In honour of Nursing Week, we talk to Dr. Joy Richards, our new Chief Nurse Executive, about the ups and downs of the role so far, her vision of nursing at UHN, and the impact of changes like the Nurse Practitioner role and technology upon the profession.

Joy Richards imageFirst, I'd like to welcome you to UHN and ask you how you're adjusting to the role thus far.
Well it's week 16. I've been here four months and I think I've pretty much settled in and I think the honeymoon's over. So I'm into the work; I am really starting to set priorities and work with the team around getting some clear direction on where we're headed. Learning about some of the great work that's happening and where some of the areas are that we need to pay some focussed attention.

So I kind of feel like I've arrived home and am feeling good about it.


That's great. Are there things that have surprised you about UHN or about your role so far?
Thankfully, no. This is the third organization that I've lived this role so it's not my first time being in this kind of position and I had the great benefit of knowing many of the folks. Mary Ferguson-Paré [UHN's previous Chief Nurse Executive] was my friend and mentor. I followed her once before in a transition at Baycrest. And so I've been involved on the sidelines and knowing the work that's been involved here [at UHN] since Mary arrived. So I've been kind of connected for the last eight years in a way—I knew what I was coming into, and I knew the great team that I was going to be joining—and it's been a nice transition that way. 


What brought you into nursing in the first place and how did you end up in an administrative capacity?
That's an interesting question. I'd like to thank Ms. Lyle who was my grade 11 physics teacher who told me I'd never be a physician. And because I did so miserably in physics I started thinking about other options. It was my mother who suggested that I think about nursing and that I think about getting my degree in nursing, which back 30 years ago was pretty amazing. 

So I just sort of fell into nursing because I didn't want to be a teacher and I didn't want to be a secretary. And I've never looked back. I've loved every single aspect of my career.

The funny thing is, I've never actually planned my career. I've always happened to be in the right place at the right time. Somebody would say, 'You should think about teaching' and I'd say 'Okay, I'll do that.' 'You should think about working in pharma.' So I went off and did that. And so I just happened to work my way through. I was a manager in a couple different organizations and director opportunities came along. And then Mary Ferguson-Paré left Baycrest when I was a director there and she said 'You're going to be the next vice-president so go and ask for the job.'

So I just have been very fortunate. I've been surrounded by very strong mentors who have just seen my strengths and opened up opportunities for me. Sometimes they dragged me in or pushed me in when I didn't want to go and other times it just seemed like a natural fit. 

It's kind of by, maybe divine planning, but certainly nothing that I've deliberately sought out. So if you would have told me that this is what I'd be doing in this part of my career, I probably would have laughed. But my passion is still at the bedside and so whatever roles I do, I always stay connected to patient care. 


Before your grade 11 physics teacher had said that, was your plan to be a physician?
Yes, I thought that's what I'd like to be. Either that or a pharmacist because my uncle was a pharmacist. So I've always had an interest in health care. And I'm not really sure why thought I wanted to be a doctor other than I just thought that I always thought I wanted to help people. I've always had a part of me that enjoys engaging with people and making a difference.

But I don't know why I'd never thought about nursing. There were no nurses in my family and nobody was ever sick so I never really had exposure to hospitals. But my mother obviously knew me very well and it's just been an absolutely wonderful career.

I can't imagine doing anything else. 


What has been the most challenging part of your role so far?
Well you know, UHN is a big organization and it's a complex organization and so really trying to get a sense of what the issues are, what the strengths are. I think my biggest challenge has been is that I've got two directors that have either left or are leaving. 

My first week that I was here, I knew that Petrina McGrath [Director of Nursing, TGH] was going to be moving on to a wonderful position in Saskatoon. And now Deb Bournes [Nursing Research] is taking on an exciting position. So trying to stabilize the team and work with the team when things are changing. Which I think is just part of the natural trajectory. Both of these women have moved on to amazing careers and we're still connecting so there's nice ways to continue to work with them.

But that I think has been my biggest challenge. Just when I think I've got it figured out, something changes. Which is about life. So learning to go with the flow and living with a bit of ambiguity. That's probably been my biggest challenge and just the sheer size of the organization and trying to get to know people. But nothing I can't manage. Just have to take one day at a time and bite off one piece of the elephant at a time. 


