Nurse Discipline: Lessons from 2019
For over 10 years, I’ve represented hundreds of nurses before the Nevada State Board of Nursing. I truly love helping nurses! They are the heart and soul of health care in this nation. They work tirelessly to alleviate pain and suffering--helping the sick and afflicted to heal and return to full health. In addition to providing critical care to people in need, they must also have the ability to work well with others, including their employers, administrators, other medical professionals, patients, and the family members of patients.
Nevertheless, nurses are not perfect—none of us are! I’d like to share with you some of the types of issues I handled in 2019, so you can avoid the mistakes made by others:
1. Do not cross the lines of professional boundaries. Patients can become very attached to the compassionate nurses who care for them. Sometimes it’s tempting to go beyond the scope of your work and do things for them that cross the line. Ignoring professional boundaries can come back to haunt you when your patients or their relative decide to report you, landing you in trouble. Up until this year, I hadn’t seen much of this, but if 2019 is any indication of the future, it could be a growing trend. Here's two things you should avoid:
a. Do not accept money from patients. If you’re employed full time or as a contract nurse, do not accept any money from patients. Sometimes, patients—especially home care patients—will ask you to do extra things for them, such as taking them shopping, to the bank, to a doctor’s appointment or to run errands. I would strongly advise against accepting such requests if it's not part of your job description. Moreover, you should refuse to (a) fill out any checks for them—especially checks made out to you, (b) receive cash without a receipt, (c) go with them to the bank to withdraw money, or (d) use their debit or credit card to make purchases. Family members might report you if they find out any of this is going on. I've seen patients later deny requesting that nurses engage in such activities. If you ignore my advice and decide to offer after-hour services to a patient anyway, do it while you are not on the clock for your employer. Also, be sure that (a) you are not providing nursing services, (b) you have a written, signed agreement setting forth the exact terms of your services, (c) you give receipts for any payments received, and (d) have the consent of your employer in writing if you are assisting their patients while not on the clock. Never commingle your personal business with the patient's; for example, do not buy your groceries with a patient's debit or credit card.
b. Do not become personally involved with patients. Avoid developing personal relationships with patients, while they are patients, at all costs. Do not give them a ride home from the hospital when they check out. Do not give them your personal phone number. Do not engage in private messaging, even if they beg and plead to do so. Nurses by nature are sometimes persuaded to ignore such professional boundaries; ignoring them can lead to a host of problems for you and your employer, however innocent your intentions.
2. If you can’t handle the workload, demand an adjustment or seek other employment. Most nurses I've represented fall into one of two categories: (a) those who will not tolerate unreasonable demands placed on them in the work place and will seek employment elsewhere where they feel they can safely practice nursing, and (b) those who will work in very difficult environments, simply “sucking it up” and slogging through their jobs, despite the unrealistic demands that are placed on them. Most nurses fit the latter category. Some nurses hang in there because they received a big signing or renewal bonus if they stay for a set period, and they quickly spent the money. Those who stay are the ones who wind up committing violations because they are overworked or have too much to do during their shifts, committing unintentional violations, such as inaccurate record keeping—which is one of the most common violations of an overwhelmed nurse. If you’re over your head, insist on a change or get out: know your limitations. There are plenty of other jobs out there that fit your abilities and temperament—which offer better working conditions.
a. If you decide to leave your job, do it safely. Do not walk off the job in the middle of a shift unless you know that your patients will be taken care of. I’ve seen nurses blamed for “patient abandonment” when they quit because working conditions were intolerable, but it must be done in the proper manner. Exercise caution!
b. Don't spend signing bonus money right away. If a potential employer offers you a signing bonus, think twice before you spend the money immediately. Sometimes those employers have a hard time retaining nurses because the work conditions are bad, so make sure your new job suits you before you spend the money. Alternatively, negotiate less restrictive contractual terms for keeping the money if things don't work out.
c. Make a record. Clearly document in writing all efforts you have made to warn the Charge Nurse, Director of Nursing, Human Resources or Administrators about improper or unsafe working conditions. If changes aren’t made by the employer, then you need to seriously consider leaving and look for another job.
3. Smile, you’re being recorded. Cameras are everywhere these days. Hidden cameras in people’s homes are proliferating. You should assume that everything you are doing while on the job is being recorded. Always act in a professional and appropriate manner. I’ve seen nurses caught on camera doing all kinds of things that later get them in trouble, from patient abuse to idly standing around, not monitoring patients as they should.
4. Always remember your independent obligations as a licensed nurse. As a nurse, you are required to follow best nurse practices at all times. Sometimes, nurses are lulled into doing things the way their employer wants them done that violate standard nurse practices. You have to follow the nurse practices you were trained to do, regardless of what your employer says. It’s never an excuse to say, “everybody else is doing it” the wrong way. Moreover, the Board often only disciplines one nurse among many violators—the Board isn't required to discipline everyone with equal justice in order to discipline you.
a. Don’t rely blindly on doctor’s orders. If a doctor gives you orders or directions that you do not agree with and that may harm the patient, don’t be intimidated or afraid to question those orders. If you're still in doubt, immediately seek the opinion of your CN or other experienced nurse. You can get into trouble for not questioning a doctor’s orders. Document everything.
b. Just because someone says it's ok doesn't make it ok. If you get permission to do something from a doctor, CN or DON, that doesn't mean you should do it. For example, nurses who work in hospitals that deliver babies should not try to influence a patient's adoption decisions arising from unwanted pregnancies—even if superiors approve your request—if it falls outside of acceptable norms and nursing practices.
5. Patient Privacy. Make sure you dispose of private patient information properly. Documents containing HIPAA-protected information should be put in designated trash bins intended for shredding, not common waste baskets. Also, do not take pictures of patients, babies or their family members, or share them with anyone.
6. Don’t Use Legal Marijuana. Even though marijuana is now legal in Nevada for medicinal and recreational uses, find out your employer’s policy on the use of marijuana. For most employers, it is still a terminating offense if any marijuana is found in your system while on the job, even though it's legal. Check for a medicinal use exception in your employer's employment handbook.
7. Don’t use prescribed medications that aren’t yours. Do not borrow or use the medications prescribed to another person. If you are ever randomly tested and found to have unprescribed medications in your system, you will be treated harshly by the Board, including restrictions your license—or worse yet—suspension or revocation of your license.
In closing, I'd like to identify two more trends I saw in 2019:
The rise of complaints against nurse practitioners. In 2019, I also saw a sharp rise in the number of Nurse Practitioner clients who were being investigated for possible violations. This is probably due to two factors (1) the Board recently hired an APRN to investigate APRN cases, and (2) the steady rise in the number of NPs in Nevada. So far, all of the cases that I’ve handled for NPs have been dismissed, with no disciplinary action taken.
Software glitches, malfunctioning equipment and lack of training. I’m starting to see nurses blamed for problems arising from malfunctioning equipment or poorly designed “beta” software programs implemented by employers, and mistakes made from lack of proper training. You must report such problems to administration as soon as possible and always in writing, don’t look for work-arounds for systems that don't work. Insist that these problems be fixed. Insist on proper training if you don’t understand how these systems or equipment work. This should all be kept in writing. Always keep everything in writing!
I’m looking forward to helping more of you in 2020. Have a Happy New Year!