Problems at Work for Nevada Nurses

You've probably heard the parable about the group of blind men who went up to an elephant to learn more about the animal. One man feels the leg and says the animal is like a pillar. Another man touches the tail and says the animal is like a rope. Another touches the trunk and says it is like the branch of a tree. And so on. Each man felt a different part of the animal and came away with a different impression or partial understanding of what an elephant was like. Each one gained a different perspective.

I'm telling this story because I'm going to talk about problems nurses have at work in the State of Nevada, from my perspective. I'm sure the NSBN, the medical facilities, patients, and doctors all have different perspectives on the conduct of nurses at work. Here's my chance to share mine.

In many cases that I have handled, and the many stories I have heard, nurses take the brunt of the blame when something goes wrong at work. The best analogy I can think of is the party game, "musical chairs." Everyone is walking around chairs in a circle, suddenly the music stops, and everyone dashes for a seat, but there's not enough chairs, and the one left standing loses and is left out of the game. I often picture working at a medical facility as being like this. Everyone at work is a player in the game. When something goes wrong (the music stops), and everyone looks for someone to blame. Usually, it's the nurse who gets the blame (the one left standing) and the nurse gets fired (kicked out of the game).

Don't get me wrong, this is not always the case. Sometimes nurses mess up all on their own. There are no excuses for that. But oftentimes, nurses are part of a system that they neither create nor control, and that’s the situation that this article addresses. But most of the time, nurses are working very hard to do their job the best they can, adapting to the environment they are placed in—an environment they did not create. Work environment is usually created by the employer and by the administration.

Nevada nurses at work can face a difficult balancing act. On the one hand, they must maintain professional independence. On the other hand, they have to adapt to the environment in which they find themselves, interacting with patients, doctors, administrators, their supervisors, and fellow nurses. Norms are sometimes established at work that quite frankly can fall below a nurse's statutory standard of care. But when the music stops, the nurse, "low man on the totem pole," is left standing there, receiving all of the blame. Everyone else seems to walk away scot-free. The nurse gets fired and loses her or his job, then faces discipline from the Board. The Board has no control over anyone else, just the nurse. Does anyone else get investigated? Does the medical facility get investigated? Is a doctor disciplined? Do the administrators ever share in the blame? We'll never know. And it's true; that's not the NSBN's scope of authority. They can only look to the conduct of the nurse. It's not a holistic approach, it's very narrow, and often it seems unfair to fail to consider the entire episode of what occurred and why.

I'm going to give some examples of what can happen to a nurse, how a nurse can get caught up in a problem at work that is not entirely their fault and how the environment of work can lead to mistakes for which nurses usually get the sole blame (i.e., no one else is disciplined, and no changes are made at work). Remember, I've already admitted my perspective may be skewed, because I see these situations from the point of view of my clients—the nurses:

No Patient-to-Nurse Ratio

In the State of Nevada, no law exists (like in California) where a medical facility can limit the number of patients that any one nurse can handle. In my opinion, the number one cause of nurse errors at work occur because the facility is understaffed. Facilities and administrators, perhaps in an effort to improve profitability, perhaps because they cannot find adequate help or maintain proper staffing levels, often give nurses more responsibility during their shifts than they can comfortably handle. This is a ticking time bomb; what is a nurse supposed to do? Complain, and they'll tell you find another job if you can't handle it. If you don't complain and keep working, sooner or later, there could be a serious mistake. Walk off the shift because you can't handle it, and you can imagine the accusations that might arise. Perhaps if you report the unacceptable conditions, and you get written up or are labeled as not being a "team player."

When nurses are overbooked, all kinds of bad things can happen

Nurses cannot get adequate assistance when they literally have to be in two places at the same time. Dispensing meds and suddenly there's a code red and you have to go and assist, but you have to void a drug. No one is available. Or you are watching over patients recovering from anesthesia, they give you one too many to supervise, and no one is around to help. Or you cannot dispense all of the meds on your shift due to sheer lack of time, then you go for help, and you face walking off the job because you cannot handle it, and are accused of patient abandonment. Patient comes out of surgery, tugging and pulling at the tubes, and you have to decide whether to call up the doctor at 3 in the morning or restrain the patient yourself because no one else is free to help. You try and transfer a patient to another bed, or change the pads without proper assistance because you can't find help, and the patient is injured.

Facility Standards Fall Below Sound Nursing Guidelines

As an attorney, years ago, I've had commercial truck drivers tell me that they have two sets of books: one set for their actual miles logged and hours worked, and another set to show the inspectors. They claimed they could not make a living with the hours the federal government allowed them to work. So they came up with this work-around. "Everyone does it" they would say.

