by Geneviève M. Clavreul, RN, PhD.
Many, if not all of us, have read or heard about Nurse Charles Cullen, the notorious and self-admitted Angel of Death. He has admitted to killing at least 23 patients, though authorities believe that the number may be even higher. What boggles the mind is that this nurse was
able to continue working with patients, even though he was a suspect in the unexpected deaths. At the very least, there was the suspicion that medication was disappearing. The question that begs to be asked is how many nurses suspected that there might have been an Angel of Death
among them? And how many of them actually took steps to put a stop to his actions?
Thankfully, it appears as though Angels of Death are rare in nursing. But, when they are discovered, they can, and do, shake the public's trust in our profession. I have often wondered why nurses seem so reluctant to report their suspicions. I believe that this reluctance is
rooted in the nursing culture. Nurses are taught to question many things, but authority or the status quo is not one of them. To understand just how an Angel of Death can successfully operate in a hospital and in one unit in particular, we have to look at how nurses usually interact with their nursing peers, doctors, other health care team members and even administration.
In most cases, nurses assume a subordinate role, even when interacting with other nurses. This may seem contrary to the nurse's usual role as a patient advocate, but given the retaliatory "good old girls" network that seems to dominate nursing today, it is not entirely surprising.
The same nurse who fights for the patient one night, may choose to say nothing about suspicious actions of another nurse the next evening.
Take, for example, an experience at a local Los Angeles hospital. One night, as I prepared to start my shift I happened upon another nurse who was sniffing what appeared to be an illicit drug (the only thing missing was the mirror). As I was on assignment with the registry, I
wasn't sure to whom I should report my suspicions. Later that evening, that same nurse came to relieve me for my break. One look at her fully dilated pupils and her panting expression, and I politely informed her that I'd take my break later. When she left I got another nurse to
cover for me for a few minutes while I went down to the nursing office and voiced my concerns to the appropriate person.
End result? Suddenly I found that I went from being in great demand to almost no demand, and this nurse (to my knowledge) continues to work at that hospital. In nursing, it is not uncommon for those in a position of authority to "kill the messenger," especially when the person who is
the subject of the complaint is perceived to be a "hard worker," and always "Johnny on the Spot" to meet the demands of the Director of Nursing, DON, or charge nurse.
This was true in this nurse's case. She was always willing to work that extra second or third or even fourth shift; take on an extra patient even if it meant exceeding a safe patient care level; come in to work a half shift in the middle of the night, no problem. If you read the
background stories about Nurse Cullen, you will find that he was also one of those "pleaser" nurses. Many of his superiors had lauded him for this willingness to work extra.
The management structure of nursing may be what allows an Angel of Death to operate in the hospital environment. Since the typical nursing management style is often retaliatory in nature, it is not uncommon for the conscientious nurse who is unwilling to compromise good patient
care and sound nursing practice to be seen as a "troublemaker" nurse, and be treated accordingly. Meanwhile, a marginal and potentially dangerous nurse can, and often does, get away with either literal or actual murder, just because she is willing to ingratiate herself to her
superiors. This is often true with physicians as well. It is a trait shared in common by many fraternally-structured occupations.
I think it is comedian Chris Rock who made an insightful observation on serial killers. In his joke, he comments that, isn't it interesting when a serial killer is finally discovered, the neighbors and friends usually all offer the same observations, such as, "he was such a nice guy," and "he was always there with a helping hand" and so forth. Meanwhile, Chris Rock ends his joke with, "Just once I'd like to hear the neighbors say that man was a raving lunatic. Everyone was scared to
death of him." His joke touches a nerve, because it shows how murderers are able to behave within social norms. It is this behavior that allows them to remain below the radar of detection for long periods of time.
