Elizabeth R. Plumer, PhD, JD, is a biochemist and intellectual property attorney. She lives in Saco, ME.
When an MRI revealed that my four-year-old daughter’s brain cancer had returned, I took the only action possible: I bought a dog. I scoured the Sunday papers and found just the puppy I was looking for, a Rottweiler. No deep psychological analysis was necessary to decipher my choice. I wanted a dog to protect my daughter from external threats, even if it could not protect her from the one threat that mattered most.
We named our puppy, Maggie, after Rod Stewart’s Maggie May, because from the moment she entered our lives, she stole our hearts. Maggie whimpered through that first night until I fell asleep on the couch with her gently snoring on my chest.
It was like having a newborn in the house again, and just as I had filled photo albums of my daughters, I took pictures of Maggie and my girls together. In one, taken the first summer we had her, Maggie lies in the shade beneath the swing set as if on sentry duty for my four-year-old and her seven-year-old sister. My girls hold steady on their swings and smile into the camera. The younger one wears one of my husband’s T-shirts over her bathing suit and sports a pixie haircut, the short hair a legacy of her recent surgery and radiation treatments. In my mind, the still photograph morphs into action as my daughters jump off their swings and pounce on Maggie, who luxuriates in the attention and rolls over to request a belly rub.
My younger daughter was 18 months old when she was first diagnosed with brain cancer. Her tumor was an astrocytoma, named for the star-shaped cells from which it had originated. Her tumor was benign, a meaningless term since benign brain tumors can be just as deadly as malignant ones, if left untreated. The location of my daughter’s tumor made it impossible to completely excise without risking paralysis. Radiation treatments were not recommended for children under six because of their harmful effects on a child’s developing brain. The surgeon removed as much of the tumor as possible. The rest was left behind until a second operation became inevitable.
When my daughter turned four, an MRI showed that the tumor had increased in size, she underwent a second operation to reduce the mass as much as possible. This was followed by daily radiation therapy for eight weeks. The doctors gave my daughter a one in three chance of surviving five years.
A Rottweiler’s life expectancy is 10 to 13 years. I didn’t need a statistics course to understand that Maggie likely would outlive my younger daughter. Rottweilers are pack animals by nature, and Maggie treated my daughters as if they were her own. She ran along the inside perimeter of our fence and intimidated strangers who dared to approach her territory and threaten her family.
At 105 pounds, Maggie frightened strangers, but she was only ever loving to us. As she aged, her joints stiffened and she struggled to patrol our yard. Her symptoms of hip dysplasia, an inherited degenerative joint disorder, grew worse. At 10, her hind legs failed her and her brown eyes begged me to end her discomfort.
The girls stayed home on the day I brought Maggie to the vet for the last time. I cradled her head in my hands as he injected the overdose of anesthetic into a vein in her neck. I thanked her for having protected us. My daughters and I buried Maggie’s ashes next to the fence where she used to run back and forth. I planted a rose of Sharon bush nearby, and one year after her death, the bush blossomed for the first time.
In the years following Maggie’s death, my younger daughter struggled through public school. Her teachers taught her strategies to cope with the learning disabilities left behind by the radiation. She wrote notes to remind herself of assignments and created to do lists to organize her daily life. It was difficult for her to fit in socially. Other students spoke at too rapid a pace, often leaving my daughter behind as conversations moved forward. But when the time came, my daughter decided to apply to college, and when she was accepted, she left home to live on campus. Her medical history became invisible.
My daughter continues to meet annually with her medical team. Although many have moved on to other hospitals, a few original team members remain. Their joy in seeing her each year is palpable. A doctor once told me that having a patient who overcomes the odds is like experiencing the earth tilt.
My daughter’s petite appearance and soft-spoken nature belie her seismic abilities. She is the tilter of worlds, the shifter of galaxies. The one in three who nourishes hope.
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Sign in nowA hospital in the U.S. can pursue this form of accreditation. It requires a fairly rigorous process of assessing and improving nursing care. It is one useful way of looking at hospital quality, but it doesn’t mean that every good hospital has Magnet status, nor that every hospital with Magnet status is good in all respects. For more information, here’s a website: http://www.nursecredentialing.org/Magnet.aspx
My current hospital is not a magnet hospital (though we are working on attaining magnet status), but we do act as the large medical teaching center you described. We have great managers and leaders that follow up and hold each individual accountable for their actions.
The noise control though, I’m just not sure how to control. That is definitely one of our patients’ biggest complaints, but some of it is completely out of control.
I also agree with this great article.
To add the the confusion and messy degree/certification overlap in the nursing industry is the existence of the LVN nurse.
Vocational nursing is lumped together invariably with LPN nurses, however LVNs can only practice in California and Texas, and they can only get “tainted” RN certifications.
They are all too often washed into LPN but vastly different in a lot of respects !
Thank you for suggesting the separation of vocations. I find myself in a bit of a dilemma. I am a nurse, and I am a student who happens to be writing a lot, and I am trying to develop into a “nurse writer” for future vocations. Hmmm. I’m a nurse, writer, educator and student. Nurses are not traditionally trained to write for publication, but for any nurse interested in speaking to other nurses and sharing information, knowledge and experience beyond the conventional classroom, then the environment best to support this is as “nurse writer”.
Thanks for affirming my discomfort in a similar setting. The healthcare people around me have discounted this as an issue, which leaves me feeling alone. I try to listen intensively, and act like a beginner – which I am.
The decision to go back to school can be both exhilarating and terrifying. Deciding whether to stay at a local college, move to attend a school across town, across the state, or even Cross the county, or opt for a distance learning program can be one of life’s most daunting, and rewarding, choices.
