Another Nurse on Nurse hostility story

  1. So very frustrated at a recent experience that I had at my job. I work in a busy ED and occasionally we receive patients who are "referred" from an outside urgent care. I have personally received phone calls from a particular urgent care informing us that there is a patient coming over and they continue on by providing ALL protected information about this patient, after they have discharged them, and why they cannot treat them there. It is important to note that the urgent care completes their care of the patient and then discharges them from their system, the patient leaves and may or may not elect to come to our emergency department. The last phone call that I received from this urgent care went about the same as usual but at the end of the conversation the nurse on the other end of the phone call says and what is your name. I paused, as this is not a common request and stated, I have no problem providing my name, heck I answer the phone stating my name, but I must clarify that there is no RN-to-RN report occurring here as this is not a transfer and there is no transfer of medical authority and/or medical accountability between facilities, additionally providing all of the protected information about the patient could constitute a violation of HIPAA as we do not have a need to know since it is not a transfer. I brought this up to the nurse due to her requesting my name as it made me think she was charting it somewhere, which really seems like a bad idea for HER and HER ORGANIZATION to be documenting an inappropriate release of patient information.


    So... you can probably imagine how this was received. The nurse didn't say anything to me regarding the issue, but was actually agreeable stating oh yes we are just providing info on the patient (smiles and warm fuzzies here), phone hangs up no big deal, and by the way the patient never came to our ED. Fast forward about two weeks I receive a phone call from my director stating she has a disturbing email about a phone call that occurred with an urgent care. For the sake of the readers time I will summarize, the email stated I did not want to give my name in addition to me be terse and maybe rude (can't remember), and the final sentence stated "should we not be sending patients to your ed any longer as you don't want info on them", a basic threat to pull business away. You, the reader, should know that I work for a for profit hospital and this last sentence had all the teeth to ensure my director would act, and act she did. I get a call, she is super matter of fact, basically telling me to just listen and don't say anything back to those who are calling us regardless of appropriateness as customer service is our goal and... well you can fill in the rest.


    I am disturbed to my nursing core. I have been a nurse now for about 6 years, to some thats nothing and others thats a good amount of time. I haven't seen a lot of malicious behavior like this and I think it is why I am struggling with it. I guess my issue is when nurses cannot listen to constructive criticism without personalizing it and making it about the person communicating it. I get my directors response, she MUST act on this as it is threat to community business relationship and thats to be expected. What I don't get is the fabrication of scenario to elicit a response from my leadership, it really feels icky. I do know that the nurse I was speaking with has been a nurse for about two years, I offer this for context. I assure you that I was nice and pleasant in my conversation with the nurse, and cannot understand why she would paint our conversation in such a way. I can only assume her intellect was offended and she "reacted", instead of considering what she was actually doing, violating protected information (albeit trying to be helpful). I read a post on here by Riseupandnurse that stated due to nurses having to take whatever is dished out by admin, physicians, patients, families, etc, that there is a great deal of free floating anxiety and hostility and sometimes finds its release valve on an unsuspecting victim. Additionally, I feel that there is a great deal of insecurity that we all deal with and sometimes instead of recognizing this and overcoming how it makes us feel then learning from it, we fall victim to self preservation and restructure reality in order to ensure we are righteous and the other, perceived adversary, is wrong and we demonize them and their actions or intended message. When this occurs it is a hugely flawed weakness in psyche, that ultimately is self defeating and greatly inhibits personal growth.


    I guess I am posting this for therapeutic purposes, and maybe some stimulating conversation can result.
    •  
  2. Visit clandestine2 profile page

    About clandestine2, BSN, RN

    Joined: Oct '15; Posts: 21; Likes: 20
    from US
    Specialty: 5 year(s) of experience

    29 Comments

  3. by   JKL33
    Interesting post.

    First of all, I can't help but be a little impressed that at least you acted upon a thought process - in contrast to the common problem of not thinking any further than "what we usually do" or situations where people are ignorant of other factors that directly affect their jobs.

    That said, one would be very hard-pressed to make a HIPAA violation case out of this nurse's actions. Think about it - people are referred (without being transferred) constantly in our healthcare systems all across the country. Within systems and between systems. Think about the simple act of being referred to a specialist - - the patient may indeed not show up. But, due diligence has been taken in order to be prepared for them if they do show up. That is called taking care of the patient, as opposed to not being prepared for the patient due to adherence to someone's idea of a technicality (in which their concern may actually be unfounded). Actually, what this nurse did is refreshing in comparison to what has begun to happen more and more - which is providers sending people to the ED from some outlying site without a single word, yet they have told the patient dozens of things that we (the ED) are going to do when they get there. In our "everyday" systems, records are sent all kinds of places such as referrals - - and review of records to see if a referral is even appropriate. This is part of the business of taking care of the patient. These do not violate the spirit of HIPAA, which is that people not access and divulge information for no good reason.

