Nurse Safety

Whistle-Blowers Summon Moral Courage

Posted in Nurse Safety, Nursing, Nursing News

Image courtesy of ElectronicFrontierFoundation via Flickr

Whistle-blowing is both a morally important choice and one that is frequently very difficult. This article on explains that it can be a long and difficult process, that can chip away at a whistle-blowers’ sense of self-worth. They may be shunned by peers or lose their job. It’s not uncommon for people who have been through the whole process to say that if it happened again they’d just look away.

This despite the fact that studies have shown that whistle-blowing is the most important resource for detecting and reporting corporate fraud.

The ANA defines whistle-blowing as is the act of going outside a place of employment to report serious problems, such as those that endanger patients.

Nurses have a responsibility to report these kinds of problems, even when doing so is far from easy. The article lays out some of the things that are important to know, including knowing your options and knowing about organizations like the Whistleblower Support Fund.

Ideally, all organizations swiftly would resolve circumstances that threaten patient or worker health, or are otherwise unethical or illegal. The facility already would have mechanisms through which problems are reported and analyzed so they can be prevented in the future.

“Any place where a nurse works … there’s a responsibility to have a culture of safety as opposed to a conspiracy of silence,” said Cynthia Haney, JD, senior policy fellow for the ANA. Nurses, she added, have a vital role in shaping and supporting this type of environment, known as a “Just Culture.”

Most people know up front how their supervisors will address a serious problem, Murray said.

“They either provide the resources and demonstrate concern for what the individual has brought forward, or they do everything they can to dismiss it, change the topic and ask the individual to let it go,” Murray said. “Most people who go outside have reached a plateau where they’re so frustrated and have endured so much hardship that they don’t see any other option.”

Yet navigating “outside” isn’t easy, either.

Know your options

Multiple government agencies, partners, laws and regulations might come into play.

Among these:

The False Claims Act allows people with direct knowledge of fraudulent claims made by any entity receiving federal funds, such as Medicaid and Medicare, to pursue action. Because most hospitals and nursing facilities, as well as many private physician practices, participate in these federal programs, “it’s really a powerful tool for fighting fraud and abuse,” Haney said.

Anyone with evidence of fraud against a federal agency can seek the aid of an attorney specializing in “qui tam” cases, said Nayna Philipsen, RN, JD, PhD, CFE, FACCE, director of program development and assistant to the dean for legal affairs at Coppin State University’s Helene Fuld School of Nursing in Baltimore. “Qui tam” refers to someone else’s suing on behalf of the government and recovering a substantial portion of funds if the suit is successful.

The Occupational Safety and Health Administration addresses workplace safety. Issues such as exposure to hazardous materials and use of personal protection equipment fall under OSHA’s jurisdiction. Federal law related to job safety includes a protection called the “general duty clause,” which requires employers to provide safe environments for workers. That clause, Haney said, has been extended to include protection against circumstances that create hostile or threatening work environments.

The Affordable Care Act protects whistle-blowers in healthcare settings when patients’ consumer rights under the law are violated, Haney said. For instance, it protects nurses who report insurance company abuses or discrimination against patients with government-subsidized coverage.

The National Labor Relations Board can protect employees, both union and nonunion, who engage in certain “concerted activities,” such as discussing concerns related to safety — false charting and record tampering, for example — or other workplace conditions with colleagues.

Quality improvement organizations. In each state these are designed to ensure the effectiveness, economy and quality of care delivered by providers serving Medicare beneficiaries. These organizations address various complaints related to patient well-being, such as unneeded treatment, and concerns regarding healthcare law and appropriateness of care and billing.

State professional boards. These monitor professional behavior and are charged with protecting public welfare. When two nurses in Winkler County, Texas, thought a physician was providing unsafe patient care, they turned to the Texas Medical Board.

Arduous ordeals

The Texas nurses’ action was just the start of their journey. The two women were fired by the hospital that employed them, and county officials pursued felony charges of misuse of official information against them. The charge against one nurse was dropped, and the other was acquitted. They eventually accepted a $750,000 settlement in a lawsuit stemming from the incident.

Because whistle-blowing can be a long and grueling process, depression is common among whistle-blowers, said Don Soeken, LCSW-C, PhD, a former whistle-blower and founder and president of the nonprofit Whistleblower Support Fund. “They’re facing a terrible onslaught on their minds and bodies because society is set up so you have to have a job” to support yourself and your family, he said. Soeken asks potential whistle-blowers: “Do you have a family that can help support you?”

