Patient-centered care, evidence-based practice, administrators who are also clinicians, not business people

 

The nursing literature reflects the importance of patient centered care. Evidence-based practice means that nurses should cull evidence from their field of work to evaluate the policies and procedures, putting the patient as the center of the equation of what works for them.

In Israel, a signature on a health form differs in its legal weight than a signature on say a mortgage agreement. If the person signing the mortgage agreement claims he did not know what he was signing, that carries no weight, but if a patient signs a medical consent form and then claims that he did not understand what he was signing, the patient can claim wrongful action on the part of the health-care worker.

Since about 2016, school nurses in Israel were told that the health declaration that parents sign, which contains a clause regarding vaccines, is sufficient permission to vaccinate the child.

Some critical thinking questions could be brought forth regarding the health declaration:

1 - after eight years of implementing the policy that a signature on this form is enough to allow vaccines, what have school nurses seen in the field?

2 - do parents understand that this form is an agreement for vaccines?

3 - are nurses free to call the parents to asses their true desires regarding vaccine administration? That is, do they hide from their administration that they call the parents to ensure their wishes?

4 - are nurses comfortable vaccinating kids only using the health declaration?

5 - how have parents reacted when they discovered that their child received a vaccine that they did not intend, that is, they did not expect that the health declaration meant full consent?

6 - how do nurses feel about the reaction of the parents? How does this policy dovetail with the value of trust-building between health care professional and patient, indeed, is trust-building an important value, held by nurses and by management?

7 - regarding nurses who have announced this (that a signature on the health declaration means consent) at parents' evenings, on emails, and what's apps - do they find that parents still do not comprehend this policy?

8 - how many contradictions abound between the consent on the health declaration and, on or around vaccine day, parents contacting the nurse or teacher to refuse vaccine administration? It would take maybe a day of a few nurses scanning vaccine records and noting the contradictions - not a huge study.

9 - with all those potential contradictions, as noted above in number 8, shouldn't this policy be revised?

10 - how free do they feel to speak up about this?

These would be pro-active, preventing and evidence-based questions which would improve what is known in nursing as "best practice".

In Israel, nurses do not need to take continuing education classes to maintain their license, as they do in the USA.

Israel tends to be a reactive and not proactive and preventive society. Hourly emergency-sounding calls to listen to news updates on the radio condition people to hear a constant state of emergency, grooming reactivity and not prevention.

The populace's energy is thus sapped and redirected, people are distracted from wondering, say what happened to school nurses in the last two decades.

We went from belonging to schools and being a trusted presence there, to being nurses-on-wheels, arriving at a school to perform vaccines and growth checks. Doctor's visits in the first and seventh grades were cancelled, growth checks dwindled from every two years to performed only in first and seventh grades, We went from being in charge of say two schools, to nine schools, to, at last count for me - one nurse per 16 schools.

There have been "tachluot", Hebrew for "outbreaks" of measles, chickenpox and whooping cough in Israel at various times in recent years - none of them occurred in Imanuel. During my time as school nurse and the time of the nurse before me, there were no outbreaks. The previous school nurse and myself would engage with our neighbors on a one to one and personal level, encouraging vaccine administration, reminding people say in the store or at a bar mitzva, "I am holding a vaccine day in a week, please bring your son". I was touched that the previous school RN did so to me after my Aliyah 25 years ago, I passed her in the street and she stopped me - "your daughter needs her second Hepatitis A vaccine" - she was on top of the population's needs and so was I. I also confronted a local resident several times and said she really must take her daughter for an evaluation at an endocrinologist due to her height - the mother finally intervened and thanked me.

Again, in the last 30 some years, in Imanuel, where I reside, there were no outbreaks of infectious diseases that are covered by vaccinations (I am not including corona and I do not know the statistics for that).

That may have something to do with having a known, respected, constant and dedicated presence in the community.

Back to the tendency towards reactivity and not prevention in Israeli society: how reactivity, instead of prevention and evidence-based practice, affect society is another larger question.

We cannot simply put out fires, we cannot be a cog trying her best in a larger system that could use some improvement regarding patient advocacy.

I realized something, a little too weakly and a little too late: if you are putting your finger in a crack in a wall to prevent a flood then you are depleting your personal resources and not fixing the problem at its root.

If your community or school nurse is listening to you, putting you first, she may be at odds with her management.

If your health care professional has no managerial support as she advocates for you and spends time with you, she is getting drained slowly in many ways.

The stress of being at odds with management, with choosing your conscience over following rules that are man-made, economically motivated, and ignore patents wishes, takes a toll.

You are no hero for pushing back against a flood, you have to fix the problem at its root.

I realized this a little too weakly and a little too late. One's idealism cannot push back against a machine.