Thursday, March 14, 2019

How does having a disabled neighbour 'dash your dreams?'

Families protest the Weyburn, Sask. decision to keep a small group home out. This photo is from CBC News

By Louise Kinross

I’m embarrassed.

This isn’t the Canada I know and love. But apparently, according to two recent news stories, it is.

Last night I read about how the city council of Weyburn, Sask. rejected a home for four adults with disabilities in a new subdivision called The Creeks.

Four people!

According to this Toronto Star story, there was “tremendous pushback” from residents who’d bought expensive homes in the neighbourhood. “It kind of dashes the dreams and hopes of the people that live there currently,” said Coun. Brad Wheeler at a council meeting on Monday.

Just how, exactly, does having a person with a disability living on your street dash your dreams?

Oddly, the Star story includes a photo of the Weyburn sign welcoming people to what it calls “the opportunity city”—just not for the people waiting for the small group home that was tossed.

The developer of The Creeks supports the home.

This story played out as Ryerson disability scholars spoke to CBC Radio about a Nova Scotia human rights inquiry that found the government discriminated against three people with intellectual disabilities by locking them away in hospital psychiatric wards, for no medical reason, for years. When the complaint was launched in 2014 they were still living in hospitals.

“The conditions of their life were described as soul-destroying,” said Esther Ignagni, an associate professor in Ryerson’s disability studies program. For example, one person was locked in a room with a television for 23 hours a day.

The Nova Scotia applicants argued that the province should have provided them with the supports to live in the kind of small group home that Weyburn, Sask. residents just snubbed.

However, Walter Thompson, chairman of the Nova Scotia inquiry board, rejected the argument that timely placement in a small group home is a human right.

According to the CBC radio interview, there are 1,500 other disabled Nova Scotians waiting for such a home.

He also rejected the idea that ableism was behind the lack of community options.

Ableism is the “idea that disabled people are not valuable or vital parts of our society and it’s permissible to send disabled people away and …lock them up,” said Eliza Chandler, also an assistant professor in Ryerson's disability studies program.

Doesn’t the first half of that description perfectly mirror the attitudes and actions we see in Weyburn, Sask.? 

“These people have invested a lot of money into their dream homes, their retirement homes and to have the provincial government come in and pick a lot directly across from them, I don’t think that was the best choice,” Wheeler was quoted saying.

Chandler was asked what a world without ableism would look like. It would be “accessible and inclusive of disabled people and would value us as citizens and want us in your cities, in your town and as your neighbours,” she said.

Meanwhile, here in Ontario we're told the wait for a group home placement for adults with intellectual disabilities is over 20 years. I have been told, by a person at the end of the Developmental Services Ontario line, that it doesn't happen until someone in an existing home dies. 

I think Canadian kids need a new word on their spelling tests: ableism.

Wednesday, March 13, 2019

Time for a parenting reality check

By Louise Kinross

It’s so easy to look from the outside of someone’s life and make assumptions about how they’re doing. In the last 24 hours, I read a couple of posts that showed me how wrong we can be. 

When we ask someone how they’re doing, do we really want to hear the answer? Do we make room for people to share candidly? Or do we just want the sanitized ‘fine,’ so we can go on our merry way?

Susan Senator and Maya Wechsler are what I think of as super parents. People who have literally moved the world to give their kids fabulous lives. Trailblazers.

But yesterday, they were both waving distress flags.

Susan is a Boston author who’s written a number of books on raising her son Nat, who has autism and doesn’t speak. The most recent was Autism Adulthood: Insights and Creative Strategies For a Fulfilling Life. She’s also written for BLOOM.

I always looked to Susan with envy at her ability to work with Nat and her family to come up with creative ways for Nat to live in the community with support. There had been some horrific bumps. But the last time I checked in, it seemed he was in a great living arrangement and doing cool things like playing in a band.

So it was a shock to hear yesterday that Nat had returned home, and to read this Facebook post:

“No matter how hard I work to help make this world a better place, to actually give a sh%t about people like Nat, I get obstacles thrown in my path, I get fight after fight for just basic inclusion and decent treatment of him. I want to f%cking just give up, I am too old for this, and not getting any younger.”

Ironically, The Washington Post also ran a piece called People don’t want to hear the ‘ugly details’ of our struggle to raise and educate our autistic son. That piece is behind a paywall, so you can find it here on the author’s blog.

I was surprised to realize it was written by a mom I'd interviewed in BLOOM: Green acres is the place for me. Maya and her husband moved their family from Washington, D.C. to a farm in Virginia and opened A Farm Less Ordinary, a business selling vegetables that employs adults with intellectual disabilities. They wanted a better life for their son with autism.

In a post from earlier this year, Maya wrote about her experience connecting online with people who were celebrating the 15th reunion of her graduate university program:

“I found myself staring at the conversation, wondering exactly what the hell to say to these people. 'Do I tell them that we are broke? That paying for my son’s therapies and child-care has ruined us, financially, so a trip to Chicago isn’t really in the budget at the moment?...Or do I tell them that I really don’t want to sit around and have polite conversation about their PhDs and growing resumes...?

I am in awe of what Maya and her husband have accomplished with their farm. When I interviewed her, I told her I wished I had the courage to do something like that for my son. I still do.

Back to Maya's piece: “No one wants to hear the truth, when they casually ask how I’m doing, or how my holidays were. They wouldn’t know what to do with the truth, however much I sanitize it for their comfort and digestion. People want to hear about progress.”