In the medical profession, sometimes nurses work in facilities where best practices are not followed. Sure, there are written rules and procedures, but they are often ignored or worse, a culture develops where corners are cut and this becomes an institutional problem. Efficiency becomes more important than patient safety. Usually, when facilities cut corners like this, and nothing (usually) goes wrong. Nurses can be lulled into thinking that these relaxed rules and standards are "acceptable," but they are not, and when a mistake occurs, these facilities take no responsibility for the lax environment their administration has created, and nurses get the blame for conduct falling below acceptable standards.

Fear, Intimidation and Peer Pressure

Nurses are only human! They want to get along with the doctors, other nurses, staff and administrators. There is a great deal of pressure to conform, even when standards of care are compromised. I see this not only from the point of view of the nurses I talk to. I’ve seen this as a personal injury attorney.

Nurses are put in compromising situations from time to time. I've seen nurses intimidated by overbearing doctors, who yell at or convince them to do things that eventually can or do result in mistakes, or pressure them to engage in conduct that falls below the standard of care. They fear they will lose their job, written up or demoted if they speak out.

I've heard of nurses who see doctors come to work drunk or stoned and have to decide whether to report the misconduct "perhaps" unable to perform their job. Will a nurse face reprisal if he or she reports the obvious impairment of a physician? What if the institution fails to encourage such forthrightness?

Decisions that are beyond a nurse's control can lead to problems. I have seen it in the personal injury cases I have handled over the years. I have seen deplorable cases of medical malpractice. The first case of malpractice I ever saw was where surgeons at a hospital removed the healthy left lung of a woman who had cancer in her right lung where the cancer had metastasized. The wrong lung! She died of the cancer two weeks later. I have seen patients dropped. Perhaps worst of all, I saw a elderly woman with Alzheimer’s wander out of a facility (she should have been in the Alzheimer's unit but was not) and through a side door (whose alarm had been disconnected) and outside into a blind yard. Hours later she was found dead on the steps by the facility door she had exited, unable to use the disconnected door bell, and covered with severe black burns all over her body from the 110 degree June weather. A nurse could probably share in the blame for this patient wandering off, but what of the facility that had disconnected the alarm and kept these nurses so busy they did not notice she had exited into the scorching sun? Did that facility lose their license? What happened to them?

What to Do When You are Blamed for Misconduct

All of this leads to this one question: what do you do if you are accused of misconduct? Here are your choices: fully cooperate or fail to cooperate. I'll give you my take on each one.

If you are accused of misconduct, you are usually (a) asked to write up what happened, and (b) are brought in for questioning. Most nurses, in an effort to keep their job and be cooperative, allow for both.

Reminding everyone again of my bias, most of the nurses I talk to did both. They wrote up what happened, they allowed themselves to be questioned, and they were then fired for cause. Kicked to the curb, usually, no matter how small the violation. The information, your statement, and your interview, are forwarded to the NSBN for action.

So now I have to draw from my criminal law experience, put on my criminal defense and advise you of the following; writing a statement and allowing yourself to be interviewed are acts of self-incrimination. You have the right to remain silent. Yes, you will probably still lose your job. But oftentimes, the best evidence that gets used against you are your admissions.

Most nurses won't think to talk to an attorney until after they wrote a statement, after they were interviewed, and after they were fired. So don't feel bad if you saw this article after you have fully cooperated.

I think nurses should be unionized in Nevada, and that they should have collective bargaining agreements with the facilities in which they work so when an accusation is made, or a hearing is going to be held at work, that there is a right to a fair hearing, with representation, and a right of appeal, so that a single administrator cannot summarily fire someone. Police have it; you've heard of people on leave with pay while a matter is investigated. The Clark County School District has similar provisions. Nurses should have similar protections.

But I digress. If you have a problem at work, think hard about whether you should cooperate in an investigation. I can promise you that the best evidence that they will ever get against you is your own testimony.

I've seen nurses, in order to be transparent, explain the circumstances, and guess what? They make mention of facts that lead to additional disciplinary charges. If you don't think it happens, trust me it does, because I've seen it with my own clients.

If you are accused of something that you did not do, proceed very cautiously. I strongly advise you to seek legal representation. What's an example of this? Someone says you stole medication off of the cart, and it's on video. What appears to be a violation may be a false accusation.

When a nurse does make a mistake, in my opinion, discipline is proper. But I wish that the totality of circumstances were taken into consideration. Oftentimes, explaining the totality circumstances looks like "excuse making" to the Board. And that is unfortunate. The Board wants to see that the public is kept safe and that you take responsibility for your misconduct. In those situations where you did make a mistake, the discipline should relate to the nature of the misconduct. In other words, the "punishment" should fit the "crime," to use a phrase from criminal law.

When you are accused of a mistake at work, you have a lot to consider. Seeking legal advice, in my opinion, is one of the most important steps you can take. The earlier, the better, for all of the reasons I talk about in this article.

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