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Does our BON System Need to be Reformed?

Nurses   (4,802 Views 23 Comments)
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The more I find out about the boards of nursing and their discipline methods, the more I think that there needs to be a reformation of a poorly run, and outdated system. On the one hand, the BON states its primary function is to protect the public. Yet, it often takes months or even years for them to investigate and hand out judgements, leaving possibly dangerous nurses to continue to practice. The boards seem to rely on outdated methods of tracking nurses, and some judgements seem like ridiculous overkill, while others a slap on the wrist.

I recently found out that a nurse who was largely at fault in a sentinel event at my hospital was finally brought to justice after a year, and her license is on probation. After this event, this nurse resigned. She had a Per Diem job at a different hospital, and switched to just working there. It happens that I used to work at that hospital, and contacted a friend there when I found this out. She's still working there. According to the stipulations published on the BON site, she is supposed to be under the direct supervision of a supervisor, who's supposed to be assessing her patients. It doesn't sound like this is occurring.

My concern with this type of case is that 1) If a nurse is possibly a danger to patients, why should it take a year to investigate and hand down a ruling? and 2) Often nurses resign whenever there's a concern. They become like a moving target. Like this gal, they may have another job. Or, they'll move out of state before the BON even gets around to their case. Why, isn't there a national standard to make this impossible?

Then, there are the cases of substance use. From reading the Recovery site here, it sounds like taking a friend's Vicodin for a migraine is treated the same as stealing drugs from your employer and being high on the job. Pot on ones day off is treated the same as heroin. There seems to be a Puritanical approach that is really outdated. I read about people with a DUI when they were 18 having to go through the same hoops as a hardcore drug user and diverter, with expensive drug screening, employment limitations, and inability to give controlled substances.

I also suspect that there isn't always a fair trial for some of these people. I've read about some shocking miscarriages of justice here on Allnurses and other sites. There is a 142 page thread on a popular discussion site with story after story of folk complaining of mistreatment by their BONs. Some complaints are groundless whining, but others have the ring of truth and gross injustice.

I wonder if it's even possible to reform agencies that are only monitored by themselves? One can't take ones case to a higher court. Who monitors the BON? It's kind of like the Vatican, insular and in charge of itself, with very little accountability to outside forces. They can be like all bureaucracies, with some toxic people mostly interested in career preservation and advancement, who can easily fall into the habit of abuse of power over time.

I do think that the current system is not a fair one, neither to the public, nor nurses. I believe we need fundamental reform. A unified, National system on some level would probably be in order. Improved tracking, uniform guidelines on reportable circumstances by employers, and enough personnel to get unsafe nurses out of the workplace ASAP. We nurses need to be be assured of a just system, not one subject to the prejudices of individuals. And, BONs need to be monitored by outside, neutral entities to keep them from going off the rails and ruining lives.

Edited by Joe V

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Then, there are the cases of substance use. From reading the Recovery site here, it sounds like taking a friend's Vicodin for a migraine is treated the same as stealing drugs from your employer and being high on the job. Pot on one's day off is treated the same as Heroin. There seems to be a Puritanical approach that is really outdated.

I also suspect that there isn't always a fair trial for some of these people. I've read about some shocking miscarriages of justice here on Allnurses. Is there too much subjectivity?

I wonder if it's even possible to reform an agency that is only monitored by itself? One can't take their cases to a higher court. Who monitors the BON? It's kind of like the Vatican, insular and in charge of itself, with very little accountability to outside forces.

Thoughts?

In both of your examples (taking friend's Vicodin vs. stealing from work and smoking pot vs. using heroin), while you may not agree or approve, both behaviors are equally illegal (at least, on the Federal level, and I haven't yet heard of any state BONs relaxing their stands on pot). As for the "shocking miscarriages of justice" one reads about here, while I'm not saying that those situations are not miscarriages of justice, it's always worth keeping in mind that we are hearing only one side and version of the story here.

As for the length of time it takes to render a decision on allegations of dangerous practice, while I agree it seems a shame, I don't see that as significantly different from criminal charges; it often takes a long time within the criminal justice system for charges to be brought, cases to be built, trials to take place, appeals to take place, etc. Often, experienced attorneys intentionally prolong the process as long as possible in order to delay a final judgment that they realize they won't be able to avoid, just postpone. People charged by the BONs do have due process rights, as well as rights to appeal Board rulings, and that takes a long time. Are you saying you would prefer the Boards to move precipitously?

What kind of "reformation" do you have in mind?

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Regarding your question about why it takes a year to investigate and hand down a ruling. That is to be fair to the nurse involved. An agency should do a thorough investigation and then allow the nurse in question to respond. The way my state investigates goes something like this:

- a complaint is made to the board

- a state's attorney reviews the complaint to determine if the elements of the complaint violate any state regulations. If not then nothing further happens. This step can take a month.

- if what is alleged does violate a state law, then investigators are assigned to determine if what is alleged actually occurred. They will start by requesting records. It could take the hospital a month or more to provide the records. (2+ months have now passed)

- The investigator may then request information from the nurse. The nurse will contact a lawyer. (3+ months have now passed.)