So I post this story here as a pause. Let's take a pause and acknowledge the lengths our families go to to try to make the world a livable place for their child. Let's recognize the immense challenges and barriers, that stubbornly persist.

Because if parents like Susan and Maya find themselves at wits' end, we need to sit up, pay attention, and extend compassion, to ourselves and to every family walking a similar path.

Friday, March 8, 2019

A pharmacist who burnt out has a new mission: mental health

By Louise Kinross

Amy Hu is a pharmacist at Holland Bloorview who became interested in children’s rehab after doing a student placement here. She’s been with us for seven years, was the clinical pharmacy coordinator, and is moving into a new role with our quality team. I know Amy from the weekly staff mindfulness sessions offered by social worker Anne-Marie Batelaan. Amy says it was her own experience with burnout that made her want to talk about the importance of staff mental health. ‘I’d like to make staff mental wellbeing a priority in our organization,” she says.

BLOOM: How did you get into this field?

Amy Hu:
I fell into pharmacy because I wanted to do something with science that involved helping people. In second year I had a placement here and discovered this amazing place. I learned about the uniqueness of working in a rehab setting. Most people in pharmacy work in an acute-care or community setting, and pediatric rehab is such a niche. The unique part is how we get to follow clients for much longer than in acute-care. That means you really get to know not just the client but the whole family, and it’s very gratifying from that perspective.

I came here after the hospital moved into our new building. The natural light throughout the building, and the idea of bringing nature in, was so different from other older hospitals I’d been in. It's a healing environment.

The clients and families are resilient and courageous and inspire you every day, and the staff are incredible. The breadth of care we offer, and the amount of skill and passion people bring to their work, left a huge impression on my mind as a student. After my schooling and training, there was an opportunity here and I snatched it up.

BLOOM: What is a typical day like?

Amy Hu:
There’s a lot of activity happening in the basement. That’s the control hub of medication management in this hospital.

The pharmacists could be rounding with the interprofessional team, reviewing medications with families, calling a community pharmacy to help transition a family back to the community, or helping to wean a client off of pain medicines.

Our technician team could be preparing medicines for our inpatients and adjusting them constantly as they change over time. We also sit on many hospital committees to ensure medication safety and do project work at a higher level. We mentor many students and end up hiring about half of them. So there’s a great variety of clinical and project and teaching work. We also support clinical trials at the hospital.

BLOOM: How many people work in pharmacy?

Amy Hu:
There are 10 bodies overall and we have just under three full-time pharmacists.

BLOOM: How did you move from being a pharmacist to your coordinator role?

Amy Hu:
I think it speaks to the increasing complexity and acuity we’re seeing in our population, which I feel started about five to six years ago. I realized that the clinical skills I learned in school weren’t enough to serve the clients here, whose needs were shifting. It required more collaboration and problem-solving at a higher level and more leadership skills. So I went back to school for a master’s of health administration while I was working here.

BLOOM: How did you do that?

Amy Hu:
It was an incredible program at the University of Toronto that enabled me to take two days off every three weeks, and you carry close to a full-time work load and do courses back to back. It allowed me to bring real-world problems and issues into the classroom, and what I learned I could apply back here. I loved the program and use the skills I learned every day.

Now I’m about to move onto our quality team in a new role the organization has supported. The goal is to support front-line teams on projects related to quality or process improvement. It’s something I'm passionate about, and have done for the pharmacy team as a coordinator, but I haven’t had a chance to work with many other teams. This role will allow me to work with inpatient and outpatient teams across the hospital. I'm really looking forward to meeting and learning from our teams, understanding their work flow and hopefully bringing forth meaningful change.

BLOOM: What is the greatest joy of your work?

Amy Hu:
Meeting the amazing people at our hospital. It takes special people to work here, to be a nurse or a social worker or a therapist or a therapeutic clown. It’s incredible to have everyone working together, and that includes the non-clinical staff from departments like information systems, teaching and learning, the research institute and our leadership team.

BLOOM: What is the greatest challenge?

Amy Hu:
The greatest challenge is that there’s so much that can be done here and so many well intentioned people, that it’s easy to go overboard.

BLOOM: You mean in terms of staff?

Amy Hu:
Yes. These days on the frontline I feel like it’s rare to bump into somebody who is coping really well. There can be a lot of stress and symptoms of burn out. That's concerning. It affects people’s capacity to do the work they love to do. Clinicians are put in positions where they have to say I would really like to do this, but I just physically can’t. How do I choose? That’s a tough place when you’re trained as caregivers to give.

BLOOM: What kind of emotions come with the job?

Amy Hu:
All the myriad of human emotions. Like many other people, I have high expectations on myself and feel guilty when I feel like I should be doing more. There’s work stress, and then conflicts between team members can be challenging as well. A couple of years ago it really kicked in for me and I burnt out.

BLOOM: What happened?

Amy Hu:
Work was really tough and I had a family crisis on the side. I remember one day sitting in front of my computer, double checking a medication order before it went to the unit, and the words were not registering. I thought to myself: ‘What am I doing here? This is not safe. I need to stop.’ With the support of our occupational health nurse, my physician and my team, I was on stress leave for almost two months.

BLOOM: What did you learn?

Amy Hu:
As a clinician, you never intend to get to a point where you can’t work. I really learned my own limits. I’m human and I’m fallible and I need to take better care of myself. I needed to actually learn how to be kind to myself. While I was off, I took the mindful self-compassion course, and that was transformative for me.

BLOOM: That’s the course that our social workers Anna Marie and Dagmara offered to staff here recently.