Thank you for your sharing, Marcy. You have experienced great in-depth “vision” on human care. It was great in ICU. It was great at the clinic. Your heart is great!
I thought that just your experience at the clinic raised you up – all your psycho-spiritual and biophysical senses and power (not only “vision”) emerged up and grew to form “you” as “you” then. Often, “poor situation” extracts “the best of human”.
Nursn iz a noble professn
The summer before my daughter entered high school, she told me she had to go to the doctor for asthma medicine. I was dumbfounded: She did not have asthma, and had never been on asthma medicine. She explained to me that she needed medicine for physical exercise, that in high school she had to meet a minimum standard, and in jr high, she just had to do her best, and she could stop when she got winded. So I took her to the doctor, a test was done, she did indeed have ‘exercise-induced asthma’, and received her medicine. I said, but Sarah, you bike all over town. She said, Mom, I stop when I get tired! (Duh!). And there was this vague memory of a camp nurse, saying to me, as Sarah was running, ‘she has asthma’, and me ignoring her, because I did not hear it. In my defense, at that time I was a Rehab nurse, with no experience with children other than my own, and had never ‘heard’ asthma, except for the tapes in nursing school, and she didn’t sound like that, and didn’t seem short of breath. After high school, I asked her if she was going to keep taking the medicine, she said no, she just will stop when she gets tired. And she kept biking all over town.
Beautiful, heart-warming story, thank you for sharing. many blessings upon your daughter.
Awesome! Thank you so much for sharing your story.
Thank you for sharing this story. I am the mother of a severely impaired man with autism. I was encouraged to give up on him at age 4, to put him away and forget about him. He hasn’t been able to live at home for the lasst 20 years, but he is always in my heart even when I can’t spend time with him. May you have a lifetime of memories of your daughter!
I try to always use them if the drug infusing is available. I consider it a third check on cardiac meds and pressors and makes me feel just a little safer. however, when I find a mistake it scares me even more.
Im trying to remember the goal of the Arkansas sbn. “Protect the public and act as their advocate by effectively regulating the practice of nursing.” That doesnt mean protect nurses to me and it has always given me pause. I have never felt the asbn would be there if I were in a situation such as this. I have been close and had to make the best decision I could, then just ‘white knuckle’ through the fallout afterwards. So far I have survived. I do put money in savings, In case my luck runs out.
I think this answer, i.e. “we must wait for facts through a formal adjudication process” is pretty much a dodge and an evasion. Either Trujillo is cleared of any misconduct, in which case, hey no problem, or is found guilty of misconduct, which, from your point of view, would settle the matter. Either outcome means both the ANA and the AzNA have to do, well, nothing.
In the meantime, who advocates for nurses? Not only Trujillo, but the many other nurses who are victimized by their employers?
What has been an eye-opener in all of this has been the utter failure of nursing’s formal leadership to advocate for front line nurses. By taking a position of “neutrality” the ANA and AzNA effectively support managerial/corporate abuse of front line nurses — and front line nurses are left to wonder who really supports *them*.
To say this is disillusioning would be an understatement.
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I am so glad to see that AJN is following this story. We do need the facts but we need the support so much more. Support for nurses through our trials from a reputable organization like AJN will set the tone that we do care about each other and our profession. Physicians do it all the time. It’s long overdue that nurses do the same.
Incidentally, this blog had no compunction about “getting all the facts” and “both sides of the story” before the Winkler County nurses trial concluded. I think the blog pretty encouraged readers to contribute to their legal defence fund.
I could engage in some snark about the difference being these nurses were managers, but you see the point.
We did get the facts in the Winkler case – and that was vastly different, as it was CRIMINAL charges brought against nurses after they were exonerated by the Texas Board of Nursing. (The Texas Medical Board also supported them.)
Well stated, Shawn.
Remember: in the case of the Winkler County nurses, the TNA became involved because the two nurses were criminally indicted for misuse of patient information, not because they were fired. Neither were the licenses of either nurses called into question before the Texas BON. The internet uproar surrounding this case supported Texas’ Whistle Blower Laws, and defense of colleagues wrongfully charged with felony within the court system. Their licenses, albeit their livelihoods, were not in question.
State Boards of Nursing may not be perfect, but they are the established method of self-regulation in nursing.
I am following the case of our colleague, Amanda Trujillo. Unanswered questions lead me to keep my opinion to myself for the time being. Until more information is available, my support of Amanda Trujillo is silence.
True we don’t know all the facts in this case; but to me this situation sounds plausible at the least. I agree that a lot of healthcare professionals are afraid to speak out and speak up about the grey areas they are asked to step lightly over in their daily duties because they don’t want to lose their jobs, upset their co-workers with more power, or irritate administration. Let’s be honest, hospitals are a business and doctors are pressured to perform one procedure after another. Unless a physician, nurse, administrator has a strong conscience it’s easy to become bogged down by the bottom line of business and money-making in a hospital. And not every employee even realizes when this is happening, which is not an excuse to let it persist.
This story can serve as some encouragement for healthcare professionals to look around in their place of work and see if they agree with the ethics of what takes place from day to day. Yes, you can lose your job when you speak up. That is an absolute reality. But I hope when the time comes I will understand that it is more important to live by my values and ethics as an advocate for patients and communities then to please the business people that run the hospital. Would the civil rights movement have happened if Rosa Parks just did what the people in charge asked her to do? This is truly where we are right now. As we all know, these are people’s precious last moments on earth we are dealing with – not just a number on a fee slip.