- The investigator may then interview witnesses. It will probably take time to get something scheduled with the witnesses. (4-5 months have now passed.)

- Eventually the investigator will write a report and present it to the board. (6 months)

- The board only meets once a month, so they won't discuss it until their next meeting. (7 months have now passed.)

- If the board decides to take action, they have to notify the nurse/her lawyer of charges. (We're up to the 8 or 9 months.)

- The nurse/her lawyer gets a chance to come before the board. Another month or 2 has passed. (10 months since the initial complaint.)

- Finally the board makes a ruling.

Regarding your question about people receiving a fair trial - How the board investigates probably varies from state to state. I have read the records from these investigations. (Public records are available on the web in my state.) It appears that they bend over backwards to investigate thoroughly and to be fair to the nurse.

You mention the shocking miscarriages of justice that you read about here on AllNurses. Remember that you are only hearing one side - the nurse's. The nurse may be providing the whole story, but s/he may be presenting a sanitized version.

In my state the charges are not the same for taking a friend's Vicodin and for stealing narcotics from your employer. In both instances you are taking a narcotic that was not prescribed for you, so that would be one charge.

If you take drugs from an employer, they add a theft of property charge.

If you are high at work, that is another charge.

In my state the things that will get you in the most trouble are

- illegal use of drugs (you license will be put on probation)

- working under the influence (you could lose your license)

- theft (lose your license)

- abuse of patients (lose your license)

- falsification of documentation (lose your license)

Anything else results in required CEUs and sometimes a fine up to $500.

I also question whether the BON or Board of Medical Examiners are able to be fair, thorough, and impartial. An outside agency might do a better job.

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I'm a huge fan of standardization - especially when it could reduce bureaucracy and improve the end result. So, I'm definitely on board with OP's suggestion for this.

However - and this is BIG... take a look at how little funding our BONs receive. It's shockingly low. It's very common for states to have to levy an additional license renewal fee to fund a very basic improvement. If you take a look at how little our BONs receive in comparison to the medical board, or even electricians, welders, etc.... it is pretty disgraceful.

So - in order to achieve standardization and provide adequate resources (like qualified staff) to improve the pace of BON activities.... we'll need to tap into some significant funding sources. Maybe a nation-wide GoFundMe?

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You are aware that this is a state by state issue and that each state has their own board determined usually by their Nurse Practice Act? Not all states handle discipline in the same manner. Besides, if you wish to increase investigation times that necessarily means increasing staff size which means increasing the budget.

The budget is determined by your state's legislature.

Why isn't there a national standard? Because of the phrase, "The powers not delegated to the United States by the Constitution, nor prohibited by it to the states, are reserved to the States respectively, or to the people." You can work around this, the ACA is a good example, but legislation of this magnitude would be incredible in size and complexity. More than likely it would require the creation of a national nursing license and then each state would have to decide if they wanted a state license in addition to practice. The issue then is who investigates issues and more importantly, who's Nurse Practice Act do you follow since they are all different?

Who determines who's NPA will be followed and what educational requirements will there be? California is very different from Minnesota which is different from Georgia.

When it comes to drugs that is not just a state matter, that is federal. Don't blame the BON on marijuana related issues...talk to the federal government and get it deregulated or talk to your governor and push for him or her to stop enforcement.

Don't like the BON, then talk to your governor and serve on the board yourself. Don't like the speed of investigation? Talk to your local state representative and get the budget increased. Don't like the drug laws? Talk to the federal government and get them deregulated or talk to your governor to stop enforcing the law.

Don't blame the BON for an imperfect system, blame the bureaucracy for creating the imperfect system. Besides, serve yourself and fix the system :) Easy to complain about a problem, harder to fix it.

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www.thelayoff.com/t/KuNinwy

The above is a link to a very good writer who has provided a synopsis on an article which first appeared in "Forbes" magazine and then republished by the Conservative Think Tank

"The Manhattan Institute."

It goes a long way towards explaining how accrediting bodies for schools of post secondary education operate in a sort of quid pro quo self perpetuating enrichment scheme that renders the concept of unbiased accreditation just another insider's way of making money while doing students, nursing students, a great disservice.

If you ask how this is pertinent to the the issue at hand concerning the reformation of BONs throughout the country, one has only to look at how the BONs instead of being independent entities are merely subservient pawns to the will of their state legislatures whether they act in Nursing's best interests or not.

The author's allusion to the Vatican more or less policing itself is an apt one. Under that system the door is wide open to corruption for obvious reasons. Because of this lack of unbiased third party oversight I'm despondent to think that money will continue to rule the day and people of good will who are trying to effect change for the better will be subverted by those whose goal is to enrich themselves often at the expense of the naive, trusting and obedient puppy dog nurses, nursing students and nurse wannabees of the world.

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I've never been investigated by the Board of Nursing, no do I know anyone who has been. Or if they were, I didn't know about it. I have to comment about the sentinel event story, though. I have been involved in that.

