Another reason to buy malpractice insurance

A nurse was recently sued by a patient's family (all the doctors and nurses involved were named in the lawsuit). Typically the hospital will provide legal defense for the nurses (but not always, be sure to read my other posts on malpractice insurance). In this case, the hospital had gone bankrupt and was no longer in business, which means---NO Paid Legal Defense for the nurses.

There are so many scary traps out there for the uninsured and here is another one to add to the list. This economy is tough and so you can expect more legal actions taking place and ALL health care practitioners should insure their licenses and their careers. Malpractice insurance is for more that defense in a lawsuit, it can also pay for your legal defense for a complaint with the Board of Nurses. Defense Attorneys recommend malpractice insurance in order to protect your interests and shouldn't you listen to those people who work to help you out.

In case you are wondering, I have no financial relationship with malpractice insurance carriers; I just see the financial problems caused by nurses having to defend themselves out of their own pocket and I hope to prevent the same problems for others.

Job Evaluations are not just for your job

Do you realize that your job performance evaluations are reviewed by the Board? Whenever a complaint is filed, the Board requests copies of your personnel file including your last 2 evaluations. The Board reviews the personnel file because they are looking for a pattern of problems.

Your job evaluations can help or hurt you. It is hard to argue that you were attentive to patients and focused on their care when your evaluation states that there were complaints about you spending your time talking to co-workers or surfing the Internet. It is also hard for your employer to complain that you were a problem nurse when your evaluations show otherwise. So, watch those evaluations and if anything is incorrect in your file, be sure to correct it because you never know when someone may be looking.

Nurses and Addiction

I still continue to find bias against nurses battling addiction. There continues to be a misconception that addiction is a personality defect or a choice. A recent article on Addiction Nursing was published in Advance for Nurses. This article discusses the specialty field of addiction nursing. I thought the article also contained a good description of addiction.

Berthilde Dufrene, MSN, RN, CARN, PRI-C writes, "Addiction is a chronic, incurable, but treatable brain disease. Patients with this disease undergo recurrent cycles of relapse and recovery. Much like other chronic diseases, such as diabetes, hypertension and heart disease, patients usually receive care during an acute phase of the illness and are stabilized with the aid of medication. Pharmacotherapy during the acute care stage aims at interrupting the addictive process through medically supervised detoxification and relieving withdrawal symptoms and discomfort.

Continuing care involves counseling and behavior modification with hope of guiding the patient toward a recovery lifestyle."

So, since addiction is a disease, why does it continue to be treated as a crime or a choice. Why are we so supportive of co-workers that are diabetic or have cancer, but we turn on nurses with drug or alcohol issues. Why are we not fighting to get a non-public rehabilitation order to help nurses with addiction (it also applies to mental illness). In Texas, physicians, physician assistants and acupuncturists all have the ability to be put under a rehabilitation order, which is a non-public, non-disciplinary monitoring of a practitioner's practice. Why is there such a push to punish addiction rather than support people on their recovery road? Some of this push comes from public advocacy groups, so why are we not educating them so that they see that the steps they have instilled have only resulted in health care providers not seeking help for fear of retaliation.

Horrible Medication Error!!

A patient in error has an IV medication injected into his spinal canal and then learns that there is no cure for the error and that he will die a painful death usually within days. What a horrible medication error for a nurse or physician to have to live with. every day.

The ISMP error newsletter has a very good article on the erroneous intrathecal (via the spinal route) administration of IV vinca alkaloids, primarily vinCRIStine. The article has helpful hints regarding this error and other medication errors. Nurses should be reading every issue of this newsletter to help protect patients.

Buy Malpractice Insurance Now!

All nurses that provide patient care should have a malpractice insurance policy. It is not enough that your employer covers you under their policy, every nurse should have their own policy. I think with the financial situation, it is even more important to protect one's career and how horrible to have to go without legal representation or reimbursement for expenses because of financial constraints.

You most likely have health insurance, car insurance and home insurance. Isn't your job worth protecting? Isn't your career more important than your car? You may never get sued, but the number of nurses being reported to the BON is increasing. Insure yourself and be protected.

What Did You Do?

Since we are dealing the after effects of Hurricane Ike and I have posted about the need to be prepared for any disaster, I wanted to hear from any nurses affected by the Hurricane. What did you do in regards to work? Were you able to work? Did you refuse to work (if so, why)? What were the problems at work? What steps did you have to take to provide for your family while you worked? These comments may help others to see the issues that can occur and thus, help them prepare for future disasters.

So, leave a comment (no need to identify yourself). There is also a poll.

