by Tilda Shalof
“It’s Key Performance Indicators,” she whispers back and introduces herself. Her name is Irene Holubiec, and she’s a nurse who is the senior director of quality and risk management. She helpfully interprets these unfamiliar terms for me. But when they start talking about “kaizen,” and “lean,” I am equally baffled. I’m just about to ask Irene what these terms mean when one of the corporate suits gets up on the podium to explain this management philosophy.
“Lean is flowing like a stream, no rocks or boulders disrupt the flow. It’s respect for the experts, those on the ground. It’s about eliminating waste and non – value adding activity.”
Yeah, right. Come visit the hospital if you want to see disrupted flows, obstacles, and waste.
Between wandering in and out of meetings, and helping myself to the snacks during the coffee breaks, I stroll around and manage to pick up a few choice nuggets.
“… the greatest expenditures in the health care system are in acute care, yet hospital patients represent only 1 per cent of the population.”
“Seniors now outnumber children. More of the population is over sixty-five than under fifteen … this ratio is predicted to double as baby boomers enter their sixties.”
“Home care spending in Canada amounts to only 5 per cent of total health care spending.”
“Homelessness is a national disaster. Over thirty thousand Canadians are homeless on any given day or night.… Poverty is the single greatest risk factor for health.”
“Health care to First Nations’ communities like Sioux Lookout and Attawapiskat is a disgrace … an 80 per cent rate of substance abuse and mental illness in this population.”
“The future is about keeping people out of hospitals …”
“We drive people into institutions when support is not in place for them to stay home.”
Yeah, yeah, yeah. These factoids could be lifted verbatim from my notes as a student nurse, circa 1983. Back then, they said the same things; nothing has changed. As for the vaunted “paradigm shift” that our instructors predicted – the movement away from the hospital to the community, the transition from an acute care, disease-focused health care system to a more preventive, primary care health care one – shows no signs of happening. To most people, health care means hospitals and doctors. We’re still obsessed with medical interventions and the latest technology. In the huge, sprawling medical centre where I work, we offer “quaternary care”– above-and-beyond heroic measures for the most difficult cases. After primary care for prevention, secondary for early detection, and tertiary for acute problems, there’s this fourth level of care. In fact, many of us who care for people with extraordinary and extreme medical conditions don’t know much about basic first aid or even how to treat the common cold.
I leave the dark, cool casino and step out to the steaming pavement of a hot June afternoon to walk the streets of downtown Windsor. A down-and-out panhandler strums his guitar and chants his song: “No sex, no money, no love, no drugs. No sex, no money …” He stops, stoops down, picks up a cigarette butt, and attempts a few dry puffs. On either side of the street are out-of-business shops and boarded-up storefronts covered in graffiti. Pawn shops and a tattoo and piercing parlour: “Are You in Need of a New Hole?” There’s a First Nations’ detox clinic with dream catchers in the window, a new immigrant welcome centre. I walk back to the waterfront casino – with its ferris wheel, game arcade, and cotton candy – and return to the conference centre for more meetings. During a coffee break, I continue to schmooze and mingle. I can feel the participants’ passionate engagement. You’d be hard pressed to find so many positive attitudes in the hospital. There, we go around looking grim and grumbling a lot. Here, you’ll hear things like:
“I feel motivated to support my staff to provide great care,” a manager says.
“I love doing work that makes a real difference in people’s lives,” another enthuses.
“Where else do you get the opportunity to work and serve?”
VON seems to be one happy place. Yet, they are candid about the problems in this venerable old institution. Their computer system is outdated, their administration inefficient, and, worst of all, they’ve lost market share and brand awareness. But they are working hard on improvements. A senior member of the national board of directors, a gentleman who looks like he’s been around for awhile, provides the background. “For years VON was a household name. You’d come home from the hospital and a VON nurse would be there. Back then, hospital stays were longer. Once, VON was synonymous with home care in Canada,” he says wistfully, “but not anymore.”
“What happened?”
