Mandated minimum nursing hours – will it work to ensure safety and productivity?

The question of whether mandated minimum nursing hours would work has been asked previously. The workload of care and nursing staff is frequently discussed with staff reporting they are pressured for time to complete all the necessary duties assigned.  The Nursing staff have different but over-lapping functions to care staff.  When reviewing your staffing, it’s important to include a number of factors into any review when looking at the productivity and efficiency of your team.

We suggest you look at not only leadership and skill-mix, which are vital for safe services but also consider other factors. These can include the location of high acuity needs residents within your service.  With an increase in the use of dual beds, the mix between rest home and higher acuity hospital level of care are now intermingled and not specifically allocated to one area of the building.  This means the Registered Nurses providing clinical monitoring and oversight may have to spread their attention to a much more fragmented and broader geographical area in your service than was previously the case.

The location of resources and time spent looking for items of use and equipment could be minimised if more thought was put into the design of new facilities and the locating and management of replenishing stores for ready access by staff as and where they need them.  Who does the running and fetching could also be considered in work roles so staff with high end clinical skills are spending the bulk of their time on performing functions specific to their role and skill.  Not doing tasks that could be better delegated to others.

After the recent sudden closure of a care facility in Australia without apparent planning or communication with families, there has been outrage that such a thing could happen.  The “Queensland Premier Annastacia Palaszczuk announced her Government would order fixed nurse-to-resident ratios in state-owned aged-care facilities.”  The ABC news report (19th July 2019) goes on to say “at least 50 per cent of staff having contact with residents in 16 publicly run aged-care centres to be nurses.”  I don’t know if by nurses they mean Registered Nurses only and not Enrolled nurses but I can’t help wonder if this alone will ensure safety.

One year on from Simon Wallace (NZACA CEO) reporting on staffing shortages, we haven’t seen any improvement it would seem!  In New Zealand an increasing proportion of our Registered Nurses have come to New Zealand to practice with no prior working knowledge of aged care services. They frequently have limited aged care related experience to conduct the complex assessment and clinical management of high acuity residents in a residential care setting.  This is not to diminish their value as we can’t provide the services needed otherwise.

What I’m trying to highlight in the current circumstances is, we’re frequently seeing nurses set up to fail or provide less than safe care as they simply don’t have the experience in this specialised field of nursing.  I recall conversations in the early 1990’s predicting a massive nursing shortage.  It appears that in the time-span between then and now, we haven’t addressed this issue.

We welcome comments and suggestions of how this could be addressed here in New Zealand before we end up in the depths of a staffing crisis which halts care.

Models of care and addressing Isolation

Since the emergence of residential care facilities in New Zealand, the models of care have continued to change, but are they changing fast enough? The clinical needs of residents have escalated and so the way services are provided must also reflect a change in practice to meet changing resident needs. A common theme being reported among older member of our communities is that of isolation and depression. Isolation, according to the Collins dictionary relates to separation, withdrawal, loneliness and segregation.

I was fortunate to visit Greece recently which is reputed to have a larger proportion of older adults than most other EU countries.  Gerontology is derived from the Greek words geron, “old man” and -logia, “study of” so it made sense to discuss models of care with families and health care professionals including pharmacists.  I discovered there are few residential care services in Greece and those that do exist are found mostly in Athens rather than the islands. Families provide the majority of care with ‘family’ being noted as the key foundation to Greek society. Grandparents are frequently living within the extended family with the younger generations and taking responsibility for caring for their grandchildren.  The economy is poor and social networks are heavily relied on to provide support.

From my observations, conversations with others, and literature, the older adults of Greece are kept actively engaged in the community. They are frequently involved in running family businesses if they are not relied on for supporting the needs of their children or grandchildren. Family networks remain strong and when interviewing people about how older adults will be cared for, the automatic assumption is that family will provide that service. Dr Elizabeth Mestheneos told me that approximately 1% of their older population may well be in residential homes. There are Open Care Community centres in virtually every Local Authority which are called KAPI. There are also Help at Home services and Day care centres in some Local authorities.