NOTE: The power is still not on in most of Houston and the remaining Gulf Coast, so it is of no surprise that there have been no comments from those impacted. Just another reminder for all reading that preparation needs to happen now. Perhaps once the power is back on and once lives are back to normal, I can get some comments in order to let others know what it was like for your fellow nurses.

Legislature, Are You Listening?

The next session of the Texas Legislature is quickly approaching and movements are underway to decide what issues should be addressed by new statutes/laws. I have been asked what issues for nurses and the Nursing Board need to be addressed and changed:

1. The State Office of Administrative Hearings [SOAH] should make the final decision in a contested case hearing. Currently if a nurse chooses to go to a hearing before a SOAH Judge to resolve pending allegations the Judge is only allowed to issue a Proposal for a Decision and not a final decision. This means that the Judge’s decision is presented to the Nursing Board and the Board can decide whether to accept all or part or none of the Judge’s recommendations. Thus, after spending a great deal of time and money litigating the case, a nurse could receive a dismissal form the Judge only to have the Board reject that recommendation. The better resolution, and the more fair, would be to have the SOAH Judge be the final decision maker and if either side disagreed with the ruling, they can appeal to the District Court.

2. Deferred Adjudications should not be considered convictions. Frequently, individuals agree to deferred adjudications because they do not have the resources to fight the criminal charge or they are advised that due to external factors a jury/judge may convict them even though they are innocent or harsher sentences might be imposed then what was necessarily warranted. Some nurses are even told that the deferred adjudication will be removed from their record once probation is completed (NOT TRUE!!) or that the Board will not take action on a Deferred Adjudication (once again, NOT TRUE!!!)

Under the Board’s current rules a deferred adjudication subjects a nurse to the same punishment as a conviction. The nurse can attempt to explain the factors surrounding the decision to accept deferred adjudication, but if the Board decides against them, there is little recourse because of the statute. The Legislature should look at this part of the Nurse Practice Act again and consider the unfair impact it has and that it goes against the initial rationale for development of deferred adjudication provisions.

Inflammatory Breast Cancer

My closest, dearest friend continues her fight against inflammatory breast cancer (IBC). If you have not heard about this disease, it is crucial that, as nurses, you know about this disease. It is very aggressive and often it is first diagnosed as a breast infection and precious time is lost searching for the right diagnosis. Since nurses may be the first health care provider to see a patient, it is very important that you are aware of the signs/symptoms of IBC in order to alert the patient's physician for further diagnostic tests. For more information:

The IBC Research Foundation has some helpful info, such as

There is more than one kind of breast cancer.

We have been taught and are reminded frequently by public service announcements and by the medical community that when a woman discovers a lump on her breast she should go to the doctor immediately. Inflammatory breast cancer usually grows in nests or sheets, rather than as a confined, solid tumor and therefore can be diffuse throughout the breast with no palpable mass. The cancer cells clog the lymphatic system just below the skin. Lymph node involvement is assumed. Increased breast density compared to prior mammograms should be considered suspicious.



Houston Chronicle - FORT WORTH, Texas - American Airlines will unveil two planes Monday featuring a pink ribbon running the length of the fuselage in
honor of its partnership with Susan G. Komen for the Cure, which includes a
$7.5 million pledge from the airline to research a rare form of breast cancer.

The two planes will be the first of eight featuring the pink
ribbon. In press releases Friday, both groups announced American's pledge
will fund research of inflammatory breast cancer, an aggressive and
frequently fatal form of the disease, at the University of Texas M.D. Anderson Cancer Center in Houston. Komen said that kind of breast cancer represents 2
to 5 percent of all breast cancer cases.

Dallas-based Komen said the grant will fund a team of patient
advocates,oncologists, pathologists and scientists working to
improve the ability to diagnose and treat the disease.

Fort Worth-based American, the world's largest airline, has
pledged to raise $1 million annually for eight years to fund the grant. The rest
of the money raised will fund health and community programs.

American said most of the funds will be raised at its annual American
Airlines Celebrity Golf and Tennis Weekend. (press release found in the Houston Chronicle. http://www.chron.com/disp/story.mpl/ap/tx/5932483.html

Also, there is a youtube video taken during the unveiling of the plane that features a survivor of IBC.

A change in name for APNs

The Texas Board of Nursing posted proposed rules for advanced practice nursing. One of the proposed rules is to change the name of an Advanced Practice Nurse (APN) to Advanced Practice Registered Nurse (APRN) because it reflects that the nurse is both a registered nurse and an advanced practice nurse. There has also been some clean up to the advanced practice rules. The rules are available for comment at this time. [There are also other rules being proposed dealing with the Jurisprudence exam, fees, and vocational nursing education]

Extended Evaluation Program - EEP

The Board has more information about the Extended Evaluation Program in their current newsletter. The article explains the basis for the program:

The EEP is primarily intended for nurses who have a one-time positive drug test without any other practice issues and who fail to receive a substance abuse or substance dependency diagnosis. Previously, when RNs and LVNs were reported to TPAPN by third-parties and failed to receive an abuse or dependency diagnosis they were ineligible for TPAPN participation and were subject to possible licensure investigation and action by the BON.