Amy Hu:
Yes. It's amazing that this program was offered here. I did it elsewhere. It helped me to get back to work stronger than I was before—to be more present, and to take time to reflect on what’s important to me, what I value, and how can I bring more of that into what I do. I acknowledged that I needed help from counsellors and mentors. It was a very humbling experience.

BLOOM: What do you do differently now?

Amy Hu:
 With practice, I can take micro pauses throughout the day and become more aware of my experience. I notice if I’m getting triggered, or if certain emotions are coming up, and I allow them to be there. By pausing, leaning in to the emotions, and befriending them, I find I can respond in a kinder way. 

In the past, I was relentless at pushing myself beyond my capacity. Now I say ‘Let’s take a breath.’ The self-awareness helps to regulate my emotions and I also find it helps me to be with the challenges that other people may be experiencing. Finding inner compassion helped me to be a more empathetic person and to better support the people around me.

BLOOM: I think many staff may feel burnt out, but are afraid to approach someone with what they’re going through.

Amy Hu:
That’s why I want to share this story. I think there can be a lot of fear and shame and guilt around recognizing that you may need more support. And it’s not your fault.

The work is quite challenging: we go towards people’s suffering every day. There can be stigma around seeking support, and it’s so important to share the message that getting help is okay. In fact, it takes a lot of inner courage and kindness to go towards our own challenging experiences and emotions.

I had to learn that getting support didn’t take away from my ability to perform—it enhances it in so many ways. I gained so much self-knowledge from this experience and that enabled me to bring a lot more depth and care into my work.

BLOOM: So when you came back from leave, were your hours staggered?

Amy Hu:
Yes, it was a very gradual approach over many weeks, and I kept the counselling support on the side. My manager and teammates were very accommodating, and I'm grateful for their support.

BLOOM: Was it hard to find a therapist?

Amy Hu:
I started with our Employee Assistance Program, and then they suggested I find someone I can work with over the long term. That has been incredibly helpful. 

As I transition into my new quality role and train my team members, sometimes they ask me ‘How do you do it all?’ I remind them that I continue to seek counselling support for my own wellbeing.

For another person, maybe it’s not a counsellor that makes the difference—maybe it’s a friend or a colleague that you trust who is able to be there for you. Through that relationship and self-reflection, you come to a deeper level of understanding yourself. There are people who care and can support you. No one has to do it alone.

BLOOM: What qualities are important on the pharmacy team?

Amy Hu:
The medication safety process is so intricate that you need to be detail oriented. Collaboration is also crucial because it takes the whole team to deliver the right drug to the right person at the right time. One person can’t do it. You need a lot of problem-solving skills. And more and more, we need resilience to change.

BLOOM: You said there’s been a change in the type of clients who come through our doors.

Amy Hu:
They’re coming in with more medications, and more acute medications that have higher risk profiles. Our clients are also younger, so they’re more vulnerable in general to side effects of medicines. We’re also seeing a psychosocial complexity with the families we’re working with.

BLOOM: What’s an example?

Amy Hu:
We may be supporting families who are involved with children’s aid, or who are trying to cope with huge financial challenges. Finding them drug coverage is becoming more challenging. Our families are pulled in so many directions. Trying to figure out equipment, where will they live, how do they feed their child, and on top of that there’s the medication. It’s a lot for them to manage, and in a short period of time. We work with our social work colleagues and our whole team to try to problem solve.

BLOOM: How do you cope when, despite best efforts of everyone on the team, an error occurs? Because we know that every person in this building has made a mistake at one point or another.

Amy Hu:
When medication incidents happen they can be very challenging. We have a good system from a problem-solving perspective. We have a clear process to disclose to the family. As a team, we come together to debrief about where the system could have gone wrong, what the contributing factors were, and what we can do to reduce risk moving forward. From this process perspective we’re very experienced.

The part I find more challenging—and I know other clinicians find challenging—is the emotional impact. It’s the guilt and self-judgment of ‘How could I have done that? How could we have failed?' It’s a tough burden.

No clinician wakes up with the intention to harm somebody. When the stress isn’t so high, these incidents don’t happen. They happen when the system is being stretched, often for a long time, and relies on humans to hold it together, and something eventually falls through the cracks.

These incidents stay with you, and they affect your sense of competence. There's not too much about this in the literature yet. I know from speaking with colleagues at other hospitals that this is something they struggle with.

BLOOM: I know that in the narrative group for inpatient nurses we ran, participants came into the intervention thinking that they were the only ones who struggled with guilt or regret when an error occurs.

Amy Hu:
I agree. That’s why I believe we need to place more priority on debriefing, and foster psychological safety in these conversations, so clinicians aren’t living with the guilt and fear by themselves. If you can process as a group what happened, find support in each other and feel you’re not alone, it helps everyone to cope better. I think it takes time, and every person may be at a different stage of readiness for conversations like this.

BLOOM: If you could change one thing about our workplace, what would it be?

Amy Hu:
It would be to make staff mental wellbeing a priority in our organization. That could be at multiple levels. We could support teams to have open conversations about challenging experiences that make clinicians feel vulnerable. It could be supporting more mindfulness programs at the hospital, so more staff have access to these tools.

It could also be at the individual level—for each of us to reflect on what wellbeing means to us, what matters to us, and what we can each do to support ourselves and each other. It takes a whole village to run this operation and care for our children and families. We need a cohesive approach to addressing this.

