Andrew Lopez, RN, Really is Nurse Friendly

February 22nd, 2012

By Jennifer Olin, BSN, RN

I first met Andrew Lopez, RN, when the Amanda Trujillo story broke out in Arizona. He was one of the first nurse bloggers to run with the story on Facebook and Twitter. In short order, a group of nurse-writers gathered together on line and adopted Trujillo’s fight as their own. I don’t think anyone in that group would disagree that Lopez is one of the ringleaders of this band of RNs out to right Trujillo’s wrong and hopefully bring some changes to nursing: how we see ourselves, how we are seen and how our professional organizations represent and stand up for us.

Andrew, you have been so passionate about Amanda’s case since the first minute anyone heard about it, and you continue to stay at the forefront of the effort to help her…why is this so important to you?

”With Amanda, I continue to help because I'm in a position where I can. Am I a ringleader because I'm around, because I contribute my time, efforts? If that qualifies me, then yes, I'll accept the role.

”Amanda is in a difficult spot. She is there because she advocated for a patient and the doctor didn't like it. He decided to destroy her career, he was so upset. Her employer, Banner Del E. Webb Medical Center went right along with it. They even filed the charges with the Arizona State Board of Nursing, as the doctor requested. Amanda, for the first ten months of her ordeal, had no support.

”Her situation is wrong on so many levels. It is something I've seen repeatedly in my Nursing career and often felt powerless to do anything about. It is empowering to be able to act on Amanda's behalf and have a group of like-minded nurses with the same mission. Together we can do some serious damage to the powers that be. It is almost worth the risks that we each take by getting involved.

”Since we received her initial call for help, we've had a consistent stream of dedicated, enthusiastic and supportive nurses willing to help. It is a very good feeling to be fighting for something you believe in. It is one thing to "Save the Whales" it is another to fight a war that can significantly improve not just one nurse’s life, but hundreds, thousands, tens of thousands.”

We’ve established you are a revolutionary, rabble-rouser and ringleader….how did you get here? Tell me about becoming a nurse.

”From the beginning I was attracted to the health sciences. I liked biology, psychology, wanted to be in a helping profession. Went to school to be a laboratory technician, got a four-year degree in it. While doing clinicals I found my favorite part of the day was the patient contact I had at 5 a.m. every day drawing labs. While I was doing phlebotomy, got to see and talk to the nurses on the floors. I saw what they were doing and caught the nursing bug.

”Nursing school was two years including pre-requisites. The hospital where I was working had a school of nursing on site. I could work, go to school, and live in the dorms, it was perfect for me. I signed up for an accelerated program using my laboratory degree credits and was a nurse inside of two years. I’ve been a nurse for 14 years now.”

When you graduated from nursing school did you know what area or specialty interested you?

”It was 1997, HMOs were squeezing hospitals for costs, and was having a hard time finding a job in New Jersey as a new grad. I relocated to Laredo, Texas for my first nursing job. I worked in med/surg telemetry for the first 14 months of my career, got homesick, got a non-nursing job offer, and left for New Jersey.

”I worked for a malpractice insurance company or a little over a year, reviewing cases, getting a birds eye view. Soon after realized I needed to get back to staff nursing. I went into homecare for almost two years. I enjoyed going to work in people's homes, getting to know them. Did not enjoy the excessive documentation and paperwork that went with homecare. Most of my work was visits versus shifts; travel and pay got to be an issue. I decided to go agency to do 8-12 hour shifts in hospitals and nursing homes.

I did a bit of everything: telemetry, med/surg, respiratory, and ortho in the hospital. I did find it difficult going from place to place. I was splitting shifts in between floors; learning my way around. It was typical for me to come in at 3 p.m., work till 7 p.m., then give report to work 7-11 on a different floor. That got to be too much. Decided to move into Rehab, LTC where it was more predictable, slightly slower paced.

” In 2001, my daughter Autumn was born. My wife (also a nurse) worked full-time 3 12s a week, so we decided that I would work around her schedule so childcare would not be an issue. “

Andrew, I know you are the proprietor of a very handy nursing reference website. Tell me about the genesis of Nursefriendly.com.

”As a student, I became involved in the National Student Nurses Association. I had contacted the outgoing editor of their newsletter and mentioned I had published newsletters before. Next thing I knew, I had a 14,000 dollar budget for the New Jersey Student Nurses Association Pulsebeat publication.

”I was asked to build a website for them also, learned how to do that, and started researching the web for healthcare information. We were encouraged by our nursing instructors to find supplemental resources, and I figured there had to be plenty online. I was in for a rude awakening. I was spending hours and hours looking for very specific disease topics and getting lost, frustrated, and disappointed. I thought to myself there had to be a better way. I decided to put my own website up, (lopez1.com) and start organizing, collecting resources to make them easier to find.

”My website took on a life of its own, started getting traffic from the search engines, advertisers started offering me money to have their ads on my site and it grew from there.

”I should mention as a student nurse, was exposed to Laura Gasparis Vonfrolio, who published the Nursing Journal "Revolution." She both inspired and awed me. Caught the entrepreneur bug from her and it has persisted to this day.

”I set up a corporation, named it Nursefriendly, Inc. and my site is www. Nursefriendly.com.”

And that’s where we are now?

”Since then, a decade now, I have been a part-time stay at home dad, part-time nurse-entrepreneur, part-time bedside nurse in sub-acute rehab (my favorite) and LTC. Seen it all: hips, knees, laminectomies, and all types of surgical aftercare. At the same time, I see a lot of long term care patients with Alzheimer’s, Parkinson’s, pneumonia, and end stage renal disease—lots of patients for hospice.

”I have had two in-laws die on hospice, comfort care. I am very comfortable having code status discussions with patients, families, doctors. I have given the last dose of morphine on more occasions than I care to remember.”

”The Nursefriendly National Directories are a labor of love. It was nice when money started to come in. There is always more to learn in nursing and healthcare. I don't see an end coming to Nursefriendly. I decided I'd keep adding and adding to it for as long as I could. Along the way I’ve met other nurse entrepreneurs, decided to help them get started on the internet via NursingEntrepreneurs.com I ask them to fill out a detailed survey profile that I post to my site by state, category of business, and other questions in the profile. It is a win-win situation. Our site has a steady stream of new nurse entrepreneurs to showcase to our audience and they enjoy and benefit of being showcased.”

What do you see Nursefriendly evolving into?

”I see more of the same. Expanding nursing resources, covering as many disease processes, drugs, medical specialties as resources allow.

”I want Nursefriendly to be one of the "go to" sites in healthcare. Where, if you need it, you can come here and find it quickly, painlessly, with a minimum of frustration.

”Would I like to make enough money to live off the Nursefriendly? Sure, every dollar in advertising helps. However, I'm not in it for the money. That is not why I put the website up. If I aggressively pursued advertisers, sponsorships—we could bring in substantially more. I'm more comfortable earning passive income through our chief advertising agency, Google AdSense. I place the code on my site where I want the ads to appear, they choose what ads, bill, collect, and send me my share. It lets me focus on what I like to do, build and improve my website for my visitors.

