An interview with Lorie Brown, Brittney Wilson, + Jamie Davis
There is little doubt these days that one of the most important questions on the minds of nurses is “if I am assigned a patient infected with the Ebola virus, can I refuse to take care of that patient?”
The answer is “no!” I know how scary it can be to take care of a patient with a highly contagious disease with no cure. Unfortunately, nurses cannot pick and choose which patients we want to care for. As an employee, it is considered a master-servant relationship and we are required to tend to those patients for whom our employer asks us to tend.
Should you refuse to take care of certain patients it is not only discrimination, it is patient abandonment. I know that in the early stage of this disease in the United States, where there is not much known about how to protect ourselves while treating patients with Ebola, it can be very terrifying. But even in considering that, it is still our responsibility to take care of the patients we are assigned.
However, if you are asked to provide care outside your competency, you must express your concern. If your employer insists that you take the assignment, you should write a letter to your supervisor explaining your concerns and keep a copy for yourself but do not refuse to accept the assignment.
Now, let’s say this fear is so great that you resign and walk off the job, that also is considered patient abandonment.
I understand that some States have a statute that should you refuse to accept a patient assignment and quit, that is permissible. The ANA has a position statement “a unilateral severance of the established nurse-patient relationship without giving reasonable notice to the appropriate person so that arrangements can be made for continuation of nursing care by others. Refusal to accept an assignment (or a nurse-patient relationship) does not constitute patient abandonment” (ANA, 2001c). However, there is a footnote which notes that state laws may differ in some respects from the professions definition. So check the laws in your State to determine whether that is a valid act or not.
When I first entered the nursing profession, it was in the early 1980s during the height of the AIDS outbreak before there was a known treatment. Back then, we did not even have universal precautions. Even though we were required to gown, mask and glove for certain patients, it was difficult to perform the required tasks in such garb. The gloves at that time were not well fitting and there was not a plethora of sizes (at least not on the floor) available as is the case today.
I recall in particular one AIDS patient on our floor who I was terrified to treat. Fortunately, I was not assigned to his care; however, I was called in to help on numerous occasions.
At one time the patient was vomiting and the treating nurse could not reinsert the NG tube with her gloves on. She had removed her gloves to reinsert the NG. She felt it was so important that this patient got the treatment needed that she chose to risk her own health and safety by taking off the gloves to insert the tube. I think of her often and I hope she is doing well.
Our current crisis with Ebola is just as scary now as AIDS was then since not much is known about the disease. One point to note: while AIDS was a 100% fatal, Ebola has a 60% fatality rate. What separates the two is that with Ebola patients supportive treatment is provided to counter the bleeding, hypertension and volume depletion.
Another factor that helps people to survive an Ebola epidemic is a healthy immune system. Therefore, it is important for nurses to take care of themselves and strengthen their immune system with proper diet, exercise and vitamins.
I do urge that nurses come together to improve our profession so that we can have more freedom and autonomy to get more pay for treating patients who require more care, especially those with deadly illnesses for whom we are required to treat.
We can even call this “combat pay!”
I wish I had better news for health care providers about this outbreak but, unfortunately, I do not.
My new client, Katie, sits across from me because of a situation that happened at work and resulted in a complaint before the Nurse Licensing Board. She’s scared and crying. I can tell by talking to her that she is a very compassionate nurse and does a great job. Yet, she doesn’t understand why this is happening to her.
Like most of my nurse clients, few ever thought that they would be called before the Board. But it happens every day: 7,000 nurses have their licenses charged before the nursing boards across the country.
I reassured Katie that almost no client who has come to me ever thought that they would find themselves before the board. But, there are ways we can protect ourselves from having a matter reported.
When we take a driver’s license test, we are tested on “the rules of the road.” We’ve learned them and have to show we know them in order to get a driver’s license. But, one reason that a nurse gets into trouble is because she typically doesn’t know the laws she needs to follow. On the NCLEX exam, the questions are based on how to be a nurse rather than on the laws we must abide by to be a nurse.
Even if we do read the laws, they are written by attorneys and are difficult for lay people to understand. Another thing is that the laws are sometimes subject to interpretation which can further complicate our knowledge of them.
The laws you need to follow as a nurse are found in your State’s legislation in what we can call a “Nurse Practice Act.” The goal of this Act is to protect the citizens of the State by ensuring that a nurse is safe to practice. The American Nurses Association has published a model nurse practice act to guide the States in creating and maintaining such laws. https://www.ncsbn.org/12_Model_Act_090512.pdf
The laws empower the State to appoint a board of nursing which has the authority to develop administrative rules and regulations to assist in setting the standards for the practice of nursing.
Each nurse practice act includes the following:
- COMPOSITION OF THE BOARD OF NURSING
- EDUCATIONAL PROGRAM STANDARDS
- STANDARDS AND SCOPE OF NURSING PRACTICE
- TYPES OF TITLES AND LICENSES
- PROTECTION OF TITLES
- REQUIREMENTS FOR LICENSURE
- GROUNDS FOR DISCLIPARY ACTIONS, OTHER VIOLATIONS AND POSSIBLE REMEDIES
Russell, K., 2012, “Nurse Practice Acts Guide And Government Nurse Practice,” Journal of Nursing Regulation, page 37.
