as to whether or not admission is appropriate. The' team would then make a decision with respect to admission. 35. A psychiatrist must sign the formal admission slip of the patient and generally sees the' patient once every six months in order to prepare a progress report. The psychiatrist, is available as a Consultant should he or she be needed. - 14- 36. If thc patient is to be admitted into the program, that patient is usually assigned to the individual who conducted the patient's assessment. A treatment care plan would be prepared by the individual to whom the patient is assigned. If it is determined that the patient requires vocational or recreational assessment, the patient would be referred to 'the appropriate source and arrangements made for the vocational or recreational assessment. 37. Wendy Beaton had approximately thirty-five (35): patients in her' case load. 38. An annual formal performance evaluation of Wendy Beaton is done 'by the' Clinic Coordinator, Lee Haviland. The clinic Coordinator does not supervise Wendy Benton on an ongoing basis as she treats her entire nursing staff as independent clinicians. However, if a problem is brought to her attention or if specifically requested by her nursing staff, she will meet with them, either individually or as a group. 39. The Clinic coordinator schedules and chairs a weekly nursing meeting for her nursing staff. At this meeting, the discussion focuses-on education, business matters, new hospital policies, as well as any practical problems the nursing staff may have. The nursing meetings do not include discussion with respect to patient care. 40. The Clinic. Coordinator has an office located at the outpatient clinic of the ClVIHS Unit at whitby PsychiaU'ic Hospital. The Clinic Coordinator has her own case load and is a member of a mulfidisciplinary team. However, she is not on the same multidisciplinary team as Wendy Beaton. 41. The secretarial staff of Whitby Psychiatric Hospital review patient charts on a regular basis to ensure that the charts are being completed and that no documents, such as' progress notes.~ are lacking. - 42. Wendy Beaton conducts home visits of patients in her case 'load on a ~egular basis. The majority of the home visits are conducted alone. 43. Wendy Beaton serves as a consultant for different community agencies. Upon request, she provides miscellaneous information and advice concerning patients with Psychiatric illnesses. Wendy Beaton also counsels other members of her muhidisciplinary team with respect to medical a~d nursing issues. ~,4. Wend), Beaton functions as a liaison wi'th Spectrum, one of the outpatient clinics of Queen S~rcct Mental Health Centre. She meets with the liaison from Spectrum on a regular basis to discuss common problems and patient care. 4:5. Wendy Beaten is responsible for nursing students. On average, the CMHS Unit receives between ! and 2 students each week. Ms. Beaten gives them on-the-job training with respect to how to conduct patient interviews and assessments as well as teaches them the appropriate action in specific clinical situations. 46. Ms. Beaten monitors the progress of the Students and provides input to the student initructor with respect to that student's formal evaluation. 47. On the days' that Wendy Beaten works at the satellite ' clinic, the Nursing Coordinator is not present. As well, Wendy Beaten on occasion is the only staff member located at the satellite clinic and in effect operates that clinic for that time. If a crisis situation occurs, Wendy Beaten would have to deal with the situation herself, as no crisis team is readily available. 48. .The days in which Wendy Beaten works out of the unit located at 'vVhitby Psychiatric Hospital, the hospital's resources are available to her. To highlight, these include rehabilitation t~am, occupational ther. apists, recreationists, emergency teams, as well as others. 49. Wendy Beaton does not administer medication. A medication clinic is set up both at the satellite clinic, as well as at the hospital clinic for this purpose. DATED at Toronto, this' -, day of December, 1991. For the Employer For the Grievors -: 10 We will reserve our jurisdiction to deal with the other grievances mentioned at the outset of this award, which have not yet been disposed of. Done at London, Ontario, this ~/~ day o ,1991 .~~ue~, v ice-Chairperson S. Urbain, Member D. D~gharty, ~