You mentioned just a second ago about the size of UHN—that leads very nicely into the next question. UHN being such a large organization, how do you plan to get to know or have you been getting to know all of the various areas and units within UHN?
I've had a plan of attack, so to speak, since I've arrived. Since the first week that I was here I've had a key strategy of, first of all, meeting my counterparts at the vice-president level and spending time getting a sense of their portfolios; drilling down and meeting with the directors across all three sites; and then to the managers. And at the same time, spending time on the unit.

So this morning, for example, I was up on psychiatry on the 8th floor and I was also on general medicine on the 13th floor. Spending time with the managers there spending time with the staff, getting a chance to hear from the nurses—what's working really well, what keeps them up at night. 

I've been connecting with all of the counsels so the Nursing Practice Counsel—any opportunity to actually engage with clinical staff across all the disciplines has been really helpful. 

So it's going to probably take me six months to eight months to actually connect with everyone and get to all three sites but I try and spend every week, a little bit of time at every site. Hopefully once I've sort of done my initial go-around and meeting with people that I'll get into a routine of blocking off significant time so I hope to spend one full day a week over at the Western and I hope to spend a half-day over at Princess Margaret. 

I'm doing walkabouts with the site directors on a regular basis so that I can actually get up to the units and meet with the teams. So it's just a matter of timing but I've got a plan and I'm slowly connecting with people so it's good. It's all good. Now I can walk down the hall and see familiar faces and know who they are. 


What is your vision for nursing at UHN?
Coming to a place like UHN, I want to honour the work that's been going on before me. I think that when Mary arrived 10 years ago, nursing didn't have much of a profile. Mary Ferguson-Paré's work and the work of Deb Bournes, and the teams that have been working with her, have really been about developing depth and breadth within nursing. Every discipline needs to have that—needs to be grounded in strong, academic discipline-specific research, a strong education component, and then best practice, using evidence-based practice to guide that work. Mary has spent a necessary amount of time building depth and breadth within nursing. And it has been very siloed within nursing in order to develop that strength, that bench strength and bedside strength.

My vision now is to take that great work, and continue to build depth and breadth, but at the same time, start to integrate it in a tapestry with other disciplines. So just as depth and breadth needs to happen in social work and medicine and occupational therapy, part of my mandate is to start looking at interprofessional practice, interprofessional collaboration, and how do we come together as disciplines around the patient and family in a patient-centred approach—patients as partners—to be able to make sure that the teams are communicating in a way that the patient is in a container of safety? And that there aren't gaps that currently exist sometimes across disciplines.

So part of my focus is to be really looking at models of care, around both discipline-specific and how do we come together. Patient-Centred Care—I'm working with the senior team and the rest of the organization around taking Patient-Centred Care to the next level. So thinking about patients as partners and developing a strategy around that. So how do we allow patients access to their charts? How do we get patients and families sitting on committees so that they're actually helping teams guide the work? How do we engage them in Rounds? How might we leverage patients and families as auditors around hand hygiene, to help hold us accountable? Helping to find their voice in a different kind of way.

So there are a number of themes that we're working on that come together in a beautiful tapestry. It's kind of the "both/and" not "either/or". As I'm thinking about building depth and breadth and continuing in the work around best practice, looking at role clarity, good news around nurse practitioners and their increased scope of practice. So how does that role clarity, how do we support the evolution of that? At the same time that we're looking at what's happening around clinical interface with clinical nurses—other roles within other disciplines, and how do we come together in a different way?

And then how do we push the boundaries of the organization out? As we're thinking about Toronto Rehab and the potential merger there, we have a wonderful opportunity to think about continuums of care within the organization in a different way. And that can only support better patient care, better patient safety, and better autonomy for patients, but also great learning opportunities for staff. So it's kind of an exciting time to be joining the team.


What additional skills are needed for nurses to compete in a growing technological environment?
That's a very good question. It's something I've been spending a lot of time thinking about, because I've been teaching a third-year health sciences course, out at the University of Ontario. I had 125 young adults in this class who are highly technologically savvy. It humbled me, because I realized how little I know; I also realized that their brains are wired differently than mine.

So I think as technology is taking over our lives, learning how to be savvy, I think there'll be a tipping point eventually when young people, who understand computerization, use technology in everything—downloading apps, and communicating and multi-tasking through electronic media—as we think about patient services, like telehealth and other technologies that are helping us to provide care remotely, I think it behooves all nurses to understand and get comfortable with that technology. At the same time, there's a balance.