“It’s a sad story.” He looks very sad indeed. “Deregulation back in the nineties led to competitive bidding and VON was ousted by big businesses. A not-for-profit charity like VON couldn’t compete with big American corporations that moved in. Judith has worked to create a hybrid of a business and charity model. She has streamlined our administration and reorganized our operations. It used to take 227 steps from a referral to a nurse arriving at the client’s doorstep. Now, it’s down to nine. We’re determined to be the best once again.”
Judith gets up on the podium to give the keynote address. She opens with a quip about her version of CPR – Conviction. Passion. Relationships. She says what everyone here already believes. “Home care can no longer be an afterthought. It is the centre. Health care must include home care for all. As Canadians, we value our universal health care system and must protect and preserve it. There is absolutely no evidence that privatization of health care or for-profit health care benefits patients or saves money.”
She speaks and everyone listens. No one is drifting off, no one is looking down at their phones. All eyes are on Judith. I notice she’s pushed the microphone to the side so that the sound waves from her throat’s vocal emanations will not be electronically transmitted on this Saturday afternoon. Even without amplification, Judith can easily project her resonant, Hungarian-accented voice, and considerable charisma, throughout the grand ballroom.
“Canada is world class in acute and critical care, but falls short in health promotion, disease prevention, and primary care. We have an illness care, not a health care, system.”
She speaks about the need to empower the people on the ground, the ones actually providing care, by giving them the supports they need – technological, educational, et cetera – to care for clients. In particular, she praises the role of home care workers. “So often they feel invisible and undervalued, but they bring independence, peace, and comfort. So much of what people need is basic, hands-on, and low-tech. It goes unnoticed and takes place quietly, in the privacy of clients’ homes and behind closed doors. It is seldom witnessed, but intensely felt by those in their care.”
I’ve never met someone like Judith, an intellectual powerhouse, an accomplished scholar, a corporate executive, and, up there on the stage, a commanding presence. Yet she’s also completely down-to-earth, humble, approachable, straight-talking, and authentic. Cosmopolitan, open-minded, and at home in the world (she calls herself a “global citizen”), she is quiet, thoughtful, and serious – even introverted – and also grandmotherly, playful, and charming. I wonder to what extent nursing is an expression of her religious beliefs. Perhaps for Judith Shamian, nursing is her way to fulfill tikkun olam, the Jewish imperative to repair the world. Her purpose is no less serious, her vision that encompassing. Some people view the world through a microscope, others with a telescope, but Judith’s wide-ranging vision and capacious mind takes in the details as well as the big picture, the individual and society at large. She looks to the future while staying firmly rooted in modern nursing values and ancient Jewish ones, too.
After her speech, Judith receives a standing ovation. Then, an attractive, energetic lady with bright red hair and a Newfoundland accent, Lynn Power, who is chair of the national board, bounds up onto the podium to lighten the mood by leading the crowd in a stretch break and a singsong of her rendition o
f “My Bonnie Lies Over the Ocean”: “My body lies over the sofa. My body watches too much TV.” These people have fun – especially the Maritime contingent. (In fact, one of the executives from Nova Scotia had so much fun last evening that today she’s in a wheelchair with a sprained ankle. I’ve been bringing her ice packs from the kitchen.) Their lively spirit is infectious.
I’ll have what they’re having.
They make good sense and I love being around their enthusiasm. I’m definitely warming up to Judith’s offer, but I’m holding back, still thinking it over – perhaps over-thinking it? My instinct tells me to go for it. There could be some sweet perks to this gig. I’d get to travel, see the country, stay in hotels with big, fluffy white towels and those tiny bottles of shampoo and conditioner – maybe I could even order room service? What fun! And it’s not like I have any other commitments or projects on the go at this time. Yes, the timing might be just right to start something new.
A whoosh of pure energy flies at me. It’s a tiny package of a woman with bright blue eyes, curly hair, and an impish grin. She’s just hurtled out of the bathroom and plowed straight into me. She grabs onto my arm to steady me as I stumble, trying not to fall.
