When the Injured Nurse Returns to Work: An Institutional Ethnography by Laurel Ann Clune A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Lawrence S. Bloomberg Faculty of Nursing University of Toronto © Copyright by Laurie Clune 2011 When the Injured Nurse Returns to Work: An Institutional Ethnography Laurel Clune Doctor of Philosophy in Nursing Science Laurence S. Bloomberg Faculty of Nursing, University of Toronto 2011 Abstract Nursing is a high risk profession for injury. A Canadian survey reports many nurses are in poor physical and emotional health; they sustain more musculoskeletal and violence related injuries than other occupational groups. In Ontario, an injury management approach called Early Return to Work (RTW) requires injured workers, including nurses, to go back to work before full recovery. The Workplace Safety and Insurance Board cite this approach as beneficial to both the employer and employee. This study uses an institutional ethnographic approach to examine critically the RTW process from the standpoint of injured registered nurses. Through interviews and mapping activities with nurses, other health professionals and managers, a rendering of the social organization of hospital injury management emerges. The findings suggest that the implementation of RTW is complicated and difficult for nurses, their families and hospital employers. Injured nurses engage in significant amounts of domestic, rehabilitation and accommodation work in order to participate in the RTW process. When the returning nurse is unable to engage in full duties hospital operations become disorganized. Collective agreements and human resources procedures limit the participation of injured nurses in creative and/or new roles that could utilize their knowledge and skills. As a result, nurses are assigned to duties, which hamper them from returning to their pre-injury positions and cause their employment with the hospital to be reconsidered. The unsuccessful return of injured nurses to employment is counter to provincial retention initiatives, which seek to sustain an adequate cadre of nurses ready and able to care for the increasing health care needs of an aging population. Sites of change which could support and promote the successful return of these injured workers to nursing work are identified in this study. ii Acknowledgments My journey to this culminating point in my student career has been long and bumpy. Many people have assisted me along this path: picking me up when I stumbled; cheering me on as I moved towards the PhD finish line. I would like to acknowledge and thank these people. To the nursing informants interviewed in this study: Thank you for sharing your stories of how things “really work”. I hope that what I have presented in this text will be a catalyst for change in our profession. To my supervisor, Dean Sioban Nelson and committee members, Dr. Jan Angus and Dr. Karen Yoshida: Sioban, you have been with me during the high and low points during this journey. Thank you for persevering and sharing your wisdom about writing “academically”. Jan, thank you for your guidance through the entire journey. Karen, you brought calmness to this journey. I am grateful for the time and energy you collectively channelled to my academic development as a researcher. To Dr. Dorothy E. Smith and Dr. Jancie Kinch: Dorothy, you are a wonderful mentor and teacher who supported me in understanding institutional ethnography. It is an honour to have worked with and learned from you. Janice, you always knew when to call and how to encourage me. Thanks to you both. To the numerous graduate students who have engaged with me in scholarly dialogue over the past seven years: There are too many of you to mention by name. We all know that a doctoral journey is an isolating and difficult one. Thanks to your friendship and support. I have “PhinisheD.” To fellow IE‟ers Sarah, Laura, Janet and the IE working group: Your feedback, insights and willingness to let me “talk this out” have been instrumental in the development of this text. Thank you for listening. iii To my colleagues and the students of Ryerson University‟s Daphne Cockwell School of Nursing: You are the best academic cheerleaders around. I am grateful to be part of a community that has stepped in to help me juggle the multiple challenges of being a working woman, graduate student and mother. To my dear friend Dr. Lee Anne Harper – Femson who pushed me to finish this dissertation. I am so glad that we could celebrate the completion of this work together. I will always miss you my friend. Lee Anne was “promoted to glory” twelve days after the final examination of this dissertation. To my Mother, Carole Clune: Thank you for taking me to my first and last days of school. You have shown me the importance of pursuing academic dreams and demonstrated by example how to be strong. I hope now you can see what I can do with a “sociology degree”. My “girlies” Katie, Shannon and Robin: You have graciously endured a mother who was in school for many years. Thank you for understanding, providing diversions, and being there to say, “Keep going, Mom!” Remember that YOU are my life‟s accomplishments about which I am the proudest. This dissertation is dedicated to Kathleen O‟Brien (1910 – 2004), a working woman with a grade 8 education: My Nanny was my rock. While she was there at the beginning of this journey, she could not be here to see me cross the finish line with the end of my dissertation. This is a special gift for you on your 100th birthday. I love you. iv Table of Contents Abstract ........................................................................................................................................... ii Acknowledgments .......................................................................................................................... iii Note to the reader ......................................................................................................................... xiv Glossary ........................................................................................................................................ xv Chapter 1 Introduction to the problem ............................................................................................ 1 Background and context ............................................................................................................. 2 The health of Canadian nurses ............................................................................................ 2 Canadian nursing demographics ......................................................................................... 2 The health risks associated with staff nursing work ........................................................... 3 Ontario nursing recruitment strategies ................................................................................ 4 When the nurse gets hurt ..................................................................................................... 5 Early Return to Work ................................................................................................................. 6 Why a study about RNs and Return to Work? ........................................................................... 6 Identifying the problematic of the research ............................................................................... 7 The Researcher‟s standpoint ...................................................................................................... 7 The research approach .............................................................................................................. 11 Significance .............................................................................................................................. 11 Study Overview ........................................................................................................................ 12 Chapter 2: Literature review and synthesis ................................................................................... 14 Introduction .............................................................................................................................. 14 Search Strategy ......................................................................................................................... 14 PART 1 ......................................................................................................................................... 16 Discourses of disability ............................................................................................................ 16 Injured worker research ............................................................................................................ 21 v Injury management ........................................................................................................... 21 The injured worker and issues of mental health ............................................................... 22 Return to work .................................................................................................................. 23 Canadian Nurses and their health ............................................................................................. 25 Nursing injuries and illnesses ........................................................................................... 25 Aging illness and injury ...................................................................................................