I hope the facts about Ms. Trujillo’s case can come out. I hope she has a good lawyer who cares about justice and can therefore participate in a fair match against the powerful lawyers employed by the hospital or what-have-you. But I can definitely say that most people I see in a hospital are more afraid of losing their jobs then dealing with the ethical slips that occur daily, so they don’t say anything.
There are so many ways in which healthcare needs to change in this country. Let’s all be agents of change and work to make it a better place to work, a place in which we would be proud for our families and loved ones to be cared for. For example, would you want your mother cared for at a hospital where one nurse is in charge of 10 sick patients on a tele floor? How about working at a hospital where the radiology receptionist is being asked by his manager to help transfer an obese patient onto an MRI table? Does that sound right? Wake up! This is happening people! Little exceptions often slowly or quickly lead to big breaches of ethics.
From the rural community hospitals, to all county hospitals, to all private hospitals and more, we have a responsibility to our communities to improve delivery of care in spite of the powers that be. We can do it and it needs to be done.
I agree with Mare, RN……All I know is that whatever I do to another human being on this earth will be be remembered by those who DO MATTER in the end and because of this belief I will NEVER be afraid to speak up for what is right and what my patient wants!!!
Shawn,
Thanks so much for writing about Amanda’s case! It’s pretty clear where I stand on the matter. I am in contact with Amanda daily.
In 34 years, I’ve never seen anything like this. Maybe I’ve just been lucky, but what they want you to do in a case like this is shut up and stay isolated.
When you speak out or garner support, it is seen as retaliatory behavior and psych evals are requested (that is the reason Amanda was given for the eval).
It’s like something from the Twilight Zone.
All because a patient received information. If the patient had received the information and said, “Hey, thanks, you know, I’m am so glad I am getting this procedure, thanks!”, none of this would be happening.
Scary.
@Shawn: I’m not sure the difference here is as great as you make is out to be, and I would urge you to read carefully the original documentation at http://vdutton.posterous.com/94287821 or the voluminous amount of commentary and other materials here: http://www.nursefriendly.com/amanda/ . You are correct that the Winkler County nurses were cleared in their state BON proceedings. But still, they faced legal proceedings with consequences potentially far worse, i.e. a criminal record, prison term *and* subsequent loss of licence because of a criminal record record. This blog did not wait till all the prosecution’s evidence came out before making a judgement about the veracity about the prosecution’s case. True, they were innocent until proven guilty, but why does that make me think the attitude of ANA and AzNA is Trujillo is guilty until proven innocent. I’m a bit puzzled by this, frankly.
@JParadisiRN I admire you a lot, but I think you are wrong. I’m disturbed and disappointed, in fact, that your first response, when hearing of a fellow nurse in trouble, that your only response is “silence.”
We also here at NursesNetwork.com would like to join your blogroll. We post at least 1-2x/week, mostly about nursing education, “in-the-trenches” type articles, and how to improve our overall practice.
Thanks!
@torontoemerg, our admiration is mutual. I applaud your passion. In clarification, silence is not my ONLY response to a nurse in trouble. In this case, however, I feel it is my best response.
My hope, like yours, is for a favorable outcome for Amanda.
Getting all the facts is very important, but so is promoting nursing and supporting nurses. AJN, ANA, and the AZ State Nurses Association should be using this opportunity to educate the public about the important role nurses have in patient education and patient advocacy. In addition, they could use this crisis to help understand how not allowing nurses to practice to the fullest scope of their education and licensure impacts health care. The future of nursing is too important to stay neutral and sit it out on the sidelines. I call on AJN, ANA and all state nurses associations to use this situation to educate the public and inform opinion leaders..
@JParadisiRN Thanks, I really appreciate it, and the clarification.
This case concerns me on so many levels that I am unsure which one is the priority. I am confident though one of the main messages this situation sends is that nurses should not do the right thing by the patient (patient advocacy and education)and jeopardize their own moral integrity and character out of fear of retaliation and punishment. In addition, nurses are continuously put into positions where inadequate ‘informed’ consent or factual information was provided hence nurses are left to clarify and educate the patient on alternatives, risks, etc. in effort to provide patient centered care and allow the patient to share in the decision making. It is a perilous situation for a bedside nurse as they are not the revenue generators and are not seen as customers. I am also concerned as others have stated that there is no professional support system for her or another nurses. I too can’t help but feel my state board of nursing would do the same thing leaving me to rally my own support; it does not seem just.
This does not say much for the Arizona Board of Nursing and puts them in a very bad light. If any inappropriate coercion was involved surely this should immediately become a criminal proceeding and not a matter for a state board. I am therefore assuming that the patient in this case was a decision making adult and once they had made a decision, that should be the end of it. If the medic involved was unable to convince the patient thereafter about the efficacy of the procedure, that is a matter for his/her own knowledge base and communication skills. Ultimately I fear it comes down to a matter of ego. The Board does it’s reputation no good when it calls for a psychological evaluation of the nurse, whilst at the same time saying she is still fit to continue practice. If they cannot see the glaring flaw in this logic and what that says about their own decision making ability, I can only pity the poor populace of that particular state regarding the quality of their healthcare.
This is pretty scary–I do believe that the more the public realizes the important role the professional nurse holds as a patient rights advocate the more the public will insist that nurses be protected in that advocacy role. For that reason I like that this case has been made public.
Like it or not a conflict of interest exists in our country in the md/pt relationship and patients don’t seem to make that connection–I mean the person advising you to have that procedure is the person benefiting the most financially from you having said procedure. Mds & hospitals don’t like it when nurses interfere with the revenue stream. So unsettling that the Az Nursing Association isn’t supporting her.