Wednesday, February 27, 2019

'I love it if someone needs help and I can help'

By Louise Kinross

If you're a parent staying at Holland Bloorview with your child, chances are you know Berthe Nabico. Berthe has been a housekeeper here for 30 years, and her ready smile and willingness to sit and chat with parents and kids makes the hospital feel more like home. Berthe speaks four languages, which comes in handy for some of our clients, and she's a master seamstress who adapts clothes for children with disabilities and in casts. In Holland Bloorview's accommodations for families, Berthe has sewn playpen mattresses, recovered furniture upholstery and made all kinds of positioning cushions. Her day begins at 6 a.m., when she puts in three to four hours at her sewing machines at home, before coming to her job here. In addition to adapted products, she makes all kinds of bedding, pillows and window coverings at Berta Beds. We spoke about her long history at Holland Bloorview.

BLOOM: How did you get into the field of housekeeping here?

Berthe Nabico: Thirty years ago I came from France. My husband was looking for a job, and somebody told him that Bloorview was hiring. I went with him to apply and we were told 'No, it's not for a man. It's for a lady.' At that time, there were jobs for men and jobs for ladies.

My husband said maybe I should ask about the job for me. I had been cleaning houses and all of the people I worked for loved me, and I loved them, too. But my husband said it's better for you to have a steady job. I thought he's right, so I asked for me. I got an interview with Mrs. Parker, and she asked me a few questions. I didn't have any English then, so I was trying to use sign language.

She said we'll send you a letter if you're not going to get the job, and we'll call you if you have the job. 

When I arrived home my phone was ringing. I took the phone, and it was Mrs. Parker, asking if I wanted to start the next day at 8 a.m., and I said yes. That was April 11, 1989.

BLOOM: What made you stay all these years?

Berthe Nabico: To tell you the truth, when I started, there was a 17-year-old boy who was a patient. The nurses told me 'If you see his door closed, don't go in the room,' so I always respected that. But one day the nurses were at the nursing station and I was cleaning another room and I heard this boy crying. Sobbing. I said 'I don't care what the nurses tell me, I can go inside this room because the boy is crying.'

I opened the door, and the boy's g-tube was wrapped tight around his neck. I screamed and said 'Come here, this boy needs help!' The parents were very happy and said I had saved their son's life. When their son went home, they asked me to go and work at their house every day. I said no, my place is here. 
Something inside me told me 'I think this is the right place for me to be.' 

BLOOM: Wow! What is a typical day like for you now?

Berthe Nabico: I'm working in the accommodations for families. It's a place I love. So many people, when they come, they're in a lot of stress. I let them sit, and every day I'm asking 'How is your son today?' or 'How is your day going?' I encourage them, and when they leave they wrap me [in a hug] and want to stay friends with me. I have many friends from work on my Facebook. 

I clean 10 rooms every day, and also do some cleaning in other areas. In the rooms I make beds and do everything perfect. 

BLOOM: What is the greatest joy of your work?

Berthe Nabico: I love it if someone needs help and I can help, and after I like to see their smile, or they thank me for helping them. 

BLOOM: What is the greatest challenge?

Berthe Nabico: At the end of the day I'm tired. It's very physical work.

BLOOM: What kind of emotions come with the job?

Berthe Nabico: I feel sad when I see suffering, and sometimes I like to teach people how to survive, how to do this better.

I remember one family arrived and the husband came in the room and said 'It's very hot. Do something!' I said 'Okay, I can open the window,' and I did. Half an hour later, he comes back and says 'Now it's cold.' I could see it wasn't him, it was his nerves. So I sit with him, and I touch him, and I say 'Can you say please, or give me a little smile?' A few days after he came to me and [hugged] me and said 'Thank you so much for understanding how we were feeling.' 

It's things like that. We have to see how people are feeling inside, and give them what they need.

I had a family and the first day they came, the mother told me that for two months she was in stress, because she was afraid the room here would be dirty and very ugly. She even brought cleaning supplies. When she arrived, the floor was spotless and everything was clean, and she was so impressed and said 'Everything is perfect.' After that she bought me a coffee and asked if we could be friends.

Sometimes I feel stress, but I calm down. 

BLOOM: Does anything help you manage stress?

Berthe Nabico: It helps me when I'm sewing, especially when I'm doing something new. Sometimes if a child here has a cast and it's very hard to pull on their pants, I will adapt their clothes so the parent can open and close them with Velcro. Creating something like that takes out my stress.

BLOOM: What kind of qualities are important in your job?

Berthe Nabico: You have to be polite, always with your smile. And if you have problems, don't show the people your problems. Make sure you are doing a good job. I'm very picky. 

BLOOM: What have you learned from families?

Berthe Nabico: Everyday I learn with them and they learn with me. Everyone is different. Every situation is different. All these years I've learned how to handle different families and help them. It's the same with the kids. I have so many stories you could write a book.

BLOOM: How do you compare the care we provide now, with the care we provided when you first began?

Berthe Nabico: Now we have kids with more complicated medical problems. More therapists are involved and I think it's good. Patients are better supported by a whole team of people. The other change is that when I began, children lived here permanently. 

BLOOM: You told me that many families abandoned their children at the old site.

Berthe Nabico: Yes, they did. But we also had some amazing parents. I remember when Emily Chan was a little baby. Every day, we were expecting her to pass away, but her parents were amazing.

Two months ago I was at an event in the cafeteria and I saw Emily, who is now working here, drinking a glass of wine. I went to her and gave her a hug and said 'Emily, you make me so happy. You make my day today.'

BLOOM: That's an incredible story! I remember Emily racing down the halls in her electric chair to go to the MacMillan site school.  She was part of our integrated kindergarten. Is there anything we could change to make our care better?