”One of the reasons I'm probably not rich by now, is that I've put my family first, before the website, for a very long time. When my daughter asks me to come play, I go more often than not. It is very important to me to be there for birthdays, teacher conferences, and dance classes. She is only going to be young once. She is 10 years old now. It’s just a matter of time before she becomes a teenager and is no longer interested in spending time with her parents. My wife Melanie enjoys going out to eat, seeing movies, traveling. She and my daughter will always be my number one priority before work or business.”

Nurses Must Be Aware of Patients’ Rights

February 21st, 2012

By Jennifer Olin, BSN, RN

There’s a big election coming up in about eight months and one of the many topics we are hearing about from both sides is the current state of healthcare in America. Back in June of 2010 President Obama announced his “Patient’s Bill of Rights” that was basically new regulations for insurers that covered annual and lifetime limits, pre-existing conditions, choice of doctor, and access to out-of-network emergency care. Now, I’m not saying this isn’t important, but when I think of a “Bill of Rights” I think of issues that are a little more personal.

The movement for patients’ rights in healthcare started in the late 1960s as a way to improve quality of healthcare and make the health care system more responsive to clients’ needs. Today’s patients seek self-determination and control over their own bodies when they are ill. Informed consent, confidentiality, and the right to refuse treatment are all part of self-determination and what most nurses and other healthcare providers think of when they define a patient’s “Bill of Rights.”

In 1973, the American Hospital Association (AHA) published A Patient’s Bill of Rights to promote the rights of hospitalized clients. They were revised in 1992. Since that time the only real change to these fundamentals has been the packaging. In 2001, AHA hospitals replaced "A Patient's Bill of Rights" with "The Patient Care Partnership: Understanding Expectations, Rights and Responsibilities." The messages are still the same.

1. The patient has the right to considerate and respectful care.
2. The patient has the right to and is encouraged to obtain from physicians and other direct caregivers relevant, current, and understandable information concerning diagnosis, treatment, and prognosis.

   Except in emergencies when the patient lacks decision-making capacity and the need for treatment is urgent, the patient is entitled to the opportunity to discuss and request information related to the specific procedures and/or treatments, the risks involved, the possible length of recuperation, and the medically reasonable alternatives and their accompanying risks and benefits.

   Patients have the right to know the identity of physicians, nurses, and others involved in their care, as well as when those involved are students, residents, or other trainees. The patient also has the right to know the immediate and long-term financial implications of treatment choices, insofar as they are known.


3. The patient has the right to make decisions about the plan of care prior to and during the course of treatment and to refuse a recommended treatment or plan of care to the extent permitted by law and hospital policy and to be informed of the medical consequences of this action.

   In case of such refusal, the patient is entitled to other appropriate care and services that the hospital provides or transfer to another hospital. The hospital should notify patients of any policy that might affect patient choice within the institution.

4. The patient has the right to have an advance directive (such as a living will, health care proxy, or durable power of attorney for health care) concerning treatment or designating a surrogate decision maker with the expectation that the hospital will honor the intent of that directive to the extent permitted by law and hospital policy.

Health care institutions must advise patients of their rights under state law and hospital policy to make informed medical choices, ask if the patient has an advance directive, and include that information in patient records.

   The patient has the right to timely information about hospital policy that may limit its ability to implement fully a legally valid advance directive.


5. The patient has the right to every consideration of privacy. Case discussion, consultation, examination, and treatment should be conducted so as to protect each patient's privacy.

6. The patient has the right to expect that all communications and records pertaining to his/her care will be treated as confidential by the hospital, except in cases such as suspected abuse and public health hazards when reporting is permitted or required by law.

   The patient has the right to expect that the hospital will emphasize the confidentiality of this information when it releases it to any other parties entitled to review information in these records.


7. The patient has the right to review the records pertaining to his/her medical care and to have the information explained or interpreted as necessary, except when restricted by law.

8. The patient has the right to expect that, within its capacity and policies, a hospital will make reasonable response to the request of a patient for appropriate and medically indicated care and services. The hospital must provide evaluation, service, and/or referral as indicated by the urgency of the case. When medically appropriate and legally permissible, or when a patient has so requested, a patient may be transferred to another facility. The institution to which the patient is to be transferred must first have accepted the patient for transfer.

   The patient must also have the benefit of complete information and explanation concerning the need for, risks, benefits, and alternatives to such a transfer.


9. The patient has the right to ask and be informed of the existence of business relationships among the hospital, educational institutions, other health care providers, or payers that may influence the patient's treatment and care.

10. The patient has the right to consent to or decline to participate in proposed research studies or human experimentation affecting care and treatment or requiring direct patient involvement, and to have those studies fully explained prior to consent.

    A patient who declines to participate in research or experimentation is entitled to the most effective care that the hospital can otherwise provide.


11. The patient has the right to expect reasonable continuity of care when appropriate and to be informed by physicians and other caregivers of available and realistic patient care options when hospital care is no longer appropriate.
12. The patient has the right to be informed of hospital policies and practices that relate to patient care, treatment, and responsibilities. The patient has the right to be informed of available resources for resolving disputes, grievances, and conflicts, such as ethics committees, patient representatives, or other mechanisms available in the institution. The patient has the right to be informed of the hospital's charges for services and available payment methods.

You will see these patients’ rights posted in most hospitals, most everywhere you look—in elevators, in bathrooms, on hallway bulletin boards and in cafeterias. The wording may be slightly different. The phrases may be shorter. The may be written in different languages. The intent is always the same. They are there so no one, not patients, not doctors, not nurses, ever forget what the patient deserves and how we as care providers must respect our patients’ rights.

Michelle Obama Urges Nursing Licensing Support for Military Spouses

February 20th, 2012

By Jennifer Olin, BSN, RN

Nearly 4000 spouses of members of the United States military are nurses. Every time they move with their husband or wife they have to look for a new job and get a new license to practice. In a time when there are noted nursing shortages and the unemployment rate among military spouses is double that of their civilian-life counterparts this seems like an unnecessary burden.

Now, the Obama administration has set a goal that all 50 states will pass their own legislation addressing these licensing issues for military spouses and make it easier to transfer professional licenses and certifications from one state to another. “We know it’s an ambitious goal. We know it won’t be easy to achieve, but we also know that our nation’s military families have waited long enough,” said first lady Michelle Obama, last week during an address at the Pentagon.

Obama said the issue of licensing difficulties is the number one problem military spouses talk about when she and Dr. Jill Biden, wife of Vice President Joe Biden, travel around the country promoting the “Joining Forces” campaign. Joining Forces is a comprehensive national initiative to mobilize all sectors of society to give service members and their families opportunities and support. “So on the rare occasion when our military spouses do speak up and ask for our help, then it’s time for all of us to take action,” Obama said.

Defense Secretary Leon Panetta joined the first lady and Dr. Biden during the Pentagon address. He noted that these licensing issues often inhibited his own wife’s ability to practice as a nurse when he was in the service.

It’s In The Numbers

More than 100,000 military spouses—or 35 percent of military spouses in the workforce—are in nearly 50 occupations and professions that require licenses or certifications, says a new report authored by the Department of Defense (DoD) and the Treasury Department. Of those 50, the top three professions are teachers (5.2 percent), childcare workers (3.9 percent), and registered nurses (3.7 percent).

Also according to the report, between 2007 and 2011 an average of 15 percent of military spouses reported moving across state lines in the previous year, compared with 1.5 percent of their civilian counterparts.

