January 29, 2012, 3:03 pm
I’ve been blogging for 6 1/2 years.
I have a twitter account and although I went to Facebook kicking and screaming, I’m firmly ensconced in the world of status updates, messages, and the occasional “poke.”
I never miss BlogWorld New Media Expo, and if I can make it to BlogHer, I will be at the party (can you say “swag”?)
You might say I’m into social media.
The best thing about social media? It enhances the ability of people to band together, to support causes, and each other.
This week, we’ve seen nurses band together online to support one of our own, fired and in danger of losing her license for acting as a patient advocate and providing patient education.
Patients use social media to band together with others who share the same challenges, to find support and encouragement.
They use the internet and social media to gather information; to be able to decide, in discussions with their healthcare provider, the best treatment to pursue.
The “patient” is you. And me. We are all patients.
Knowledge is power. Knowledge empowers a us to advocate for ourselves.
But what happens when you are sick, lying in a hospital bed with new information flying fast and furious, with no time (or access) to “look it up”. No time to find an “online support group”.
What if the quality of the rest of your life depends on the decision you make with the information you get, now.
Who advocates for you/us then?
The entire healthcare team advocates for you.
Nurses and physicians advocate for you.
They advocate for you by making sure you have all the information you need to make an informed decision on any plan of care.
They advocate for you by telling you all of the options open to you, including no treatment.
They advocate for you by making sure you understand all of the information and education provided.
They advocate for you by respecting the fact that you are able to advocate for yourself and respecting the decisions you make.
Doing all these things is the right thing to do.
It’s also the law.
When a nurse assesses that a patient does not have the information needed to make an informed decision about their care, either because they have not been informed, or because they did not understand the information provided, the nurse has a duty to:
a. provide the missing information, or the needed education and/or
b. refer the patient to the appropriate source of information
There is no choice.
It’s not a case of making a note and hoping the next shift deals with it.
It’s not a case of thinking, “oh well, they need this surgery/procedure anyway.”
The nurse is mandated by law, and obligated ethically to act if they discover a patient does not have the information they need to make an informed decision about their care.
Here’s the ethical principle in operation here, as defined by the American Nurses Association, who have a great website on nursing ethics:
Autonomy: agreement to respect another’s right to self-determine a course of action; support of independent decision making.
This is why the firing of Amanda Trujillo, RN, MSN, an experienced transplant RN, by Banner Del E. Webb Medical Center is so mind-boggling.
She was doing exactly what she was supposed to do as a registered nurse, for a patient with a knowledge deficit regarding an upcoming transplant.
For the record, to those who have written to say I don’t have both sides, Banner Health isn’t talking. They made a statement on their Facebook page to that effect.
I have written to the Arizona Board of Nursing for a copy of the original complaint, which should be public record.
I’ll post any response I get from them.
In the meantime, Amanda’s legal response to the original complaint, which answers the complaint point-by-point, can be found at vdutton’s posterous.
I encourage you to read the comments, as there is some interesting dialog there, as well
I am not militant.
I rant now and again, but I am very happy in my corner of the couch with my trusty old MacBookPro.
But I would take to the street for this.
I am that angry.
If I thought for one minute that there was more to this case, I’d be watching from the sidelines,too.
My gut tells me, there is not.
My nursing instinct tells me there is not.
My nursing instinct tells me that a hospital corporation got upset because a “rainmaker” (in the legal world, that means “moneymaker”) got angry at an RN, ergo, she must be punished.
Most hospitals just fire people, Banner Health reports them to the Arizona Board of Nurses.
God help the nurses at Banner Health, because I’d be watching my derriere 24/7 if I worked there.
Corporate healthcare at it’s finest.
January 28, 2012, 12:03 pm
(ADDENDUM, ADDED FEBRUARY 14, 2012 – When this post was written, I mistakenly thought the patient in question had a transplant operation pending. The patient was actually scheduled to be transferred the next day to begin pre-transplant testing. Surgery would have come at a later date.
I now understand that Amanda assessed that the patient had a deficit of transplant knowledge in general, and provided general transplant teaching concerning the evaluation process, the waiting process, and the care regimen. The patient changed their mind about undergoing the testing, and requested a hospice consult.
So, although the patient did not fully understand, and may not have been “informed” about what the entire transplant process required, surgery was not imminent, and “informed consent” for surgery was not the issue here.
I have a firm belief in not altering a post once it has been posted, and owning the mistakes/misunderstandings therein, so I have added this addendum for clarification.
The issues remain the same – a patient was uninformed about what was happening to them and needed education on their illness, a physician/hospital did not support/respect a patient’s decision/request for information, and a physician behaved in a disruptive fashion.
I apologize for the misunderstanding.)
Nurses and physicians share a collaborative relationship, working with the patient in a team effort.
That is how it is supposed to work.
As a nurse, my duty is solely to the patient.
If I am needed to be anyone’s “right hand”, it will be my patient.
I’m very lucky. I work with great docs who get it. I’ll write a post about that.