The models of care and workforce capacity currently in place in New Zealand are unlikely to meet increasing demands so change is needed.  The aged care sector could lead change as new models are developed, trialed and advanced.  Multiple studies confirm these new models need to include holistic, consumer directed services.  Not only meeting physical needs but also social connections and the opportunity to be involved in meaningful activities that contribute to others. This also includes some use of technology to support connections with others. While they are of assistance to some, there is no substitute for human connection, person to person, face to face. The experience of ageing, social network supports, funding models and the context in which care and support are provided certainly differ from country to country.

In New Zealand residential care settings we have activities / recreational programmes which support inclusion and engagement.   Being involved in meaningful activities are also key factors in contributing to a sense of well-being. I observed older adults in Greece undertaking meaningful activities in the community like feeding the communal cats of Kos or looking after grandchildren, continuing to run a second hand open-air shop to add to the family income or playing games with friends games. Groups of older men often congregated outside cafes for conversation, coffee and playing cards or board games.  A Menzshed story reflects on how one New Zealand community are attempting to address the gap ageing can create in the life of some men. While funding is different in NZ to Greece and the family network is more often scattered geographically in New Zealand, there remains more opportunity to include community. The care setting could also be enhanced more by reflecting the smaller numbers of people we are used to living with in the family home, rather than the larger numbers in some care facilities. A model that more closely reflects the life patterns our community members have been used to, with them directing how these continue into the latter years of life with the goal of ageing in a healthy way, optimising body, brain and social networks.

 

 

 

Mattresses – are your mattresses causing harm?

Mattresses aren’t just something to lie on but if not maintained and cared for appropriately, also have the potential for causing harm.

As I travel a lot for work, I have the opportunity to test many different mattresses, all with varying degrees of comfort.  This reminds me how difficult it must be for those who may be suffering painful joints to get a good night’s sleep.  Appropriate mattresses are not only required to reduce pain from positioning discomfort but also reducing risk to residents. This include ensuring the mattresses are of a suitable standard and fit for purpose.

I’ve seen a number of mattresses which had hardened and torn linings and were well past being able to provide much comfort or an appropriate degree of pressure support. Some had masking tape used in an attempt to cover splits in the mattress cover.  Others had holes in and were badly stained from exposure to body substances.  As the residents in care are becoming frailer, with increasing acuity, the need for ensuring appropriate pressure support is crucial to preventing pressure injuries, maintaining comfort and maximizing the opportunity for good sleep.

There is the potential for old and in poor condition mattresses to be a potential source for infection transmission.  For those of you operating newer facilities, this may not yet be an issue. For older facilities, part of stock and resource control should include mattress stock checks to verify they are in fact still fit for use.  When conducting checks, determine the mix of mattress types you have and speak with your supplier about a replacement programme should this be necessary.  As mattresses differ, so do beds and it’s important to make sure the mattress you use is appropriate for the particular bed type and size.

When reviewing your mattress stocks and purchasing new mattresses you might like to think about the following factors:

  • Only purchase from reputable suppliers. Review the manufacturer’s instructions for use to ensure they include verification of cleaning instructions and ask about preventative maintenance. This may include staffing training e.g. via the use of online training videos or instruction booklets.
  • Make sure you record the date of purchase and do your best to track each mattress and pillow to maximize warranties and make plans for replacement. Add the item to the facility cleaning schedules for regular cleaning and drying of exterior surfaces which should be durable, water-repellent and quick drying. They should also be seamless, if possible. When there are seams or edges, much sure these are situated away from resident skin contact to prevent absorption of liquid into interior and increased friction.
  • All seams must be tightly closed and sealed. Masking or packaging tape is not appropriate for sealing. When mattresses become worn and tear, you might like to have a supplier representative review to see what options are available for repair or replacement.
  • When reviewing the condition of mattresses, inspect all mattress surfaces, covers, seams and zippers for proper function and damage including wear, tears, splits, cracks, punctures, permanent odours and stains. If visible contamination from body substances are present, determine appropriate steps (eg. replacement or repair).
  • To support longevity of mattresses, remind staff not to place any furniture or sharp objects on mattresses. Protect the mattress with mattress protectors only if advised by the supplier this is appropriate. A number of pressure support functions in mattresses may be adversely impacted by the use of additional mattress coverings to do check.
  • Cleaning and disinfection must be considered in relation to mattresses, covers, wedges, cushions and pillows which are all classified as non-critical medical devices. Clean and low-level disinfect according to the manufacturer’s instructions between different resident use and when visibly soiled. Some mattress covers are removable for laundering so remember to verify which ones can be cleaned separately.
  • Remove damaged or stained items from service and report these in your maintenance book or to the Manager. Follow manufacturer’s instructions for use and disposal of damaged mattresses, covers, and pillows, and in accordance with infection prevention and control guidelines.
  • Ensure when using alternating therapy type mattresses that there is a process in place for a shift by shift verification that the pressure is maintained at the current level for the individual resident utilizing that mattress. If you plan to use an air alternating topper pad on a mattress, ensure it’s suitable for the mattress as depending on heights and size, it may not be appropriate.