So far, 11 states have adopted legislation that supports military spouse license portability: Alaska, Arizona, Colorado, Florida, Kentucky, Missouri, Montana, Tennessee, Texas, Utah, and Washington.

Another 13 states have proposed legislation to help spouses in these situations: Colorado, Delaware, Hawaii, Indiana, Kansas, Nebraska, New York, North Carolina, Ohio, Oklahoma, South Carolina, Virginia, and West Virginia. Officials would like to see every state pass legislation streamlining licensing processes by 2014

“We’re not asking any state to change their standards. These state rules are important, and states have every right to set benchmarks just like these. In doing so, they hold our professionals to a high bar and they give us all peace of mind whenever we walk into a hospital or enroll our kids in school,” said Obama. “But it’s also clear that this system poses very unique challenges for our military families.”

Best Practices Suggestions

The Defense Department’s state liaison office has been working on this issue since 2008. In 2011, the office presented some options to state policymakers that would ease the process for spouses, while preserving the integrity of the licensing process. The report provides tips and ideas for states, “not edicts and decrees,” Obama said.

The best practices that the DoD and Treasury officials identified in their report include:

• Licensure by endorsement, if the license from the previous state is based on requirements similar to those in the receiving state, and without a disciplinary record.
• Temporary or provisional licensing, allowing applicants to be employed while they fulfill the requirements of a permanent license, such as examinations, applications and fees.
• Expedited application process: For example, an official overseeing licensing with a state also can approve license applications for the boards.

Since each state sets its own licensing requirements, the report explains, these requirements often vary across state lines. A lack of license portability — the ability to transfer an existing license to a new state with minimal application requirements — can cause spouses to bear high administrative and financial burdens as they attempt to obtain a license.

DoD officials admit this issue has been a long-standing concern for the department. Each year, the DoD chooses 10 issues of importance to present to state policy makers, he noted, and this issue has been making the cut for many years.

Helping wives and husbands of military personnel with employment can have a resounding impact, both on a families' well-being and on military readiness, the report noted. A spouse's employment plays a vital role in the financial and personal well-being of military families, and their job satisfaction is an important component.

"Without adequate support for military spouses and their career objectives, the military could have trouble retaining service members," the report said.

"Our military spouses support the well-being and safety of our nation, and we can best appreciate their sacrifices and unique challenges by adopting practices that lessen the burdens of their frequent moves," officials wrote in the report. "They have a compelling need, and we are suggesting tangible solutions. All that is needed is the willingness to take action."

The first lady and Biden will present this issue to all 50 state governors and their spouses later this month at the National Governors Association Conference. They are also rallying professional organizations and advocacy groups to engage on this issue at a state level.

In Other Military/Nursing News

In a move that will help military trained nurses in the state of Georgia, last week Governor Nathan Deal signed legislation amending a state law that inadvertently excluded some military-trained nurses from a license to practice in Georgia. According to a release from the Governor’s office, HB 675 revises the definition of “approved nursing education programs” for registered professional nurses and licensed practical nurses.

“Legislation sometimes has unintended consequences, and no one ever wanted to prevent these professionals from working in Georgia,” the governor said. ““With the current shortage of healthcare professionals in our state, this bill will provide more opportunity for highly qualified nurses to practice here. “

The bill passed the Georgia General Assembly unanimously and now approximately 150 more nursing professionals will be eligible for employment as healthcare providers.

Don’t Ask, Don’t Tell Shouldn’t Apply in Nursing Either

February 17th, 2012

By Jennifer Olin, BSN, RN

Don’t ask, don’t tell may be on its way out for the military, but it is still a pretty firmly entrenched way of thinking in the world of nursing and substance abuse. With somewhere in the neighborhood of one in 10 nurses abusing illicit drugs, prescription medications, and/or alcohol, the problem is as widespread as in the public at large. The difference is nurses are the people charged with caring for the public and that becomes a dangerous proposition when the nurse is working under the influence.

As nurses we usually feel compelled to inform, to educate, and to help our patients with chronic, progressive, and often fatal health problems. Substance abuse is certainly one of those health issues yet when it involves a colleague we often stay silent. It’s not easy to report someone you work with daily, side by side. Whether out of friendship, loyalty, guilt, or fear of jeopardizing a coworker’s ability to earn a living we stay quiet. What we must keep in mind is that our primary concern as nurses is patient safety. A nurse who is practicing while impaired is a danger to his or her patients.

Filing a Complaint

In the not so distant past the only way of dealing with a nurse who was suspected of working while impaired was dismissal from the job and filing a complaint with the state board of nursing (BON). The complaint would be reviewed, the nurse given a chance to respond then the BON makes one of three decisions:

1. If there is enough evidence indicating disciplinary action is warranted the will start the disciplinary process.
2. They may dismiss the complaint.
3. They may determine more information is needed and conduct and investigation.

The thing to keep in mind here is there is no guarantee that this is a speedy process. While this is happening the nurse is likely not working and earning a living. If stressors were part of the equation for leading to the substance abuse you can only imagine how stressed the RN is going through this.

Earning a license to practice nursing means that the nurse has the ability to earn a living. Therefore, the license is a form of property and cannot be taken away without giving the participant due process of the law as granted in the Fifth Amendment to the United States Constitution and made applicable to the states by the Fourteenth Amendment. Once a decision is rendered the nurse has a right to appeal, which differs from the previous hearing.

In many states regulations include certain acts that are cause for disciplinary action against the nurse. The most common are:

• Drug diversion.
• A positive drug screen for which there is no lawful prescription.
• Violation of a state or a federal narcotics or controlled substances law.
• Criminal convictions.
• Addiction to or dependency on a habit-forming drug or controlled substance.
• Illegal use of the drug or controlled substance.
• Use of a habit-forming drug or controlled substance to the extent it impairs the user physically or mentally.
• Failure to comply with the contract provisions of the nurses assistance program.

Nurses Assistance Programs

Nurses assistance programs, also known as peer assistance programs, are often alternatives to flat out being fired for working under the influence. They were created at non-punitive, confidential, and voluntary alternatives to reporting nurses to the boards of nursing. Currently, all 50 states, the District of Columbia and Puerto Rico offer assistance programs.

After reading the goals and mission statements of about 20 different states’ nurses assistance programs it is clear they all have, generally, the same aims with the first being to protect the public. Following that in some form or another they want to:

• Identify nurses experiencing mental health, alcohol/drug problems that have been or are likely to be job impairing.
• Assist these nurses in obtaining appropriate treatment.
• Monitor the nurse's return to the work force.
• Educate employers and nursing colleagues about the negative effects of addiction/mental illness in the work place and the potential for rehabilitation and return to productive work.

The Texas Peer Assistance Program for Nurses (TPAPN) is a prime example of how these programs work and the philosophies that guide them. “TPAPN adheres to a philosophy of providing an opportunity for recovery combined with protecting the public from unsafe nursing practice. Nurses who have substance use disorders or certain psychiatric disorders should be offered the opportunity for education, treatment, and recovery. This philosophy is based on the belief that recovery from substance use disorders and certain psychiatric disorders is possible, and that the return of nurses to safe nursing practice is in the best interest of the profession and society.”

