Blog Archives

By Genevieve M. Clavreul, RN, Ph.D.

Working Nurse Magazine

I know that for a lot of nurses, talking about politics is about as appealing as going to the dentist. However, legislation and policy decisions can shape the way we practice at every level, sometimes dramatically. That’s why it’s important for nurses to pay close attention to proposed laws or new regulations affecting our profession.

Let’s take a look at some current healthcare-related measures and what they could mean to you.

Opioid Restrictions

If you or any of your patients suffer chronic pain and have a liver condition that contraindicates acetaminophen (the active ingredient in Tylenol), you should be very alarmed by S.2134 and H.R.4241.

These bills, prompted by the recent fear-mongering about prescription opioid abuse, would ban Zohydro ER, the only FDA-approved opioid that doesn’t contain acetaminophen. The legislation would also prohibit the FDA from re-approving Zohydro “unless it is formulated to prevent abuse.”

Aside from its impact on chronic pain sufferers, this attempt by some members of Congress to usurp the function of the FDA would set a frightening precedent. If Congress can summarily ban a drug that’s already passed the FDA’s approval process, what’s to prevent legislators from banning other approved drugs, like contraceptives, in hopes of scoring political points? I shudder at the potential consequences.

Safe Staffing Ratios

There’s brighter news in the area of nurse staffing requirements. As most of us know, California has had mandatory nurse-patient staffing ratios for the past decade and Congress is now considering national requirements.

The federal Registered Nurse Safe Staffing Act (H.R.1821 and S.2353), which would apply to all Medicare-participating hospitals, is quite different from California’s rules, which mandate specific ratios for each type of unit. Instead, the proposed federal law would require each hospital to establish a committee — at least 55 percent of which must be RNs providing direct patient care — that will create staffing plans based on patient acuity, staff experience and other factors.

Longtime readers know that I’m very critical of California’s “one size fits all” approach to staffing ratios. I strongly believe that an acuity-based system makes more sense, allowing managers to match nurses to patients based on the nurse’s skills and training rather than arbitrary legislative dictates. The federal law would also give nurses a greater voice in those decisions.

Unfortunately, these bills wouldn’t change California’s current requirements. If this law passes, Medicare hospitals in our state would still need to organize the required committees and create staffing plans, but those plans would have to comply with existing state laws.

Lab Result Reporting

Till now, patients have always been told, “The doctor will call you when your test results come back.” However, in February, the Center for Medicare and Medicaid Services amended the Clinical Laboratory Improvement Amendments of 1988 (CLIA) to give patients the right to request test results directly from the laboratory. All entities subject to HIPAA must comply with the regulation by October 6.

It will be interesting to see how the new rule will affect the patient-provider relationship. Will patients be better informed or will they be panic-stricken after trying to interpret their test results based on Internet searches? Will patients even be informed of the new rule? (I know my and my daughter’s providers have yet to say anything about it.)

If your facility’s lab is subject to CLIA, have you been educated about the new regulation? How do you feel it’s working so far? Drop me a line and let me know.

MRSA and Worker’s Comp

If you’re unlucky enough to contract a methicillin-resistant Staphylococcus aureus (MRSA) skin infection while working in patient care, a proposed state law (AB 2616) would make it easier for you to file a workers’ compensation claim. The bill, which is supported by the  California Nurses Association and National Nurses United, passed both houses of the Legislature in August and now awaits the governor’s signature.

AB 2616 states that MRSA skin infections contracted while providing direct patient care will now be presumed to be work-related unless there’s specific evidence to the contrary. That means if you file an MRSA-related claim, the burden of proof will no longer be on you, which is good news.

Workplace Violence

Workplace violence is an ongoing concern for nurses and other healthcare workers. There’s been some progress since Napa State Hospital psychiatric technician Donna Gross was strangled to death by a patient in 2010, but nursing organizations and unions have been calling for more.

SB 1299, which went to the governor’s office on August 28, is intended to light a fire under the state Occupational Safety and Health Standards Board and push state hospitals to take action. The bill would require acute care and acute psychiatric hospitals to establish plans to prevent workplace violence in both inpatient and outpatient settings.

The plans must include training and education for workers, procedures for investigating incidents, and policies for documenting and reporting incidents to the Division of Occupational Safety and Health, which would be required to post anonymized reports online starting in 2017.