Harm prevention can also be supported with advances in technology such as Pressure Monitoring sensing devices to ensure appropriate pressure distribution.  I’m not aware of anyone who can rent or lease out Pressure Mappers in NZ. However Cubro have one that they can bring onsite to facilities for training and education. Make contact with your supplier to see if they can assist if this could be useful for you.

Also remember that other devices used in beds should be checked  as well to ensure they are still safe and appropriate for use eg; wedges, rolls, pillows, seat cushions, mattress covers (where these are appropriate for use), bed sensor monitoring pads.  For reading on how to choose the best mattress option for your needs go here.

For more related information view here.

Article compiled by Gillian Robinson (RN, BN, Lead Auditor) for Healthcare Compliance Solutions Ltd.

Leadership of your team

 

Empathy and perspective are two concepts well known Leadership author Simon Sinek speaks about in relation to leaders. He talks about the real job of a leader as not being in-charge but taking care of those in our charge.  How many leaders play the blame and shame game when things don’t go as planned?  Instead how would it be if leaders in aged care services worked in accordance with a Leader’s Oath.  My version is noted below as an example.

You may want to create your own for your organisation, or adopt this.

The Leader’s Oath

I focus on the betterment of this organisation above my own career needs

I  focus on accountability above the need to be popular

I focus on caring for those in my charge over being in charge

I focus on clarity above certainty

I share clear expectations

I hold myself accountable for all employees poor performance including my own

I welcome respectful challenges

I will table the tough issues

I treat all interactions as though my career depends on a successful outcome

I am committed to personal and professional development

I am focused on excellence.

 

While the above Leadership Oath forms a focus for clinical leadership, it’s necessary to make sure your nurses are familiar with the ARRC funding agreement responsibilities for Registered Nurses. These are also clearly defined in the HCSL policies and procedures to ensure they’re integrated into practice.  The ARRC includes time-frames for nursing documentation responsibilities, while the nursing council guidelines for delegation define staff delegation of staff working under the supervision of Registered Nurses are appropriate led and supported. When we refer to tabling the touch issues, one key aspect of leadership is holding staff accountable.  Nurses are often not keen to hold others responsible for their conduct and performance and therefore avoid performance managing staff when performance is below the expected standard.  This in turn means the service provided will be below the expected standard.  If you want to provide the best care and support to those in your care, these are skills you must learn and put into daily practice. To learn more about these skills and others needed for leading a team of care and support staff, go here.

Spiritual care and Pastoral Care

As we age, the need for spiritual care and pastoral care often come to the fore.  This is particularly so as people near the end of their life.  The need for comfort and peace of mind on a holistic basis.  Let’s firstly lets define the difference between these two concepts.

Pastoral care is an ancient model of emotional and spiritual support that can be found in all cultures and traditions. It has been described in our modern context as individual and corporate patience in which trained pastoral carers support people in their pain, loss and anxiety, and their triumphs, joys and victories. Spiritual care attends to a person’s spiritual or religious needs as he or she copes with illness, loss, grief or pain and can help him or her heal emotionally as well as physically, rebuild relationships and regain a sense of spiritual wellbeing.

For most of human history, in all major religions, an ultimate goal of spiritual practice was accomplishing a good death. When this goal was held in common by the whole society, spiritual care could focus on the interaction between a dying person and his or her caregivers.

A number of clergy have commented to me that spiritual care is not recognised by many aged care facility staff as important. They have frequently commented on services being interrupted by staff activity, or being asked to hold services or provide pastoral care in areas of the facility that are very close to the main entrance or actually in main thoroughfare areas. This is not respectful of the needs of the residents who choose to attend, or the need to peace and calm to receive spiritual care. In learning more about the importance of these concepts, it may support good holistic care for residents if you were to discuss with the clergy and pastoral care workers whether the circumstances being provided for them to support residents are appropriate.