When nurses volunteer for a peer assistance program they agree to several factors including abstinence, monitoring of their recovery via compliance with treatment recommendations, return-to-work restrictions, attendance at self help meetings and random drug tests. Participants are responsible for the costs of the treatments and the drug screens, but sometimes, if their employer has made it possible, their insurance will help defray the expenses.

Nurses may refer themselves to a assistance program, employers can refer the offending nurse in an effort to support and maintain their employment; and family or friends can make the recommendations. Most programs will not accept anonymous referrals.

Alternative-to-Dismissal plans

About a year ago, in February 2011 a study was published in the Journal of Clinical Nursing explaining how punitive substance abuse programs actually stop nurses from seeking recovery from an addiction. This shouldn’t really be a surprise because who turns themself in, in order to be fired. Their paper, titled “Don’t Ask, Don’t Tell: Substance Abuse and Addiction Among Nurses” supported programs that offered assistance and possibly the eventual return to work for nurses suffering from drug and alcohol addiction.

Authors Todd Monroe, PhD., RN, and Heidi Kenaga, Ph.D. provided six key elements for an effective alternative-to-dismissal (ATD) plan, citing that ATD plans can allow administrators to better protect patients while simultaneously supporting the nurse in their recovery. They are also cost effective since traditional disciplinary plans can take many months while an ATD can be much faster and more efficient. The six key elements are:

1. Promoting open communication by discussing substance abuse in every work or school orientation.
2. Encouraging an atmosphere more amenable for reporting by ensuring confidentiality.
3. Providing information about the signs and symptoms of impairment.
4. Conducting mock interventions to help allay fears or feelings of discomfort about confronting a co-worker or fellow student about suspected chemical dependency.
5. Inviting ATD experts to speak to the hospital or school administration.
6. Participating in scholarly forums about addiction among health care providers.

ATD programs have taken hold in this country and all the major nursing organizations support ATD strategies including the American Nurses Association, the National Council of State Boards of Nursing, the National Student Nurses Association, and the American Association of Colleges of Nursing.

Another positive aspect of ADT programs is that they allow nurses to handle a lot of the problems that come with the discovery of a substance abuse problem, such as obtaining liability health insurance after discipline. Monroe estimates approximately 9,000 nurses return to work successfully each year thanks to ADT programs.

While every state offers some kind of ATD programs, they are still not universally accepted. And, even though the state has such a program, not every hospital participates. Hospitals are not required to take part in ADT programs and some choose not to.

As I said at the beginning of this article, surveys show that one in every 10 nurses has some kind of substance use or abuse problem. What that means is you know someone who is currently working or studying to be nurse who is doing so while impaired. It is our job to protect our patients—it is also our job to protect ourselves, and our colleagues. As scary as it may be, if you suspect someone it is better to err on the side of caution. Enlist the help of a colleague, contact your manager or company’s Employee Assistance Program (EAP) and figure out the best way to help your fellow nurse.

RNCentral.com Invites You to Our New Home on Facebook

February 17th, 2012

As most of you know, RNCentral.com is all over Twitter bringing you the latest in nursing and healthcare news and listening to what you have to say. But, if you are looking for something more than 140 characters come check out our new Facebook page at RNCentral.com.

Feel free to ask questions, make story suggestions or share your own nursing journey. We are here for you and are always interested in your perspectives on this career path that offers so many opportunities for growth.

And, check in regularly to see what our own blogger, Jennifer, is thinking about. She loves to hear from you, appreciates your support and is always open to any questions, comments or concerns.

Hope to see you on Facebook, very soon!

Whitney Houston and 10 Percent of Nurses: What Do They Have in Common?

February 17th, 2012

By Jennifer Olin, BSN, RN

Celebrities live in the public eye, it is the nature of being famous. They also suffer and die in the public eye. On February 11th singer, actress, Whitney Houston was found dead in her Los Angeles hotel room. While the coroner’s report has yet to be released there is little doubt in most minds that ultimately her much publicized addictions will factor in. She would join the pantheon of celebrities lost to illicit drugs, prescription medications, and alcohol: most recently Amy Winehouse and Heath Ledger, and looking back Jim Belushi, Elvis Presley and Marilyn Monroe, to name a few.

Addiction is a beast. And it doesn’t only bite celebrities. In 2011, the Los Angeles Times reported that after an analysis of government data deaths from drugs have now exceeded deaths in traffic accidents. In 2009 the U.S. Centers for Disease Control and Prevention reported 37,485 people died nationwide from drug overdose.

And, it’s not all illegal drugs. Deaths from prescription pain and anxiety medications, usually combined with one another or with other drugs or alcohol are the most dangerous and commonly abused.

The Substance Abuse and Mental Health Services Administration (SAMHSA) estimates more than 22 million people in the United States abuse drugs or alcohol. Now for a truly disturbing statistic, the American Nurses Association (ANA) estimates that six to eight percent of nurses use alcohol or drugs in amounts sufficient to impair professional performance. Other studies say as high as 10 percent of nurses misuse drugs and alcohol. The number of RNs with addiction and abuse problems is about the same as the percentages in the general population.

In other words, of 3.1 million nurses in this country, one in 10, are struggling with some form of abuse or addiction. Look around you, one in 10 is a pretty big number, and that number represents the people most often responsible for the health and well-being of the rest of the population.

Where Do Nurses' Addictions Begin?

Work related stress and easier access to pharmaceuticals are factors that help make nurses particularly vulnerable to drug addiction and abuse. Some of the work related factors attributed to higher levels of drug addiction in RNs include:

• Working a night shift or rotating shifts.
• critical care work.
• Excessive overtime.
• Musculoskeletal injuries and pain.
• Knowledge of medications.

Some nursing specialties, such as anesthesia, critical care, oncology, and psychiatry, are believed to have higher levels of substance abuse because of intense emotional and physical demands, and the availability of controlled substances in these areas, according to "Substance Use Among Nurses: Differences Between Specialties," a landmark study in the in the American Journal of Public Health.

In the March 2007 issue of Hospital Pharmacy a study monitoring the diversion of controlled substances details the typical ways nurses get drugs at work. An RN may ask a physician for a prescription or steal a script and forge one for themselves, the study said. “Nurses have also been known to divert drugs by administering a partial dose to a patient and saving the rest for themselves, or by asking a colleague to cosign a narcotics record saying a drug was wasted without witnessing the drug's disposal. Some nurses have signed out medications for patients who have been transferred to another unit or obtained as-needed medications for patients who have refused or not requested them.”

Nurses who abuse drugs frequently go undetected. Peers and patients may know the symptoms but it’s often like the story of the blind men and the elephant. Each person sees one strange or odd behavior but it takes all the stories to put together a real picture of someone under the influence.

The redirecting of drugs from a legitimate use to illicit channels is called “diversion.” Signs a nurse may be diverting drugs include:

• Arriving early, staying late, and coming to work on scheduled days off.
• Excessive wasting of drugs.
• Regularly signing out large quantities of controlled drugs.
• Volunteering often to give medications to other nurse’s patients.
• Taking frequent bathroom breaks.
• Patients reporting unrelieved pain despite adequate prescription for pain medicine.
• Discrepancies in the documentation of controlled substance administration.
• Medications being signed out for a patient who has been discharged or transferred or who is off the unit for procedures or tests.