Katie explained how she was working in a sub acute long term care ventilator facility. The patients were being weaned off the ventilator. There were alarms for the call light and alarms for the ventilator which both sounded similar. The only difference was that the alarm for the ventilator was in quicker, shorter bursts. The ventilator alarm would go off if the device had become disconnected, was not working properly or the pulse oximeter probe came off.
The unit where Katie and the others worked was oval shaped. She was sitting at the nurse’s station looking towards the five rooms of patients she was responsible for when the alarm went off. Looking to see if it was one of her patients, she found that it was not.
The alarm kept sounding and Katie turned around to ask her co-worker if she needed help. The co-worker replied, “No” and said she was taking care of it.
The alarm stopped and shortly thereafter, another alarm erupted. Once again, Katie looked down here hall and once more confirmed that it was not one of her patients. As the alarm continued to ring, Katie got up and saw the nurse whose patient’s alarm was ringing still sitting at the nurse’s station. Katie addressed the other nurse saying, “Let’s go see what’s going on.” They found that everything was fine with the patient.
The following day, Katie was surprised to be called into the manager’s office and told that there was a ventilator alarm that went off and no one promptly responded. Katie was shocked to find herself fired and, more to her dismay, she received a complaint from the Board of Nursing. She was beside herself. It wasn’t even her patient.
Katie told me that all of the people at the nurse’s station that night and did not promptly address the ventilator alarm were terminated and reported to the Board of Nursing.
I asked Katie what where the policies and procedures for the facility in answering ventilator alarms. She replied that she did not know. Just as it is important for nurses to know the Nurse Practice Act, it also is important that they know and follow their facility’s policies and procedures.
Then I proceeded to share with Katie a tool that she could use to protect her license. I call it GIFTS, an acronym well worth remembering. Brown, L., 2014, Law and Order For Nurses: The Easy Way to Protect Your License and Your Livelihood,
“G” Is For Giving
The “G” stands for giving. As nurses, we are always giving to our patients but we may not necessarily be as giving to our co-workers and ourselves. Although Katie’s actions seemed innocent because it was not her patient and she was busy documenting on her patients, she was not being giving to her co-worker and the patient whose ventilator alarm was sounding.
“I” Is For Integrity
The letter “I” stands for integrity which is being honest and forthright and being in line with your core values and what matters to you. Katie had a core value of making sure that all the patients at her facility received good care. She was not in line with her core value by not providing care to a patient that was not hers.
“F” Is For Focus and Follow Through
“F” is for focus and follow through. This is so important in nursing and usually one of the more common areas where nurses tend to get in trouble.
We are programmed to go on “autopilot” at times. When we are on autopilot, we can miss important things. Have you ever driven home and missed your turn because your mind was focused on something else? That’s how easy it is to lose our focus and fail to follow through on what’s required of us.
It is imperative for nurses to follow through. When we give a medication, we need to follow through and make sure it was effective. It is part of the Nursing Process to evaluate so the follow through portion cannot be neglected.
Also, because of being so involved in organizing their work load and thinking about what’s next, nurses sometimes are not focused on what’s happening in the moment. Here, Katie was concerned about getting her charting done rather than focusing on the most important issue at hand which was responding to a sounding ventilator alarm.
It took a little while before she realized that her co-worker was not responding to the alarm and asked if the co-worker was handling it.
“T” Is For Trusting Your Gut
Trust your gut is the meaning with the letter “T”. Katie’s gut was telling her that there’s an alarm going off and we need to take care of it. Rather than responding immediately and making sure that her co-worker was going to answer the alarm, Katie ignored her gut and continued to chart.
We seem to have a heavy reliance on technology but our gut is really our best guide. When something doesn’t feel right, rather than ignoring your gut and talking yourself out of the situation, it is important to act on what your gut is telling you.
“S” Is For Source
And the letter “S” stands for “source.” You are the source of everything that happens in your environment. As the source, you are not at fault or to blame, but it is a position to stand in. If you are the source, it means you have the power to do something about it or change it. Katie was not being the source when she did not immediately respond to the ventilator alarm.
If you think of any situation in your career that is not working, you will find that one or more of the GIFTS are not present. It goes to reason that if you use your GIFTS, you will be surprised how quickly the situation improves.
However, the GIFTS take practice. It’s not natural for smart confident nurses to trust our gut. We think through problems rather than trust our instincts. But our instincts can be very strong. Have you ever walked into a patient’s room and knew the moment you entered the door that something was wrong? You couldn’t see it or put your finger on it but you just knew. Chances are, you were right!
Although Katie was disheartened by being fired from work and being reported to the Board, she was grateful to have learned about the GIFTS and became committed to using them in her practice to protect her license thereafter.
Learn about the GIFTS and practice them so they can become a permanent way of your life. They just may be the thing to keep your license safe in the future.
