JCAHO: "Behaviors That Undermine A Culture of Safety"

Well at least JCAHO is publicly recognizing the problem. This is the first of many steps needed to begin to solve/eliminate the types of behavior described above.

I had a horrible situation happen to me at the place that I currently am employed. I am an LPN there and started at the facility when they had a "Nurse Supervisor" position there. My nurse supervisor took an immediate liking to me and I liked her personally as well at first.

About a month into my employment she started calling me at home drunk and asking me things about other employees. she wanted to know things like what they said about her behind her back, did they like her, etc. This happened several times and because I Liked" her, I let it go. Then one night she called me and asked me to set up another nurse. She wanted me to say bad things abouther to this nurse then report to her how the nurse responded. I told her that I was not that kind of person and would never do something like that for many reasons, the first of which is that it was unethical. I told her never to call me at home unless it was an emergency, that my off time was exactly that, and I told her never to call me drunk again.

The next day she was very cold to me, but that didn't stop her behaviors. She continued to call me drinking and threatening my position at work. She even started calling me drunk at work.

I ent to my DON with complaints repeatedly over about a one month time frame about her calls to me, and about the fact that she ws coming to work more and more frequently with the smell of liquor on her breath so strong it was nauseating. Even the patients were complaining about her behaviors and her seeming drunkeness.

Finally THe DON took it seriously enough to do something about it and the calls stopped... for a while anyway.

One day I followed her shift as I swing 1st and 2nd. I found that she had not passed a single noon med to aprox 12 of the 30 pts on her hall. I am not talking about missing a tylenol here, some of those missed were very serious medications! I took it to my DON and she told me to write it up. Once that happened it really hit the fan.
My nurse supervisor then began to set me up at work.

First it started by her giving me an order to write up from an MD round that was done while I was doing treatments. She told me to resume the clonazepam order that one of my residents had taken prior to a recent hospitalization. She took the PO out of the chart and had me write it up on a telephone order. Mistake #1 for me. Nursing 101, never take an order from anyone but the physician. But I did because she was my supervisor and I was a little bit afraid of her. I ended up ordering and dispensing a medication that was almost 6 times the dose that it had been changed to during his hospital stay. No ill effects to the resident, but there certainly could have been. At the time I thought it was an innocent mistake on her part. I knew she had problems, but no one would do that on purpose, right?

The next thing that happened was that she changed two insulin orders on the MAR fora resident on my hall. I know she did it, and on purpose this time because when she was giving me report on this new resident, I was looking throught the MAR and questioned the order. It was hand written and said novolog 4 uu sq in AM and novolog 7 uu sq at PM. I wasn't sure what it said so I showed it to her. She said, "Oh, I was here when she was admitted, it is 40 u and 70 u. I told 'soandso" not to write it up like that anymore.

I gave her the 40 units inthe morning and by noon I gave her 1 mg IM glucose followed by another 1/2hour later. If an aide hadn't been walking by this womans room and saw her "convulsing", who knows how low her serum glucose would have dropped. As it was it tested at 22 on the glucometer reading.

Lesson learned. I questioned everything that came out of that womans mouth after that. She became frustrated, I think, because I tried to stay one step ahead of from that point on. She started telling my peers taht I said awful tings about them, all untrue. She started calling me drunk and threatening again at bot home and work.

I went to my administrator about it and while she seemed sympathetic, her hands were tied... You see, My DON is also the owner of the facility, and this Nurse supervisor and she were friends outside of the work place.

Finally I went to work on a Friday. I started my day with report and hopped on the med cart. you wouldn't believe the mess in there! "Betty's" meds were mixed in with "Joe's" meds were mixed in with "Edith's meds" and so on down the line. OF the 30 + patients on my cart only three residents were in order. My 45 minute med pass took me 2 hours to complete. I even found some meds in the med cart for the other hall and in the pharmacy return box. My rear end was chapped to say the very least.

The following day, a Saturday, for some reason my administrator decided to stop in. She asked how my weekend had gone so far and I told her about my med cart from the day before. How all but three residents had their meds displaced. I couldn't prove that it was my supervisor, and I knew it probably wouldn't do any good, but I told her about it anyway.