Berthe Nabico: I think they're doing a good job. Something that is very important is the summer camp.

BLOOM: Spiral Garden?

Berthe Nabico: Yes. The garden is very, very important for the inpatients. Think about if you were in your room, sick, and you don't have anyone to talk to. The volunteers come and talk to these kids, and when they are out in the garden, they're distracted, and they forget they are sick.

Tuesday, February 26, 2019

'I wanted to make sure this didn't happen to another kid'

By Louise Kinross

Laura Oxenham-Murphy is the interim director of Quality, Safety and Performance at Holland Bloorview. Laura first thought about improving hospital care when she was a child. That's because at age eight, she was on the receiving end of a medical error. "It ended up having a huge impact on my life," Laura says. We spoke about how this experience spurred her career.

BLOOM: Can you tell us more about your story?

Laura Oxenham-Murphy:
When I was eight I was scheduled to have a routine surgery to remove three child teeth. That was that, and I was supposed to go on my merry way. But the surgeon that was operating on me had the wrong patient chart. He ended up doing a procedure that was completely incorrect and removing three adult teeth.

It meant three or four follow-up surgeries that I wouldn't have had to have. And quarterly visits to a specialist, who lived over an hour from my house, from age eight to 18. What was most significant was that the incorrect surgery was visibly obvious for many years. For all of junior high I was missing teeth. It wasn't pleasant.

BLOOM: Why did you have to have the follow-up surgeries?

Laura Oxenham-Murphy:
They removed enough adult teeth that the bone disintegrated, or stopped growing, so when I was old enough to have a permanent implant put in, the bone structure wasn't there. I had to have bone grafts and the recovery from that involved missing a lot of school. Then I had to have surgeries for permanent implants. It was painful. And none of this had to happen.

BLOOM: How did you initially cope?

Laura Oxenham-Murphy:
Even as an eight-year-old you're concerned with what will people say, or what will people think at school? I'm going to look a bit different from other people. At eight, I didn't really understand why this happened. Why did he make the mistake?

When I went back to follow up with a different specialist, even as a child I could recognize that he was trying to cover up what happened and minimizing it. 'Well, you might have had to have these teeth taken out anyway' was the argument he got into with my mom. I piped up: 'No, I specifically remember I was told it would only be my baby teeth and it wouldn't have affected my adult teeth.'

BLOOM: How did that experience lead you into quality?

Laura Oxenham-Murphy:
From a young age I wanted to make sure this didn't happen to another kid. At first I thought that meant going into clinical practice.

But my mom is a health-care practitioner and she said if you really want to make change at a system level, you should consider doing a master's in health administration and work in an administrative and leadership capacity. That spurred me into taking a pretty non-traditional route into the role I have today. I went straight into the administrative role, as per my mom's coaching.

BLOOM: Has not having a clinical background been challenging?

Laura Oxenham-Murphy:
It can be, and certainly comes up from time to time, primarily in job interviews and when I meet new colleagues for the first time. However, I think I'm able to bring a different lens and ask different questions.

That said, when working on quality and safety improvement projects I make sure to have a strong team that always includes clinicians.

I don't regret the path I've chosen. When I got into my master's and was able to take a couple of elective courses in quality improvement, that's where it hit me. Yes, yes, this is what I've been thinking about since I was 10 years old!

BLOOM: What is a typical day here like?

Laura Oxenham-Murphy:
Oh boy. You may have a plan for what you hope to accomplish, which are mostly projects at a strategic level. But then incidents, complaints or concerns come up, and most often those are things that require immediate attention, so your plan for the day gets derailed. I manage urgent risk cases as they come to me, or privacy concerns.

I work closely with the people on my Quality, Safety and Performance team, as well as others across the hospital. We're a very close-knit QSP team, so to meet deadlines and get the work done, I rely on my colleagues. It's a very dedicated team and I'm proud to be part of it.

I spend a lot of time in meetings, and work with my counterparts in other hospitals to further the quality agenda at a system level. We share resources and best practices we can take back to our own organization.

BLOOM: What's the greatest challenge of the job?

Laura Oxenham-Murphy:
The unpredictability. Some days you might have nothing out of the ordinary, and you're able to get into a good flow on some of our projects and initiatives. Other days, one thing after another happens and you're not able to open your e-mail till 5 p.m.

BLOOM: How do you manage stress?

Laura Oxenham-Murphy:
I wake up at 5:30 every morning and exercise. We have a bare-bones home gym/yoga studio and my husband and I are both very committed to getting each other out of bed. We go down to the gym or if the weather permits, we go for a run. It's the only time we get to spend together on weekdays as our jobs pull us in different directions in the evenings.

I wouldn't be able to do what I do here without that. We'll exercise for 45 minutes to an hour, then spend time together eating a solid breakfast of oats, coffee and some fruit. I find it really grounds me. And we try as much as possible not to talk about work.

BLOOM: What's the greatest joy of your job here?

Laura Oxenham-Murphy:
I love when there's been a risk issue and I'm able to interact with clients and families, as well as front-line staff, and we're able to come to a resolution, or even to see small differences, that shift the relationship to a more positive one.

I love bringing together passionate people—clinicians, leaders, clients and families—to work collaboratively on a particular quality improvement initiative, and supporting their capability and commitment. We are so fortunate as a hospital to have such a highly engaged group of clinical and non-clinical staff, and I see my role as enabling our staff in their commitment to quality and safety.