So, too, is it with a nurse who is an "Angel of Death." I have often wondered if nurses who exhibit this behavior are suffering from a form of Munchausen by Proxy. Sufferers of this syndrome are adept at hiding their actions and of playing the role of an innocent or hapless
caregiver who is at his wit's end trying to help their charges. Others rarely suspect them as being involved in creating the illness or event until it is often too late. Additionally, our society has a difficult time believing ill of someone in a trusted position, such as a nurse, so common sense steps that would usually be used to investigate the suspected "serial killer" are ignored.
What is a nurse to do? How do you make your concerns known, without inadvertently making false accusations? In addition to fearing the retaliatory nature of hospital and nursing management, fear of wrongly accusing a fellow nurse is probably the next most common reason a nurse fails to report their early suspicions. However, one must put those fears aside if you see indicators that a nurse may be jeopardizing patient safety.
Some signs to look for are:
. The nurse who always wants to work the graveyard shift for no external other reason (such as children at home, going to school during the day, and so on).
. Patients seem to crash (again for no apparent relevant cause) when being cared for by a particular nurse.
. Drugs are short-counted after that nurse's shift. This applies especially to narcotics, potassium chloride, insulin, digoxin. Most nurses appear to prefer this mode to hasten death. For example: Charles Cullen said he used digoxin, John Bardgett said he used morphine, Kristen Gilbert said she used epinephrine, Orville Lynn Majors said he used injections of potassium chloride, epinephrine or both, Donald Harvey said he used morphine, cyanide, and arsenic-whatever he had at hand, and Terri Rachals said she used potassium chloride.
By this point many may think that I am making a mountain out of a molehill. A quick Internet search, however, reveals there are at least eight nurses (besides Cullen) who have either been convicted or pleaded guilty to hastening the deaths of patients over the last several
decades. This tally does not include LVNs, or other healthcare team members, such as Respiratory Therapist Efren Saldivar (the Glendale Adventist Angel of Death).
The statistically likelihood of a serial killer nurse on your floor is very remote. However, during the course of our career, at one time or another, many of us have had doubts about a coworker's competency to treat patients.
In a perfect world, hospitals would have highly proficient management professionals supervising all levels of the healthcare team. If these professionals were skilled in human relations and management principles, they would foster a milieu where nurses could freely express concerns as they relate to the overall "well-being" of the hospital. It would be safe for a nurse to raise warning flags when they suspect that poor and dangerous nursing care is taking place. Nurses
would feel freer to do so if there were written policies in place for them to use when reporting suspicious behavior. Such reports would then be thoroughly and objectively investigated by a team trained to perform this duty. Reports would be prepared that protect the whistleblower and the accused until the process is concluded. At any point, if evidence suggests that a nurse is hastening the death of patients, that nurse would then be reported to the appropriate agencies, the State Board of Nursing, and law enforcement.
Unfortunately, we do not live in a perfect world, and all too often, it is fear that prevents a nurse from reporting suspicions early. These nurses will have to live with a burden of guilt knowing they did not act in the best interests of their patients.
Geneviève M. Clavreul is a health care management consultant. She is an RN and has experience as a director of nursing and as a teacher of nursing management. She can be reached at: Solutions Outside the Box; PO Box 867, Pasadena, CA;
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When Smart Nurses Do Not-So-Smart Things
by Geneviève M. Clavreul, RN, Ph.D.
Sometimes we nurses are our own worst enemies. I often see, hear about, or read about nurses doing things that not only produce negative consequences for their patients, but for themselves and their hospitals. For example, those of you followed the King/Drew Medical Center series in the Los Angeles Times may remember how one of the patients died. Reports identified that the death was due to a nurse having turned the sound down on a monitor so low that she didn’t hear it when it alarmed after the patient’s heart rate had begun to slow. By the time someone discovered that the patient was in distress it was too late.
I don’t know this nurse and can’t judge if she was a good nurse practicing poor nursing skills, a careless nurse doing what careless nurses are prone to do, or a bad nurse who was finally caught by her own incompetence. Whatever the situation, a patient suffered for her mistake. This story reminded me once again that smart nurses can do not-so-smart things!