    Anyway. Your place of work really should have some understanding of 1) How these situations will be handled and 2) What, if anything, will be done with the information received. Their system should have a process, too, but that's not for you to worry about (and now you know why)!

    I think it's too bad that this nurse changed a few details in order to make your conversation seem worse than it was. Regardless of why she complained, though, this is exactly why I don't correct others unless rights are clearly being violated and/or there is some detriment to the patient or to patient care in what they are doing, which was not the case here.

    In the future, your best action would be to inform your NM of concerns like this that you come across. They can finesse it with others in the community as needed. That way, no personal harm done to yourself whether your concern is correct or not.
  4. by   JKL33
    Apologies...double post.
  5. by   clandestine2
    Good points, I absolutely will not correct the other moving forward. The intention of the original communication with the "other" nurse was to ensure that was an understanding that there was not a legal transfer of care.

    Yes the HIPAA is less likely to be acted upon, but despite the common place activities you refer to above, in a technical sense, and legal relies on the black and white nature of technicalities, HIPAA is being violated here. If the care provider who discharged the patient called and did a DOC-2-DOC, then no there would not be a violation as this is covered under PHI as permitted uses and disclosures, but between two nurses this is not appropriate or permitted
    "Treatment is the provision, coordination, or management of health care and related services for an individual by one or more health care providers, including consultation between providers regarding a patient and referral of a patient by one provider to another.".

    Refer here Summary of the HIPAA Privacy Rule | HHS.gov

    As common place as it may be, violations do occur and HIPAA is not a "in the spirit of" it has rigid definitions in order to protect the publics PRIVATE information. The reality is that I, the nurse, do not have a need to know until the patient walks through the door to seek care, unless a health care provider has done a consultation before hand, which did not happen in my scenario.

    According to Health and Human Services:

    Protected Health Information. The Privacy Rule protects all "individually identifiable health information" held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. The Privacy Rule calls this information "protected health information (PHI)."12

    "Individually identifiable health information" is information, including demographic data, that relates to:
    • the individual's past, present or future physical or mental health or condition,
    • the provision of health care to the individual, or
    • the past, present, or future payment for the provision of health care to the individual,

    Permitted Uses and Disclosures

    Permitted Uses and Disclosures. A covered entity is permitted, but not required, to use and disclose protected health information, without an individual's authorization, for the following purposes or situations: (1) To the Individual (unless required for access or accounting of disclosures); (2) Treatment, Payment, and Health Care Operations; (3) Opportunity to Agree or Object; (4) Incident to an otherwise permitted use and disclosure; (5) Public Interest and Benefit Activities; and (6) Limited Data Set for the purposes of research, public health or health care operations.18 Covered entities may rely on professional ethics and best judgments in deciding which of these permissive uses and disclosures to make.
    *
    (1) To the Individual. A covered entity may disclose protected health information to the individual who is the subject of the information.
    (2) Treatment, Payment, Health Care Operations. A covered entity may use and disclose protected health information for its own treatment, payment, and health care operations activities.19 A covered entity also may disclose protected health information for the treatment activities of any health care provider, the payment activities of another covered entity and of any health care provider, or the health care operations of another covered entity involving either quality or competency assurance activities or fraud and abuse detection and compliance activities, if both covered entities have or had a relationship with the individual and the protected health information pertains to the relationship. See additional guidance on *Treatment, Payment, & Health Care Operations.

    Treatment is the provision, coordination, or management of health care and related services for an individual by one or more health care providers(this is not referring to RNs as we are not providers), including consultation between providers regarding a patient and referral of a patient by one provider to another.
  6. by   JKL33
    Ah, okay, I see the distinction you are making with regard to the report being provider-generated and provider-received as opposed to "just" staff-generated and -received, but your understanding is not correct.

    My first reply was made with an understanding that we are all acting as agents of covered entities. Reading your second post, I believe maybe that is the point you are not realizing (?)

    I've reviewed all of this information quite a few times in my life. It point blank says that the "covered entity" may disclose the information so that providers can treat. The nurse's actions are permissible because she is acting directly as an agent of a covered entity. If her place of employment qualifies as a covered entity then she is within the law acting as their agent. If it doesnt, then it doesn't matter because the law doesn't apply to that place of business.