To read more on this topic go here.

 

Audit Tips for Clinical Documentation

Clinical documentation and clinical management relate to section 1.3.1 to 1.3.8 of the Health and Disability Services Standards and are referred to in section D5.4 of the ARRC.  There are key reference documents which provide reference at residential care facility level which should be used in conjunction and addition to your organisation policies and procedures.  These reference documents include:

 

  • Age Related Residential Care (ARRC) contract
  • NZS 8134:2008 Health and Disability Services Standards
  • Clinical best practice (EBP) guidelines – eg; Lippincott
  • The Code of Health & Disability Consumers Services Rights 1996

 

Clinical documentation errors of any type noted during audits will result in partial attainments at best.  This is an indication there could be risk associated with gaps in service. In a previous article about medication management we noted that even a single signature missing off an administration signing sheet was enough for the auditor to assign a partial attainment finding.

 

Below are some of the common compliance gaps which relate to clinical documentation:

   
General compliance

gaps

Missed signatures off notations.

Not dated.

Not signed by the author with a full signature.

No designation written with signature.

Not legible.

Inconsistent structure of resident files.

Unclear or unsecured archiving of documents.

Privacy breaches due to clinical documents placed in a situation that allowed unauthorized viewing.

Initial assessments

including InterRai

Not completed within time-frames defined in ARRC.

Baseline recordings at time of admission not recorded.

Assessment outcomes not used as a basis of care planning to link assessment to goals and interventions.

Additional detailed assessments not reviewed in a timely manner eg; six monthly to coincide with InterRai reassessments.

Failure to re-assess for each period of admission eg; respite care.

Clinical risk

Assessment not describing risk.

Risk not reflected in care plan interventions.

Lack of risk reviews.

Level of risk noted in interRai assessments not included in care planning

Progress notes

Not recorded in on a shift by shift basis.

Lack evidence of regular registered nurse input.

Writing beyond the bottom line of the page.

Failure to put resident identifiers on each side of each page (this applies to other clinical documents as well).

Lack evidence of interventions being implemented.

Lack evidence of RN response to clinical symptoms reported by care staff.

Lack of evidence of rationale for PRN medication administration or the resulting effect.

Short Term

Care Plans

Not developed for changes in clinical status eg; increased pain; infection; wounds, change in medication (to allow evaluation of effectiveness).

24 hours plans not developed for residents displaying behaviours of concern (challenging behaviours).

Not evaluated regularly (I suggested at least once every 7 days) by a Registered Nurse.

Not recorded as resolved or transferred to Long Term Care Plan.

Not developed to implement instructions included in General Pracitioner consultation plans recorded in notes.

Long Term

Care Plan (LTCP)

Not reflective of all presenting potential and actual medical / clinical problems.

Not documented within 3 weeks of the date of admission (ARRC requirement).

Not changed at the time of health status / functional change.

Interventions not reflective of each medical diagnosis.

Interventions not changed within LTCP to reflect changes recorded in care plan evaluations.

Frequency of clinical assessment for each actual clinical presentation eg; pain.

Do not clearly indicate the level of function, assistance required for each component of care / support.

Do not clearly evidence input and instruction from Medical or Nurse practitioner / Physiotherapist, Diversional Therapist, Dietitian,Psychiatric services             for the elderly etc.

Care Plan

Evaluations

Review of care plans not reflecting changes in residents health status as they occur.

Not reflective of how well the care plan goals/ objectives have been met since the previous evaluation.

Not completed within ARRC defined time-frames (at least six monthly).

Multi-Disciplinary

Input

Lack evidence of MDT input into care plan reviews and/or evaluations.

Lack evidence of resident, Next of Kin (NOK) / Family / Whanau / EPOA input into assessment and care planning.

Lack of evidence of timely referral in response to clinical presentation eg; unintentional weight loss not referred to Dietitian.

Failure to evidence implementing instructions ofMedical or Nurse Practitioner eg; B/P to be recorded daily for the next 7/7 may be noted in the medical           consultation notes however not evidenced as having been done.

Lack evidence of notification to NOK / EPOA relating to resident adverse events, change in health status, medical consults etc.

Policy and

procedures

Not consistent with service delivery as noted in clinical documentation.