“The hand dryer almost blew me away! You have to take a strong stance in there, or you’ll be blasted into outer space,” she exclaims.
Who is this person?
They’d told me I’d recognize Nurse Jackie Wells. She’s a “force of nature,” one executive said. “The goddess of community supports,” a nurse manager called her.
“What d’you wanna know?” Jackie asks as she sits across from me at lunch. We’ve loaded our plates at the buffet, breezed past the many people who called out to her and wanted a piece of her, and have finally taken a seat at a table at the back of the ballroom. “Ask away,” Jackie says with a huge, inviting smile. “I’m an open book.” She spreads the heavy cloth serviette on her lap and picks up her fork.
“For starters, what is ‘community support’ and what does it have to do with nursing?”
Jackie puts down her fork. “Here’s the first thing you need to know,” she says. “Home can be a mansion or a log cabin, a teepee, a yurt, under a bridge, or over a sewer or subway grating.” Hardly pausing for a breath, Jackie moves on. I put my plate to the side; I don’t think Jackie is going to eat at all. “Second, everyone needs a home and wants to be at home. People do not want to be in hospitals or institutions. Third thing: nurses can’t do it all. Nursing is not only about nurses.”
“It’s not?” I guess I’m one of those nurses who thinks it is, who likes to do it all.
“Some of the best nursing care is given by family members, a volunteer, or a neighbour who’s willing to travel the journey with the family.”
I feel as if I have to “listen fast” to keep up with Jackie’s lightning-bolt mind.
“In the hospital, do we ever ask people what they want, and if we do ask them, do we really want to hear their answer? If I worked in a hospital today, I’d challenge that. In the community, it’s my job as your nurse to ask that question and mean it. If we can’t do it ourselves, we have to bring in people who can. I went into one home. There must have been twenty cats roaming around, no running water. Dirty, dirty, dirty. Every nursing instinct in me told me to take a mop and bucket and get to work. ‘He shouldn’t be at home,’ my manager said. ‘Try to bring him to the hospital, Jackie.’ But to him, that was his home, where he wanted to be. I put old mattresses on the floor in case he fell out of bed. Neighbours checked on him daily. Now, that’s nursing. You won’t find it in any textbook.”
There’s no time to ask another question, as Jackie has segued into another story.
“There was a farmer who used to catheterize himself. Kept his catheter woven into the brim of his hat. Out in the field, he’d stop, use the catheter and put it back on his hat. He had to go into the hospital for surgery, picked up some superbug, got a bladder infection, and died there.” Jackie’s fork, laden with Greek salad, suspended mid-air, doesn’t make it to her mouth. “Home care is about caring for people where they are, without bias or imposing our values on them. You won’t get that in the hospital, and that’s what people want. If someone told me I had to eat dinner at five o’clock and shower by eight, I’d pretend I didn’t hear them. I’d want to spit at them.”
“That’s a common scenario in the hospital.”
“Let’s say you’re a proud veteran who’s served in the war and fought for our country and now someone tells you, ‘Take your pills, dearie.’ We are the boss of you. We decide when you can move your bowels and when you can’t. It’s inconvenient for the staff if they have a bowel movement at change of shift, am I right?” I nod. This is so true. “Now, imagine that’s your loved one. Once you do that, it becomes clear to you that the hospital takes away your independence and dignity. That’s why I love palliative care. Nothing brings you closer to another person than caring for them when they’re dying. It’s not something every nurse can do or even wants to.”
Food for thought. Just as well because I can’t eat. Listening to Jackie commands my full attention.
“I could never work in a hospital. Early on, I realized I couldn’t give the kind of care I wanted to give in a hospital. In the hospital, everyone’s so caught up worrying about getting sued, but should that be the rationale for our nursing care? I would challenge that. The whole place is run by conformity and fear of litigation.”
Paradoxically, it was Jackie’s most memorable experience that made her leave bedside nursing.