I’m sure that this experience strikes a familiar chord with many nurses. We have all either known a nurse in a similar circumstance or perhaps have been just such a nurse at one point in our career. Not only do careless mistakes harm the patient, but they destroy the trust our fellow nurses have in our ability to perform our job well. Some of the things that nurses do that make us our own worst enemies are:
• Turning off or turning down the sound level of monitors, pagers, and other “alert” instruments;
• Advance charting, especially in anticipation of an upcoming break or end of shift; and,
• Not admitting to having made a mistake, then trying to cover it up by altering the medical records.
The above list is just a few of the ways that nurses behave carelessly. I’m sure that many of my readers can think of others to add to this list, and feel free to do so in an email to me. It is not my intent to ruffle feathers or to accuse nurses of practicing bad behavior, or, even worse, turning a blind-eye to it. I believe that as a group we can agree that our profession faces challenges from other health care practitioners and, of course, administration (the bean counters), so we don’t need nurses making it tough on fellow nurses.
TURNING OFF OR TURNING DOWN THE SOUND LEVEL OF MONITORS.
Are you guilty of this practice?
What I do know and recognize from my years both practicing nursing at the bedside and in nursing administration is that a nurse turning the sound down on a monitor is not uncommon. When a nurse makes the poor decision to turn down a monitor, it usually is in response to two things: 1) the constant barrage of noise pollution that assaults nurses in today’s hospital, 2) frustration with poorly calibrated equipment or defective equipment that is constantly setting off false alarms. These can cause serious and adverse events for our patients.
It is important to remember that if you have monitors that are constantly setting off false alarms, then those machines need to be calibrated. The department responsible for calibrating is the engineering department, not nursing. Engineering should have a rotating schedule that ensures all monitors are recalibrated to company specifications at pre-set intervals. If this is not happening, alert your superiors, mention it at staff meetings, and don’t forget to document that you requested that the monitor you are concerned about get checked. It is not the nurse’s job to chase down engineering and make the engineer do his/her job, but it is the nurse’s responsibility to know if the equipment is functioning properly. If it isn’t, put in a work order or follow your hospital’s reporting protocol and then document your actions. If you email your request, be sure to tag it so that you received a notification that the message has been read, if your email system permits this. And, be sure to keep a print-out of your email after you send it so that the day and time it was sent appears on your print out.
Another “pain in the nurse’s backside” is equipment that has well-known or documented flaws. For example, a local Los Angeles area hospital uses a cardiac monitor that has a flaw that is so well documented that the manufacturer even references it in the handbook. You have to wonder why this monitor is even allowed to be sold to hospitals, not to mention why J.C.A.H.O., the self-proclaimed guardian of patient safety, hasn’t come out with a prohibition against this particular model of monitor. I wonder how many patients are going to have to die before hospitals stop buying it or before the manufacturer develops a conscience and pulls it from the market?
The other challenge to monitors sounding false alarms is the incredible noise pollution that nurses are subjected to, especially those of us working in the critical care areas of the hospital. I have often thought that studying the noise pollution in ICU’s and its impact on the nursing staff would make for an interesting research project. Since NICU is one of my specialties, I am often frustrated when overly cautious physicians, who really don’t have any trust in the nursing staff, order that the infant’s pulse/ox sensor be set for high limit of 98% and not 100% and low limit for 90% or other low limit as ordered when the infant is on oxygen. When these ranges are set the monitor alarms every time the infant moves so much as a muscle. Of course, there are usually eight infants in the bay or room, all whose monitors are set in the same range, so you have to multiply the noise pollution by a factor of eight.
It takes a concentrated effort for a NICU nurse not to block out the sound of the alarms, since more often than not the infant is not in distress. I am not advocating that nurses ignore alarms, but I can understand how even a highly competent nurse may become so inured to the constant barrage of false alarms that his/her reaction time is ultimately slowed. Just as the villagers failed to respond in Aesop’s fable, The Boy who Cried Wolf so do nurses sometimes fail to act appropriately because of the expectation that this is another false alarm.