BLOOM: What's an example?

Laura Oxenham-Murphy:
One of the things I'm most proud of is our recent success with our last Accreditation cycle. It's not about the exceptional results we received from the surveyors. What I'm really proud of is playing a role in having our clinicians, leaders and clients and families partner together more closely on quality and safety.

BLOOM: How often do you work with parents and kids?

Laura Oxenham-Murphy:
On a weekly, even daily, basis. When I'm wearing my risk and privacy hat I'm dealing with clients and families. In the quality world, I'm interacting with family and youth leaders. Interacting with our clients and families is truly one of my favourite parts of the job, and really helps to ground me in what we are collectively striving toward.

One of the interesting dichotomies to get my head around is the perspective of how we merge, or think about, what are the important issues from the perspective of family leaders—a cohort of individuals that are very educated about the system and how to navigate it, and have a clear vision of where they want it to go—with a family that is concerned because their child didn't get the correct medication at a certain time.

BLOOM: What are common risk issues?

Laura Oxenham-Murphy:
There's a lot around informed consent. Parents saying something wasn't explained in a way that they understood, or that resonated for them. When there's a complex family dynamic, there might be two parents who have varying custody arrangements, and one wants to go one way and the other disagrees.

There are concerns about timely access to services or delays in treatment. With all risk cases, I partner closely with clinical teams, Client and Family Integrated Care and Bioethics together with the client and family to come to a mutual resolution.

BLOOM: How does your firsthand experience with a medical error help in these discussions?

Laura Oxenham-Murphy:
I believe it helps me empathize a little differently. It's not something I would ever say. I would never use the words 'I know what you're going through,' because clearly I don't. Every experience is different. But in the back of my mind, I can call up some of those feelings and emotions that I experienced, and my family experienced, which can help me relate to what a family is feeling.

BLOOM: What have you learned from families?

Laura Oxenham-Murphy:
I've learned so much, I don't even know where to start. One of the things I've appreciated the most about working here is the opportunity to interact with patients and families and family leaders. It's helped me to come back to that true sense of why I want to do what I'm doing, and why I'm committed. I want to promote optimal experiences for patients and families and when I get to have conversations with them, it grounds me and makes why I've started on this journey more tangible.

BLOOM: If you could change one thing about children's rehab, what would it be?

Laura Oxenham-Murphy:
I think making the system easier to navigator for our clients and families. So getting certain services doesn't require being connected to the right people and knowing the right questions to ask. If there weren't gatekeepers, and people could just come and learn about different services that were available. If the solutions were simple, we would have implemented them.

Also, from a health equity perspective, I've been thinking a lot about how we ensure our services are meeting the cultural needs of the diverse population we're meant to serve. I credit Aman Sium with helping me understand this better than I had previously. 

Thursday, February 21, 2019

Health care for disabled Ontarians fails to measure up

By Louise Kinross

Ontario adults with developmental disabilities are nearly four times more likely to die early than their non-disabled peers, and fare worse on four other health indicators, finds a
study released by the Institute for Clinical Evaluative Sciences today. 

Researchers from ICES, the Centre for Addictions and Mental Health and the University of Ontario Institute of Technology looked at the medical records of over 64,000 Ontario residents with a range of developmental disabilities, including Down syndrome and autism, between 2010 and 2016.

In addition to dying earlier, the population-based study found adults with developmental disabilities were over six times more likely to spend at least one day stuck in hospital when ready to be discharged; nearly two times more likely to have repeat emergency-room visits; over three times more likely to be readmitted to hospital within 30 days of discharge; and 17.5 times more likely to spend at least one day in long-term care.

Adults with developmental disabilities faced these problems regardless of their age, sex, or the income level of the neighbourhood they lived in.

The study defined premature mortality as dying before the age of 75. In the general population, the rate of premature mortality was 1.6 per cent. In those with developmental disabilities, it was 6.1 per cent. For people with Down syndrome, the rate was 12.3 per cent.

BLOOM interviewed study co-author Dr. Yona Lunsky, director of the Health Care Access Research and Developmental Disabilities Program and the Azrieli Adult Neurodevelopmental Centre at CAMH.

BLOOM: Why was there a need for this study?

Yona Lunsky:
The study is part of our ongoing program to look at how to improve the health of adults with developmental disabilities in Ontario. We wanted to take indicators of health care that are used in the general population and look at them together, in this population, to bridge silos that exist now. These indicators were chosen because they’re issues that have been flagged as concerns. When we’re thinking of hallway medicine, we may get an image of an older person in a hospital bed in the hallway who needs to get into longer-term care. But the person we’re talking about may be 25 years old with a developmental disability and need something different.

BLOOM: What were the key findings?

Yona Lunsky:
The main finding is that across health-care outcomes this large group of adults with developmental disabilities fares worse than adults who don’t have developmental disabilities. That means we need to do something that impacts all of those areas of care, and not just one of them. 

We’re also learning that not every single person with a developmental disability is the same. That’s why we studied different groups. How is it different if you’re a man or a woman, young or old, or living in a lower versus higher income neighbourhood? How is it different if you have Down syndrome or autism? By looking at subgroups, we see that there isn’t one solution that will fit everyone. There are unique issues.

BLOOM: Is there a reason why race wasn’t considered?

Yona Lunsky:
That’s a great question. We didn't have data on race available to us through ICES. We were working with existing administrative health data and that information is not available at the population level.

BLOOM: How would you describe health care for this population in Ontario?