One of the things that I also observed in young people is that they're losing their ability to have meaningful conversations—because they're so reliant on electronic communication—and understanding non-verbal communication, coming together and having courageous conversations and difficult conversations. So there's a balance, like with everything. And I think I'm always—perhaps it's my age—thinking about everything is good to a limit, but making sure we're not losing some of the inherent skills about inter-relationships. So developing relationships in a way that all work is done and all practice is done through building relationships with colleagues and with patients and families, and understanding that way to communicate.

So we can't lose that side, as well as, how do you enhance our communication through technology. So I think there's lots of opportunity, and more and more we'll see technology being embedded into health care. As we think about treating patients beyond the walls of our hospitals—virtual wards, technology connecting patients from distances when they've gone back home again—we all need to get comfortable with it. But again, in a balance of also recognizing we still need human-to-human contact, and understanding those relationships and building those relationships are key.


And that human-human contact, is that especially paramount within the nursing spectrum?
Absolutely. Although I think human-to-human is important, I think that often miscommunications happen when we're not paying attention and we're not listening. So part of the skill set of communication, whether it's face-to-face or over video conferencing—but not necessarily with texting—is the ability to actually hold that space and listen and understand the context of that conversation.

So what I've learned from the students in my class is that's something they're not comfortable with. And it's important for all clinicians to be able to understand, and pay attention to someone who's in pain. What's that body language really telling you? If they're not really understanding, or they're not engaged in the conversation, what are the non-verbal cues?

So those relationships—building trust and being able to have tough conversations with colleagues or patients and families—comes with a particular skill set that nurses absolutely have to have it, physicians have to have it. It's part of the human condition, is to be able to create those relationships that people trust. And as length-of-stay is becoming shorter and shorter, those sound bites of communication become much more important. So every opportunity that we're engaging with another human being is an opportunity to create space to actually inform the other. And we know that when two people are sitting together, the magic of our DNA shifts. We're influence, and our bodily structures are influenced by being with each other. You know when you're in a room with someone who's really excited and got high energy, you feel happy when you leave them. If you're sitting in a meeting with someone who's really depressed and is always chronically down, you feel depressed when you leave. So there's all these dynamics around relationships and communication, that I think are so important that we don't talk enough about.

I'm always a big proponent that you can have all that technology, but we still need to know how to be together with each other.


You'd mentioned earlier about the changes in practice. Premier Dalton McGuinty announced on Friday, April 8 that nurse practitioners can now start discharging patients in July, and will be able to admit patients to hospitals starting in July 2012. How do you envision that this change, whereby NPs can discharge patients from hospitals as of July 2011, will affect the practices at UHN?
I think first of all, mazel tov. I think that this is just an amazing, an amazing thing, and has been in the works for a very long time. I think Nurse Practitioners are a vital role, and I think that in partnership with our physician colleagues really provides a wonderful partnership for providing care for patients. And it speaks to and honours the work and the knowledge and critical thinking of nurses and our advanced practice roles.

I think here at UHN, I don't think it will shift our practice substantially. I think that we already have very strong nurse practitioners who are working in strong partnerships with our physician colleagues, who value the role. So we're way ahead of the curve in terms of how that will transition. There'll probably be some process and structural issues we might need to think about, but overall I think it will be a fairly seamless transition. I think where we'll see speed bumps are in smaller community hospitals where there may only be one or two nurse practitioners, who maybe don't have as clearly a defined role. I think this will be the beginning or the tipping point of the role continuing to evolve. So right now acute care nurse practitioners are needing medical directives. I can see a time when that might shift and that the scope of their work may become much more autonomous. But I think what this talks about and what this demonstrates is the capacity and the openness to be thinking about evolving roles and new roles that will support patient care. And it speaks loudly to the skills set that nurses have and what nurses bring to patient care in a much more complex way.

So I think it just honours and validates what nurses have been doing for a very long time, and legitimizes that work. So it's a win-win all around.


What do you do to unwind?
Well, I'm a swimmer. I don't swim as much as I would like, but I try to get to the pool a couple times a week and do my 2K laps. I like to swim, I like to walk my dog. I like to read—I'm a voracious reader. I wouldn't say no to a glass of wine. And spending time with friends and regenerating. I'm an introvert by nature, although people find that hard to believe. So I get my energy by being quiet and just cocooning. So I'm quite happy when I'm at home in my PJs with a good book, and quiet and some nice music. Doesn't take much to keep me happy.

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