Therefore, it is important for nurses to remember that they, as the patient advocate, are ultimately responsible for adverse events, especially if they failed to take measures to correct the adverse event beforehand. So, if your monitors are “false alarming,” request that the engineering department check and calibrate them according to manufacturer specifications. If no action is taken on your request, inform your immediate supervisor. Document the action you have taken. Also, make sure that you have been given a full and complete orientation or refresher on each of the specific monitors so that you know how to appropriately set all limits for HR, resp, BP, pulse/ox, and so on, as they are prescribed or needed.
ADVANCE CHARTING, ESPECIALLY IN ANTICIPATION OF AN UPCOMING BREAK OR END OF SHIFT. NOT ADMITTING A MISTAKE, THEN TRYING TO COVER IT UP BY ALTERING THE MEDICAL RECORDS.
Know someone who’s done this?
I am sure that no one reading this article has ever advanced charted. But in case you have contemplated doing this unacceptable practice–don’t! I believe that advance charting is a tool most often used by what can be described as a “careless” nurse. This is a nurse–we have probably known at least one in our career–who exhibits poor work ethics, either because of burnout or because they lack pride in their work. A “careless” nurse often falls into the practice of advance charting when she/he is carrying for a non-critically ill or long-term stable patient. Sure, there are probably no surprises with this kind of patient and the treatment is very cookie-cutter.This is still no excuse to advance chart.
Some nurses advance chart in anticipation of the end of shift rationalizing that there is so little time that nothing will happen, so what would it hurt? Never forget Murphy’s Law and remember that a patient’s condition can change in a heartbeat. It is always better to chart as the event occurs or after it occurs than risk your license because you wanted to save a few minutes.
In my 30-plus years as a registered nurse I can think of a few occasions when a nurse has altered a patient’s medical record, as well as a few physicians who have. There is never a good reason to alter a patient’s record. If you find that you made a mistake or have to “back chart,” then label your entry as such, but never alter the record.
The acceptable manner in which to correct an error in the patient’s record is to cross it out with a pen, write “error” and initial it. Never, ever use white-out – this is a no-no. If it is a late entry, label it as such and again be sure to initial it. More often than not, a nurse might alter a patient’s record under duress or perceived duress. A psychologically strong nurse, with a good character, is usually equipped with the self-esteem to resist the temptation to alter a patient’s record.
Nurses make mistakes; we are human. When a mistake is made own up to it, seek help, and get training so that you do not repeat your error. When a nurse compounds the mistake by hiding it through altering the patient’s medical record, she/he starts down a slippery slope that can only end badly for everyone: patient, nurse, and hospital alike.
The next time a monitor is “false alarming” and driving you nuts, take an extra minute and make sure the limits have been properly set. Put in a work order if necessary. By doing this you will keep from developing an environment where false alarms are the norm and, therefore, increasing the threshold that it will take to illicit a response to the alarm. It looks as though nursing is going to continue becoming more and more hi-tech. Let’s embrace it and make it work for us. The first step in that direction is for us to control and master the machines–not the other way around. The nursing leadership must create an environment where nurses can report faulty equipment without concern for retaliation (either real or perceived) that the messenger will be “killed” for delivering the message.
When nurses are appropriately trained, provided with good leadership, and the correct equipment, they are less prone to make negative errors. In too many hospitals today there is a profound lack of nursing leadership, both in union and non-union hospitals. Too often the Chief Nursing Officer (CNO) is too busy looking out for herself and the hospital administration, rather than supporting the nurses. When this happens, you begin to see a breakdown in nursing practices. This is when smart nurses might do not-so-smart things. Will a strong and competent CNO make a difference as to how the nursing staff performs? You bet!
