On the Carpet:

Open Letter to Arizona Governor Brewer re AZ BON

The Honorable Janice K. Brewer, Arizona Governor

Executive Tower

1700 West Washington Street

Phoenix, AZ 85007

Greg Mercer, MSN

Governor Brewer,

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 AssociationCode 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

About Big Red Carpet Nurse (1750 Articles)
Along with other stuff I enjoy that pays the bills (a plus!), I'm a budding nurse comic. I plan, like fake Opthomologist Rand Paul, to create my own professional organization solely so it will grant me a Doctorate. In my case, the org will be something like the AANC (American Association of Nurse Comics), and it will (trust me on this point) agree to make me the first ever DNC: Doctor of Nurse Comedy. I'll keep you posted!

6 Comments on Open Letter to Arizona Governor Brewer re AZ BON

  1. The latest on the case:

    Facing a Crossroads, #AmandaTrujillo, MSN, RN & the Arizona State Board of Nursing:”At the heart of Amanda’s case is Patient Advocacy. Her patient was having second thoughts about a Liver Transplant evaluation, and Amanda helped fill in the gaps. The doctor, Dr. Keng-Yu Chuang (Source AZBON public records), who had only offered the liver transplant, went ballistic when the patient asked for Hospice info instead. He demanded the hospital serve Amanda’s head up on a platter and that the Arizona State Board of Nursing be contacted.”


  2. Thank you Greg for following Amanda’s case, this is from TruthAboutNursing.org

    Fired for educating a patient? TruthAboutNursing.org, May 2012:”On February 1, the Phoenix CBS affiliate KPHO-TV ran a short but good item by Peter Busch about veteran local nurse Amanda Trujillo, who said she had been fired by Banner Del Webb Hospital and had a complaint filed against her with the state board of nursing because she had educated a patient about the risks of an upcoming surgery and scheduled a consult about hospice. A hospital spokesman reportedly said that “the doctor, ultimately, is the focal point that directs care for patients” and that “company policy” forbids nurses to order a case management consult. The report does not mention other accounts suggesting that these events were set in motion because the patient’s surgeon was displeased that the patient had decided against the surgery.”

    For the latest, please visit: http://www.nurseup.com/


  3. Thank you Greg for following Amanda’s case, this is from her blog.

    The Moment of Impact: April 21, 2010: by #AmandaTrujillo, MSN, RN, #nurseup #nursefriendly #healthcare:”The day my life collided with something greater than I could ever wrap my head around in this lifetime…..I heard a quote recently that conveys the enormity of the year’s events…its message, perfection, but not in the way I would like to envision life perfected, the way I want it, the way I wanted it, the way I thought I had it…..in any case, I like this quote because it encompasses the past, the present, and the future all at once.”

    The day that changed Amanda’s life forever. To follow her case and others, kindly visit http://www.nurseup.com


  4. Thank you Greg for covering Amanda’s case, here is the latest:

    The War Against Amanda Trujillo, April 25, 2012, Mother Jones, RN, Nurse Ratched’s Place:”I still support Amanda Trujillo and some people who have read the allegations against Amanda have questioned my judgment. Frankly, I don’t believe these allegations because I personally know two other nurses who have been reported to their nursing boards by their former employers. One of my friends was reported to the BON after she spoke up about unsafe nursing practices at a shady nursing home, and the other was reported after he chastised hospital administration for placing psychiatric patients and staff in an unsafe environment. Their former employers cooked up all kinds of false allegations against my friends who are both stellar nurses. Their former employers crucified their character, but in the end they were both cleared of any wrongdoing by their respective state nursing boards. There is an escalating pattern of abuse as more unscrupulous employers are using nursing boards as the ultimate scare tactic to keep nurses “in their place. ” Amanda is just another victim of this ploy.”


  5. Excellent. If I can’t advocate for my patients, which seems there is more and more pressure as an OR nurse to just get more surgeries done, who will? No one-not the surgeons, not my director (who last time I checked was an RN–just like me), not the organization (unless they smell an eminent lawsuit brewing)…. Nursing has become fraught with so many ways to be “punished” as a nurse where do you start to change health care to support us versus villify us? I start with standing up for my patients and my co-workers.

    Bravo on a well written and poignant letter.


    • Thank you so much – A century of research and practical experience proves that positive feedback exerts much greater influence on behavior than does the negative flavor, and yet within health care, as you have noticed, these facts are neither known nor utilized. We see an overwhelming emphasis on punishment and the detection and eradication of errors, with virtually no attention to praise or rewards, even symbolic measures. As a result, Nurses learn well to avoid risks or attract attention, and certainly to avoid the innovation that health care so desperately needs. It is one of many examples of the pervasive ignorance in health care regarding basic people skills and social psychology that led me to found and develop GRC training tools. We Nurses tend to go well out of our way, with all good intentions but little knowledge, to effectively ensure that our education and management efforts have the least impact possible, and cost us the most time and energy and frustration possible. We have been far more successful, sadly enough, in generating comforting rationalizations with impressive clinical language to ensure ourselves, in a quite fictional fashion without our noticing, that we’re doing the best we can and should attribute our failures to characteristics of our audience: resistance, poor insight, etc. With easily learned skills, I and my students have quickly developed much stronger rapport and cooperation, making all our work far easier, more pleasant, and less time-consuming.

      The time to continue allowing such nonsense to hold us back has long passed: our patients and our colleagues need our best, as do we ourselves. The subjective assurance we’re doing our best is no substitute for the real growth available to us, if only we accept it.


2 Trackbacks / Pingbacks

  1. When Nurses Attack At the Highest Levels: A Blatant Abuse of Power // Emergiblog
  2. #Nurseup #AmandaTrujillo, #RN, #Blogposts Let us know what is missing! We want them all :) #nursefriendly | Nurse Up!

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