I’m curious–Ms Trujillo appears to be a nurse practitioner with MSN and Doctorate of Nursing Science. Was she working in an RN or NP role at the time of this incident? Not that it really should matter, as an RN I call case management in for help all the time, Mds should never be allowed to keep information from a patient…where is the medical board in all of this? Where is the MD psych eval?
Make a difference with this case: we can influence the outcome. Its easy to join and participate, you don’t even need to leave home. Details:
wp.me/s278fi-178
LET BANNER HEAR US ROAR!
Join now!
Thank you for highlighting Amanda’s cause.
This is much bigger than just this once case with Amanda.
This is about nurses being able to advocate for their patients without fear of retaliation and losing their livelihood. Cultures in healthcare need to change. This is especially true in hospitals who will act on a tantruming physician’s request to fire a nurse for providing education.
As a graduate in Philosophy (BA) , I think Have some minor ability to assess limited data for patterns. The pattern here does not add up particularly well at face value – hence suspicions of various forms of foul play become much more reasonable than they might otherwise. To say we must hold all opinions until given all the facts by parties apt never to be fully able or willing to do so, seems self-serving and circular to the point of absurdity. We are to simply trust our corporate and regulatory authorities, as they act in secrecy? Given American and other history, the track record of blind trust for secret decision-making is rather dismal . I argue that the reasonable course in such unusual circumstances is to think like a detective with limited data: look for means and motives, and make working assumptions on which to proceed. Such pervasive conflicts of interest as seen in any corporate hospital ( primary responsibility to stock holders , not employees or customers) and in health care regulation (part of the political process currently so heavily influenced by money), coupled with such unusual known facts, render dire suspicions sadly reasonable.
Alzheimer’s Disease is as cruel as life gets. My mother know longer remembers me, wears clothes she would have quickly donated to the poor years ago, cannot eat without someone feeding her, no longer talks. I travel 350 miles each way every 6 weeks to see her for an hour and wish that things were different. God bless the health care providers that work in dementia facilities for the jobs they willingly and cheerfully due daily.
Mare,RN
I appreciate your insightful look back at Rosa Parks in regard to her individual rights as well as what her bold stand did for Equal Rights. One Black Woman- who just had a strong conviction- and stood against a “system” that no one else- as one person- such as Amanda Trujillo- was willing to do.
I am a #patient, a cancer survivor- twice. I would not have done as well, nor maybe even still be here were it not for so many dedicated and skilled nurses. I have been hospitalized many times and never realized that nurses had to deal with such pressure.
I am an outspoken #nurse advocate, and also advocate of doctors of conscience. I’ve had very doctors who at their core are simply put, just good people. Period.
If you as nurses stood with the nurses in the ate as case, why not now? And those of you “waiting on the “facts”, how do you know you will ever know them? Without you coming together as one body, you are all in danger of it happening to you. Quote; ”
A house divided against itself will fall.” Matthew 12:25
Bottom-line: If you band together now and fight to make sure the already established rule of law for nurses are kept, you will certainly not fail as individuals or as groups.
I wish a good and just defense for Amanda TrujilloRN. The original legal statement @innovativenurse, as well as many blogs state that she was advocating for a sick person, a #patient. What of it had been you? I can tell you she has many more for her than against her.
I wish all #nurses a good and decent place to work. You have my deepest respect.
Hey Greg, I agree with you about the secrecy in this whole situation, it does make you wonder. One thing I want to mention here is that this is not an unusual case in nursing. Bedside nurses are subjected to mistreatment and bullying on a regular basis. Which is why, although the story here is sad and Amanda needs our support, the issue is much bigger. It is an issue of how bedside nurses are often at the bottom of the rung and the importance of truly having a collaborative model of health care across the board. A model in which all healthcare providers are partners and work for one and one cause only, the well-being of the patient according to what the patient believes is important to them. This includes through education of the patients by physicians and the nursing staff about the treatment being proposed, its consequences, good or bad, and all the alternatives available. The key is of course a true collaborative process that puts patient at the center of the care. We have talked about such models of care for decades, they look really good on paper. Now is the time to use these models to transform healthcare from money centered to patient centered.
For me the central issue is clear – to achieve our full potential and make the greatest, most positive contribution to patient care possible, we need to adjust the relationship between Nurses and other providers, especially Physicians. More collaboration and teamwork, however, will not happen, until we unite sufficiently around effective strategies to make it so. History proves: no group in a position of power and prestige ever cedes either to anyone else, until it decides such is in its best interest or has no choice. Nurses will never improve our situation by merely discussing amongst ourselves how things should be. We will have to raise our voice in unison and demand what is right. Will we make things better, or merely regret that it hasn’t happened?
Why Nurses are Furious about the Amanda Trujillo Case
http://torontoemerg.wordpress.com/2012/02/07/why-nurses-are-furious-about-the-amanda-trujillo-case/
Magnet designation does not equal professional accountability or compassionate care by staff. I believe it is the responsibility of each individual nurse to deliver care to his/her own highest standard.
Amanda Trujillo – Emergency Physicians Monthly
http://www.epmonthly.com/whitecoat/2012/02/amanda-trujillo/
Thanks for covering this story.
An observation concerning potential conflict with the Arizona Nurses Association- it appears it is the president who is an administrator at the same hospital. The person who was interviewed was the Executive Director works full time for AzNA, according to their website.
Teri Wicker
President, Arizona Nurses Association
Director of Professional Practice Banner Del E. Webb
https://m360.aznurse.org/GroupDetail.aspx?id=50755
Conflicts of interest in health care have become so common as to be customary and expected in many contexts, unfortunately. Regardless of intentions, good or bad, COIs cause corruption that erodes care quality and increases the bloat and waste so rife in our system.
