Nurses Call the Governor of Tennessee

Wuzzie · Feb 14, 2019

9 minutes ago, juan de la cruz said:
Sorry but I was referred to as a "she". Seriously, I'm sorry if I offended anyone. Perhaps I should go away.

No, don't go away, that would be silly. Just take a deep breath!?

TriciaJ, RN · Feb 14, 2019

12 minutes ago, juan de la cruz said:
That's just a term used to describe the after-effects of a serious medical error (including medication errors) on the healthcare provider involved. It is well studied and some of these providers do go through traumatic feelings, guilt, depression, etc. That does not minimize the loss that the family of Nurse RV's victim is experiencing.

I understand the terminology and I know when a nurse is involved in a systems error he/she experiences a tremendous amount of guilt. (Like our previous posts about wondering if we could even continue to practice nursing.) I'm just reluctant to assign victim status to someone who practiced in the manner depicted in the CMS report.

This is why I think a criminal trial is in order. If things happened the way they are outlined in the report, then the behaviour certainly meets criteria to be considered criminal. But what if we're not getting the whole picture? At this point she deserves to have her day in court. It will give her the opportunity to exonerate herself and I will happily change my opinion about the whole thing.

JKL33 · Feb 14, 2019

28 minutes ago, TriciaJ said:
I'm just reluctant to assign victim status to someone who practiced in the manner depicted in the CMS report.

Agree. I can't.

I am admittedly having a very hard time with the fact that there are clues, even within the report itself, of the same ridiculous chaos we are all navigating every day. Chaos, that in my personal exp/obs/opinion, has ramped up to crisis level.

This corporate BS does have something to do with this, even if it's simply that you can't view people who are performing critical tasks as widgets. The next new grad NURSE isn't a widget and isn't there to perform business duties. The way they are trained (oriented) matters. The responsibilities (privileges/duties/assignments) they are allowed to have, matter. What is the next ICU nurse (orientee) doing in this scenario? Learning about chaos. Trailing around behind someone who runs around the hospital doing tasks in a slipshod manner (to put it mildly) and has been allowed to be in the position of help-all and preceptor despite being completely capable of skipping the entire nursing process while doing a "task." Culture of safety my a$$. This is purely a culture of expediency with a very thin veneer of safety.

"Immediate jeopardy" that is almost immediately retracted (or "satisfied," apparently) is one of those insults that is just outrageous.

I've told myself a few times (okay, quite a few) - "this really isn't the case for making your point." Yeah, I get that, but when no one dies no one even remotely cares.

Advanced Practice Columnist / Guide · Feb 14, 2019

And I do agree because my initial instinct was why is she back at work so soon at another hospital...no second victim syndrome here?

Davey Do · Feb 14, 2019

2 hours ago, TriciaJ said:
Maybe they need to invent a big robot arm that slaps your hand away from grabbing the wrong med.

Hey TriciaJ! I like that idea!

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LilPeanut, MSN, RN, NP · Feb 14, 2019

BarrelOfMonkeys, BSN, RN · Feb 14, 2019

I must say with all the passion, professionalism, experience, and thought provided on this topic - thank you!

It’s been eye opening, thought provoking, and making me question how I perceive things. You’ve all contributed such value to this profession. It’s because of your passion for nursing that this is so polarizing and clearly why you’re all in the right field. To make changes and provide better outcomes for our patients. I don’t doubt for a moment you all want that same thing.

I hope with this case changes will be made that we can all stand behind.

Wuzzie · Feb 14, 2019

kbrn2002, ADN, RN · Feb 14, 2019

On 2/10/2019 at 2:33 PM, Wuzzie said:
I can’t answer that because I don’t have an opinion on what her punishment should be. I don’t know if I even care if she doesn’t go to jail at all but I believe she should, at the very least, face a judge and explain herself. The courts can decide from there.

Agree 100%. I am with Wuzzie on this. While what happened is sad and unfortunate it also goes way beyond a simple mistake. Do I feel bad for the otherwise upstanding citizen that makes a mistake by driving under the influence and kills somebody? Of course I do as that person has to live with the knowledge of what they did for the rest of their lives. Do I think that person should not face the legal consequences of that choice just because I feel bad for them? No, of course not.

A public trial might even bring out into the open in a forum that can't be ignored the circumstances the facility put her in that allowed such an error to occur in the first place.

