The View From Under the Bus

[Teresag_CNS]

A year ago I got a certificate in the mail celebrating my 30^th year of certification as an intensive care nurse (CCRN). I smiled to remember how proud I was when I attained certification, 30 years younger and just 2 years into my nursing career. But the anniversary was bittersweet, because I no longer practiced in ICU.

It was time to leave. I had begun to dread each workday - too much rising early, too many weekends, too many hours pushing buttons, scanning wristbands and ticking the boxes in electronic forms. Too many burned-out coworkers just getting through the day.

When stress overtakes me, I write. My writing began as private journaling and eventually extended into the blogosphere as venues for blogging multiplied. For years, I wrote popular blog posts that my coworkers read, laughed at, liked” and talked about. I communicated the realities of nursing – the stress, the decisions to be made, the humor, the unreasonable demands, and the joy. It was fun, and I felt I was doing a service to nursing by telling readers what we REALLY do, until one of my posts hit a nerve. I wrote about two errors that had been made and how they were handled. In one case, a tourniquet had been left on a patient's arm too long, and in the other, a dangerously low potassium level was overlooked. These happened on the same day, done by the same RN who was new to our unit. In the chaos and complexity of a busy trauma intensive care unit at a top trauma center, a new RN can easily overlook a few things. Fresh off orientation, she (and the resident who also should have noticed the potassium) made mistakes. I've made mistakes, and any nurse who says she has not is likely to be lying. So it wasn't the fact of the errors that was uncommon. Errors in health care are a scourge about which much has been written. What distinguished these errors was the fact that a nurse wrote about them.

In describing the errors, I said I apologized and gently informed the family of the potential skin damage done by the tourniquet. I wrote that I quickly got an order and gave a couple of horse-sized potassium tablets to the man with the low potassium. I disclosed one error, and not the other, because of who the patients were, what else they were going through (deciding to have a risky surgery or not), and timing. It would have been inappropriate to interrupt the surgeon explaining the risky surgery to disclose an error that had done no harm. And that was the point of the post. That sometimes it makes sense to disclose an error promptly, and sometimes not.

The powers-that-be in the hospital didn't take well to my sharing this information publicly. No names or places were revealed. No protected health information was shared. Identities were always masked in my blog by changing essential details and omitting identifiers. No part of the Nurse Practice Act or HIPAA was violated.

I was informed one morning at 7 a.m. by a coworker, as we waited for report, that I was to phone the nurse manager. The the charge nurse came in and repeated the message. She told me to phone the manager immediately. The manager told me to go home because there was a complaint pending against me. She would not describe the complaint, in violation of the union contract.

I waited seven tense days for a meeting with Human Resources, Information Security, the director of intensive care, and the nurse manager. Fortunately, union representation meant I did not have to face this phalanx of institutional soldiers alone. In preparing for the meeting, the information security officer searched every logon I had ever made onto the electronic health record to build his case. He presented a list of names of the people whose records I had accessed. His first question was, Have you ever taken the HIPAA course?” followed by, Do you know what protected health information is?” He was taken aback when I defined the 18 elements of PHI. He continued, implying that I was mining” medical records for material for my blog. At one point, I stated, This feels like an interrogation, and one in which I am presumed guilty of some violation.” A week after the initial meeting, my computer access was suddenly cut off. I had no access to my research files, emails, nor to my calendar. Human Resources informed me this was routine.”

Most of the incidents of unnecessary” medical records access were accounted for by a study I was conducting. The information security guy wanted to know if it was approved by the Institutional Review Board, implying I was too naive to understand that requirement. Although he'd research all my computer accesses, he obviously hadn't research my education. I assured him it was, and I securely shared with the administrators the names of my study subjects so they could see I had legitimately accessed their records. There were a few medical records left over that I did not recall accessing, and which I had no reason to access. The only way to account for these was that I left my work station without logging out of the computer, and someone else used my login to view a patient's record.

And that is why they asked me to resign. It was the only infraction they could find.

While employed there, I worked with staff nurses on a study that improved glycemic management in the cardiac surgery intensive care unit. The study generated several presentations and a publication. It was included in our application for Magnet status as an exemplar of how research is used to improve our care. I was the only faculty member at the School of Nursing with a clinical practice in the hospital. I lent my expertise as a clinical nurse specialist and certified skin and wound care specialist to the Trauma ICU, and to the hospital nursing quality committee. I sat on the hospital nursing research committee and mentored staff nurses who wanted to do research. None of these were requirements of my position.

And none of these contributions mattered when the hospital felt threatened. The hospital filed a formal complaint against me with the Board of Nursing, which was later dismissed. The hospital would not disclose what was in the complaint, and the Board informed me that they were not permitted to share it. I still don't know what I was accused of.

The hospital gave me the opportunity to resign, which I took, and now that I've survived being thrown under the bus, life is good. I've taken a new and much-needed direction in my career. I learned some things. An acquaintance harshly warned me, Those information security guys are Nazis,” which seems like it may be accurate now. There seemed to be a deep desire to catch and punish me. The presumption of innocence that one might expect was absent, and information that was due me was withheld. Like other nurses before me, I witnessed a willingness to toss me aside, disregarding my contributions, in order to support the aims of the institution.

I'm not the first RN to tell this type of story, nor am I the first to bemoan the practice of hospitals treating nurses like a consumable commodity. This attitude does hospitals a disservice, yet it persists. Throwing away nurses for not being good little compliant employees is extremely costly. Recruiting and orienting a nurse can cost $100,000, not accounting for the harm potentially done when novices make mistakes.

So why does this attitude persist? Partly, because our profession is almost entirely female, and females are less valued than males in our culture. Partly, because nurses are still viewed by administrators as interchangeable widgets that can be removed and replaced readily, in the face of obvious contradictory truths. Partly, because the anachronistic image of nurse-as-any-woman is still endorsed by many healthcare leaders, whose willful ignorance of nursing continues to drive decisions in health care. Partly by lateral violence; nurses report other nurses if they have any suspicion that one among them is no longer drinking the Kool-Aid. The psychological origins of lateral violence are beyond the scope of this article, but have been explored elsewhere, by authors more knowledgeable than me.

When the causes of any phenomenon are complex and arise from multiple foci, the solutions are not easy. You can't tweak one single step in the inflammatory cascade and expect to cure septic shock. My one hope is that the gradual progress we've seen in our profession will continue, and some day fewer nurses will find themselves staring up at the oily undercarriage of the bus.