I appreciate this information – had been unable to find it and had to move on to other priorities. Truly, it pays to network!
If interested, I offer some analysis and information including a plan to offer Amanda support and influence and increase the power of Nursing overall, at wp.me/s278fi-178 and other Posts on my blog, grchealthcareblog.com Amanda has recently learned of and approved this plan, although we have not involved her in it for her protection.
Excellent post. Unfortunately, I understand completely as my grandmother has advanced-stage Alzheimer’s. After my great-grandmother and now my grandmother, my mother is terrified her future (and ours) will be a repeat of the same cruel joke, one that we’ve already heard too many times.
All the best to you and yours.
Question is “Why are nurses furious with the Trujillo case?” One reason being is she stepped out of her scope of practice. Another reason is she didn’t advocate for the patient as best as she could as a nurse. And also, she tore apart the treatment plan that the healthcare team seems to have been working very hard on. She should have FIRST consulted with the attending, the surgeon, and other doctors on the case regarding the patient’s lack of confidence with the surgery or treatment plan. Due to the lack of details of the patient’s case, this “major invasive surgery,” as Trujillo quoted, could also have been life-changing for the patient! Liver transplants have a high success rate! Trujillo should have been a better patient advocate, become a good liaison to her team members and involve the physicians in the plan to question hospice. Trujillo should’ve called the surgeon right away BEFORE calling a hospice consult (which she had without an order) and inform the surgeon and simply say, “Hey Doc! This patient needs more information from you, can you come over and explain it to them?” Maybe the patient just needed reassurance from the surgeon or maybe not. Who knows the actual details, but don’t just rip apart the team’s plan of care without consulting anybody about it. You can’t just call case management and tell them the patient needs hospice without consulting the physician or without an order. This wasn’t her decision and it wasn’t her right to alter the plan of care behind the surgeons’ back…and this is what got her fired. Her nurse manager and hospital didn’t even support her. Why? Because she made a mistake. She enacted solely without discussing the issue with her team members. Her being fired could’ve been prevented if she had just stopped being so gung-ho with, “I’m an independent nurse who can make my own orders without the doctors’ knowledge” kind of attitude. Granted, she claims this is all about being there for her patient. It was nice that she acknowledged the patient’s concerns. However, her method of correcting the issue was wrong. So why are nurses so furious like I am about this case? Its making us look like we can’t critically think before we do something that can alter a patient’s life. I understand why the surgeon was so angry at Trujillo.
I feel bad for her. At all times, we juggle between being a patient advocate and following doctor’s orders. In this case, it seems like we couldn’t win doing both.
With all due respect to RN to MD, Amanda’s patient requested the consult. Repeat – the patient requested the consult. Also, this all occurred on the night shift. Amanda left full and complete documentation on the chart AND passed along to her day shift colleagues the full report on what had transpired during the night. She also conferred with her nurse manager prior to initiating any action on her shift.
You going to call a physician – ANY physician on the NIGHT SHIFT saying “Hey Doc, come on in, your patient has questions!”
Answer truthfully, we’re talking real life, here.
Clicking a button for a case management order for a consult that a patient requested does not constitute tearing apart a care plan. The patient was provided paper, pen and encouraged to write down any and all questions for her physician the next morning.
The only problem that occurred here was that the patient actually HAD questions and wanted something different than the physician did.
Even the nurse investigator was impressed at the amount of documentation done by Amanda on the case.
So I’m sticking with the RN on this one.
MD makes big ruckus and the nurses run for cover and don’t stick up for the one nurse who isn’t there to defend herself. He calls for her license, and Banner Health capitulates. Arizona BoN takes this WAY beyond where it needs to go.
Just my humble opinion.
With limited data, it’s not surprising that folks have come to a diverse set of opinions, reflecting individual priorities, assumptions, values, and experiences. Different parties to these debates are also likely to have little information as to what preparation others bring to the table. Personally, I spent nearly as much work studying the situation before I ever mentioned it on line, a deliberate approach that prevented any comnent on the Komen episode until the latest chapter had already come to a conclusion. Others have likely been more decisive, and also better skilled with thes tools to gather relevant data quicker than newbie Greg. I’d suggest not attacking others by assuming poor preparation or judgement or character on no more basis than a different interpretation of a complex situation than your own. Instead, we should look at available facts, relevant context, and the validity of others’ reasoning. Its a common but serious mistake to judge critical reasoning skills on nothing more than the final output. For me, passion for this case derives not from certainty re all the facts or any sense that Amands is perfect (no one is, right?). Instead, I see the response to her actions that night, regardles of interpretation, as grossly out of proportion to the facts all seem to agree on. We all err in judgement, especially if we push ourselves to do the most good possible – often work environments contribute to such errors w overwork, inefficiency, and distraction that are generally ignored in favor of individual blame. And in many difficult clinical situations, reasonable conscientious professionals can often disagree how to proceed. And a well-intentioned attempt to educate a pt and respect their wishes on a very serious crossroads with very high stakes and no turning back later with a choice like surgery, should not lead to termination in my opinion. That is a private business decision, of course, and if that were the only consequence I might never have become involved, but seeking loss of licensure is far more serious, and a public matter and open to public review, as are most all aspects of democratic governance. Involving AZBON when termination effectively ended Amanda’s involvement with Banner’s clinical operations strikes me more as a vendetta than any measured response. Letting an unemployed RNs license hang in limbo for a year, while taking inflammatory actions like the Psych evaluation we’ve discussed, also seems unreasonable and perhaps punitive. Conflicts of interest between AZBON and Banner are troublesome regardless of other facts, and inherently lessen the credibility of the process. You simply don’t have to assume you know all the facts on the ground to find this case worthy of attention.