Yona Lunsky:
Our study gives us a big picture of the type of things that are extremely stressful and difficult for people, and costly, and that are happening at higher rates than in the general population. This is a big problem. This isn’t a study of why. We can’t say how much is due to a person’s disability or how much is due to health-care training gaps, or stigma, or non-health related services.

BLOOM: When you looked at early deaths, were these deaths considered preventable?

Yona Lunsky:
That’s a really good question. We didn’t look at the causes of death, and that’s something we need to do. In the U.K. and Australia, where they have looked more closely at mortality data for this population, they’re finding many causes are preventable.

BLOOM: We’ve seen in other countries people with developmental disabilities dying of completely treatable conditions like constipation.

Yona Lunsky:
It's possible that could happen here as well, but we didn't look at why the deaths happened. We need to do that and then ask whether any of these are preventable deaths.

BLOOM: How did the health-care outcomes differ based on whether the person had Down syndrome, autism, or any developmental disabilities with a mental illness and/or addictions diagnosis?

Yona Lunsky:
I think the bigger message is that there are things we can do to benefit the entire population, but there can also be value in understanding the unique needs of subgroups. If you’re walking into a health-care setting, you want your disability to be recognized so you can have appropriate accommodations. And the transition from one health setting to another has to be a good, smooth supported transition, regardless of the disability you have.

But then, are there specific things we can do for adults with Down syndrome who have a higher premature mortality rate or a greater likelihood of living in long-term care?

BLOOM: We’ve heard about how youth with all kinds of disabilities fall into a care gap when they graduate from pediatric to the adult system. Why is this problem so striking for adults with developmental disabilities?

Yona Lunsky:
You work at Holland Bloorview, which is the most family-centred place on the planet. You’re used to talking to the family and the person with a disability at the same time. You make the space fun: Your floor lights up when you step on parts of it. Everyone says hi, and everyone is friendly.

Adult-care settings are not designed to be family-friendly, or to address different developmental stages. No one says hi in the elevator. If you’re an 18-year-old patient, you give the consent to the person you talk to, and health-care providers are less accustomed to including the family or other carers in the same way.

Crystal Chin has spoken about how we have developmental pediatrics, but we don’t have developmental medicine. So in pediatrics, there’s a whole area where people are trained to work with different disability groups. But in adult care, we don’t have that. There isn’t a Holland Bloorview for adults to go to. We don’t have specialized settings that are more accommodating to the unique needs of people with disabilities. And in the adult world, you’re not trained to work with people with disabilities and their families.

BLOOM: How does the devaluation of people with developmental disabilities influence care?

Yona Lunsky:
If a person with a disability is going to Canada’s Wonderland, they know that if they make their disability known, they receive accommodations. Maybe they won’t have to stand in line for so long. But what incentive do people have in adult care to make their needs known? What if from the patient perspective, you believe you won’t be taken seriously if you have a certain kind of disability? What if you think providers will attribute your problems to behaviour? What if the attitudes of professionals may make your care worse?

BLOOM: I guess even if the person does self-identify, does that mean they will receive what they need?

Yona Lunsky:
It’s the first step. Once I say ‘I have this disability’ we need staff who have skills and resources, and knowledge of what to do. From our study, we can't tell how much a lack of skills, resources and knowledge—or negative attitudes—impacts the health-care interaction.

BLOOM: How likely is it that new resources will be brought to bear on this problem given your study?

Yona Lunsky:
I can’t predict how likely it is. But in a perfect world, numbers are part of what informs decision-making.

BLOOM: What advice would you give people with developmental disabilities and their families?

Yona Lunsky:
We’ve developed some resources in partnership with adults with developmental disabilities and their families. It would be great if people could look at these resources and tell us what works, and what doesn’t work well. It’s important to look at what is already there, and if something isn’t there, to be part of the solution. We also need to learn when things go right. Everyone should have a voice.

Friday, February 15, 2019

Racism and ableism stack up against black moms, study finds

By Louise Kinross

Last month York University researcher Nazilla Khanlou presented results on a study of black mothers with children with developmental disabilities at the Racialized Maternal Health Conference in Toronto. Her team interviewed seven black mothers and three service providers to learn about the challenges the mothers faced and how these barriers influenced their own health. BLOOM did an interview, by e-mail, with Nazilla and two of her co-researchers—Luz Maria Vasquez and Attia Khan.

BLOOM: Why was the study needed?

Nazilla, Luz, Attia:
According to the literature, racialized mothers of children with developmental disabilities bear a disproportionate burden of stress, illness and health inequities. They are triply marginalized due to factors related to their Black, Latino, Asian or Indigenous backgrounds; their gender; and because they are the main caregiver for their family. Studies associate these factors with poor health outcomes for mothers.

The study was needed because our programs to promote the health and wellbeing of women do not consider the specific experiences and needs of racialized mothers of children with developmental disabilities. Based on our previous studies, we discovered there was a need to reach out to this population to hear their specific perspectives on how society and institutions can support their wellbeing.

BLOOM: How did you define racialized mothers in the study? Were they all immigrant mothers?

Nazilla, Luz, Attia:
We used the term ‘racialized’ to recognize the existence of power imbalances among the population that favour certain groups in our society and disadvantage other segments of the population. Some racialized mothers are immigrants, and others are Canadian.

BLOOM: What kind of questions did you ask in the interviews?

Nazilla, Luz, Attia:
Some examples:

-What is ‘racism’ to you?

-What does a health-care provider or social-service provider need to know about your experiences with racism, and other barriers, to more effectively meet your needs?

