Addendum 3

MEMORANDUM OF UNDERSTANDING
for
CIRCUMCISION PROCEDURE
January 31, 1995

It is the policy of St. Vincent Hospital to continue offering circumcision procedures to families in this hospital. Nursing staff, physicians and the administration (all parties) agree that patients and parents will continue to be offered as positive an experience in the hospital as possible, recognizing that the parents' choice in this informed decision. All parties are interested in providing the highest standard of quality patient care. All, also, acknowledge the rights of nurses to conscientiously object to circumcision (CO nurses) and also, the rights of nurses who are willing to assist in the circumcision procedure (consenting nurses).

The MOU has been written in a specific effort to set parameters, boundaries and guidelines for handling the circumcision procedure on the maternity units of St. Vincent Hospital. This MOU is limited to the issue of circumcisions and specific to nurses assigned to work in the maternity units. This MOU will apply to all persons working in the department, and supersedes any conflicting policies, agreements or procedures except as expressly incorporated herein.

Scheduling Guidelines for Procedure:

1. The Hospital will request that the physicians try to schedule circumcision procedures from 7 am - 7 pm, Monday through Saturday, in advance of the actual procedure being done.

2. The Perinatal Committee has agreed to establish written guidelines as soon as possible for performing the procedure, which will be posted on the maternity units.

3. The physicians, consenting nurses and conscientious objector nurses will jointly create an information packet to be offered to parents, as far as possible, in advance of the procedure.

Staff RN Scheduling by Administration

The administration has agreed, within the following guidelines, that the conscientious objector nurses will be relieved of duties of circumcision. Those duties are: witnessing the consent, dispensing pre-op medications, preparation of the room, immediate post-op care such as stopping the bleeding and applying vaseline dressing, cleaning up afterwards and stocking the room. Subsequent post-op care is not considered part of the circumcision procedure. Subsequent post-op care includes the following: periodic observation of the wound, wound care as needed, teaching of the family, and in the event that the wound has not been shown to the family by the doctor or assisting nurse, the CO nurses are willing to perform the task.
The administration has agreed, within the following guidelines, that the conscientious objector nurses will be relieved of duties of circumcision. Those duties are: witnessing the consent, dispensing pre-op medications, preparation of the room, immediate post-op care such as stopping the bleeding and applying vaseline dressing, cleaning up afterwards and stocking the room. Subsequent post-op care is not considered part of the circumcision procedure. Subsequent post-op care includes the following: periodic observation of the wound, wound care as needed, teaching of the family, and in the event that the wound has not been shown to the family by the doctor or assisting nurse, the CO nurses are willing to perform the task.

1. Scheduling is the prerogative of management, taking into account as priorities the needs of the unit, patient care needs and individual staff's scheduling preferences. As always, schedules developed by staff on the unit are subject to review and final approval by the manager/director.

2. Those nurses claiming conscientious objector status to circumcision shall report their status, in writing, to the manager/director of the unit, who will then submit a copy to Human Resources.

3. Nurses will notify the manager/director if they are willing, on occasion, to adjust their schedule by starting their shift earlier or staying later if necessary. For example, if a nurse is scheduled for an evening shift and a doctor wants to do a circumcision at 1300, the evening nurse could come in to work from 1100 to 1900 instead of from 1500 to 2300. This avoids time and one half.

It is a priority that all nursing staff represent the Hospital in a positive manner to families. It is understood by all parties that in order for the maternity units to run smoothly and efficiently, there must be an emphasis on teamwork among the staff nurses. This MOU in no way changes the current standard of practice regarding cross-training to other related areas, assisting fellow staff members in translations, starting IV's, and specific teaching for mothers on how to care for their babies. The nurses agree to continue to communicate with management at the beginning of the shift regarding staffing needs. With that understanding, the following parties agree to:

Consenting Nurses are Expected to:

1. Do duties and tasks associated with the circumcision procedure.

2. Assist the doctor while CO nurses take their assignments during the circumcision.

Conscientious Objector Nurses are Expected to:

1. Make a fair exchange in trading units of work with consenting nurses.

2. Take the consenting nurses' assignments while they are assisting the doctor with the procedure. CO nurses will cover assignments on peds & med/surg. if the consenting staff are drawn from those units, and while the consenting staff are on the maternity unit to assist with the circumcision.