It would be a delight if you could add a category for retired nurses. Most of us worked in nursing (and were active in ANA and had subscribed to AJN) for around 40 years. AJN’s blogroll could help get us and keep us together and share ideas about life after nursing.
Please check out my blog, Lois Roelofs, at lroelofs.wordpress.com A new blog just starting up by retired nurse practitioner Marianna Crane is nursingstories.org.
Also, I think it could be helpful to current nurses to read about our lives after nursing–memories and perspectives of nurses that have become a part of our being. Thanks for your consideration. Lois Roelofs
Lois, your suggestions are appreciated. The category of retired nurses does seem important, and underrepresented. Jacob
Thanks for keeping me!
Lois:
Great blog! I put you on my blogroll.
I hope more retired nurses blog about their experience. They are truly valuable to those of us who still have to practice many more years!
RehabRN
I write a blog for an online nursing education website and would like to have it included on your rolls. It can be found at http://www.rncentral.com/blog/
I have been a nurse for over 10 years and writing “Notes from the Nurses’ Station” for almost a year now. It is great fun; I have learned a lot and it has been a great opportunity to look into any area or topic of nursing that catches my eye.
We have talked about everything from pre-reqs to get into nursing school, basic nursing academics, current events and just finished a whole week on nursing, death and dying that was well received. Thank you for your consideration.
Jennifer Olin, BSN, RN,
Jennifer,
Thanks for getting in touch. You have some very good articles but, due to our confict of interest policy, we tend to confine our blogroll to nursing blogs that are independent, rather than those that are subsidiary to such Web sites as those that focus on the promotion of particular products such as online nursing degrees.
Jacob
Thanks for keeping me on your list!
Stephen
Thanks, Jacob, for your supportive comments and Rehab RN for your interest. We retirees have informative, inspirational and often funny memories that could help today’s active nurses view the practice of nursing over time. As a former nursing professor, I’m always interested in teaching! Lois Roelofs
While we don’t focus solely on nursing, our blog focuses on staffing and scheduling issues specifically at hospitals, which greatly affects nurses. Please consider adding us! Thanks!
- Jackie Larson – Avantas
http://avantas.biz/healthcare-labor-management-blog/
I am a practicing RN,OCN for 28 years and have a nurse blog on WordPress which I would like to have included in your blog.
I am always interested in what other nurses are encountering in their field of practice.
http://onbeinganurse.wordpress.com/
Please keep me in your address list under rhjh1321@gmail.com
Thankyou!
I have a friend who is an RN and serving as a Peace Corp volunteer in Africa. She has shared her experience through letters and they are very inspiring.
Joyce, thanks for letting us know about your blog. We’ll keep an eye on it, and if it’s regularly updated we’ll consider including it. In general, we favor blogs that are updated at least every week or two weeks on average. -Jacob
Lois,
That’s an interesting idea. I’m not sure we have enough blogs by retired nurses to add a separate category, but we’ll see if one emerges over time. For now, we’ll add your blog to our blogroll. It looks like it’s updated fairly regularly, and at least a good percentage of the posts have to do with nursing…two crucial criteria. Best wishes.
Jacob
What’s Missing in the Amanda Trujillo Story? by @jm_healy
http://nursingnotes.posterous.com/whats-missing-in-the-amanda-trujillo-story
Thank you, Jacob. As a former nursing prof–who loves to educate forever, I appreciate your lisitng my blog at loisroelofs.com in AJN’s Blogroll and supporting access to a retired nurse’s voice. It is always fun for me, also, to read the posts of nurses currently in the workforce.
I do wonder how many of us retirees are out here blogging. Maybe not many. No one from my diploma Class of 1962–a few don’t even have computers yet, so I guess that tells you something about our age group. But I don’t know of others either from my bachelor’s, master’s, or PhD classes.
Thanks again, Lois Roelofs
Jacob,
Thank you for adding my new blog to your “Blogs and Sites (by and for) Nurses.”
And thanks to my fellow nurse friend, Lois Roelofs, who suggested my site: nursingstories.org.
Like Lois I am a retired nurse who believes we nurses have to tell our stories. I started my blog to encourage nurses, both in practice and retired to get those stories out. Stories about our practice, our patients, our contributions to the health care in general.
Thank you,
Marianna
[...] by the case of Amanda Trujillo, and as stated in the American Journal of Nursing‘s blog (Off the Charts), at the heart of the controversy sits informed consent: “…she was fired for, as she [...]
[...] Bullying Wars: Theresa Brown vs. ‘the entire physician profession’ « Off the Charts. [...]