It’s almost too easy. Diversion is a crime and when a nurse is accused the police can be called in to investigate and the nurse may be arrested. Add to that forging prescriptions is a crime and practicing while impaired by alcohol or drugs is professional misconduct and grounds for being fired.

Management’s Role

It is the basic role of the nurse manager to recognize and manage nurses who are practicing while impaired. When the manager meets with the nurse under suspicion they must have a basic understanding of a substance use disorder as a primary disease, their 
course and signs or symptoms, and be prepared for all contingencies. Nurses will rarely admit dependency; drug addiction is still often considered morally reprehensible, not an illness, and impaired nurses are always certain they will lose their jobs and have their licenses revoked.

The manager must:

• Know the workplace policies and procedures related to substance use disorder among nurses.
• Know the workplace’s policies and procedures pertaining to medication administration, wastage and inventorying of controlled substances.
• Know who the resources are in-house and externally regarding substance use disorder in any nursing staff.
• Recognize personal attitudes about substance use disorders as supportive or as a barrier to helping a colleague.
• Know how to document a problem properly.
• Feel confident in personal intervention skills (if a problem requires action, know the 
personal reporting responsibilities as they pertain to hospital administration, board of 
nursing and state alternative or peer assistance program).

Back in 2007, unpublished research at Baylor University Medical Center in Dallas, TX estimated the facility saved over four million dollars in turnover cost avoidance involving RNs identified with a substance abuse disorders and certain psychiatric disorders over an eight-year period. Baylor worked to retain nurses whenever possible rather than summarily terminating them. Through the proactive advancement of education, identification, intervention, re-entry to practice and policies and procedures system-wide Baylor administration was able to help save the lives and careers of many employees as well as money.

Empowering nurses to seek treatment, allowing for their insurance to help cover their treatment and making it possible for nurses to return to practice is a win-win for employee and employer alike. There are many resources available both inside and outside the workplace for nurses to find help to beat addiction. We will talk about those options in the next installment of this article.

Here’s What You Think About RN Amanda Trujillo’s Story

February 15th, 2012

By Jennifer Olin, BSN, RN

I rarely worry about losing my job as a nurse. I’m generally professional, mostly on time, anal retentive about patient safety and for the most part people seem to like me. I am bossy, but I am a nurse (specifically an OR nurse so that comes with the territory). I am demanding on my patient’s behalf (but sometimes that slips over into my personal life) and I hate charting (which is hard on my chart reviewers and why I love medical mission work).

I share all this because I am human; just like every nurse. Most of us don’t consider we will lose our jobs for doing our jobs, sometimes no matter how difficult we are to work alongside. Arizona nurse Amanda Trujillo never considered she would lose her job and possibly her license for being safety conscious and demanding on her patient’s behalf.

This story of one nurse’s trials and tribulations is raising many topics for consideration, discussion, even argument. Many of you have weighed in with your thoughts on the subject. I blogged one day about what made other nurse/writers pick up this banner and run with it. Many of them were kind enough to share their thoughts with us at RNCentral.

Many readers, nurses, have also shared their opinions with us about this controversial case. I also know that once I have read an article I rarely go back and read it again. But, there is some great stuff here, from nurses just like you and me. So, let’s take a look at what nurses across the country are thinking about the situations and topics surrounding Trujillo’s story.

What Threatens One Arizona RN Threatens Us All

• Christine Esquivel says: 
”This is a travesty. Ms. Trujillo was well within her scope of practice by ordering a hospice consultation. The MD was way out of line and was probably upset over loss of revenue. As nurses we see this happen all the time and should be addressed.
• Rene W. Neville writes: "This case is BEYOND outrageous. What is described is a perfect and extreme example of Why nurses have no desire to report unsafe practices and/or violations of Patients’ Rights. This RN appeared before the Arizona State Board of Nursing TODAY to ‘explain herself’ for doing what we ALL have a responsibility to do-Advocate for our Patients!
As of today, Jan.24,2012, her license on the Arizona State Board of Nursing’s’ Verification website is stated as: ACTIVE: UNDER INVESTIGATION.
Why should any nurse want to work in Arizona after THIS?”
• Gail Gabel says: "What happened to this nurse can happen at anytime to any of us. I am appalled at the surgeon, the hospital that fired her and Arizona State Board for suspending her license “pending investigation” AND they send her for a psych eval. 
Since when are nurses “crazy” for educating their patients? Are we all nuts? To strip her of everything she has worked for the sake of a surgeon’s ego? 
This is tragic and should not be happening, this is the 21st Century after all.”
• Kerri, RN, replies: ”She did the right thing to advocate for her patient. The whole issue is that she made a hospice consult without notifying the physician. If I had a patient who decided to hold off on surgery to get more information, I would have called the physician and informed him first and then suggested a case management consult. If the physician refused, then administration and the ethics committee would have been notified to protect the patient. The bottom line here is that we be advocates and protect our patients just as Amanda Trujillo did. The error lies in the order of actions that she took. We all know that nurses act with autonomy in certain situations and then let the physician know. However, when it happens with the wrong physician, it can be disastrous for the nurse’s career. I’ve seen similar situations occur where nurses were fired over it. In the case of this physician, I would bet that he wasn’t notified immediately because he’s likely one of those physicians who verbally abuse nurses when they call for orders.
This is one of those moments where it’s become obvious that there is a serious discrepancy between what is expected of nurses and what they can actually do. It’s time for physicians and hospitals to be clear on what the nursing scope of practice is because Amanda Trujillo acted within hers.”
• Penelope Rock writes:”Indeed, the case against Amanda Trujillo is not just a case against her but a case against the nursing community. The threat against her is a threat against our licenses too if we in any case will practice patient advocacy. And above all her case is against our patients who deeply need knowledge, eh.
Thanks for sharing.“

It was early February 2012 before the American Nurses Association managed to even acknowledge that something was going on across the country in Arizona. They had been written, they had been emailed, they had been called, they had been tweeted, and messaged, and blogged before they said anything (and they didn’t say much). Other nurses noticed that, too.

