If you spend any time around a nurse’s station you’ll hear certain common themes in the chatter. First is, one hopes, what the patient wants then what the doctor wants and, finally, most imponderable of all, perhaps most worrisome to the individual nurse, what “the Board” expects, in other words, the Board of Nursing. In this case, the Texas Board of Nursing which is the licensing and regulatory agency for the 370,000 nurses in the state. As part of the reaction to the first Ebola cases in Texas and how that care was handled, there’s already speculation about how doctors, hospitals, the Centers for Disease Control and President Obama will approach public health menaces in the future. But the first two domestic victims of the infection were Texas RNs and the Board of Nursing should also be watched.
To understand caregiver practice in this state and even in the rest of the country there’s a single precept or rule that governs the comportment of anyone holding a nursing license: the primary responsibility of the license holder is not to the hospital, nor to the physician—something that doctors even today still have a hard time understanding—but to the patient.
This idea has been distilled to a frequent bit of wisdom heard among RNs when presented with an iffy situation. “You can always get another job, you can’t get another license,” which may seem obvious, but as the first reports emerge on how Ebola Patient Zero Thomas Eric Duncan was treated in a Dallas emergency room it’s something to keep in mind. Duncan was sent home with a high fever after reporting he arrived from an infection hot zone. The charting that has been released is contradictory and confusing. Mr. Duncan's family has said they believe he was treated to a lesser standard because of his race, a complaint heard in hospitals across the country, that being black or Hispanic or uninsured leads to being shown the closest exit or being given second rate care. Nursing association leaders have complained about lack of equipment and insufficient protocols in Dallas. All of this combines for a case that is likely to be dissected and studied. The Texas Board of Nursing is also likely to weigh in at some point, especially since this case seems to resemble the index case for bad nursing care in the state: Lunsford vs. the Texas Board of Nursing, circa 1980.
Martha Lunsford was a hapless RN whose name has been used to frighten a generation of nursing students, hers being the archetypical example of what not to do in a hospital. A synopsis of her handling of heart attack victim Donald Floyd thirty years ago, written by the Chief Justice of the Texas Supreme Court, affirming Lunsford’s suspension by the Board, is still instructive today.
“Floyd, traveling through Raymondville with Farrell on their way to Houston, complained of great pressure and pain in his chest accompanied by a pain and numbness radiating down his left arm. Farrell also testified that Floyd was extremely anxious and quite grey in color. Farrell, in her search for medical help, found a physician sitting at the nursing station outside one of the treatment rooms. She requested his assistance, but was instructed to seek help from a nurse because he was quite busy. Farrell insisted that the physician help Floyd, who she explained was suffering from chest pains, but was again instructed to seek the assistance of the nurse on duty. Appellant Nurse Lunsford then approached the nurse’s station and was instructed by the physician to send Floyd on to Valley Baptist Hospital in Harlingen, twenty-four miles away. In instructing appellant, the physician pointed to the hospital’s only cardiac care equipment then in use on another patient.”
Nurse Lunsford testified that the written nursing policy was that anyone presenting at Willacy County Hospital who did not have a local MD was to be shown the door. Lunsford did what the physician ordered with the result that, per the court opinion, “Floyd died shortly thereafter, less than five miles from the Willacy County Hospital in Raymondville.” Later, Nurse Lunsford lost her license permanently for allowing another cardiac patient under her care to bleed out following a procedure. She said in an interview a few years ago that the worst part for her personally was when a young woman in nursing school, who was dating Martha Lunsford’s son, asked if she was the same RN who the student was hearing about in class. The bottom line is that doctor’s orders and hospital protocols are all fine but RNs are still required to do what is best for the patient. You can find another job but the Board of Nursing can be merciless.
The face of the Texas Board of Nursing for the last two decades has been Kathy Thomas, the BON executive director, a former pediatric advanced practitioner and Army nurse who has an understanding but no-nonsense reputation. She is apparently the longest-tenured agency head in Texas government. In answer to written questions submitted before the Ebola outbreak she discussed the changing role of nursing practice and discipline in the state:
“The Board of Nursing has regulated RN education and practice for over 100 years and that covers a lot of ground in the evolution of healthcare, technology and science. The amount of information and skills required for safe practice has certainly changed.” Of Board discipline, which is often what most interests nurses, she noted, “The issues reflect the environment so, for example, as electronic medical records have replaced paper charts, documentation has new challenges. Over the past five years complaints have grown for two major reasons: One, as the nursing population grows, so do complaints. They generally reflect about 1% of the nursing population. Two, criminal background checks have revealed information that the Board was unaware of before these background checks were done.” Ms. Thomas said that the three leading causes of discipline for nurses in Texas are substance use/abuse, criminal conduct and failure to follow minimum standards—the last being something like what led to Nurse Lunsford’s fall and which will likely be part of any review of the care of Patient Zero in Dallas. That means Kathy Thomas and the Board are also now in the hot seat, mistakes have been made in the hospital, the question is what will be learned?
One hint is that blaming the doctors and the hospital is probably not the way to go for those nurses questioned. That’s what Nurse Lunsford tried. Interestingly the Board of Nursing includes a number of African-Americans who are also likely to want to be reassured about the standards of care for the late Mr. Duncan, a black man. Students are encouraged to attend Board hearings if only to learn what may be the hardest lesson of all. The members of the Board are not friends or associates, even if he or she is a brother or sister nurse. The Board is there to protect the public and in a collectively-governed profession like nursing, often described as functioning like a beehive—in contrast to the independence of physicians. That means toeing a line that has been established through consensus. Which may be why talk at nurse’s stations often sounds social as well as professional: who is a “good nurse” or “bad nurse” or, worst of all, a “scary nurse,” like Martha Lunsford. The courts have ruled those distinctions are mostly up to the Board.