Dear Ms. Kennedy
I have been staying off the blogs–except for maybe 2–and I hadnt seen yours or was aware that there was a quote I apparently made about why I was fired from Banner Health. VDuttons Posterous page was the first to post my story and I reviewed it, I dont see anywhere that I made a statement indicating that I obtained informed consent and was fired for that. When i do learning assessments i ask the patient about their medications, their current illness or why they are there, we go over teaching materials if they have them in the room, and if they are to be transferred out I ask them to verbalize to me their understanding of where they are going and why. this is how i stumbled on the fact the patient thought they were going to be zipped on over to another hospital for an organ and sent right back home to start their life all over again. no consenting was involved in any way shape or form. the concern was that the patient didnt appear to have had the information needed to consent to participation and transfer, which is what i informed my management of. Incidentally—during morning report i had relayed to the next nurse that the doc needed to be paged asap before morning rounds because of the urgent nature of the patients questions, and during my teaching the patient was provided paper, pens, and highlighters and was instructed by me to write down any and all questions for the doctor to answer the next day after we reviewed the materials. If I had indeed performed informed consent I would have been swiftly disciplined by now. The nurse investigator said my charting was thorough, my nursing diagnoses and interventions were very well documented and the only thing she disagreed with was placing the case management consult for the patient because her understanding is that a patient has to have less than six months to live in order to even see hospice—I respectfully disagreed and pointed her to information that specifies a patient can self refer, as a family member to refer, or the nurse or doctor– to see hospice for teaching and getting questions or concerns answered. Where physician involvement is needed is when the the patient and team have established that the patient is to enter into hospice care. that is when the certification of a life expectancy of six months or less has to be made by the doctor. no hospice company was called in by me nor did i talk to any hospice staff. i clicked a case management consult for hospice teaching and placed a note next to it that the patient was requesting that be done on her behalf and passed on all crucial info via SBAR to the morning nurse emphasizing a page needed to be put out as soon as possible. I thought I should clear that up, because, I dont see my function as a nurse as one that involves obtaining informed consent. It isnt my job to talk the jargon about how the operation is done or its risks or benefits. I view my job as making sure the patient can tell me what is going to happen to them, why its going to happen to them, and how whats going to happen them will affect their health/self care regimen after it happens….I hope this clears up any misconceptions…..Ive asked the team of RN supporters to go back through their blog posts to make sure they have not stated anywhere that I was fired for obtaining informed consent to prevent this misunderstanding by others in the future…….I found my copy of what was mailed to me at the beginning of all this telling me exactly what the complaint was on my license–my support team is meeting about that to decide how to release that so nurses can view it themselves. There are no limitations on that document prohibiting me from sharing it with my nurse colleagues.
Amanda, thanks for the response. We will look again at the language we used, in light of what you say here, and make changes as they seem necessary.–Jacob
[...] against a society that saw us as dolls or cartoon characters with biologically limited abilities.Nursing rebels against the depiction of nurses as angels, bitches, and handmaidens (excellent post by Barbara Glickstein, MPH, MS, RN for Off the Charts). Accepting these [...]
It saddens me to read that others are experiencing the same emotions as me……………but I smiled all the way through, yeah! That is just like my mom….group hug !!
Beautiful story about your daughter… and her special dog. Dogs can add so much to our lives – they give love, comfort, security, and yes, safety. Bless you for choosing Maggie, and for nurturing your daughter to the point that she is truly “the tilter of worlds, the shifter of galaxies. The one in three who nourishes hope.”
My mother, too, has severe AD. She is completely dependent on her caregivers in the nursing home where she lives. She does not know her nine children and only occasionally recognizes her husband of 63 years. She tells stories that none of us can understand, aside from the occasional isolated word. She neither anticipates or remembers our visits with her. And as heartbreaking as the situation is, it is still possible to see her enjoying the moment. Her stories bring laughter to her face. Music is pleasurable. Holding hands is always nice for both of us. We find good where we can, but like one of the other commenters, my siblings and I live in fear of what lies ahead for us. Our mother’s three siblings died of AD, as did her mother. Dare we hope to escape the same fate?
[...] Blogroll Housecleaning Note (ajnoffthecharts.com) [...]
I used the term ‘informed consent’ , as a description of what you did: when you realized that the patient did not really understand the situation, you provided the necessary information so the patient was truly informed about what was ahead. Is that not so? .I didn’t mean it in the sense of getting a consent from a patient for a procedure and I think that’s clear in a sentence that follows later, “She makes a compelling case that she was advocating for the patient’s right to information, and one wonders why she was fired and is under investigation.” I wish you good luck,
MY opinion :did If the case is straight up and down she only advocated for the patient, then she should be compensated for loss wages, etc.
I’d like to know what Ajn has done for this RN regarding the case?
The nursing schools in all states preach about being a patient advocate, but it seems any time you explain all options to the patient and family you are open to retaliation from the facility and the physician for lost money, if the patient chooses an alternate therapy. I believe the state boards of nursing should be protecting nurses and helping us provide informed consent.
Rhonda, RN
The idea that we need all the facts to have an opinion interests me. By that standard we’d be able to offer no opinions about much any clinical practice, as we certainly have more to learn. We’d have to defer to all corporate and regulatory authorities automatically – we can never know just what facts we have missed. We’d never be able to vote – need more facts.
And as it turns out, we have plenty of indisputef facts – a BON with multiple conflicts of interest and possibly many more – what I found were only the really obvious ones in open view. We know this case is unresolved after a year. We know a transplant makes a facility hundreds of thousands of dollars more than does Hospice, and we know every corporation answers to share holders on profits. I could go on, but what more do we need? We cannot avoid a decision – we support Amanda, or we do opposite, whether actively or by abstaining.
Thank you Shawn, I guess in my mind informed consent involves taking a paper into a room, and discussing specific surgical approaches, risks and benefits–I just wanted to touch bases and make sure you knew my definition of informed consent–because in my practice informed consent has always been the doctors job. I appreciate the candor and your quick response.
Informed consent, as I see it, is largely a legal concept, with the doc ultimately responsible. Education and knowledge assessment regarding all clinical matters lie fully within Nursing scope of practice, as well as a responsibility to address inadequate knowledge and advocate for the patient, even if it may require further work by the doc to verify and ensure informed consent. Consent is not the signature on the form, and is never ‘finished’ unless the patient continues to believe it so: at any point after providing consent, patients retain the right to revoke it at their discretion, whether secondary to Nurse education or otherwise, and in no way subject to any doc’s convenience or profesional opinion. Therefore assessment, education and advocacy in no way constitute informed consent, although they may well influence it. Nurses serve as important editorial role on physicians, who nevertheless retain final responsibility.