ANA Finally Acknowledges RN Amanda Trujillo

• Greg Mercer says: “As expected for a large traditional organization with too much to lose to take any risks, ANA offers mostly standard boilerplate likely approved by liability attorneys as safe prior to any public release. Also as expected, we are told to trust the system in all its facets, and distrust anyone with the audacity to suggest otherwise. It seems traditional organizations in most all their variety have one thing in common: disdain and distrust, and perhaps fear, of Social Media upstarts increasingly encroaching on formerly unquestioned prestige and influence and power. The world is changing, and disapproval will not change that fact. It is wiser, in my humble opinion, to learn to put new realities to best use than it is to try to fight them – ask the buggy whip makers who tried to hold on as those pesky new-fangled automobiles came out. Passing fad? Social media is the next big thing – hop on or recede into history.”
• Naomi replies: “ANA strongly supports nurses and their right and responsibility to engage in patient education and advocacy.”
Do they, really? Is this not what Amanda did?? Why doesn’t the ANA support their nurses like the AMA supports their docs?”
• Aidel says: “Amanda did the right thing. It is no surprise that the ANA is not being supportive. If patients getting procedures were giving truly INFORMED consent, there would be a whole lot fewer procedures happening, which is bad for business, which is why we won’t see any meaningful change in this area. Physicians, hospitals, drug companies, and insurance companies (all for different reasons) have a long history of lying to patients. Morally indefensible but TRUE.”
• Nancy Wilson writes: “It is becoming increasingly obvious that we cannot rely on our professional organizations to support us when the chips are down. It is time for nurses to take a stand for each other and for our profession. If we don’t others will do it for us and we won’t like the outcome.”
• Annie says: “Because the doctors bring in patients which equals money for the hospitals. It always boils down to money and power.”
• Naia McCoy comments: “My brother did not get proper informed consent and he is now dead because of severe Prozac side effects. I will not go into the details. I am not sure I understand what has happened to the medical field but if they cannot even protect their “own” (nurses)…then something is terribly, wrong and unjust in this country. Time to practice the art of nursing in another more caring place.”
• Shahina Lakhani, MSN, RN, replies: “Jennifer, you have made some great points in this article. The fact that it took 10 months for Amanda’s case to be finally recognized is a proof to how unsupported the nurses are. If it was AMA a doctor would be innocent until proven otherwise, but for nurses it is guilty from the beginning and often without a chance of a fair investigation. Social media has brought nurses together like never before. Our challenge now is to create and maintain alliances at larger scale with each other, nurses for nurses. It is a great shift but one that is desperately needed so nurses can come out of this big hole of being treated as maids and gofers and finally claim our rightful place as partners in healthcare.”
• Carolyn Nelson, RN, BSN, says: “Money is the root of evil. And this is no exception. I, too, have been sited where I work of saying the truth to our patients and being placed on three days off. Amanda did the same as I and as many nurses have in the past. Go Amanda.”
• Jessica Ellis writes: “Yes, well…it’s all so clear, isn’t it? The ANA and other prof orgs are all about protecting themselves and their revenues. They can’t possibly take sides and support nurses through difficult times until proven either innocent or guilty. Seems that “guilty until proven innocent” is more the reality in the nursing world…and it takes going viral in social media to get even a NEUTRAL-sounding response from the orgs.”
• Diane Levine, RN, BSN, comments: “Amanda, you know in your heart you did the right thing. As nurses we are responsible and obligated to be sure patients understand why they are there, what is happening to them, and how the physician can treat it if possible. It is also important the patient is well aware of the risks and the benefits either way. If their physician has not explained it fully or in a way the patient can comprehend it’s our responsibility to step in at this point and be sure we can help them to be educated. Nurses are teachers too. In fact its one of the jobs we do that I enjoy best! This whole incident sounds to me as if the physician was scared you were talking his patient out of his surgery where he could be a HERO! Second, it sounds as if when you speak of hospice as an alternative with a patient you are discussing death. Death is a very scary topic to anyone. Always was, probably always will. There is something about the unknown that scares us, even though there’s so much peace and tranquility to be learned and understood as well. We need more nurses like you to help us all in that journey! You Go Girl!!! Whoever hires you will be one very Lucky Employer!! Remember…God’s time Not Your time. Good Luck.”

So, that’s what you all are saying. We need to keep talking, on forums like this one, at our professional meetings, telling our organizations we don’t want them to do what they think is best, we want them to do what we think is right. Hospitals don’t run if they don’t have nurses; organizations don’t meet if we don’t join, and patient’s don’t get proper, safe care if we don’t stand up for them when they can’t stand up for themselves.

I may be bossy, I may be demanding, but I never thought of myself as revolutionary. That’s what this is starting to feel like; a revolution for nurses to claim their professionalism, their skills and their rights as members of the health care TEAM.

Boards of Nursing-Who Do They Stand Up For?

February 14th, 2012

By Jennifer Olin, BSN, RN

How often do you think about your state’s board of nursing (BON)? I know I almost never do. I’m betting, for the most part, nurses think about their respective BONs once or twice every two to three years when their license renewals are due. We write a check, or send a credit card payment online and the BON drifts to the back of our brains for another couple of years.

This may be a big mistake.

Boards of Nursing have a lot of power. They regulate how — and if — we can practice as nurses; provide the licensing that allows us to do so and sets the standards for our education. And, to be honest, I don’t know who the people are on my state BON or how they get their jobs. And yes, I do get the newsletter. I skim it, read the headlines and look to see if they have added or changed any of my mandatory continuing education credits and then toss it in the trash. I am only talking about the newsletter I get from the Texas BON. I am currently licensed in two other states but they never send me anything: no newsletters, no emails—just a notice every couple of years to re-up.

So, maybe we should take a little look at what is a BON, where do the members come from and what do they have the power to do?

It was more than 100 years ago that North Carolina established the first board of nursing in the United States. Since them every state has followed suit. The mission of each BON is to protect the public’s health and welfare by overseeing and ensuring the safe practice of nursing. They achieve their mission by outlining the standards for safe nursing care and issuing licenses to practice. Once a license is issued, the board's job continues by monitoring licensees' compliance to state laws and taking action against the licenses of those nurses who have exhibited unsafe nursing practice.

Who Is on a BON?

The individuals who serve on a board of nursing are appointed officials. State law dictates the membership structure of the BON but they usually include a mix of:

• Registered Nurses
• Licensed Practical/Vocational Nurses
• Consumers

Each individual state determines the responsibilities and oversights of their BON. In most cases, boards of nursing report to either the governor of the state, a state agency, a combination of the two or sometimes a separate state official or organization. As North Carolina was a trendsetter in forming the first BON they are equally progressive in how they choose their BON members. North Carolina is the only state that elects the majority of nurses to its BON. In North Carolina 11 of the 14 members are elected by nurses holding valid N.C. nursing licenses. Each year the Board conducts an election to fill the open seats.

Standard powers and duties of a BON are:

• Enforcing the Nurse Practice Act and nurse licensure.
• Accrediting or approving nurse education programs in schools and universities
• Developing practice standards
• Developing policies, administrative rules and regulations.

Since scope of practice and nursing responsibilities vary state-to-state nurses in the U.S. are responsible for knowing the regulatory requirements for nursing and the nurse practice act in every state in which they are licensed and practicing.

The Nurse Practice Act

Each state has a law called the Nurse Practice Act. Nurses must comply with the law and related rules in order to maintain their licenses. The law describes:

• Qualifications for licensure.
• Nursing titles that are allowed to be used.
• Scope of practice.
• Actions that can or will happen if the nurse does not follow the nursing law.

The National Council of State Boards of Nursing

The National Council of State Boards of Nursing (NCSBN) is a not-for-profit organization through which boards of nursing act and counsel together on matters of common interest and concern affecting the public health, safety and welfare, including the development of licensing examinations in nursing. There are 60 member boards in the NCSBN including all 50 state boards of nursing, the District of Columbia, and four U.S. territories: American Samoa, Guam, Northern Mariana Islands, and the Virgin Islands. Four states have two boards of nursing, one for registered nurses (RNs) and one for licensed practical/vocational nurses (LPN/VNs): California, Georgia, Louisiana and West Virginia. One state, Nebraska, has both the board of nursing and the board for advanced practice nurses (APRNs) represented.

The NCSBN counts among its duties developing the nursing licensing exams, like the NCLEX-RN, and others. They also maintain the Nursys database, which coordinates national publicly available nurse licensure information and monitor trends in public policy, nursing practice and education.

