The Honorable Janice K. Brewer, Arizona Governor
1700 West Washington Street
Phoenix, AZ 85007
Greg Mercer, MSN
You and your legislature are can make a strong improvement in the regulation of Arizona health care, at little cost, and set a positive precedent for the rest of our nation, building on your fine government reforms to date (I wish Massachusetts would follow your lead on transparency).
There is no regulatory function or group whose work will not benefit over time from the sunlight of public scrutiny. Such accountability, as we have seen in the occasionally raucous debates over your BON and the case of Amanda Trujillo, can be messy at times, certainly inconvenient and irritating, but that is how a health democracy functions: involvement, and the willingness to form and express opinions, to speak and listen and do the hard work required to craft consensus.
“Many forms of Government have been tried, and will be tried in this world of sin and woe. No one pretends that democracy is perfect or all-wise. Indeed, it has been said that democracy is the worst form of government, except for all those other forms that have been tried…” – Churchill
This Nurse citizen agrees heartily. I advocate for democracy often: without our participation and diligence, it withers and we pay a stiff price. AZ BON may well need a dose: on the next renewal of its mandate, reforms should be considered, consistent with the fiercely and fearlessly innovative tradition of the Western States.
Consider some mechanism to initially assess and screen complaints: a system to monitor and address potential abuses of this crucial system by those who file the complaints. Courts have long had such mechanisms in place. At the very least, provide a clear record of case evidence, findings, and the identities of all involved parties including complainants. If need be, provide for a formal mechanism for record redaction by a disinterested party: protection of complainant anonymity is well-intentioned but provides a strong encouragement for abuse of the complaint process without culpability or public awareness. Also, AZBON (every BON) must have adequate resources to process cases in a timely and effective manner: 1000 Nurses, or 1 in 35 of the total, suffering over 7 months of professional limbo (on average) each year is unacceptable. It causes the innocent grievous harm, turns the presumption of innocence on its head, and has the potential to turn protection of the public into harassment and slander of those vulnerable individuals who have angered the powerful or ruthless. It also delays accountability for those Nurses, and their patients, in need of it. Both aspects harm Nursing and patients. Arizona can do much better, at little cost. Regulation without justice and accountability amounts to tyranny, much contrary to American and Arizonan values.
For some perspective, consider California, whose BON has seen far worse problems than has Arizona’s – see http://www.latimes.com/news/la-me-nursing-board14-2009jul14,0,1002564.story.
In 2009, in response to a private investigation showing an average of over 3 years per BON case, the CA Governor fired half of sitting board members: “Fred Aguiar, secretary of the State and Consumer Services Agency, said in an interview that the new board would be asked immediately to come up with a plan to eliminate the case backlog. ‘This plan needs to include how many more investigators are needed, how much that will cost. . . . I want to know now.’ “
Outside pressure does have its useful and necessary place in public affairs. In America’s most deadly war, President Lincoln gave us the enduring precedent that we are one nation. We Nurses, too, need to think more of the whole, of the big picture, and how precedent like the case of Amanda Trujillo, and the functioning of our BONs, affects that whole.
“No man, not even a doctor, ever gives any other definition of what a nurse should be than this – ‘devoted and obedient.’ This definition would do just as well for a porter. It might even do for a horse. It would not do for a policeman.” Florence Nightingale, Notes on Nursing, 1860.
“Let us have faith that right makes might, and in that faith, let us, to the end, dare to do our duty as we understand it” – Abraham Lincoln, 1860.
“The nurse’s primary commitment is to the patient, whether an individual, family, group, or community… The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient… participates in establishing, maintaining, and improving healthcare environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action… The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.” - American Nurses Association, Code of Ethics for Nurses with Interpretive Statements, © 2001 By American Nurses Association.
“Standards Related to Registered Nurse Scope of Practice: A registered nurse (RN) shall… Demonstrate attentiveness by providing ongoing client surveillance and monitoring… Determine the clinical implications of client signs, symptoms, and changes, as either expected, unexpected, or emergent situations… Provide nursing care within the RN scope of practice in which the nurse… Intervenes on behalf of a client when problems are identified… Attends to client concerns or requests… Communicates client information to health team members including: Client concerns and special needs… Evaluate the… Need to communicate and consult with other health team members [and]
Need to revise the plan of care… Provide comprehensive nursing and health care education… Advocate on behalf of a client to promote the client’s best interest… Assesses and analyzes educational needs of learners… Unprofessional Conduct… includes one or more of the following… A pattern of failure to maintain minimum standards of acceptable and prevailing nursing practice… Abandoning or neglecting a patient… Failing to take appropriate action to safeguard a patient’s welfare or follow policies and procedures of the nurse’s employer designed to safeguard the patient… [or] Practicing in any other manner that gives the Board reasonable cause to believe the health of a patient or the public may be harmed.” Rules of the State Board of Nursing, Issued by the Arizona State Board of Nursing
I am an ANA member with no leadership role, but I take ethics seriously. Words and ideas are important, but they can also be used as empty pleasing sounds signifying nothing but hypocrisy, when they are used to project a pleasing image instead of as an honest guide for action. When they are used to take more credit than one has earned. What would Lincoln’s legacy be today, if he had merely spoken all his finely crafted eloquent words, without acting on them?
When a Nurse spends a year in professional limbo and unemployment, more should be alleged than actions to assess patient knowledge, provide education regarding available care options, advocate for the patient and communicate such in writing to the relevant treatment team and its Physician. As AZ BON rules clearly state, not following employer policies or procedures qualifies as unprofessional conduct actionable by AZBON if and only if such rules are “designed to safeguard the patient.” To request treatment team discussion of a care hardly seems to qualify, as it does nothing to necessarily change the care plan in any way: it merely makes a non-binding request for private discussion. It is especially important to note: in Arizona, unprofessional Nurse conduct also includes failure to take the actions I describe, as quoted above. Allegations of an improper “order” for consultation seem, in context, to amount to allegations of fully acting within the spirit and letter of BON standards on RN scope of practice. If allegations of this nature require a year of consideration, what does it say about the state of health care regulation in Arizona? I should also point out, that on a careful review of AZ BON rules, I have have been unable to find any suggestion that public discussion of a case by the accused violates any standard or has any relevance to BON’s decisions about the case. These rules certainly do not suggest that such use of hallowed First Amendment rights somehow constitute evidence of mental illness: such an argument, historically, has typically been seen under Communist, not American governance.
One final note: just I write this note, I have learned that AZ BON has by its official rules a procedure for filing written requests for Board rule changes, open to use by “any person.” As I imagine I qualify as such, I will consider using this option in future, as opposed to bothering such a busy official as yourself. I apologize for not finding this option sooner, but in my defense it is buried in a 60 page legal document that, in of itself, was no small task to find and obtain.
Thank you for your consideration in these important matters.
I eagerly await any feedback you might offer.
Greg Mercer, MSN