 

Internal audits are available through the online HCSL quality system utilised by our clients which allows tracking of compliance status and corrective actions as part of on-site quality and risk management. This means when the auditors arrive, there will be no surprises and you’ll know you’ve achieved excellence in care in conjunction with providing a compliant service.

If you have any comments to make about this article, please contact us here.

 

Attendee Testimonial for Aged Care Education Study Day – July 2017

Topics included: Quality & Risk Management, Clinical Leadership, Clinical Documentation, EPoA, ARRC, Communication and Difficult Conversations

 

I am writing this endorsement on behalf of my colleague and myself, in relation to our attendance at the study day you hosted 5 July 2017.

The topics you presented were most relevant to our Registered Nurse role within the aged care sector, and between us both provided new learning opportunities, as well as refreshing the current knowledge we already held.

You addressed each session in a professional and engaging manner that held our attention, complemented by comprehensive written material as well as PowerPoint presentations, along with plenty of opportunity for questions and comments from the floor.

Gillian you are one of very few speakers that is able to hold my attention for more than one session let alone a whole study day, a perfect balance between speech and conversational styles!

We were also most impressed by the quality of the complementary gift bag that was given to each attendee containing not only goodies to help us through the day, but with something to take back to the workplace, I acknowledge both Cubro and Ebos for their support with this.

The venue was great with easy access and good parking, and it was clean and refreshing providing plenty of comfort and personal space for those attending. I will be recommending my associates to make a note in their diary for next time. Thank you Gillian

Kind regards

Lyn Black

Bloomfield Court Retirement Home – Canterbury

Clinical Assessment Recognises Subtle Changes

Our eyes see what is familiar and what they expect to see.  Are we good at picking up subtle changes through your assessment processes and acting on them appropriately?  The ability to see the less than obvious is essential when responsible for clinical assessment as you won’t act on those things you haven’t noticed.

On the 5th July I presented a full day seminar on a range of topics to Nurses working in aged care.  During the day I made what should have been an obvious change but I have no doubt it wasn’t noticed by all.  In the morning I wore a dress with a white jacket. In the afternoon I’d changed the dress for one of a different colour and pattern but retained the white jacket.  I made the change during the lunch break.

When I entered the room after the lunch break three people commented straight away.  I saw a small number of puzzled looks but those nurses didn’t say anything.  Others didn’t seem to notice and didn’t make comment.  We had three distinct groups.  Those that notice and comment, those that notice but don’t comment and those that don’t notice and therefore don’t comment!  Which are the nurses you’d feel safest with if it came to performing a clinical assessment on you on an ongoing basis day after day?  Which differences would they notice and which wouldn’t get a second glance. Which changes would be commented on?

We need a mix of ‘detail’ thinkers and ‘big picture’ thinkers to see everything that occurs.  Equally these two groups of people can complement each other.  Working separately they will each only see part of what needs managing.  Some over think and others don’t seem to think or reflect.  Awareness of how the members of your nursing team work and think could be important in supporting you to minimise risk resulting from subtle changes occurring which may not have been addressed.

It may be beneficial to review personality types to see how your team are working separately or collectively to ensure the best outcome for residents in their care. This increased recognition of each others natural thinking styles may also enhance the ability of the team to understand each other and consciously support others differences.  There are a raft of profiling tests however Myers Briggs has been around as a validated tool for a long time and may be a useful one for you and your team.

What subtle changes are occurring with your residents that you haven’t noticed?  Did you see the white dress in the morning change to a black one in the afternoon? If not, what else are you not seeing that could expose someone to risk?  Are any of your team seeing things but not saying anything because they don’t recognise it’s their responsibility or think someone else has commented?

Weight management goals in care planning

When care planning, the goals or objectives developed for each aspect of care need to be measurable.  This ensures you’re able to evaluate progress and determine whether the goal has been met or not.  The concern is making sure an appropriate goal is set.  While we look at this from a clinical perspective, we must always remember the resident as the central focus and director where they are able to provide input into what the care plan relays.  People have choice within their capacity and sometimes as nurses, we may not agree with a choice made by our patients / residents in aged care.

When guiding weight management goals from a clinical perspective, Liz Beaglehole, Registered Dietitian has offered the below guide.