-Who do you think can help you to do the things you want to do? (e.g. agencies, family, partner, friends)?

BLOOM: What were the key findings?

Nazilla, Luz, Attia:
In this study we learned that the challenges of mothering children and youth with developmental disabilities increase when mothers are racialized. The added challenges of mothering a child with a developmental disability included the need to provide care around-the-clock, perhaps over a lifetime; financial difficulties; social stigma; being blamed for their child's disability; and lack of social support. On top of that, mothers needed to work extra hard to protect their children from racism and discrimination. 

BLOOM: It sounds like the first barrier they experience is the challenge of getting what their child with disability needs. And the second barrier is the racism they experience in the medical system and the community. Also, I noticed in your study that mothers felt stigmatized by their own families.

Nazilla, Luz, Attia:
Mothers referred to the issue of service access and utilization. They felt they weren't treated equally, because of race, in learning about school and health-care resources. They felt service providers didn't give them adequate information. Some mothers felt service providers were intentionally unhelpful, or were saving those supports for other families.

One said: 'We will not have access to the same services, even the developmental see how they treat the white people different than how they treat the black people. They don't give you the information that's available.'

In regards to their families, some mothers highlighted a lack of support and understanding about the specific needs of their children with developmental disabilities. They also felt socially isolated from their families.

BLOOM: I thought it was interesting that five of the seven mothers interviewed were single. Would we expect this in another population of mothers raising kids with developmental disabilities?

Nazilla, Luz, Attia:
First of all, it’s important to highlight that there is stigma and stereotyping attached to marital status. In light of this, we, as researchers, don’t make assumptions about marital status among the different populations we study. In the context of our study, we understand marital status as an important factor affecting mothers’ health-promotion experiences.

As the mothers explained, lack of support from family members (including partners, husbands, mothers and siblings) is a key social determinant of their and their children’s health and wellbeing. This lack of support intersects with other determinants, such as employment, time, and other resources.

BLOOM: What were the strengths you identified in these moms?

Nazilla, Luz, Attia:
Mothers discussed these strategies they use to cope with racism and discrimination in the context of raising their children:

-They teach their children about the reality of racism and how they have to work ‘twice as hard’ as non-racialized individuals.

-They practise and teach key values to their children like tolerance, respect and understanding. As one mother said: 'I raise my child to respect everybody, because I believe racism starts in somebody's house.'

BLOOM: What did the mothers suggest would help professionals provide better care?

Nazilla, Luz, Attia:
A key suggestion was the need for service providers to be educated about the implications of racism in the lives of the populations they serve.

Service providers should be taught, as part of their professional development, the role that racism plays in limiting health promotion opportunities; that racism intersects with other social determinants of health, such as socioeconomic opportunities; and that stigma and discrimination are part of the everyday experiences of racialized mothers and their children.

In sum, service providers need to understand the negative impact that racism has in the lives of the mothers. Service providers need to be proactive and critical about how their own activities may be directly or indirectly reproducing discrimination or racism.

Mothers also suggested we need more service providers with diverse backgrounds; more information about services; more programs and services; and a hotline to support mothers.

BLOOM: You also interviewed three professionals who work with the black community. Were they seeing similar things with their clients that the mothers talked about?

Nazilla, Luz, Attia:
The service providers we interviewed, who were of racialized backgrounds, agreed that racism exists in our society. But often racism is subtle, they said. People don’t outwardly say things, but hold strong beliefs that cause them to treat other people unfairly. Those on the receiving end may not call it racism, but talk about being disrespected or feeling insulted or shunned.

The service providers felt that racism was seen more in public places, like grocery stores and malls, but was less commonly experienced in health care. They believed that lack of socioeconomic resources—such as employment and family support—as well as language barriers, were obstacles to care, or negatively impacted the mothers’ health.

They noted that people are served on first-come first-serve basis, so people who are persistent receive the support they need. They felt diversity in the backgrounds of staff and volunteers and in program activities would help mothers feel welcome and included, and that they are treated fairly. Service providers said that they, and their colleagues, would not treat one person in line differently from another person.

BLOOM: What are next steps for this research?

To transfer our knowledge, including:

-to inform equity-based health-promotion practice policy for racialized mothers of children, youth and young adults with developmental disabilities

-to include on our website an information brief in plain language and one on video. Both will outline the health-promotion framework, and its application to racialized mothers, and other strategies will be recommended.

-to continue to disseminate findings across various venues. For example, we recently presented at the Racialized Maternal Health Conference, and at the LaMarsh Centre for Children and Youth speakers series. We will be presenting a poster at the upcoming Ontario Shores Annual Mental Health Conference.

BLOOM: If a professional takes one thing from this study, what should it be?

Nazilla, Luz, Attia:
They need to reflect on how much they know about racism, and to acknowledge that racialization and racism impacts mothers’ wellbeing through their intersections with gender, privilege and power. Furthermore, they need to be critical about the assumptions or prejudices that inform their own everyday practices, and how they may negatively impact on the racialized populations they serve. Finally, service providers need to be proactive in terms of openly addressing discrimination and racism in the settings where they work.

Service providers told us that one size does not fit all. Programs that don’t really connect or resonate with the community that they’re serving are less likely to succeed. They also believed that programs need to be tailored to specific community needs. For example, they suggested dedicated programs for people who are new to Canada versus people who are born and raised in Canada.

Please watch this fabulous video about the York University study, which was funded by Women's College Hospital's The $15K Challenge. Nazilla holds the Women's Health Research Chair in Mental Health. You can follow her @YorkUOWHC.