It’s hard for potential whistle-blowers to imagine the immensity of the challenge they face, said Soeken, who helped launch an Internet archive that catalogues and preserves details of past whistle-blowing cases to inform future whistle-blowers. “What you have are David and Goliath stories,” Soeken said, noting the government, corporations and other organizations can hire top lawyers and tap a wealth of research resources.

Still, Soeken said, whistle-blowers persist because their moral and ethical beliefs override a sense of self-preservation. “They’re almost like soldiers going into war,” he said. “They pay a high price. They do a great service. What we have to worry about is: What are we going to do to help them survive?”

Healthcare Providers Have Feelings, Too

Posted in Nurse Safety, Nursing, Nursing Jobs, Nursing News

Gabriel Blaj -

While this Op-Ed that appeared in the New York Times is written from the perspective of a doctor, a lot of it applies to various healthcare providers who have more information than the patient does.

The doctor, Danielle Ofri, writes of a patient she calls Julia, with whom she had a lot in common; both were about the same age, both were mothers with two young children. They were even about the same height and the same build.

But only one was facing a death sentence. Julia had a serious heart condition that meant she would die, fairly soon.

Ofri writes of the recent findings that physicians are not always open or honest with patients within this context. An article in the journal Health Affairs found that more than one in 10 physicians had told a patient something that was not true within the past year, and almost one in five had failed to reveal a medical error. More than half had put a more positive spin on a prognosis than was warranted.

Ofri expresses some surprise that the numbers are so low, but also questions how nefarious the reasons behind those numbers actually are. While she knows that she should have gone ahead and told everything to her patient, her own emotions got in the way.

When Julia walked out of our hospital without full knowledge of her prognosis, I had been derelict in my duty as her physician. I was fully aware that my job was to have “open and honest” communication with her, in a “patient centered” manner. But I couldn’t. I couldn’t bring myself to tell this young mother that she was going to die.

It could be that I over-identified with my patient, or that I let my emotions get the better of me, or that I was an out-and-out wimp. No doubt all played some role, but I wasn’t the only doctor who struggled with the truth. Everyone responsible for her care — intern, resident, medical attending, cardiology fellow, cardiology attending — independently fell short of the Charter on Medical Professionalism. Young, old, male, female, touchy-feely, egotistical, blustery alike — not one of us could say those words to her face.

When it comes to medical error, doctors have an even harder time coming out with the truth. There is, of course, the well-founded fear of malpractice litigation. Momentum is growing for legislation to protect doctors who acknowledge error and apologize. But beyond the fear of malpractice, there is the larger issue of shame at failing at your job, of letting a patient down, that makes you want to hide. It took me two decades to speak publicly about my first major medical error.

I was one week out of my internship at the time, and my patient was admitted nearly comatose with what is called diabetic ketoacidosis, from a severe lack of insulin. After we’d brought him back from the brink and could finally turn off the intravenous short-acting insulin drip, I committed the cardinal error of neglecting to inject him with long-acting insulin. He promptly barreled downhill again. A senior resident rescued him before he had a cardiac arrest, then screamed her lungs out at me in front of the entire emergency room staff.

I never mustered the courage to tell the patient what happened. So great was my shame that it was 20 years before I could begin the “open and honest” communication that the situation deserved.

Are doctors simply cowards? Do our own existential fears paralyze us? Human beings, by nature, prefer to avoid horrible truths, and denial may be our most powerful survival skill. Doctors are no more nor less immune to this, and to the basic human drives of empathy and pity, than anyone else.

By now, even the most hard-core, old-school doctors recognize that emotions are present in medicine at every level, but the consideration of them rarely makes it into medical school curriculums, let alone professional charters. Typically, feelings are lumped into the catch-all of stress or fatigue, with the unspoken assumption that with enough gumption these irritants can be corralled.

The emotional layers in medicine, however, are far more pervasive. Emotions have been described by the neuroscientist Antonio Damasio as the “continuous musical line of our minds, the unstoppable humming …” This basso continuo thrums along, modulating doctors’ actions and perceptions, while we make a steady stream of conscious medical decisions that have direct consequences for our patients. Emotions can overshadow clinical algorithms, quality control measures, even medical experience. We may never fully master them, but we must at least be conscious of them and of how they can sometimes dominate the symphony of our actions.