What Can a BON Do to You?

As nurses, we are cautioned from early on to protect our license. Don’t do anything that might jeopardize that hard earned RN credential. The practice areas that cause the most problems for nurses are documentation, assessment, intervention, bypassing checks and balances, and not knowing policies and procedures. These are the basics of nursing practice and where we fall down the most.

Anyone can report a nurse to the BON. It can be a patient or patient’s family member, a peer, a boss or an institution. Once the board is set in motion, it is up to the nurse to try and keep up, and once that nursing license is marked as under investigation that nurse becomes almost unhireable. You’ve been hit in the pocketbook.

A BON can revoke a license, or force a nurse to surrender their license or impose restrictions that can inhibit employment. Most of us think this will never happen. Most of us are good nurses. But, good nurses sometimes make mistakes, sometimes fail to write something down or miss something when assessing their patient. It happens. And again, anyone can file a complaint and then it must be followed up by the BON. Good nurses have lost their licenses, innocent nurses have become unhireable simply because they were investigated.

The one thing to remember is that boards of nursing are not in place to protect nurses, they are in place to protect the public. BONs are like nurse police.

And, like the police, BONs are not infallible. These boards get very little scrutiny, some provide very little public information, and facing facts, they are government entities that suffer the same bureaucratic setbacks as every other form of government.

In 2009, reporters Charles Ornstein and Tracy Weber, both with Pro Publica, filed a story in conjunction with the Los Angeles Times that “uncovered broad breakdowns in California’s regulation of registered nurses.” They “found that the board took more than three years, on average, to investigate and discipline errant nurses. Positive drug tests, criminal convictions, and discipline by other states didn’t trigger immediate consequences. An attempted murderer renewed his license for years while he was in prison. In some cases, even when nurses were convicted of sex offenses, the board never acted at all.”

It only follows suit that if a BON is taking that long to discipline “errant” nurses, they are also taking that long to clear innocent nurses against whom complaints have been filed. BONs are powerful and often the final voice in how each of us is allowed to practice. I believe they should be held to same standards as the courts, as found in the Sixth Amendment to the US Constitution. A nurse, brought before the board “shall enjoy the right to a speedy and public,” in this case, hearing.

Final Thoughts

Like many of my fellow nurse/bloggers I am disturbed by the case of Amanda Trujillo, RN. There are a lot of conversations to be had about her dismissal and the complaint filed against her with the Arizona BON. In the case of the BON I can find no justification for it being almost a year since the complaint was filed and no action has been taken. This woman, this nurse, deserves to move on with her life. She cannot do this with the Arizona board’s stalling. After 10 months they asked her for a psych evaluation, seemingly after she started garnering attention from the aforementioned writers. I don’t even know how they justify that and they have not seen fit to tell her.

One of the problems I see here is the lack of standardization of what is a nurse’s scope of practice, and a lack of standardization in nurse practice acts. Carol Gino, nurse, writer, and activist, addresses these questions to the Arizona Nurses Association on their Facebook page. She says, “…can we have an example or two of what the professional body does so that the nurses who have no clue can understand what it does for all of us? To have a non-standardized scope of practice, to have nurses as professionals be part of a hospital’s budget puts all nurses in the position of non-professionals. We need a clear statement in non-legalese about what our organizations do for us or when we move into expanded practice, we can get thrown under the bus and no one is watching our back. How can any of us wait for the decree without a salary for a year or so? A bridge has to be made between the nurses in the trenches and the policy makers representing us. This is not only Amanda's story, it's a story that has happened to enough of us to back her. It's just time now. How long can we claim we're professionals without autonomy…?”

State boards of nursing were put in play to protect the public; I get that. However, shouldn’t they be responsible to us, as well?

What Exactly Is Patient Advocacy?

February 13th, 2012

By Jennifer Olin, BSN, RN

One of the many topics raised by the case of Arizona nurse Amanda Trujillo, her firing by Banner Health, and their subsequent complaint to the state’s Board of Nursing, is did she step out of bounds while advocating for her patient?

As I remember it, from day one of nursing school, it was ingrained in us that advocacy, particularly patient advocacy, is one of our most important nursing duties. I know that’s what I remember from all those years ago. Or is it?

So, I went to the sources; nursing textbooks. I still had my copy of Fundamentals of Nursing (Kozier & Erb, fifth edition) and I borrowed a friend’s textbook of the same title (Potter & Perry, sixth edition); and I asked an acquaintance who is currently in nursing school to look at her version of Fundamentals (Taylor et.al., seventh edition). In this very unscientific survey I found my memory was on point. In all three texts, from different years and different authors, nurse as patient advocate is found repeatedly in the first 100-200 pages (and these textbooks have over 1500 pages apiece).

Advocate

An advocate is one who pleads the cause of another; and a patient advocate is an advocate for clients’ rights. In that role, the nurse protects the client’s human and legal rights and provides assistance in asserting those rights if the need arises. Advocacy may include, for example, providing additional information for a patient who is trying to decide whether or not to accept a treatment (Potter & Perry). This is a central theme in Trujillo’s case. Or, the nurse may defend a patient’s rights in a general way by speaking out against policies or action that might endanger their well-being or conflict with their rights.

According to nurse and attorney Mary Kohnke Wagner, in the American Journal of Nursing article, The Nurse as Advocate, the actions of an advocate are to inform and support. An advocate informs clients of their rights in a particular situation, and provides them with the information needed to make an informed decision.

There are several steps involved in being an effective patient advocate:

1. Make sure the client agrees to receiving the information.
2. Either have the necessary information or know how to get it.
3. Want the client to have the information.
4. Present the information in a way that is meaningful to the client.
5. Accept the fact that there may be those who do not wish the client to be informed.

An advocate must know how to provide support in an objective manner. They must be careful not to convey approval or disapproval of the client’s choices. Underlying patient advocacy are the beliefs that individual have the following rights:

• The right to select values they deem necessary to sustain their lives.
• The right to decide which course of action will best achieve the chosen values.
• The right to dispose of values in any way they choose without coercion by others.

Barriers to Nursing Advocacy

When we talk about coercion by others or those who do not wish the client to be informed we are talking to about just some of the barriers nurses can face when advocating for their patients. By analyzing the barriers to effective advocacy nurses can then develop strategies to manage those obstacles and maximize their advocacy efforts.

The most common attribute is conflict of interest between the nurse's responsibility to the patient and the nurse's duty to the institution where the nurse is employed. Other barriers include lack of support and lack of power. Threats of punishment are also considered an attribute of barriers to nursing advocacy, like being reprimanded, poor evaluations, and ultimately being fired. Finally, a historical barrier of nursing being a feminine profession with a tradition of subservience to the medical profession is also considered a barrier to nursing advocacy.

The implications for nursing practice are that nurses need to overcome barriers to become effective nursing advocates for their clients. That would be in an ideal situation however, the threat of job loss, retribution, intimidation, or ostracism are very real. Nurses need strategies to overcome barriers so that they can provide the best possible education and services for their patients.