When a sentinel event occurs, everyone talks about it. Nancy may think she knows all about it because she was on-shift when it occurred, and Chauncey may be convinced that he has the best perspective because he was in charge when it happened. The nurse who "was largely responsible" may even believe that she knows exactly what happened. And then the internal investigation starts, and it is confidential.

In most cases, it is not just one error or not just one person's error that causes the sentinel event, and if you aren't part of the investigation, you may never know that. You may blame the ICU nurse on whose watch the patient died or stroked out or had some negative consequence occur. But the problem occurred because the patient was getting an investigational medication on the floor, the side effects and toxic events weren't clearly known, and it wasn't communicated to the ICU that she was on that medication because no one thought it had anything to do with the issue, and the ICU nurse didn't get a chance to go through the chart until AFTER the event. The ICU nurse carries the weight of the sentinel event in terms of the gossip, the whispers, the negative interactions with her peers who blame her, the gossip between providers about whether they should trust her . . . And the investigation concludes that she was not responsible. But that information is confidential, so the ICU nurse continues to carry the weight. The "dangerous nurse" that ought not to be practicing may not be the nurse you think it is.

I've been peripherally involved in 3 sentinel incidents and party to the investigation or the results and in every case, the investigation concluded that the nurse carrying the weight for the event in the court of her peers was not the one who bore all the responsibility or even most of it. Or, in one case, ANY of the responsibility. Sadly, the nurse who DID bear the majority of the responsibility for the incident in that she or he caused it or failed to rescue was never outed. Their peers never knew, there was no outrage that the BON didn't "stop them from endangering patients."

In some cases, the BON doesn't investigate the person you think should have been reported to them because the internal investigation proved someone else was the culprit.

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Having been on the wrong side of the BON before - I agree with the OP. I can only speak from my experience but the BON I dealt with was sorely lacking. Anonymous865 laid out a reasonable timeline for an appropriate investigation to occur. I my case it took over a year and no investigation occurred, no records were pulled until my attorney requested them (then they were incomplete), no interviews with the concerned parties - nothing - nada - zip.

So when people's livelihoods and lives are on the line, the BON has an obligation to complete all the necessary steps of a thorough investigation. It seems most BON's can do whatever they want with no repercussions - the system needs an overhaul and oversight from an objective party at the very least.

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I have to say that I disagree with any notion that the BON can do whatever they want, seemingly or otherwise. The BON has rules, policies and procedures as any other government entity, State or Federal... We all have a right to due process. This is a civil/constitutional law of protection. They can be sued for violations of those rights. They can and must be held responsible for the trust the public put in them for protection. If the BON can be perceived to "do whatever they want" then nurses everywhere is at the mercy of the board with or without an attorney. I refuse to believe that, and if thats the case, then why get an attorney? There is corruption wherever money is involved. Nurses that are a threat and/or danger to themselves and other nurses as well as the patients they're suppose to care for, are the ones still working. The nurses that report em or labeled as "whistleblowers ", troublemakers, and whatever lame reason they can come up with to fire the "good nurse". Fight back! If you cant stand up for yourselves, you wont be able to stand up for your patients, especially older ones. I love nursing, but I refuse to lay down and let anyone take away what Ive worked hard to achieve..BON or anyone with a motive. Get your own license protection and start fighting back. I AM! I am in good standing with my license, but was threatened by false allegations that has some people in trouble right now. I am very passionate about my work and the care I provide..

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Very nice overview of some potential scenarios. Thank you for a good explanation.

As a new nursing student I had not thought about any of these situations yet and now I feel more aware of the process of BON investigations and also feel more empathy for whomever could be investigated. Because like you said, as peers, we really don't know what could have occurred so who are we to judge them. Especially when this could happen to anyone for something they weren't at fault for.

Edited by Nursein2019
I was referencing Ruby Vee. (I'm still learning how the cite works. Think I meant to hit the quote button)

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In both of your examples (taking friend's Vicodin vs. stealing from work and smoking pot vs. using heroin), while you may not agree or approve, both behaviors are equally illegal (at least, on the Federal level, and I haven't yet heard of any state BONs relaxing their stands on pot).

But the BON doesn't exist to prosecute crime. It exists to regulate and enforce standards of nursing practice and to ensure that nurses are competent while on the job. Just because you may make questionable decisions off the job does not make you an incompetent nurse. This is tacitly acknowledged by BONs who do not sanction or monitor nurses who get speeding tickets although speeding is just as illegal as smoking pot.

And while illegal is illegal, the judicial system does acknowledge that there are magnitudes of illegal behavior (misdemeanors, felonies) and that not all illegal actions warrant the same punishment. This is not done very well by BONs.

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The RN, who was drunk, and driving her car, while drinking wine, that smashed into my aunt and killed her, still has her license. She has suffered no consequences for her actions regarding her RN license. I looked her up just the other day, her license is still valid and nothing about suspension. My aunt was killed by this nurse, one year ago!

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