Ideal weight range in the care process

Body mass index is still helpful in determining healthy weights for older adults.  A healthy BMI range for adults over 65 actually shifts upwards as compared to adults. So a healthy BMI for older adults has been found to be BMI – 22 – 27kg/m2. A BMI above 32kg/m2 would suggest obesity, a BMI below 20 suggests underweight, and below 18.5 is malnourished.

To work out the BMI: (weight/height²).  Example case:  height = 1.5m and weight = 45kg

  1. We need the height in metres and the weight in Kg.
  2. The height needs to be squared. So a height of 1.5m = 2.25 when squared.
  3. Then the BMI is the weight in Kg divided by the height²

Example:  weight = 45kg divided by 2.25 = BMI of 20kg/m².  This is regarded as the lower end of ideal body weight and suggests the resident is underweight for optimal health.

An ideal body weight for some who is 1.5m tall would be a BMI range of 22 – 27 so a weight range of min 50kg up to around 60kg.  Basically to work out ideal body weight just enter different weights into the BMI calculation until you get to the BMI of at least 22 and then again to a BMI of around 27.

The ideal body weight may differ to the GOAL weight.  The goal weight may be something that is set when the BMI is outside the ideal range but some weight changes are desirable.  The goal weight is more useful and practical as it considers the weight history of the resident and the ability to achieve changes in weight.  For example, a resident may be underweight with a weight of 42kg (BMI= 18.6) but they have been this weight for the past year.  Ideally they would gain weight to 50kg, but this is unrealistic.  The goal weight therefore becomes either weight stabilisation at 42kg or a slight weight gain to 44kg.  This would still mean the resident is underweight but is realistic in what can be achieved.  If the initial goal weight is achieved, a second goal weight may be identified.  This may be to stabilise weight at 44kg or to gain to 45kg.  etc…

This can work for overweight residents too.  Using the same example height of 1.5m.  Someone who weighs 78kg has a BMI of 34.6, and is obese.  However, realistic weight loss to within the ideal body weight range would suggest the resident would need to lose around 18 – 28kg, which is completely unrealistic and would never be suggested for aged care.  A more realistic GOAL weight would be weight stabilisation and then some weight loss.  5% weight loss can improve many health outcomes and this would be a realistic target.  Weight loss of 5% is still around 4kg, which is possible but still difficult.

Article contributed by: Liz Beaglehole (NZ Registered Dietitian), Canterbury Dietitians

Is the company email the employers property?

In simple terms, a work or company email is an employer’s property in the same way a direct dial phone number, phone (mobile and/or land line) and any other piece of equipment or resource is.  Therefore, as a matter of principle, the employer is entitled to have access to that email address as necessary in order to conduct its business activities.  Correspondingly, employees are obliged to co-operate with any request for access.

Where issues can arise is when an employee is allowed to use their work email for personal emails.  This can either be set out in policy or implicit.  In this case, care needs to be taken to ensure that personal emails are not read.  The access should be limited to ensuring the employer can access business related emails.

If an employee is objecting to providing access to their work email, you can address this by confirming that as a matter or principle the work email address is the employer’s property and you require access to all work emails.  Reinforce with the employee, you will not be reviewing personal emails and they can either forward those emails to their personal email address, delete them etc (as noted below).  However, you will require their password and access as needed.

If an employee continues to resist, inform them you will be making arrangements with your IT service provider to gain access to the work email and given their lack of co-operation, suspending their personal use until further notice.  If this step is required, it’s advisable to contact your employment law adviser first in order to ensure clear and succinct written communications are provided in respect of this step.

To avoid issues in the future, if there is no policy in place, or if there is a policy in place which does not address it, in the first instance all employees should be told that:

(a)       Any work assigned email address is for work purposes;

(b)       That where necessary you will require employees to provide access in order for you to ensure that email communications are dealt with as needed and to provide for business continuity;

(c)       Personal emails received at the work email address can be forwarded to a personal email address, deleted, flagged or moved into a separate folder so they remain private; and

(d)       A policy will be introduced to clarify email and internet access shortly, or recirculate the current policy (updated if/as needed).

Noting point (d), if there is no policy in place, it would also be timely to introduce an email and internet policy specifying how the internet and email facilities can and will be used.  Alternatively, if there is a policy, but it does not cover this situation, the policy should be updated.

Above article kindly contributed by: Dean Kilpatrick (Special Counsel – Employment), Anthony Harper Law,  For more information contact –  Email