HomeBound · Feb 14, 2019

4 hours ago, JKL33 said:
Agree. I can't.
I am admittedly having a very hard time with the fact that there are clues, even within the report itself, of the same ridiculous chaos we are all navigating every day. Chaos, that in my personal exp/obs/opinion, has ramped up to crisis level.
This corporate BS does have something to do with this, even if it's simply that you can't view people who are performing critical tasks as widgets. The next new grad NURSE isn't a widget and isn't there to perform business duties. The way they are trained (oriented) matters. The responsibilities (privileges/duties/assignments) they are allowed to have, matter. What is the next ICU nurse (orientee) doing in this scenario? Learning about chaos. Trailing around behind someone who runs around the hospital doing tasks in a slipshod manner (to put it mildly) and has been allowed to be in the position of help-all and preceptor despite being completely capable of skipping the entire nursing process while doing a "task." Culture of safety my a$$. This is purely a culture of expediency with a very thin veneer of safety.
"Immediate jeopardy" that is almost immediately retracted (or "satisfied," apparently) is one of those insults that is just outrageous.
I've told myself a few times (okay, quite a few) - "this really isn't the case for making your point." Yeah, I get that, but when no one dies no one even remotely cares.

It also doesn't help when a "Nurse Manager" doesn't have experience at bedside---maybe a year or so---because they're too busy pounding out papers for grad school, making sure they're going to be a chief and not an indian. I love this type---not. They hide in the office and zip off memos about how everyone is just so beneath contempt because the linen bill is too high or there are too many gluostrips being used.

Not an iota of common sense or even real nursing experience to be had with some of them (**cough Jabba cough**)......but since they read a little bit of literature and once wrote a few papers...they're just the bomb.

These are the ones who sit and spend their day on chart surveillance in order to "catch up" the nurses in the trenches---and all the safety and patient care goes right out the window---because hey---that irrelevant "BMAT score" on a vented, sedated patient wasn't done.

There is no leadership---and the ones in those positions are driving the decent nurses to either seek employment elsewhere or quit altogether. Just because someone's got the paperwork that claims "expertise" doesn't mean they have the sense or temperament to be in that position.

Bad managers give bad advice to upper administration. Sometimes---I wonder if it's not some of these "middle people" who are misrepresenting the facts on the ground. The safety issues. The patient care issues. The burnout issues. Everything's rosy because it looks bad on THEM if the unit is unhappy.

Toxic environments encourage this type of sloppy nursing--whether it's because a NM doesn't have the backbone to enforce proper procedures, or they're too lazy to actually review an employees' actual performance (self reviews, anyone?), or they simply don't have the intelligence/experience (but boy do they write a mean grad paper!) to apply academic theory to actual practice.

I suspect that the unit at Vandy is much like units all across nursing--sloppy management, focused on the wrong things, enabling sloppy nurses focused on the wrong things.

Horseshoe, BSN, RN · Feb 14, 2019

I wish every unit had my nurse manager (she's retired now) from my old ICU unit. She was exacting-you better know your stuff and practice at a high level. But respected us-self schedule and don't make me have to get involved or you might not like the schedule. She went to battle for us vs. no matter who or what position they held if we were in the right and she never lost. I saw her put a top jerk surgeon in his place when he abused one of our nurses-she had him groveling and apologizing within a couple of minutes. She jumped into patient care if we were sinking in order to help and in order to keep her skills up. She came in for an entire shift occasionally if she couldn't get an agency nurse in. She NEVER asked us to go over the established ICU and stepdown accepted ratios. Not once ever. She provided an environment that made you want to be the best nurse ever, not just because the patients deserved it, but because you didn't want to let her down. Docs fought to get their patients in our unit because they knew about that culture of excellence and the positive outcomes that kind of environment produces. Medication errors were dealt with not punitively, but with an eye to figuring out what factors contributed to it.

I wish there were a million of her out there...

mtmkjr, BSN · Feb 14, 2019

7 hours ago, juan de la cruz said:
Sorry but I was referred to as a "she". Seriously, I'm sorry if I offended anyone. Perhaps I should go away.

No don't go away!

Juan, I just want to say you are one of the most reasonable voices in this discussion and your posts have actually influenced my point of view several times. It was so odd to me that someone would go after you like that.

My 2 cents: don't engage next time ?