[...] prior post on the Amanda Trujillo case elicited many comments, on a variety of themes. There were also referrals and crosslinks to other sites supporting, [...]
[...] States Easing Up, Pediatricians Buckling Down on Childhood Immunizations (ajnoffthecharts.com) [...]
We are never justified in deceiving our patient.
When we alter the truth we take away our patient’s right to self-determination. No-one, least of all a nurse, should be considering such a thing.
Sadly, we also eliminate trust – there is no such thing as a healthy relationship of which trust is not a part.
This is a clear cut ethical decision point.
The only exception would be when our patient is altered. But even then we should request the physician’s assistance, it is not an ethical decision we make solely on our own, as the nurse.
If we have our patient’s best interests at heart, and a clear ethical education, it will make our decision making much easier!
If a person is confused to the point of being unable to make decisions about safety and the basic needs of life, common sense and compassion must prevail. That is also a case when a Living will would be helpful.
Yes, the article is focused mainly on cognitively impaired patients. We’ve added a note to the first paragraph to make that clear.–Jacob
I so totally disagree that I had to share this with you. I am a nurse. I am a writer. But more than that I am a nurse writer. What that tells the people who read my books is that most of what I say, though it may be a compilation of character and plot, it’s generally the truth. Because there are so many laws against nurses telling their truth, I write to help healing. To help take the reader into the deep recesses of hospitals where they are never allowed to go. I write to give my patients, all patients power. To educate, to share with them their choices. I am a nurse, I am a writer, and I’m a nurse writer when my writing is intended to take my readers to secret places, to classified areas of medicine, healthcare and the human psyche. I am not only a nurse, I am not only a writer, I am a nurse writer. And that is more than the sum of it’s parts.
Carol, Thanks for your comment. Here at AJN I think you can find those who think as you do, and maybe those who don’t as well. Seems a matter of self-definition as much as style! All the best, Jacob (Doug no longer works here in a full-time capacity, though he still helps us out sometimes)
Good article, and an interesting study. I would encourage everyone to take a look at it.
The study brings a number of factors to the forefront of the conversation about the nursing workplace. The study cites that 36% of nurses had planned to stay in their first job less than three years when they took it. When you look at the expense of filling a nursing position (1.3 times the salary according to this study, and more according to others), the cost of this preordained attitude of more than a third of nurses is staggering.
This makes me wonder about their motivations – are they seeking better opportunities or a more dynamic environment? Is it a simple case of the wrong person for the job, or are other factors such as a desire to avoid “unit politics” at the core?
For a hospital to function effectively it needs a number of different types of nurses: those who enjoy change, those who work best in a fast-paced environment, those who like routine, etc.
Among nurses who had already left their first job, the study states that 32% said their employer could not have done anything to prevent them from leaving. This is disturbing news, but news I don’t particularly buy. Very few people would leave a job that gave them a sense of fulfillment. Especially in healthcare, I truly believe people want to feel fulfilled from their work. We are in healthcare to help people. We can do a lot to foster environments that bring the best out of people – that empower them, and give them a sense of fulfillment. For some ideas to this point look here: http://bit.ly/wKkBpt
Thank you for this great post in honor of International Women’s Day. Globally, I’m witnessing more nurses taking their place and being their authentic intelligent competent selves with no apologies. They are confident and prepared as they challenge the status quo. Let’s all work together and keep pushing the “pre-fabricated’ glass ceiling (decorated with smoke and mirrors) until we reach equity in pay, positions of authority and power as women and health care professionals.
I often think of the Wizard of Oz when Dorothy and her pals finally get to meet the Wizard and Toto pulls back the curtain. Surprise! Not the all-powerful, all knowing giant they were afraid to face. Every time we pull back the curtain we allow the truth to be let out. When we practice fully being ourselves in all our roles in life no one gets hurt. As a matter of fact, everyone does better.
It is really unfortunate that we Americans do not have a health care system such as the one in Australia. I had the opportunity to talk to many Australians about their perceptions of their health care system. Their experiences dealing with their health care system always reflect satisfaction. Australians enjoy the benefits of a universal health care system founded by taxes. The Australian health care system covers all Australian residents despite of preexisting health conditions. I remember being speechless after hearing the story of an Australian man who needed heart surgery. He was air-lifted from his local hospital to a Sydney’s hospital where he had open heart surgery. This man had to pay nothing, since all the health care services he received were cover by the government. At the same time, telling Australians about how the American health care system works has left them with a feeling of disbelieve. They have told me how they cannot imagine how a country such as America can offer their people with such poor health care services.
The reality is that the American health care system needs to improve. It is hard to believe that a country America, a world power, has not yet implemented universal health care. Anyone could agree that universal health care is a viable option for America just by looking at the results from the universal health care implementation in European countries, Japan, and Australia. Many Americans are very hopeful about the upcoming health care reform. The health care reform offers Americans hope that, at last, they would not have to live with a constant fear of getting sick. I believe that we Americans need to support the implementation of the health care reform by letting our legislators that we want changes on our health care system. Americans need to become active participants on the implementation of the health care reform in order for it to become a reality. Much will not change if we just wait for changes and not become involved in making those changes happen.
You should have her look into the work done by Dr. Caldwell Esselstyn Jr. of the Cleavland Clinic. He has dedicated his life’s work to diet and heart disease.