Please do not rely upon the availability of this program and take the risk of taking unprescribed medications or drinking prior, even the night before, a drug screen. The Board extends its concern to many areas that you may not initially consider to be within the scope of nursing practice. For example, a pre-employment screen where you are not working as a nurse when giving the screen, but if the screen comes back positive, you will be under the Board's scrutiny. Many nurses wish that they could go back in time and make a different decision when they borrowed their friend's medication and took it or went out to a party the night before they had to give a screen. Caution will help to avoid future headaches.

TPAPN, the BON and the future

The BON is meeting July 17-18, 2008. One of the agenda items involves the Board's Legislative Appropriations Request. This is how the Board asks for money from the state to fund their activities. There were several issues brought up by the Board that I found interesting (and that also confirm what I have been telling nurses):

1. More nurses are finding themselves before the Board. The number of complaints is increasing and the Board expects 9200 complaints this year. Just two years ago in 2006 there were approximately 5185 complaints and two years before that in 2004, there were approximately 3690 complaints.

2. More nurses are choosing to fight the Board in front of a judge.

3. The cases that are going before a Judge are more complex. This means that there are more nurses challenging the Board rather than choosing not to show up at a hearing and losing by default.

4. More nurses are hiring attorneys to represent them before the Board. After hearing from prior employees of the Board that nurses should never represent themselves before the Board, I am glad to see that more nurses are seeking help when dealing with the Board.

5. The Board is getting tougher on nurses and nursing licensure applicants.

As part of the request, the Board is asking for funding for 3 attorneys, 2 legal assistants and 4 investigators. Below is part of this draft document involving the need for more money to hire more staff:


New Personnel Needed for Enforcement, Legal and Operation Processes -
The agency’s enforcement workload and expenses for its contested cases have steadily and rapidly increased and must be addressed in order for the Board to maintain its mission to protect the public and timely resolve its complaints. The Board needs appropriations to cover the increase in litigation related costs for its expert fees and witness fees. Additionally, the Board will need approximately eleven (11) additional FTEs for FY 2010 and FY 2011 for its Enforcement, Legal and Operation Departments in order to meet the growing demands. Six (6) FTEs are needed for an increased workload due to growing complaints and litigation. This number would include two (2) investigators; two (2) litigation attorneys; one (1)legal assistant; and one (1) administrative assistant. The agency will begin to process criminal background checks for students. The Board will need an additional five (5) FTEs, including one (1) administrative assistant, two (2) investigators, one (1) Attorney and one (1) legal assistant. Although this number appears to be significant, the rise in the number of investigations, plus the complexity of the Board’s disciplinary cases, supports the need to add enforcement, legal and operation staff in order to meet the agency’s mission and timely resolve cases. The Board in FY 2008 will likely receive 9,200 complaints leading to 2,400 disciplinary actions. By comparison, the Texas Department of Licensing and Regulation (TDLR) will have approximately 8,000 complaints in FY 2008 and will likely take approximately 1,240 disciplinary actions (TDLR Statistical Questionnaire, May 2008). TDLR employs thirty-five (35)investigators and ten (10) prosecuting attorneys. Other than the increase in volume of complaints, there are several other reasons why the Board’s enforcement cases will require more resources for the agency to meet its mission effectively and timely:

1. Complaints are increasing by approximately 15% annually;
2. Formal charges statistics and unresolved complaints statistics are increasing;
3. The Board’s policies have tightened with regard to enforcement and
eligibility;
4. Attorney representation has increased significantly; and
5. Proceedings before the State Office of Administrative Hearings (SOAH)
have become more complex.

We project that cost of adding eleven FTEs as follows: four (4) Investigator
IIIs - $167,576; three (3) attorney IIIs - $189,291; two (2) legal assistants -
$88,962; and two (2) administrative assistants - $62,156. Costs of computer
hardware (one time only) - $11,000. Costs of telephones (one time only) $2,750. Costs of Remodeling (one time only) - $11,000. Costs of Furniture (one-time only) $5,500. Costs of annual phone and internet connections - $1,100. Litigation and expert witness fees - $25,000. This will impact the Enforcement and Licensing Strategies.

Looking for a Nursing Job - Part II

Dear Abby's column today (I read it in the Austin American-Statesman) has some additional hints for job seekers. These hints can also be applied to interactions with the Board as well, just substitute "the BON" for "employer". In case you don't have access to Dear Abby's column, I will summarize the column and also expand somewhat below.