I’ve seen my share of the temper-tantrum throwing screamers, and I’ve been the recipient of their wrath three or four times in my career.
I should tell those stories; they happened long ago. I’ve kept them off the blog because of the emotions that come flooding back when I think about them.
I’ve been blogging on the Amanda Trujillo situation for a few days now, but lets move away from Amanda being fired by Banner Health and turned in to the Arizona Board of Nursing and look at this from a patient’s point of view.
As I see it, based on information that has been made public or is in the public record, three things occurred or nearly occurred (In hospital terminology, we call those “near-misses.”)
This should make everyone of us queasy.
1. A PATIENT WOULD HAVE HAD SURGERY WITHOUT INFORMED CONSENT.
A patient scheduled for surgery, in this case a major, life-altering surgery, did not know (a) the extent of the surgery, (b) the ramifications of the surgery – this being complex lifetime care, or (c) options other than surgery.
All of the above, along with the risks and benefits of the surgery, constitute “informed consent.” Before any surgery consent can be signed, all of the above must be addressed.
Before the discussion with the nurse, the patient did not know this information.
2. A PATIENT’S DECISION WAS NOT SUPPORTED BY THE MD, OR THE HOSPITAL
Granted, the surgery did not happen. But instead of supporting the patient’s decision as being the patient’s decision after the patient had been fully informed, as was their right by law, there was anger and recrimination from the physician and the facility.
Why did a patient’s decision to not have surgery cause this upheaval? Who lost out here?
I’m speculating, but I wonder – how much of that anger did the patient hear, or sense?
3. A PHYSICIAN DISPLAYED DISRUPTIVE BEHAVIOR AT THE NURSES STATION.
Well, this has been going on from time immemorial, but it is no longer tolerated.
Now, concern over a patient is not disruptive behavior. Anger is not a disruptive behavior. (If it was, I’d be in trouble.) Screaming and throwing a temper-tantrum at a nursing station is, no matter what the reason.
How would you feel as a patient if you heard a screaming rant going on at the nurse’s station outside your door?
How would you feel about the doctors, the facility? The nurses?
Two of these, the informed consent and the disruptive behavior are issues that are covered by licensing bodies. Joint Commission has looked at the impact of disruptive behavior by physicians and other members of the health care team. The Centers for Medicaid and Medicare Services are also concerned with the effect of this behavior of patient safety.
What happened at Banner Health Del E. Webb Medical Center was not innocuous.
If not for the actions of a registered nurse, doing exactly what she was educated to do, and bound by the Arizona Nurse Practice Act (and her ethical duty) to do, a patient would have had a surgery they were not prepared for, and would not have wanted had they known what was happening.
That should scare the hell out of every single one of us.
Because something like this has a chilling effect on all the other RNs in a facility – and I hope that the other registered nurses at Banner Health have the guts to keep educating their patients without the fear of losing their jobs and their licenses for doing their ethical duty.
As a nurse, and as a patient, I am appalled.
Now I want to see exactly what Banner Health, and the Arizona Board of Nurses, are going to do to rectify this situation.
This has huge implications for nurses, and patients.
All of us.
January 27, 2012, 9:32 am
So much of what I do as an ER nurse involves information.
As an RN, I am responsible for providing patients with information about their illness/injury, their medications and their follow up instructions.
Patient education is paramount; I find out what they know, then provide education to fill the gaps.
If they cannot access medications or follow up care, I provide information on how to access those needs.
That is called patient advocacy.
It’s the backbone of nursing, everywhere. Every hospital, every state, every country.
So you can imagine how confused I was to find out an Arizona nurse Amanda Trujillo, RN, MSN had been fired by Banner Health Del E. Webb Medical Center for doing exactly that, advocating for her patient by PROVIDING INFORMATION.
That’s right. Very simply: during a shift, she discovered a patient knew nothing about the details of a major invasive surgery. Not what the surgery entailed or what life would be like after the surgery (“complex lifetime daily care”). They did not know they had the option not have the surgery or that other options were available to them.
The patient requested further information and Ms. Trujillo provided it, including arranging for a case management consult, and documented all of this to the hilt (even the nurse investigator noted this).
The patient changed her mind, didn’t want the surgery. The doctor blew a gasket, threw a tantrum in the nurses station (sound familiar, nurses?), demanded Trujillo be fired, and her license revoked.
Bingo! Instead of supporting their nurse, Banner Health fired her.
For providing information and giving the patient the opportunity to learn more about their condition and their options.
For empowering her patient.
Within her scope of practice.
Within the nursing code of ethics.
As I said in my last post, I’m sputtering angry.
But my anger was turned onto the physician – and that is misplaced anger.
Let the doctor throw his anger all over the place, he will do what he will. If an empowered patient angers him, that’s just sad.
The problem here is Banner Health.
For not supporting patient advocacy.
For not supporting that particular patient’s right to decide.
For not supporting their nurses.
For firing a nurse for doing what she was supposed to be doing.
Her ethical duty.
Next post: this goes viral and how to support registered nurses’ right to advocate for patients.
Because next time, that patient could be you.