What Are The Reasons Registered Nurses Can Be Disiplined

Joe Flores, NP, JD, has been defending nurses against investigations past the Texas Lath of Nursing for several years. Flores, a Corpus Christi attorney and part-time hospice care nurse practitioner, rarely turns away these clients. He feels it's important they have representation if they have a instance.

But since the pandemic started, Flores has had to plough away many cases. Demand for his services is upward, he says, as nurses are beingness investigated past the Lath even every bit they struggle to perform their jobs with the added stress of the pandemic.

The nature of the complaints is also unlike: "I have never had [board] reports regarding masks, gowns; this is new, this is detail to the pandemic," said Flores, who is now representing a dozen nurses facing potential bailiwick. "They are overworked, understaffed." Only, he added, patients and management "but report them" and the lath opens cases confronting many of them -- every bit a nursing board did recently against a Minnesota nurse.

These actions aren't unique to Texas or to the pandemic, nursing advocates say. In their view, boards nationwide have aggressively pursued complaints against nurses and intimidated them for years. Boards take stripped nurses of their licenses and taken other disciplinary actions confronting them for engaging in personality conflicts with managers or reporting safety issues publicly; even for offenses unrelated to their work, such every bit missing child support payments.

"When I started digging, I was horrified, actually," said Aurora Kim Paradisis, EdD, RN, a police pupil whose 2018 doctoral dissertation was subtitled, "The Lived Feel of Unjust Discipline Among Registered Nurses."

"It's really retaliatory," she told MedPage Today. "People are scared because it's their livelihood and they don't want to get to the point where it gets to nursing boards considering in one case they get you, they don't let you go."

Lath staff and their advocates disagree. They defend disciplinary actions by pointing to their overarching mission: to ensure public safety past keeping nurses accountable.

"To my knowledge they're doing an excellent job. I know they are extraordinarily conscientious about their mission and their role," said Maryann Alexander, PhD, chief officeholder of nursing regulation with the National Council of State Boards of Nursing (NCSBN).

Simply nursing advocates cited several states for egregious deportment over several years, including California, Arizona, and Missouri.

The Texas board especially stood out in news reports and conversations with MedPage Today.

"In that location's a problem hither," said Darlene Nelson, RN, a long-time nurse who runs a Texas consultancy to assist nurses facing board reviews. "We take helped nurses in many states, and information technology'southward the same everywhere."

Board Allegiance, Nursing Experience Questioned

The Texas board is structured like the majority of nursing boards. The state'south governor appoints members, and the governor and legislature take potency over the board. Staff handle everyday tasks including triaging complaints, conducting investigations, and arguing the board's position at hearings. Board members make ultimate decisions about sanctions at hearings.

The Texas board has 13 members: 9 nursing representatives and four representing consumers.

MedPage Today conducted online backgrounding of board members and top executives as of the start of this twelvemonth -- finding that of the 9 nursing reps, just three reported being active nurses. Four worked in healthcare management, according to official bios, LinkedIn pages, and other reports.

Even some of the consumer representatives have been involved in healthcare. Mazie Mathews Jamison is a sometime healthcare executive. David Saucedo Ii is vice president of a lock company, and he invests in the Borderplex Alliance, an El Paso advisory and community grouping that has partnered with HCA Healthcare, CardinalHealth, and other healthcare organizations, according to its website.

Similarly, full-time staff -- including executives -- accept more administrative than nursing feel. Katherine Thomas, MSN, worked for six years as a nurse practitioner, but has been the organization's executive managing director since 1995.

Enforcement director Tony Diggs, general counsel Dusty Johnston, and operations chief Mark Majek don't study any nursing experience in their public profiles. Diggs oversees some 50 staff in the enforcement division. Along with Thomas, they have all been in their roles for more than than xx years.

"They're not nurses. They can't possibly understand what a nurse is trying to explain" during investigations, said Lolly Lockhart, PhD, RN, a long-time nursing consultant and Texas Nurses Association fellow member.

Board members and staff take their role seriously and are trained to handle their responsibilities, Johnston said, calculation he has never seen a member utilize the board for personal or political gain.