Julia did eventually get the truth of her diagnosis, at her first post-discharge clinic visit. The actual moment was — as expected — horrible. It took several tries for us to get the words on the table. Voices choked, eyes brimmed — and that was just the doctors. Julia was more stoic. She nodded slowly, very slowly, as she pieced it all together. The quiet that followed felt like a licking of the wounds for all parties. All wasn’t sunny and optimistic, but there was a sense of reality, and now the planning could begin.

Why did it take us so long to tell her? It might have been that we doctors first had to come to terms with the diagnosis ourselves — however selfish that might sound. Perhaps, unconsciously, we were trying to give Julia breathing room. But all this may have been mere justification to make us feel better. The fact is that we didn’t tell her the whole truth, up front, as we should have.

I’d like to say that I’d handle the situation better now, with another decade of clinical experience under my belt, but I’m not sure. Today, at least, when my medical team faces the prospect of giving bad news or admitting a medical error, I try to help my students and interns pay attention to the basso continuo running underneath. I try to point out when our emotions might be impeding us, and when, as sometimes happens, they might be assisting us in caring for our patients. Doctors can’t — and shouldn’t — eradicate the emotions that grease the wheels of patient care. But being alert to them can help us minimize where we fall short, and maximize where we succeed.

ANA Among Endorsers of Needlestick Statement

Posted in Nurse Safety, Nursing, Nursing Jobs, Nursing News

Image courtesy of Daniel Paquet via Flickr

A consensus statement and call to action to help healthcare personnel avoid needlesticks has been issued by the American Nurses Association and the International Healthcare Worker Safety Center at the University of Virginia.

The statement is meant to be “a roadmap for future progress,” according to this article on

The consensus statement and call to action highlights five especially important areas to address. They are improving sharps safety in surgical settings; understanding and reducing exposure risks in nonhospital settings; involving frontline healthcare workers in the selection of safety devices; addressing gaps in safety devices and encouraging innovative design and technology; and enhancing worker education and training.

The president of ANA, Karen Daley, RN, PhD, MPH, FAAN, contracted HIV and hepatitisC from a needle while tending to a patient in the Emergency Department in 1998. Ever since then she has been a staunch advocate for needlestick safety.

“Needlestick injuries are preventable and cannot be tolerated as a cost of doing business,” Daley said in an ANA news release. “Healthcare organizations are charged with ensuring safety and preventing harm — to patients, employees and the public. Unfortunately, needlesticks still occur, whether from lack of education and training, complacency or frugality.”

The federal Needlestick Safety and Prevention Act was passed in 2000, a boost in the effort to reduce the risk of healthcare worker exposure to blood-borne pathogens. But Daley said the law does not by itself ensure worker safety.

“Nurses need to hold employers accountable for following the law and refuse to accept anything less,” she said. “Progress has been made, but the law provides only a framework. It is up to people to create the culture of safety necessary to minimize incidents.”

Healthcare workers in nonhospital settings account for about 65% of the U.S. healthcare workforce, a proportion that will continue to grow over the next decade. Although safety-engineered devices are in widespread use in most hospitals and clinical laboratories, market data show a lag in their use in other settings.

The U.S. Centers for Disease Control and Prevention, the National Institute for Occupational Safety and Health and other government agencies, as well as nongovernmental agencies and professional organizations, should support epidemiological research that evaluates risks to workers in a wide range of nonhospital settings, according to the statement. And professional organizations representing nonhospital care settings should make sharps safety a priority and ensure availability of appropriate devices and educational and training materials specifically for workers in these settings.

“While we celebrate the progress we have made, we must acknowledge the gaps that exist,” Jagger said in the news release. “We must redouble our efforts to ensure that all healthcare workers, regardless of the setting in which they practice or the procedures they perform, are offered the same standard of protection from sharps injuries and exposures to blood-borne pathogens.”

Tougher Penalties for Harming Nurses

Posted in Nurse Safety, Nursing, Nursing News

Image courtesy of KOMUnews via Flickr

Dealing with violent patients is a fact of most nurses’ lives.

New legislation in Nebraska would stiffen the penalties for harming a nurse, bringing it more in line with existing laws about harming police officers, for example.

The Omaha World-Herald has an article explaining that about 1,300 assaults of nurses and other health professionals occur every day nationally, according to the National Institute of Occupational Safety and Health.