A 26 year old small business owner lists some hints in response to issues he sees with potential job seekers, such as:

-Always present yourself professionally. Every contact with a potential employer is a potential evaluation of you, including emails (and phone messages).

-Read all the information about a position and the company before asking questions that may have already been answered.

-Use professional writing when corresponding. Using "text-messaging" slang is inappropriate. i.e. "Thnx 4 ur help."

-Proofread everything.

-Use an email address using your name or initials, because using addresses such as "badass" or "hotnurse" may send messages you do not intend to send to a potential employer.

-Take phone calls in a quiet place because background noise can cause problems. For example, someone yelling, cursing, crying in the background can have a negative impact on you.

-If you are evaluating multiple positions, do not tell a potential employer that you are waiting to hear from a "better" employer or waiting on a "better position". (Obviously, this one does not apply to the Board).

A very helpful column and don't forget the hints when dealing with the Board. People make first impressions and it is hard to shake those impressions once made. So, it is in your best interest to make sure that impression is one of a professional.

Now is the time to be politically active

The Texas Legislature is currently looking at regulatory Boards and determining whether they need changes to their statutes and direction. For example, the Texas Medical Board has been holding town hall meetings across the state. Jeff McDonald over at Information for Physicians notes that these meetings are being held in the home cities of major Legislators, which makes it obvious that the meetings are not being held for the benefit of the public or the regulated physicians, but for the Legislature. Jon Porter at Health License Defense posts his thoughts about the meeting.

The Legislature is also looking at the other health profession boards as they prepare for next year's legislative session. Typically the only parties that let the Legislature know what they want in regards to health professions are professional organizations and consumer groups (see my blog on the town hall meetings and regulation in Texas).

TNA is in the process of gearing up for the 2009 legislative session and the National Nurses Organizing Committee has started working for next year's legislative session regarding mandatory RN staffing ratios, the right to advocate, and whistle-blower protections.

Are you a member of a professional organization? Are you letting that organization know the problems you are having with your practice? If you have interacted with the Board or if you have been following the BON's actions, are you letting your organization or your Legislator know what you like and don't like or what your concerns are?

If you don't participate, how can they know what is important to you?!!!!!!! Other professions have more say because they are more politically active. Nurses, routinely, sit by and let others make the decisions about nursing. Nurses are the largest health care profession, but we have very little power and our failure to step up and get involved and get vocal is a direct reason.

Looking for a Job

I was at the Texas Board of Nursing yesterday and saw the new nursing licenses being prepared for mailing. While there a discussion was ongoing regarding new nurses and it then led to first impressions and job hunting. A lady stated that she was contacting a potential new hire to gather information and she encountered the new nurse's phone message. There was music in the background containing very inappropriate language, so the lady just hung up and never called the nurse again. Be careful how your "personal" life impacts your career. In this situation, a nurse was deemed inappropriate for a position based on a vulgar phone message.

Gotta Read This: Why you don't want a stupid nurse

So, I was looking up some info on diabetic care and came across this posting, ponies from betelgeuse regarding "Why you don't want a stupid nurse" from 2006. I was so impressed with the frank discussion and explanation that I am putting it here, but I am also giving you this nurse's other blog site, Sinus arrhythmia, because she has some interesting stuff there.

Tuesday, October 24, 2006
Why you don't want a stupid nurse.
There's a blogwar going on this week between MDs and RNs. I'm not going to link to it, because the entire thing is infantile. The argument, in the few paragraphs that aren't raw insults and pissing contests, essentially highlights the deplorable state of communication between doctors and nurses.

Why do you care about this?

I'll tell you why you care that MDs and RNs do NOT communicate well. You have a body (presumably). The body will debilitate, sicken, fall apart and ultimately die. It is the way of bodies. It's what they do. When you come into the ER with chest pain, you bloody well want your nurses and doctors to be a flawless team, communicating well and quickly to save your life.

When your mother falls and breaks her hip, you bloody well want her nurse and her doctor to be on the same page on how to handle her pain and prevent infections. If something bad happens to your mom, you do not want a pissing contest between your nurse and your doctor. You do NOT want your mom's doctor to refuse to return pages at 0300 because he believes that the nurses "aren't calling for anything important". (True story.) The difference between 0300 and 0315 CAN be a big difference in your mom's condition. You do not want a doctor to prescribe some needed intervention for your mom, and have her night shift nurse just blow him off because she says, "Oh, that's just Dr. SonSo, he's not payin attention".

