As governor of the first COVID-19 epicenter in the country, Andrew Cuomo challenged New Yorkers to think about how the state could “build back better” after the crisis. As registered nurses with experience in health law and policy, we have recommendations for transforming the boards of nursing. The manner in which nurses are regulated must be reformed, not just in New York, but throughout the country. It must begin by understanding the dangerous environments in which nurses are working.
Staffing, safety issues affect both nurses and patients.
In May, for example, Governor Cuomo reported that 12.2% of health care workers in New York city had been diagnosed with COVID-19. Nationwide, more than 164 nurses have died, often because they lacked adequate personal protective equipment. But COVID-19 is not the only dangerous situation. Long-term and psychiatric care facilities, as well as hospitals, are often dangerously understaffed, exposing nurses to violence. Nurses and other workers have been attacked and sometimes killed because they lack necessary resources and protections. Workplace violence is a growing threat which has not been adequately addressed by health care managers and administrators. Danger to patients occurs when nurses are expected to accept assignments outside of their areas of expertise. Nurses cannot care for more and sicker patients with fewer resources and training, then display perfect judgment and never make mistakes. Employers require nurses to knit with one needle, then the board of nursing punishes them for poor quality stitches.
The steep individual cost of license suspension or loss.
The boards of nursing grant nurses the authority to practice and are supposed to protect the public from unsafe practitioners. Professionals who lose their licenses or have them suspended temporarily can lose their livelihoods and their health insurance. As such, nurses should only be separated from practice if they pose a current risk to patients. The collateral consequences of licensure discipline are disproportionate to most infractions. Any state in which a nurse has been licensed can and does impose reciprocal discipline. A nurse who is disciplined in any one state then potentially faces disciplinary action in multiple other states where no misconduct occurred. For a traveling nurse or a telehealth nurse, this can be endless and overwhelming. Nursing boards should be required to advise nurses that they can and should be represented by counsel before they make any statements or agree to any settlements.
Factoring in administrative responsibility for institutional conditions.
In addition, the boards of nursing need to fully consider the role of the administrators responsible for staffing and other institutional conditions over which frontline nurses have no control. We both have talked with or legally represented many nurses who blew the whistle on unsafe institutional practices, fraud, or other unethical or illegal acts, or who were the last domino to fall in an entire cascade of organizational failures, only to find themselves dismissed and reported to the board. Despite employer failures to provide procedural safeguards and adequate staffing or training, the nurse is then disciplined by the board of nursing. The entire weight of an adverse event falls on the shoulders of that last domino.
A ‘just culture’ approach to the disciplinary process.
Boards of nursing should adopt a standardized “just culture” approach to the disciplinary process—one that views mistakes by clinicians as arising from failures of the organization’s systems, not from individual deficiencies. The airline industry model of analyzing all contributing factors and designing systems to account for human error should be used throughout health care, including professional regulation.
Constructive penalties.
Such an approach doesn’t absolve clinicians of their individual responsibility for safe care. Instead, it recognizes that penalties should be constructive rather than punitive. When nurses do make mistakes, the default position should be to reeducate and support practice and systems improvement, rather than to punish the individual nurse. The boards of nursing need to clearly distinguish between actual professional misconduct and unintentional (and inevitable) human error.
Edie Brous, JD, MPH, MS, RN, is a nurse and attorney in New York City and Pennsylvania, and the coordinator of AJN’s Legal Clinic column; Diana Mason, PhD, RN, FAAN, is a senior policy service professor, Center for Health Policy and Media Engagement, George Washington University School of Nursing, Washington, DC.
Re: workplace violence, I am retired now, but my career basically ended in 2011 when struck in the head by a psych pt, rendering me unresponsive for 5 minutes and requiring an ambulance to the main building ER.the pt was 6 foot about 250 lbs. I am 5’4′ and currently weigh 107. He struck me on one side on my head, and the other side hit the wall. We were short staffed that day and security didn’t stay until the situation was resolved. My peers on the psych unit were supportive; administration was NOT.
I to returned to work-albeit to another unit-and much too soon due to Workman’s comp regs. .I had mild TBI symptoms and definite PTSD symptoms, a goose egg on my scalp still but the bruises were gone. I should NOT have been at work.
The new unit was an area unfamiliar to me but an “upbeat” area that I thought would be “healing” . But my new peers- even knowing my history- were less then helpful and the final straw was being publicly shamed over a minor time management issue at the nursing desk in front of a large group of staff. I resigned that day, and went into a deep depression.
Of course, I lost my medical insurance and my husband who is disabled was no longer able to afford his medicine that he desperately needed. We became deeply in debt and just now are climbing out. I was able to find a few short term jobs since then but had severe PTSD when in certain situations.
I write this just to make people aware HOW MUCH and how far reaching workplace violence can be. I was in my late 50’s when this occurred, which is the silver lining in all of this. I am now officially retirement age. I am grateful this didn’t happen early in my career.
Boards of Nursing, who do they answer to? Nurse Practice Acts and Codes of Ethics mean nothing if
there is no equal justice under the law. This has never been more evident than during the pandemic.