"If you don't want experienced nurses reviewing the competency of nursing practice, that doesn't sound quite right," he said, discounting that many board nursing reps accept non been practitioners in years. "I guarantee you we are non evaluating the standard of care today based on standards of care that may have been in place in 1983," he said, alluding to the last yr Thomas was a practicing nurse.

Alexander, the NCSBN official, praised the blend of state boards' composition in general, including in Texas: "It's what we would probably call a well-counterbalanced board considering you want a mix of public [members] who ensure the board members who are representing the profession are doing their job, and you want the expertise of members of the profession."

More Investigations, Sanctions

National and state data testify increases in several disciplinary categories at nursing boards over the last two decades, particularly from 2005 to 2016.

Nationally, adverse actions reported against registered nurses (RNs) more doubled from 2001 to 2011, according to the National Practitioner Data Bank (NPDB), and increased steadily from 14,092 in 2012 to 16,190 in 2016. These deportment vicious slightly from 2016 to 2019, the last year for which complete information were available.

Similarly, actions against advanced practice nurses (APNs) surged more than v-fold from 2001 to 2014, co-ordinate to NPDB data.

NPDB data for Texas show that adverse actions confronting RNs and other nurses more than doubled from 2008 until 2012. The number of deportment against Texas APNs in 2016 was nine times the 2013 number.

The Texas board'due south own data show the total number of deportment taken confronting all nurses increased sharply in the first decade of this century, which Johnston said is due to a change in policy: criminal background checks were mandated in 2005. Nurses with criminal histories were found to exist in violation, thus forcing deportment against many nurses. (An NPDB official said the data don't friction match exactly, in big office because not all state board actions are reportable.)

Texas board data also prove that the number of investigations involving RNs nearly tripled from 2006 to 2013, and sanctions confronting their licenses rose 70% from 2010 to 2013. Published numbers show subsequent declines, simply MedPage Today plant meaning data were missing, particularly from 2018 and on.

While the number of complaints has besides risen over time, the percentage of complaints leading to field of study has increased also -- notably in the outset half of the last decade for RNs, rise from 18.1% in 2010 to 22.seven% in 2012, for case.

In addition to practice violations, nurses can be disciplined for actions in their personal lives. The Texas lath, for instance, is required by country law to subject area nurses establish by the attorney general's part to have neglected kid support payments, Johnston confirmed, and the board has taken activeness for violations as trivial as accepting gifts from former patients.

"Attorneys agreed the nursing board had an ambitious arroyo to off-duty behavior, though it wasn't unique" among state boards, co-ordinate to a 2013 report by the Austin American-Statesman.

'Presumed Guilty'

Darlene Nelson and Maggie Ortiz run Expert Nurse Consultants, a San Antonio-based organisation that assists nurses. Nelson was disciplined by the board in 2019, while Ortiz said she worked for the lath for six months before quitting over moral objections.

Along with two other nursing consultants, Joe Flores and Texas chaser Marking Weitz, they depicted a board that unjustly penalized nurses in an overzealous and patently retaliatory fashion for years, while deliberately minimizing communication during reviews.

"They filibuster because they attempt to railroad you, they try to scare you," said Nelson, a iii-decade emergency department trauma nurse veteran. In a typical yr, more than 80% of complaints are resolved within six months, Johnston said. But amongst reviews, about half take longer -- and at least one-quarter exceed a yr.

Ortiz left her emergency department task in November 2013 to join the board as an investigator. She opened new reviews weekly as others that were a couple of years old sabbatum untouched.

"I was told any nurses reported to the lath were all guilty, and then why are y'all wasting your fourth dimension reading their response [to the initial lath letter of the alphabet]?" she said. "That is the culture of the board." Ortiz quit early on in 2014.

Another problem is the lath follows administrative law, which lacks sufficient due process protections, several sources said. For instance, the board can overrule recommendations about sanctions made by the administrative estimate who oversees hearings. One customer of Expert Nurse Consultants remained nether investigation fifty-fifty later her former employer stated she had non committed any violations.

During the pandemic, nurses have been investigated after speaking to managers and/or publicly about pandemic-era PPE problems and staffing shortages, Flores said.