Now here is the kicker, Monday morning my Supervisor comes to work, apparently a bit liquored up, because she has the poor judgment to tell another nurse, in front of an alert and oriented resident what she had done. Her words, and I quote;"I shuffled cards in Carla's med cart Thursday night" The other nurse replies, "what do you mean by that?" she then says, I shuffled all of her med cards around except for 3 residents, I even took some meds out and put them in the other cart and in the return box"

Nurse 1 tells nurse 2 who then tells the administrator and she was livid. I guess all she wanted was some proof because friend of the DON/owner or not, she was escorted to the door. It was like the weight of the world was lifted from my shoulders.

You need to learn to stand up to him. If you felt humiliated, you should not have leaned over.

I get so worn out reading how people feel humiliated by and feel they have to cajole and charm and sweet talk doctors. When will everyone realize that, just as charity begins at home, so does besting a bully?

C'mon, people, stop being so afraid of taking a quiet stand. I am not saying to discuss or argue with people. In fact, I advocate the exact opposite. Just say no or look the offender straight in the eye so they know you have heard their ridiculous or rude words and then turn and walk away. Do NOT write verbal orders when someone who needs to be writing them is right there. Absolutely do not take VO's or TO's from someone who won't co-sign them. You have got to learn to put people in their place and to stand up for yourself. Most people will walk all over you if you let them. And if you don't let them, they won't. I know it's hard but you have to learn to do it. No one can fight this battle for you.

Is included one....what if you actually have a legit concern about someone?

I once explained to an aid before we went into a room to take the fresh right breast mastectomy blood pressure in the left arm only. We went into the room together and she went straight for the right arm. I corrected her in front of the family/patient. She told my Unit Director and I was told not to correct staff in front of patients/family members.

And when you explained, the UD's response was what?

OMG!

This face:

The talk was over with. This unit director wound up leaving our floor for another, and going for a mental health break in between. Of course the floor I had been working on went through 6 Unit Manager/Directors in a 15 months period. . . maybe it's me?!

Exactly right. The IOM identified factors in the work environment such as frequent interruptions, and fatigue (overtime, no breaks, mandatory shifts/on-call) that increases the likelihood of errors. I don't remember if a hostile work environment, and specifically verbal abuse was mentioned by name as a stressor for nursing staff, but we all know it exists, and these things too are barriers to our ability to be patient advocates.

I'm afraid this new JCAHO standard will be used to target nurses who advocate for their patients by speaking out against hostile managers, physicians, short-staffing, lack of sufficient equipment and supplies and ancillary support staff. Individuals will be blamed for system problems and I've seen it time and time again at evaluation time; a subjective entry is made on a nurse's evaluation form, or a nurse is called in by management because of an "annonymous complaint." (You're not a team player, you're not approachable, we've had several complaints about you from doctors, families, your co-workers...never with any specific documentation that would stand up in a court of law--it's indefensible and often times anecdotal, without just cause.)

Anyone who's ever tried to file a complaint with JCAHO will understand that they're strictly a proprietary, quasi-governmental organization (an elective deeming body for medicare/medicaid reimbursement to which the hospitals pay a fee in order to belong to the club.) The response from our end has been a 'catch me if you can' because of their unannounced visits, or 'we may get to it during our next survey' kind of thing. No teeth so organizations never really have to change their culture.

That's why we advocate for a strong RN nurse's union and unionization for all employees, so that we have protection against workplace abuses that are demeaning and cause nurses to leave or be fired. Weingarten Rights should be available and enforceable for all! True, there may be a bad apple here and there, but I don't believe anyone sets out to do harm; everyone should be entitled to a fair hearing of the grievance against them, with representation, fact finding and a progressive discipline attempt to show and validate corrective action.

I don't have a reply but a question and can't figure how to post it (this is not a very user-friendly forum).

Does anyone have any comments/experience with having a microwave on an acute, intensive-care psych unit that staff are expected to heat food/beverages for patients? Particularly the safety aspect ie: hot things, angry patients. thanks

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