All Nurses are Expected to: Nurses are Expected to:

1. Handle themselves in a professional manner when dealing with the families before and after the procedure. The nurses will endeavour not to show their disapproval or dismay about the families' decision concerning circumcision.

2. Provide answers to questions concerning specific approved informed consent materials ordered by the doctor, but not provide additional personal counselling. They will assist the families in contacting their physicians for additional information and/or counselling.

3. Will provide post-op care for their assigned patients with the understanding that they will have some flexibility in taking those patients if sensitivity to the procedure prevents them from being able to follow through with the after care.

4. Will show respect and sensitivity to all nurses who work on the unit.

5. Participate in a mandatory inservice focussed on patient, staff relations and communications on the subject of circumcision and issues surrounding it.

Staffing Protocol:

If there is not a consenting nurse from the department on duty at the time of a scheduled circumcision, the charge nurse is expected to exercise all options available to her, which may included but are not limited to the following:
If there is not a consenting nurse from the department on duty at the time of a scheduled circumcision, the charge nurse is expected to exercise all options available to her, which may included but are not limited to the following:

- Utilize the unit's on-call staff. When scheduling, a green star will be used to indicate if a consenting nurse is needed there. (This would be done only if there is no consenting nurse already scheduled.)

- Utilize the SOS nurse, if skilled and available, and if she/he consents.

- Utilize staff from other units, if skilled and available, including peds, OR, or med/surg who consent to assist.

- The unit's manager/director could assist, if no other staff could be found.

Accountability

Any physician, patient or staff complaints that arise will be investigated, and if discipline results, it will be handled through the Union's contracted grievance procedure. Each nurse will do their best to maintain a professional and non-judgmental approach to the care given to all patients/families.

Unit preparation to accommodate staff from outside the department who come in to do circumcisions:
Clear and specific directs on how to assist will be developed by unit staff and displayed in the circumcision procedure room. The intent is that staff from outside the department can come in and easily be able to assist with circumcisions. The maternity staff will promptly and courteously hand questions that staff from outside the department may have in assisting with the circumcisions.
Clear and specific directs on how to assist will be developed by unit staff and displayed in the circumcision procedure room. The intent is that staff from outside the department can come in and easily be able to assist with circumcisions. The maternity staff will promptly and courteously hand questions that staff from outside the department may have in assisting with the circumcisions.

Related issues

- The Hospital's no solicitation/distribution policy applies with respect to the solicitation and distribution of materials regarding circumcision. Literature regarding this issue may be submitted into two reference files, located in the medical library and one in the newborn nursery. This file can be updated by the manager/director, nurses and physicians. References to new literature, pro and con on the issue that have been put in the reference files, can be noted on the appropriate unit bulletin board..

- When hiring new nursing staff, the administration will supply them a copy of this MOU and the informed consent package.

- There is a Hospital policy for reporting an adverse outcome that is at variance from the standard of care. It is understood by the administration and staff that any of them can file a variance report.

- A copy of this MOU will be maintained on the maternity unit at all times. A copy will also be given to all currently assigned nurses on the maternity units. A copy will be kept in the Human Resources labour relations file.

Both parties agree to the above language for this Memorandum of Understanding effective on the date of January 31, 1995. This agreement will be reopened upon written request by either party. If this issue cannot be resolved by the parties within 30 days, the parties will submit the matter to mediation.

______________________________

Kathy Hall
VP, Community/Human Relations
St. Vincent Hospital

______________________________

Delma DeLora, RN, VP Nurses
District 1199 NM