“This cantankerous old coot living out in the middle of nowhere was diagnosed with metastatic bone cancer. ‘Okay lady, sit down. I’ve got something to say,’ he told me. ‘Number one: if you’re here to put me in the hospital, you can get back in that little car of yours and go home. I’m staying right here. Second: I want to have some fun.’ Now, I’m a fun-loving person myself, so every visit, I made sure we had fun. He’d never been in a hospital. Born in that house, grew up there. He’d never complain of pain because he was afraid it meant he wouldn’t be able to stay home. One day, the house was dark. I could smell impending death. The wife went outside to be with her horse because that gave her comfort. I set to work and gave him a bath, listened to his chest, gave him morphine, checked his bowels. Then I asked him, ‘Hank, if I could do one thing for you, what would it be?’ He turned to me. There was a sparkle in his eyes. ‘Jackie, jump in bed with me.’ With my stethoscope around my neck, I lay down beside him and held him in my arms. He cried and I cried and it felt good. His wife walked in and hugged us both. It was a wonderful moment because caring was what this was about. He needed me to be me. That’s what made me more dedicated to nursing and also made me leave nursing. I wanted to teach nurses to challenge the status quo, to have the courage to break rules when necessary. I wanted to show volunteers how they can lessen the burden on nurses and family caregivers. People want to help, but they don’t know how and we don’t let them in.” She picks up her fork. “So, that’s what I do. Or did. I’m retiring.” Finally, she digs into her salad. “There. That’ll give you something to chew on for awhile.”
“They warned me about you, Jackie,” I tease her. She beams, proud of her “bad” rep as a “troublemaker.”
“They told me, ‘There’s mischief wherever Jackie goes. When Jackie wakes up in the morning and her feet hit the floor, Satan says, ‘Oh no, she’s awake.’ ”
Next, I meet Nurse Andrew Ward, another high-energy person who is the manager of a vast VON site that includes this very area around Windsor. We grab a corner of the packed lobby to sit and chat. He closes his eyes to concentrate, then opens them wide. “VON is a very kick-ass organization. They welcome creative solutions. We have an innovative day program, assisted living for seniors, and a nursing station on Pelee Island that’s run by an awesome nurse. We’ve started a school nutrition program. Yup, we’re feeding hungry school kids. Oh, and a video medicine network and a chronic pain clinic. You’ll ha
ve to come and see it for yourself,” he says. “Gotta run.” He hustles off to – what else? – a meeting.
Steve and Anne volunteer for VON by delivering home-cooked meals to people who are unable to shop or prepare nutritious food for themselves.
“Meals and hugs,” clarifies Anne.
Diabetic, wheat-free, vegetarian. All kinds of meals. Each day of the week, they volunteer for a different charity. Once, Anne made a thousand cabbage rolls for her church.
We sit in comfy chairs in the hotel lobby. As Anne tells me about what drives them both to be such active volunteers, Steve watches her lovingly. In 1978, Anne escaped to Canada from Czechoslovakia, fleeing a repressive dictatorship. Life was hard for many years, until they met each other and found love. Things are good now, and their gratitude is expressed in their drive to help others. They hold hands and snuggle in close to each other like newlyweds.
Steve explains their shared outlook on life. “Back in the seventies, there was a philosophy called the ‘power of positive thinking.’ Whatever happens, good or bad, you only find what you’re looking for, so look for the positive.”
I ask them the secret to their long relationship, and Steve is quick with his answer.
“A person you hate, you only have to tell them once. Someone you love, you have to tell them – and show them – every single day.” He gazes at Anne, adoration in his eyes. “We never fight. Oh, arguments, sure, but we always make it right. Because we want to. Another thing. Make sure you thank your spouse for one thing every night before you go to bed,” he suggests, and I take his advice to heart.
Perhaps I will return to Windsor to see Anne and Steve again and bask in their loving presence, to feel the passion between them – and to taste one of those cabbage rolls.
One by one, Judith has lined up these twenty-minute “speed dates” with key people in VON. Our informal “meetings” are held here in the comfortable hotel lobby.