Complications will keep your mom in the hospital another week, exposing her to the most virulent germs you'll find anywhere, continuing her convalescence and worsening her overall health every single day. Fifteen minutes can mean a life-threatening drop of 10 to 20 points of systolic blood pressure (as it was in the case of the unreturned page.) (I got a specialty doc to get the fluids order. Patient went to the ICU, but lived.)

You care that doctors and nurses treat each other with mutual respect. You get sick, your spouse will get sick, your kid will get sick. It is what bodies do. You do not have to subscribe to the buddha's ideas to know that pain and suffering are unavoidable.

Okay, so say you're with me on this idea that nurses and doctors should treat each other with respect. You're a reasonable person. You're probably even a good person, and you think respect is a good idea. But you may not be a doctor or a nurse.

You're probably just Joe Person. What you can do to help fix any problem in health care?

So glad you asked.
1) Never say to a nurse "You're so smart, you should be a doctor." If I had a quarter for every time I heard that...

Here's what is wrong with that comment:
a) The implication that all nurses are dumb. Do you know how what it means when one pupil grows larger than the other? Think that a nurse, any nurse, needs to call the doctor at 0300 and what....ask them? By the time you're done dialing, patient's dead at worst, brain damaged at least. Some nurses are dumb. Some bankers are dumb. Some lawyers are dumb.

b) The implication that all doctors are smart. I guarrantee you that this is not true. Some doctors are most assuredly dumb. I work with one day in and day out, and I am leaving my unit because I can't stand how I keep preventing him from killing people. When the actionable event happens, I'm not going to be anywhere near it.

c) That nurses want to be doctors. I don't want to be a doctor. I chose to be a nurse. I gave up a fat salary being one of those scary-smart nerds who fix large computer systems to be a nurse. Money, above and beyond meeting my needs and wants-to-travel-and-buy-more-books, is not a motivator for me. Not being on call and working 80 hours a week is a motivator for me. Doctors spend five minutes a day with a patient, I spend 12 hours with them. Nursing and "medicine" (as if nursing isn't also medicine) are complementary pieces to providing good health care. One is not the flunked version of the other. Because doctors? The ones I know would not make good nurses.

2) Learn about what nursing is
The public doesn't know. They really don't. Do you know how I know this? Because since I've become a nurse, many of my dear friends find my stories apalling. Perhaps they think I'm painting myself a hero because of the times I say, "I stopped another person from dying yesterday." But every nurse does this every day to varying degrees of urgency.

TV has no idea what nursing is. I want you to understand that. When you watch tv, enjoy tv shows, think to yourself "This is fiction just like the Simpsons is fiction." Please. ER is a great show that shows doctors being heros, and Nurse Whatsername, Julianna Marguilies, going to medical school because she's Such A Smart Nurse. Don't even get me started on Grey's Anatomy. I hate that show.

Here's a fact to know: Doctors are not employees of hospitals. This is a fact in American hospitals. Doctors DO NOT WORK FOR THE HOSPITAL. The nurses do. Hospitals are run by nurses (or should be, they're actually run by MBAs, which is why health care is the state in which it is). Does it matter? No. But it should underscore that the doctors go home. Your doctor isn't available at many times of day/week. Who's there for you? Your nurse.

Nursing is about health promotion, and preventing disasters and complications. Pain and symptom management are things we do well, and work with the MDs to do well. I actually had a urology physician assistant once re-place a foley catheter into a man with prostate cancer and huge complications with his bladder function. The patient had been given dilaudid (high octane narc) for pain for the procedure. Good. The PA sat there, writing orders for the night, and I perched on the desk. PA says to me: "He shouldn't have any problems tonight." "Good," I said, "What are you writing for me for pain?" "He won't have any pain." I laughed. "Then you're writing your phone number down so I can call you at 2:30 in the morning when he complains of pain, right?" He looked at me, and I gave him dead-serious face. "Okay, here's an order for Vicodin." "Great. Thanks. Have a good, restful night." (Do you need to ask whether the patient needed the pain pill?)

You want that nurse who is good at predicting when you're gonna feel like shit. One who knows which med is gonna make you nauseated. One who knows you'll be in pain, and helps you avoid it.

Should you be in a hospital or your loved on is, ask your nurse questions. Lots of them. Most of us love to talk to patients, because hey, it's why we're nurses. I spent an hour with a patient and his wife two nights ago talking about "foot care and diabetes." Sound dumb? I mean, 'foot care'? Ask a diabetic who's had his foot amputated. There are a lot of them. It is one of the most common adverse conditions secondary to diabetes. Three nights ago, I noticed this patient has unequal pulses in his feet. The patient probably thought I was just being a sweet nurse and rubbing his feet to tuck him into bed. That's how people get the idea that we're dumb and sweet. We don't tell them the hundred little tiny things we watch for. I do. Not to show off, but because people usually really like to understand their bodies, particularly when they're sick. It gives them control over their lives, when almost everything about hospitalization and illness rips control away.