Strategies for Overcoming Barriers

The biggest barrier most nurses face when acting as a patient advocate are institutional barriers. Every nurse must know the definition of their scope of practice in both their practice state, and their healthcare facility. How the nurse’s role is defined is different behind every door. Nurses may find little to no support in the advocacy role from administrators, physicians, and even nursing peers. Knowing the written rules will help be a more effective advocate.

Clear, effective communication will help overcome institutional barriers when in advocate mode. The nurse’s ideas and suggestions will be better received if spoken clearly and emotional reactions like anger and frustration are kept to a minimum. Body language counts. Every OR nurse knows even with the face almost completely covered the eyes can give away every secret. Leaning forward, pointing fingers, or crossing arms across the chest can all be viewed as hostile or confrontational.

Language, both spoken and written, makes a difference in the effectiveness of client advocacy, as well. Keep the focus on the patient. Document everything. If you have an interaction with the patient and they express a strong opinion, for or against a treatment option or plan of care, make sure you put it in your nurse’s notes and put a copy on the front of the chart for all to see or make a point of discussing with a nurse manager or the physician so everyone is aware of the patient’s concerns.

Knowing where your professional organizations stand on the subject of advocacy can also be helpful but don’t count on that holding any real weight if a conflict arises. Learn your employer’s administrative structure, what committees might support your advocacy track and talk to your peers; they may have dealt with similar situations and be able to provide practical advice.

Nursing education has an important role in teaching student nurses about the role of client advocacy in nursing and how to effectively manage the barriers to be successful advocate. At the institutional level, find a mentor or preceptor who has a strong record as a patient advocate to help understand and navigate the process.

Nurse as advocate falls under the heading of “professional responsibilities and roles” in all those nursing textbooks I surveyed. Nursing has claimed client advocacy as an important core component of nursing practice. Nurses who function responsibly as advocates for themselves, their clients, and the community must have an objective understanding of the ethical issues in health care as well as knowledge of the laws and regulations that affect nursing practice and public health.

As nurses we should be able to support a patient’s healthcare experience through advocacy for the patient without worrying about how our institutions, organizations, administrators, physicians, managers and peers will see our efforts. We should not have to worry about reprimands or retribution when doing the job we are, in fact, trained and taught to do. Keeping open lines of communication, forming relationships with other members of the healthcare team, and being very aware of the rules of practice should make the advocacy role easier. However, as Amanda Trujillo, RN, has experienced there still are no guarantees.

All RNs All the Time: Wave of the Future?

February 11th, 2012

By Jennifer Olin, BSN, RN

When I was a traveling nurse, whenever I started a new assignment, one of the first things I judged at my new hospital was the quality and quantity of the nursing assistants. They could make or break my assignment. It was the CNAs, PNAs, or simply NAs who knew all the stuff I needed to know, where everything was kept, and who to avoid. I valued their assistance and their knowledge. Facing facts, RNs were usually in short supply and the NAs made all the difference in a successful day. What would you do without them?

Well, one hospital in Pennsylvania is in the process of finding out how it works without nursing assistants. Hahnemann University Hospital, in Philadelphia, is going to an all RN nursing staff; no more nursing assistants.

In an article in the Philadelphia inquirer, the hospital’s chief executive officer, Michael Halter, has said he thinks the long term results of going to an RN only nursing staff will net the hospital more money, more clients and create a more loyal staff. Halter noted a pilot study from just one of the hospital’s nursing units found that using all RNs, instead of a combination of nurses and nursing assistants, produced results showing higher-quality care and improved patient and nurse satisfaction.”

Evidence

This really is merely an echo of study after study that has proven the relationship between nurse staffing and quality of patient care. In fact even the U.S. government backs Halter’s assertions with studies of its own. In March of 2007 the Department of Health and Human Services surveyed published research across the nursing spectrum to assess how nurse/patient ratios were associated with outcomes in acute care hospitals.

Researchers found that hospitals with higher RN staffing were associated with lower hospital-related mortality, less failure to rescue, cardiac arrest, hospital-acquired pneumonia, and other adverse events. Another result of having more registered nurses was better a higher level of patient safety particularly in intensive care units (ICUs) and in surgical patients. Also, more direct patient care performed by RNs instead of NAs was associated with decreased risk of hospital-related death and shorter lengths of stay.

Similar studies have been done in other countries with the same results. Last year, in Great Britain, researchers surveyed 400 wards across more than 46 hospitals showing the impact of reducing numbers of registered nurses and substituting healthcare assistants. RNs taking part in the reduction of nursing workforce reported more falls, more urinary tract infections, and more pneumonia in patients on the wards.

Peter Griffiths, Southampton University professor of health services said, commenting on the study, “This shows there are consequences for reducing the registered nurse workforce. It strongly suggests that the push to substitute nursing aides for registered nurses as a cost saving measure is unlikely to achieve adequate quality of care.”

And this is not a new conclusion, either. In 1978 in the journal Hospitals a research study was published that began with this abstract: “The emphasis on cost containment and consumer satisfaction has spurred a new upsurge in interest in all-RN nursing. Data are mounting that show that an all-RN staff doesn't necessarily cost more and that its use markedly improves the quality of patient care. Although obstacles to implementation exist, they are not insurmountable, and nurse leaders are asking, "Why not?"

Sound familiar?

What About the Bottom Line?

So, research has shown greater patient and nursing satisfaction when units or facilities go to an all RN approach to patient care. And, research shows better health and greater patient safety in units and facilities that employee an all RN nursing staff. On top of that there is the bottom line. Nurses may be more expensive than nursing assistants but if patients are getting better care and staying healthier that is cost effective. Particularly since Medicare and Medicaid stopped paying for hospital acquired illnesses and infections.

Beginning in October 2008, Medicare began a program where they would no longer pay for treatment of certain hospital acquired conditions (HACs). The changes surround the identification of certain conditions that can be “reasonably prevented” in the acute care setting. Therefore, if any of these conditions are acquired or in certain cases exacerbated during a hospital stay, the hospital will not receive payment for the care and treatment of that condition. The Centers for Medicare and Medicaid Services (CMS) selected 10 categories of conditions that fall under the HAC payment provision. Included in those 10 conditions were:

1. Foreign object retained after surgery
2. Air embolism
3. Stage III and IV Pressure Ulcers
4. Blood incompatibility
5. Falls and trauma
6. Manifestations of poor glycemic control
7. Catheter associated urinary tract infection
8. Vascular catheter associated infection
9. Surgical site infections following specific surgeries
10. Deep vein thrombosis (DVT)/Pulmonary Embolism (PE)

CMS specifically looked at conditions that are:

1. High cost, high volume, or both
2. Result in a higher payment when diagnosis presents itself as a secondary diagnosis
3. Could have been reasonably prevented through the application of evidence-based 
guidelines.

As a result of all this evidence, Halter may be on to something. Halter thinks the move will pay off financially as insurance companies change reimbursement policies to reward quality.

Hahnemann’s CEO says it will take about six months to a year to transition the whole hospital to an all RN care model. The facility currently employees 600 registered nurses and is looking to hire 50-60 more.

I have never worked in a hospital that had only registered nurses on the nursing staff but I did work in an OR once that only employed one scrub tech. It was fun to get to scrub so much and there was a level of camaraderie and communication that was easy to access. I think the patients got great care. I don’t know if it really made a difference in the patients’ outcomes. It will be an interesting phenomenon to continue to watch.