    Treatment itself is defined as the provision, coordination, and management of.....

    You are reading your last (bolded) sentence wrong, as if only the provider (doctor, PA, NP, etc) is covered because they are the ones directly providing the treatment. That is incorrect. Covered entities are "covered" for all legitimate actions related to providing, coordinating, and managing legitimate aspects of patient care.

    "Provider" does not actually refer only to "providers" as you and I know them - - see here

    Now, it may not be the most historically collegial thing that the providers themselves are not speaking to one another personally, and it may not be the best thing for each individual patient that they aren't. But that is separate from this discussion of HIPAA. The agents of the covered entities are still allowed to exchange this information if there is a HIPAA-allowed reason for them to do so, and in this particular discussion the reason is treatment by providers.

    It's all right there. The "covered entity" is the entity that is allowed to disclose. That is you, me, the nurse you spoke with - because we are directly acting as agents of the respective covered entities.

    The last line that you bolded above, I believe is a simple clarification in order to make clear that person-to-person conversations between providers themselves are also allowed/included.
    Last edit by JKL33 on Mar 5
  7. by   OldDude
    Too bad you and your director couldn't have had this dialogue instead of the knee jerk, haywire, response. Good learning experience... ahem, follow the money.
  8. by   clandestine2
    Duplicate post
    Last edit by clandestine2 on Mar 5 : Reason: error
  9. by   clandestine2
    touche!
  10. by   nursel56
    The people who are all warm and fuzzy to your face and then proceed to sabotage you behind your back are the worst.

    Can't add more than that-- the above post by JKL covers every point I can think of.
  11. by   Susie2310
    Quote from nursel56
    The people who are all warm and fuzzy to your face and then proceed to sabotage you behind your back are the worst.
    My understanding was that the nurse was probably rather shocked by the OP's inappropriate response to her when she had appropriately asked for his/her name, and was trying to diffuse the situation as gracefully as possible, having made the decision mentally to refer the situation to the appropriate administrators, which ultimately resulted in the OP's director contacting the OP about the situation. I can't say that I would have done anything differently if I had been her.
  12. by   clandestine2
    Not true. I answer the phone with my name. The point was that report was not being given. I, the OP, have the right to call into question when an attempt at legal transfer of authority and responsibility is taking place inappropriately. And nurses should be able to have a conversation that doesn't result in sending an email, largely falsified to elicit a response, due to an emotional response. Susie2310, the conversation was not heated, and the scenario outlined in the email was not accurate by any means. My response was completely respectful and appropriate, actually if it were a legal RN-to-RN report i still have the right to refuse it. So where exactly to you see my behavior to be inappropriate? Asking for my name merely triggered me to clarify that report is not being given, I could care less if the other nurse knew my name.
  13. by   Susie2310
    Quote from clandestine2
    Not true. I answer the phone with my name. The point was that report was not being given. I, the OP, have the right to call into question when an attempt at legal transfer of authority and responsibility is taking place inappropriately. And nurses should be able to have a conversation that doesn't result in sending an email, largely falsified to elicit a response, due to an emotional response. Susie2310, the conversation was not heated, and the scenario outlined in the email was not accurate by any means. My response was completely respectful and appropriate, actually if it were a legal RN-to-RN report i still have the right to refuse it. So where exactly to you see my behavior to be inappropriate? Asking for my name merely triggered me to clarify that report is not being given, I could care less if the other nurse knew my name.
    This is what you wrote in your OP:

    "The last phone call that I received from this urgent care went about the same as usual but at the end of the conversation the nurse on the other end of the phone call says and what is your name. I paused, as this is not a common request and stated, I have no problem providing my name, heck I answer the phone stating my name, but I must clarify that there is no RN-to-RN report occurring here as this is not a transfer and there is no transfer of medical authority and/or medical accountability between facilities, additionally providing all of the protected information about the patient could constitute a violation of HIPAA as we do not have a need to know since it is not a transfer. I brought this up to the nurse due to her requesting my name as it made me think she was charting it somewhere, which really seems like a bad idea for HER and HER ORGANIZATION to be documenting an inappropriate release of patient information."

    I believe JKL33's post #4 addresses this.
  14. by   clandestine2
    Ok, so why are you glazing over the portion of the story where the other nurse lied? I made an error in regards to HIPAA violation. OK. ADDRESSED. Moving on to the point of the post regarding infighting, and you did not answer the other questions regarding report. My actions certainly were not inappropriate.

close