About the author: Lorie A. Brown, RN, MN, JD is a Nurse Attorney and President of Brown Law Office, a National Law Firm for Nurses. She is licensed to practice law in Indiana and Illinois and has co counsel relationships with nurse attorneys and other attorneys nationwide. www.brownlaw1.com Ms. Brown is also the founder of Empowered Nurses. An organization designed to teach nurses how to speak their mind, stand in their power and be a change agent to improve patient care. www.empowerednurses.org
If you’ve been asked to go into a peer assistance program or if you voluntarily choose to go into the program to protect your license, here some things you should know.
First, you will need to sign a recovery monitoring agreement which basically is a contract that you are entering the program and agree to certain of its requirements. Getting into the program, you will need to know how long they want you to participate in it. Usually there is a monthly participation fee and the fact that there also is urine drug screen means that it can be costly. The shorter time you are in the program, the better.
If they offer you three years, ask how you can get that amount of time reduced. And ask that before you sign the contract!
The second thing to know is that you will be required to attend meetings. So, you might want to look at this ahead of time to see what meetings are in your area and when do they meet. Also, find out if these will qualify for the types of meetings that you are expected to attend.
There are A.A. meetings, N.A. meetings and nurse support group meetings. If you’re required to attend a nurse support group meeting and there are none in your area, you may want to challenge that provision. Again, do that before you sign the agreement.
When you go into this program, set yourself up for success and do your homework ahead of time so that you can do the program as easily as possible to get through it successfully.
Number three: you will be required to have a worksite monitor where you are working. That person will send reports to the administrators of the peer assistance program.
So, if you currently have a job and before you sign the agreement, make sure that your boss is supportive of what you’re going to do. If the boss is reluctant to support you, it might mean you should perhaps look for another job.
Random drug screens will be another facet of the program. You should research this because you will be required to pay for the screenings and you will want to make sure that you will be successful with these screenings.
I am fully aware of how difficult these programs can be. I tell my clients that they should work these programs like their lives depended on it. Some clients will tell me: “I don’t have an issue so why do I need to be doing this?” Again, it’s the best way to protect your license.
After completing the program, a number of clients have told me how it was an eye-opening experience and that they learned so much.
If you do have a problem and really need the peer assistance program, I want to congratulate you for realizing your need to take action to help yourself. This will be the way that you can be healthier and overcome the problem that you’ve been facing. Personally, I have great admiration for those who are willing to admit to having a problem and then undertake the necessary treatment to better their lives.
Although no one wants to be in a program like this, especially one where they are monitored and made to feel like they are being watched constantly, it is the best way to protect your license.
Not only will you learn about substance abuse, you will learn so much about yourself and be a better person when you get through the program.
Here’s wishing you the best of success.
Substance abuse is one of the most important issues in nursing because access is so easy. Even with Pyxis machines that distribute medications with a thumb print, there still are ways that a determined nurse can divert medication.
According to the Indiana State Nurses Assistance Program [ISNAP]:
Impaired nurses demonstrate mood swings and irritability. He/she may seem depressed for no apparent reason. There can be frequent complaints from nursing peers, patients, or family members that the nurse has responded inappropriately to their requests and/or concerns. At times, nurses have abused patients or engaged in abandonment of duty.
Impaired nurses often demonstrate problems in their job performance. They write inappropriate orders for patients, are less timely, and often do not follow policies and procedures. Impaired nurses often administer far more PRN narcotics than their peers or administer PRN narcotics to patients who have never been known to request them. They may fail to get waste of narcotics witnessed or fail to document the narcotics they administered to a patient. An impaired nurse may demonstrate poor concentration, significant problems with short term memory, an inability to learn new procedures within a reasonable time frame, and/or poor priority setting. Some nurses have blackouts, a period of amnesia in which he or she can’t recall what he or she said or did.
Impaired nurses sometimes work large amounts of over time to ensure they can obtain their drug of choice especially on midnights. They may also use their peers’ codes to sign in with a Pyxus system.
Impaired nurses may have excessive tardiness and/or absenteeism. They often call in sick on Monday’s after a weekend off or after a holiday or vacation. They may be absent from their assigned floor for long periods of time or make frequent trips to the bathroom. He/she may avoid employer sponsored social functions and may often eat alone.
If you see any of these behaviors or have any such concerns in a co-worker, please take note. I know as nurses it is difficult to say something about your peers. You certainly don’t want to get them in trouble. But, who are you protecting? Are you helping that nurse by allowing them to continue this destructive behavior? Are you depriving a patient of the best care by not sharing a suspicion about a particular nurse? Do you want to work with somebody who is not reliable?
Now, sometimes even nurses who are not impaired get in trouble for administering more narcotics than their peers. The best advice I can give you is to document, document and DOCUMENT! Not to record just the subjective that the patient is in pain and they were given two Vicodin, but document the patient’s vitals signs and their behavior. Show the clinical indication of why you are giving the narcotics. This will help protect you in the event of a license investigation.
On co-signing waste of narcotics, there’s simply no getting around this. It must be done and needs to be done as a priority! I know it takes you away from patient care but it is the best way to protect yourself and your license.
Although there is no affirmative duty to report a co-worker as someone you have a suspicion of being impaired, again ask yourself the question: “Is your silence helpful to that person, your other co-workers and the patients?”