His right dorsalis pedis was weaker than on the left. Which meant either deep vein thrombosis, peripheral vascular disease, or some type of arterial insufficiency from the diabetes. A DVT could kill him, but I didn't think it was that. (Why? No "hot spots" on his calves, 0 pain, - Homan's sign.) So I go back to the desk and call Dr. Boob to ask for a NIVA, an ultrasound of his leg veins. After struggling with Dr. Boob not returning my page, and boring me with his self-importance, I got my NIVA order. Patient gets a NIVA in the morning, and it's negative for DVT. Had it been positive, I would have stopped the patient from dying by having that test done....based on my sweet "foot rubbing". It was pretty critical to rule out that as the problem. Don't you think?

So he's got arterial insufficiency, which is typical for diabetics. I talk with the patient and his wife talking about what this means, why they need to care, and what they can do to prevent becoming like my patient from last month with PVD...who had Boxing-Helena-esque gradual amputations. (I didn't mention that last bit.) You think the MD spent ANY time whatsoever discussing diabetes (a complex, lifelong disease process with huge implications for diet, lifestyle, constant medication administration and self-blood testing 4x/day, disease and medication side effects, not to mention family teaching on what to do when the patient conks out unconscious because of an adverse event), ....much less what to do differently to make sure the patient doesn't have his feet chopped off in 2 years?

Don't make me laugh.

Dr. Boob went in, asked "how physical therapy is going", said "we'll talk about discharge next week" and went home for the day. Of course, this is why I call him Dr. Boob. However, Dr. K, the consult doc who I do respect quite a bit...went in, discussed medication changes he'd made for the patient's discharge. (Again, this was Michelle, the night RN, leaving a note for the physiatrist about patient needs for insulin scrip before discharge because I'd spent an hour and a half the day before working with the patient on how to give himself insulin, what it does, how it works, etc.) So K made the decisions about what insulin he thought was needed for discharge. Cool. This is what I want docs to do. This is why "Dr. K" is "Dr. K" and not "Dr. Boob".

You want a smart nurse. You really, really do. Again I say, I'm not special. A lot of nurses can show you how much they know about your body and the medications your doc prescribes. A huge number of people don't hear the doc's explanation (if he or she does explain) about meds or diagnoses. They're in shock a lot. They're sick and feel shitty a lot. They need to hear things again (or for the first time). A lot of patients feel more comfortable asking someone they perceive as being sweet and foot-rubbing. They want to know about side effects. They want explanations in English, and forgive me, but that is one things doctors do NOT do well. It's okay. That's part of what nurses do.

The trouble with nurses is that we're bad at explaining what we do. Most second-career nurses who were in other fields before are exceptions to this. Nursing socializes itself to act meek or deferential. A century of the medical establishment running things is part of the historical reason, another other part we can blame on the very religious Florence Nightingale, who dictated that nursing have her interpretation of Christian values of self-sacrifice and poverty. Those of us who've been in other fields are used to talking about our work and many of us have been in fields where we're on even footing with other men, and are used to being regarded as professionals. Most nurses do not have this sensibility.

So I try to tell people that nurses are smart, and WOW, people believe me. When I was a programmer, I never had to insist "but programmers ARE smart". People know generally what geeks do. So I'm telling you stories about what nurses do. Pass it on. Please.

3) (And this is directed at Americans) Support legislation that nurses support.
Nurses get into the profession because we actually want to take care of sick people. We want the system fixed. We hate accepting an assignment of 8 patients and not taking care of any of them well because we're putting out fires all night. We know you hate it. We hate it more. Unionization has HELPED patient care in California, the studies show that. Yes, there is such a thing as nursing research and nursing journals. (There's New England Journal of Medicine and there's American Journal of Nursing.) Requiring a BSN degree as professional-entry nursing (as opposed to LPNs, Licensed Practical Nursing) has HELPED patient care in North Dakota.

So if you believe me about those things, it will actually indirectly help the cause. Your cause of wanting good health care when you need it.

I will rant later on the evils of Medicare, the abuses of the pharmaceutical companies. And what I think nurses need to do to fix nursing. As well as why you should care.

For now, that's my story and I'm sticking to it.
/jo, RN, BSN

Nursing Malpractice Insurance

I have actually had several clients lately that have insurance and I am hoping that this is a new trend. Having financial resources available to fund your defense before the Board of Nursing is so helpful, not only does it take some stress off, but it also gives the nurse the resources to fight the BON if the nurse does not agree with the Board's punishment. So go read some of my older posts on insurance and don't delay, get insured today.