Quicker Licensure

Too many new RNs have passed the NCLEX, graduated from nursing school and started applying for work — only to wait and wait for the BRN to issue their licenses. A bill in the Assembly, AB 2165, seeks to address that problem by giving professional licensing boards a 45-day deadline to issue licenses to candidates who’ve completed all the requirements.

The 45-day clock wouldn’t start ticking until you have completed all the application requirements, so this law wouldn’t help if you had missing paperwork or problems with your background check. The point is to keep qualified applicants from being held up by bureaucratic backlog.

Using our Power

This list is by no means comprehensive. New measures come up all the time, including ones that aren’t specific to nursing, but may still affect our work.

The good news is that we don’t have to sit back and watch idly. With almost 400,000 active RNs in California alone, we have more political power than many of us realize. However, for us to use that power, we have to be aware of what’s going on and willing to get involved. We can’t afford to let politics be a spectator sport.


How to Stay Informed

If you want to find out more about these bills and others like them, check out the following links:

•  The Library of Congress THOMAS database allows you to look up information about federal bills.

•  is another option for keeping track of happenings in Washington. It requires registration.

•  The Official California Legislative Information webpage includes information on current state laws and proposed legislation.

•  LegTrack is another search engine for state measures. It requires registration.

•  Ballotpedia is “an interactive almanac of U.S. politics,” including neutral descriptions of federal and state measures.

•  The Board of Registered Nursing (BRN) website often provides useful information on pending legislation. The BRN’s legislative committee examines all measures and decides whether the board should support, oppose or watch each measure.

•  Professional organizations and unions such as the American Nurses Association, California and the California Nurses Association/National Nurses Organizing Committee also monitor relevant legislation, although these organizations’ information may be available only to members.

Some professional organizations also organize “lobby days,” which are a great opportunity for nurses to learn about important current issues and the political process in general.

Working Nurse Magazine – Issue

Nurses Answering the Call

Hurricanes, floods and earthquakes are no match for heroic nurses

By Genevieve M. Clavreul, RN, Ph.D.Working Nurse Magazine

Nurses across the country have long been at the forefront of disaster response, whether the crisis is an earthquake, hurricane or tsunami, a flood or some manmade tragedy. When disaster strikes, nurses respond at the drop of a hat, often putting their own lives on hold to offer their services and compassion to those in need.

Tales of Heroism

In 2001, nurses answered the call when terrorists flew two hijacked Boeing 767s into the Twin Towers of the World Trade Center in Manhattan. Some of the first nurses on the scene were sent to the Jacob K. Javits Convention Center, which had been converted into a makeshift 40-bed emergency hospital. At first, nurses could do little more than pour bottled water over the eyes of rescue workers.

Even when more supplies did arrive courtesy of the American Red Cross, the nurses had to cope with limited resources and nurse-patient ratios of more than 5,000 to 1.

After Hurricane Katrina in 2005, volunteer nurses streamed into the Gulf Coast, many taking unpaid leave and using vacation hours to help survivors in some of the hardest-hit areas of Louisiana, Mississippi and Texas. In response to the devastation, the California Nurses Association (CNA) formed the Registered Nurse Response Network (RNRN) to serve as a “clearinghouse” for RNs responding to disasters. The RNRN reports that some 300 nurses traveled to Gulf communities to offer aid and nursing assistance after Katrina.

Even nurses who were unable to make the trip found ways to help. One nurse answered phones at her local Red Cross. After watching television coverage of the disaster, another nurse volunteered to work in the temporary pediatric clinic that had been set up at the Houston Astrodome, treating and comforting children suffering from cuts, bruises, hunger, dehydration, disorientation and exhaustion.

Local nurses, too, put their personal needs on hold to provide much-needed assistance in the wake of Katrina. At the partially flooded Memorial Medical Center in New Orleans, where as many as 2,000 people and 200 patients were trapped without power or running water in stifling heat, nurses struggled for days to provide continuity of care and then navigated darkened stairwells and manually operated Ambu bags to transport patients to the helipad for evacuation.