Tonya Randolph, RN, said she was fired by Lake Granbury Medical Centre in March for wearing a mask after management asked nurses not to wearable one "considering it scared their patients," according to a Texas Public Radio study. She was reported and the board is now reviewing her case, according to a source who asked to remain anonymous, citing customer confidentiality. (Randolph could not be reached through her employer, TravelMed USA.)

Such beliefs follows a longstanding board pattern, sources said.

"[Nurses] are prohibited from reporting or fifty-fifty raising concerns and, in besides many instances, are intimidated and even fired for raising concerns. In retaliation, they are often over scrutinized [sic] and blamed for some problem and reported to the Board of Nursing," Lockhart, the nurse consultant, wrote in a January 2014 alphabetic character to the lath. "When nurses are wrongfully terminated they oft cannot find employment in other facilities shut by, and their nursing careers come to an cease."

In full general, state boards tend to over-bailiwick because "boards of nursing, especially in Texas, are so terrified of making a error" and letting a guilty nurse off, Lockhart told MedPage Today. "They don't take bad intentions."

"The issues are structurally how this nursing board functions," Weitz said. A review is "simply such an arduous procedure."

Weitz has represented nurses in some cases that had been open for and then long, "information technology's like the staff attorney has never seen the file because they probably haven't looked at it in a year."

Weitz has an ongoing example in which a nurse is accused of a medication error involving a male patient. A lath witness had not worked on men in 25 years and did non know anything about the patient's procedure.

Physicians are normally affluent enough to resist strongly when accused of wrongdoing. Many nurses, however, "don't have the financial wherewithal to fight the kind of fight that a doctor tin can."

"Once you get in the system, it sucks," he added. "It breaks my heart sometimes because a lot of women I get accept never had a complaint."

Agape to Practice Nursing

Johnston, the Texas board's general counsel, denied that the board acts aggressively or overzealously. "I would not be surprised if there are cases when we accept over 12,000 matters being investigated that these attorneys wouldn't be complimentary of how their detail case is being handled," he said. "But I'm satisfied with our efficiencies, but we are always working on that; it'southward something we need to meliorate."

A recent 5% state-mandated upkeep cut means the board cannot add any staff, Johnston said, although it has been permitted to fill up a few open up investigative positions.

Johnston likewise denied the allegation that the board doesn't provide due process: "The lath is required to follow the due process provisions outlined in the Texas Administrative Procedures Act ... and in the Texas Nursing Practice Deed."

The Texas board is "one of the near respected" nationally, NCSBN'south Alexander said, with a "highly regarded" staff.

Nursing advocates feel differently, and not just nearly the Texas lath.

While the NCSBN publicly catalogues violations on a national database called Nursys, Alexander confirmed that no national guidelines exist concerning discipline. "Information technology would be too difficult," she said. "At that place are a number of different reasons why a nurse tin exist disciplined."

The NCSBN has not weighed in on how its own members could handle issues during the pandemic, including nurse discipline, other than recommending they let previously disciplined nurses to temporarily render to work.

Investigators are also motivated to at least sometimes build cases finding nurses at fault, Paradisis and others said, to demonstrate they are doing their jobs.

Paradisis noted that the boards are non conducting enquiry on administrative intimidation of healthcare workers, particularly during the pandemic.

Nor does the NCSBN study the effectiveness of nurse discipline. MedPage Today institute little research on the topic, salvage for a 2019 review that concluded, "More systematic research is needed, together with clear definitions of disciplinary procedures."

"It's a topic that people don't want to accept on," said Paradisis, who spent most of her 20-yr nursing career in direction. "These are giants in our order. These are unabridged institutional structures and they are not going abroad."

Nelson said that because of nursing boards' behavior, "nurses operate in a culture of fear."

Said Lockhart: "Nurses tin can't be afraid of practicing nursing, which is what's going on now."

• 

  Ryan Basen reports for MedPage's enterprise & investigative team. He oft writes about issues apropos the practice and business of medicine, nurses, cannabis and psychedelic medicine, and sports medicine. Send story tips to r.basen@medpagetoday.com.

What Are The Reasons Registered Nurses Can Be Disiplined,

Source: https://www.medpagetoday.com/special-reports/exclusives/91322

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