Protect Yourself Now

Malpractice Insurance Will Get You Sued

But My Employer Has Insurance

My Employer Will Pay for My Legal Representation

Suing Nurses

Renewing a License While Under Investigation

You are under investigation and it is time to renew. Here are some answers to common questions:

1. Go ahead and renew. Do not put your life and job on hold while you wait for the Board to complete their investigation. If you have any difficulty getting your license renewed, contact an experienced attorney. For example, if the Board tells you that you cannot renew due to the investigation or due to formal charges being filed.

2. Start the renewal process as soon as you are able to. The Board allows you to renew 60 days prior to the end of your renewal period. For example, if your renewal month is June, you could start the process on May 1. You want to start early because you will most likely have to submit the renewal by mail and not do it online.

3. The Board has stated that the answer is "no" to the question "Are you currently the target or subject of a grand jury or governmental agency investigation" if you are under a current Board investigation because obviously the Board knows if they are investigating you. This question is asking about any other Board/agency or grand jury investigation.

4. Take your time and answer each question truthfully. Keep a copy of your renewal (actually every nurse should do this for every renewal, not just when under investigation and fyi you are able to make a copy of each renewal page when online)

Looking for nursing websites?

If you are looking for some old favorites or maybe want to explore some new, have a look at RNCentral.com's listing of 100 useful websites.

It Is Nice For A Change

At the next Texas Board of Nursing meeting, the Board staff is requesting the following according to the agenda for that meeting:

That the Board reduce the renewal fees for Registered Nurses from $67 to $65 and and for Vocational Nurses from $58 to $55 due to a $4.75 reduction in the fee for an FBI
fingerprint-based criminal background check and the increased income from a higher number of RNs and LVNs renewing their licenses. Any excess funds collected from licensees go into the general revenue fund (which means that the excess money goes to the general fund for Texas for all agencies to use and that the excess money cannot be used by the Board of Nursing although they would raise it).

It is nice for a change for the government to try to save us money rather than always taking money from us. Hopefully this rule change will be approved.

The BON may just be the beginning

A nurse is offered a voluntary surrender to settle the allegations against the nurse at the BON (or maybe the nurse is suspended or revoked, losing his/her license). The nurse agrees to the surrender because the BON tells the nurse that he/she can request the license back after one year and that the nurse either give up the license or have it taken away (more about this later). The nurse is able to work as a nurse aid or even a secretary for a hospital in order to bring in some money to his/her family, right? that type of work does not require a nursing license, so it is acceptable for the nurse to use his/her knowledge as long as the nurse does not overstep professional boundaries, correct?

Not so fast--there is another governmental agency ready to have a go at the nurse. Years ago, Congress gave power to the Office of Inspector General (OIG) to punish physicians who committed fraud in the Medicare program by excluding the physicians from the ability to get reimbursement. The power given to the OIG has increased so that it is no longer limited to only Medicare fraud. The OIG can exclude anyone, not just physicians, but also nurses, aides, administrative personnel, therapists etc. An exclusion means that the person cannot get Medicare reimbursement or work for any entity that receives Medicare reimbursement.


The OIG has two types of exclusions: 1) mandatory, meaning that there is no recourse to argue mitigating factors in order to decrease the amount of time excluded, and 2) permissive, which does allow the presentation of mitigating factors.

The type of actions leading to a Mandatory Exclusion according to the OIG's website are:
1. Conviction of program-related crimes Minimum exclusion period-5 years

2. Conviction relating to patient abuse or neglect Minimum exclusion period-5 years

3. Felony conviction relating to health care fraud Minimum exclusion period-5 years

4. Felony conviction relating to controlled substance Minimum exclusion period-5 years

5. Conviction of two mandatory exclusion offenses Minimum exclusion period-10 years

6. Conviction on 3 or more occasions of mandatory exclusion offences Permanent exclusion

7. Failure to enter an agreement to repay Health Education Assistance LoansMinimum period-until past due loan obligation is repaid

You are not protected by having pled nolo contendere or received deferred adjudication because the OIG's definition of conviction is as broad as most of the BON's.

There are many more permissive exclusions and here are some of those that may impact nurses:

1. Misdemeanor conviction relating to health care fraud. Minimum exclusion period -3 years.

2. Misdemeanor conviction relating to controlled substance Minimum exclusion period -3 years.

3. License revocation or suspension.Minimum exclusion period - the same or greater than the time period imposed by the state licensing authority

4. Default on health education loan or scholarship obligations Minimum exclusion period -until default has been cured or obligations have been resolved to Public Health Service's satisfaction

So, with the example above, the nurse voluntarily surrendering the nursing license would soon receive a letter from the OIG informing the nurse that he/she is being considered for exclusion from Medicare reimbursement. Since this is a permissive exclusion, the nurse can hire an attorney and attend a hearing to argue why the exclusion should not apply. So much for surrendering in order to reach a quick resolution.