In an example of such an assault, one ER nurse reached out to a large man who seemed extremely nervous as he entered the emergency room. She was just doing what she was trained to do but the man turned on her and beat her horribly, which left her out of work for six months and permanently traumatized.

That and similar stories helped push passage in the Nebraska Legislature on Thursday of a bill to toughen penalties on those who assault nurses and others who work in hospitals and health clinics.

Under Legislative Bill 677, sponsored by State Sen. Steve Lathrop of Omaha, assaulting a health professional would bring the same potential penalty as assaulting a police officer: It would be a Class 3A felony, punishable by up to five years in prison or up to a $10,000 fine, or both.

Each emergency room and clinic would also be required to post a sign at the entrance warning that assaulting workers is a felony.

Currently, a typical assault would result in a misdemeanor charge, which carries less serious penalties.

Lathrop said health professionals deserve special treatment because they are particularly vulnerable and because of the work they do. Nurses, he said, must work in close proximity to patients and assume a level of trust with them.

“Nurses open themselves up to provide care to someone and, unexpectedly, they’re assaulted. They’re not expecting to be hit,” he said. “It’s becoming more and more of a problem.”

Lathrop, an attorney, represented a registered nurse at Papillion’s Midlands Hospital who was assaulted by a mentally disturbed patient in 2007. The nurse now has permanent eye injuries.

Several other stories of violence in emergency and hospital rooms in Nebraska were aired at a public hearing on the bill last year. Health professionals say they can be in harm’s way when gang members or upset family members go to an emergency room seeking retaliation after a shooting or an assault.

Officials from Omaha-based Alegent Health testified that 65 assaults occurred in a year’s time at their five hospitals in the Omaha-Council Bluffs area.

“Violence is part of our society, and it’s brought in from the streets to the emergency ward,” said Karen Wiley, an Omaha nurse. “People who are intoxicated will act out and hit someone. Because it’s a misdemeanor, arrests are not always made.”

Minnesota Nurses Lobbying for Safer Workplaces

Posted in Nurse Safety, Nursing, Nursing Jobs, Nursing News

Minnesota State Capitol courtesy of TBoard via Flickr

Nurses in Minnesota are calling for new legislation that would set a limit on how many patients may be assigned to hospital nurses.

A one-day strike by the Minnesota Nurses Association in 2010 was focused on the issue of safe staffing, and union leaders are now accusing hospital officials of breaking promises made after that strike to address staffing questions. The nurses feel that inadequate staffing is endangering their patients, and have collected nearly a thousand reports in just the last half of 2011 to support this claim.

The president of the nurses association, Linda Hamilton, said in this article in the Minneapolis Star-Tribune, “”We’ve been left with no choice but to take our concerns to the state Legislature.”

The new legislation, called the 2012 Staffing for Patient Safety Act, would set a maximum number of patients for each nurse, depending on the level of care required. For example: no more than three patients per nurse in emergency departments, or four patients per nurse in medical and surgical units.

Union officials were joined by two legislative supporters, Sen. Jeff Hayden, DFL-Minneapolis, and Rep. Larry Howes, R-Walker. Hayden said the Legislature generally “doesn’t like to get in the middle” of such disputes, but that in this case, “it’s a necessary evil.”

Two years ago, the union tried unsuccessfully to get hospitals to set specific nursing ratios as part of a new contract, a goal the national union has pressed in other states as well.

Ratios termed unworkable

Hospital officials argued that staffing ratios are expensive and unworkable.

The standoff led to a one-day walkout by some 12,000 Minnesota nurses in June 2010. They eventually reached an agreement that called for the two sides to work together on staffing concerns.

But the problem is “worse than ever,” according to a statement released by the union. Hamilton said the hospitals have been “stonewalling” attempts to address safety concerns, and that “we need legislation like this to hold hospital administrators accountable and keep our patients safe.”

The union cited several examples of staffing reports filed by nurses in 2011, although it declined to give details because of privacy laws. One said that a patient had fallen, “with significant injuries,” because the nurses had too many sick patients at the time. Another said a nurse was unable to properly comfort the parents of a dying baby because she had to care for another infant at the time. The union said the incidents are typically reported to hospital supervisors at the time.

Massa, though, said hospitals need flexibility to respond to changing demands, not inflexible ratios. “We both want to see the best quality care for our patients,” he said. “We just don’t think that this is the right way to approach it.”