It is an election year, which is the perfect time to advocate through your professional organizations that the broad exclusions need to be scaled back down to those actions that affect the Medicare program and not as another level of punishment for licensure actions or criminal incidents.

Now to revisit the other problem with voluntary surrender: Another problem with voluntary surrender is that in Texas(I do not know what other states do, but I do know that there are many states that do not accept the surrender of a license), nurses are told that they can reapply for their license in one year. So, the nurse submits a reinstatement packet and appears before the Board only to be told that not enough time has passed or that the nurse needs to meet certain requirements and then apply again in a year (requirements the nurse did not know he/she would need). I hear from many nurses that are distraught because they thought it would be an automatic reinstatement when they gave up their license a year previously.

Office of the National Nurse

There is a movement to establish an Office of the National Nurse. I think this would help to elevate nursing in the public's eyes. According to the organization promoting this position:

An Office of the National Nurse would:
Establish symbolic national leadership by elevating and strengthening the Chief Nurse Officer of the USPHS to make this position visible to the nursing profession and the public.
Compliment the work of the US Surgeon General.
Promote involvement in the Medical Reserve Corps to improve the health and safety of the community.
Incorporate proven evidence-based public health education when promoting prevention.


There is much more information available at the blog www.nationalnurse.blogspot.com

Helpful Clinical Information for Nurses

I found a new blog packed with helpful information on clinical issues: Dear Nurses. Go check it out.

Nurses Rock!!

The results of the Gallup poll for which occupations rate the highest when it comes to honesty and ethics. Once again nurses rule!!

The article states "Eighty-three percent of Americans rate nurses' honesty and ethical standards as very high or high, easily the most positively rated profession. Nurses were first included in 1999 and have averaged an 81% very high/high rating since then. That has been good for first place each year except 2001, when firefighters were included after the 9/11 terrorist attacks and received a 90% rating."

Funny patients and how to fix health care

I just read a fun blog that has a funny post about terrible patients and a list of ways to fix health care; both are an interesting read. Go have some fun.

Texas Medical Board Attorney

I have received calls from physicians that find my blogs asking me to represent them before the Texas Medical Board. I refer physicians to one of my law partners, Jeff McDonald, Jon Porter or Tim Weitz. Please go to our website at www.healthlicensedefense.com to read the bios of each of my partners.

Board stipulations

If you are under stipulations by your Board of Nursing, here are some helpful hints for a Board Order/Stipulations/Restrictions:

-Make sure you understand what is being required of you. Read the Board's Order completely and ask questions as needed.

-Be sure that you comply in all aspects with the Order/Stipulations/Restrictions because the Board gets very angry with nurses that agree to certain stipulations or restrictions and then fails to adhere to those stipulations or restrictions.

-Keep a record of all conversations you have with the Board staff (name, date, time and exactly what was said). If the conversation was important, follow it up with a letter detailing your recollection and understanding of the conversation.

-When sending in any information or documents, send them by certified mail, return receipt requested so that you know when the Board receives it.

-If documents have to be filed with the Board by employers or supervisors, set up a way for your employer/supervisor to notify you when the report/document has been sent to the Board so that you can ensure that the report/documents are sent in timely.

-Set up a calendar system so that you can keep track of deadlines and submission requirements.

-If you are subject to drug screens, have a system (calendar, another person) to check that you called in as required each day. Also, be VERY CAREFUL with EVERYTHING that you put in your mouth because you could hurt your sobriety record.

-Do not wait until the last month to obtain any required courses. Many approved providers give a limited number of courses per year and so it is better to take any required courses immediately so that you do not miss out.

-Keep the Board informed of any changes in your address or phone numbers.

-Keep copies of all documents in an easily retrievable, organized manner.

A Fun Look at Nurses

Be sure and read the current article "What Makes Nurses Tick" in the December issue of Advance For Nurses. It is information about what nurses have stated that they like and think. I thought the answer to "What medical TV show do you most enjoy" was interesting. The number one answer was "House", followed by "Grey's Anatomy" and closely by "ER". So the top two answers are shows that rarely show nurses and that are full of inaccurate representations of the medical field (not to say that I don't watch these shows as well). My personal peeves are when it is always the physicians who are first at the bedside in a CODE, surgeons scrubbing without having their masks already on, and people stripping their dirty gloves off and throwing them all over the place (not to mention how they remove their gloves). Go read and have fun.