International Efforts

The disasters to which American nurses have responded have not been limited to the borders of our country. In 2010, U.S. civilian nurses joined their military colleagues aboard the amphibious assault ship USS Iwo Jima for Operation Continuing Promise 2010, a four-month humanitarian deployment. Nurses provided medical assistance to Haitians after Hurricane Tomas, treating a total of 4,054 patients onboard and ashore (as well as more than 1,200 veterinary patients). As part of that operation, nurses went on to participate in seven other missions in Latin America and the Caribbean.

In 2013, Typhoon Haiyan struck the Philippines, killing more than 6,000 people and leaving almost 30,000 injured. Medical and nursing teams from hospitals and nursing associations through the U.S. raised relief funds, donated food and clothing and assembled healthcare teams to aid in disaster relief.

One team saw more than 250 patients a day, many of whom had suffered injuries that became potentially life-threatening due to the harsh conditions and delays in obtaining treatment. In addition to treating physical injuries, the healthcare teams also assisted survivors with mental health issues like anxiety, insomnia and overwhelming grief in the wake of this horrific event.

An Ethical Obligation

When a crisis strikes, people look to nurses and other medically trained professionals for information and guidance as well as care, which makes it all the more important that we learn basic disaster preparedness skills.

An article in the Australian Nursing Journal estimates that each nurse who is helpless in the face of a disaster may leave 50 or more patients in the lurch. That’s why Joanne Langan, RN, Ph.D., CNE, coauthor of the 2004 book Preparing Nurses for Disaster Management, argues that every nurse has an ethical obligation to be prepared for disasters.

Responding to a disaster doesn’t have to mean jumping on a plane at a moment’s notice. Relief efforts often need volunteers to help organize and coordinate the first responders, a role in which a nurse’s training and experience can be invaluable. Of course, nurses can also get involved by donating food, clothing, medical supplies or money to aid the victims of the disaster.

Many hospitals have established on-site disaster response teams, but nurses should also consider joining an outside organization involved in relief efforts. It’s a great way to learn more about disaster response and find opportunities to help. Below are a few places to start:

I think what nurses bring to crisis response is best summed up by a remark made by Marirose Bernard, MN, APRN, CNA-BC, then a nurse supervisor at Memorial Medical Center in New Orleans. When a reporter asked why Bernard and her colleagues didn’t leave the devastated hospital, Bernard responded, “I would never have thought of that. We were there; we were there to take care of our patients. Because we’re nurses, and that’s what nurses do.”

So, to all my fellow nurses: Keep doing what you do and have a Happy Nurses Week!

Here’s my latest article in Working Nurse Magazine —

One of nurses’ most important and underappreciated duties is advocating for our patients. While much of that advocacy takes place at the bedside, we are also in a unique position to address the larger issues that affect the practice of nursing and medicine.

The latest issue that demands our attention is the controversy over prescription opioids and the efforts of the Medical Board of California to crack down on these dangerous but necessary medications.


If you listen to the fearless pundits of the Fourth Estate, deaths related to prescription drugs are a national crisis. According to the Centers for Disease Control and Prevention, 38,329 Americans died of drug overdoses in 2010 and about 60 percent of those deaths involved prescription medications, many of them opioids.

Back in 2012, the Los Angeles Times ran a four-part investigative report on the human cost of opioid abuse and the role of some physicians in overprescribing painkillers. The story reported that between 2006 and 2011, there were 3,733 deaths related to opioid use in just four Southern California counties: Los Angeles, Orange, San Diego and Ventura. That story and others like it have put pressure on the Medical Board of California to respond to the growing “epidemic.”

I put the word “epidemic” in quotes because the outcry is somewhat out of proportion to the reality. As alarming as the number of opioid-related deaths sounds in isolation, the L.A. Times report failed to contextualize that statistic in terms of the combined population of those four counties (16.9 million as of July 2011), the population of California as a whole (37.7 million) or the number of deaths due to other causes during the same period. For example, according to the California Highway Patrol, car crashes killed 18,416 Californians between 2006 and 2011: almost five times the death toll of the headline-grabbing opioid menace.


I don’t mean to diminish the significance of those deaths or suggest that there isn’t a problem, but it’s important not to let alarmism triumph over common sense. While the number of collision-related deaths may indicate a need for better traffic safety, no one is seriously suggesting closing our freeways or restricting how far commuters are allowed to drive!

Unfortunately, when it comes to drugs, such overreaction is the rule rather than the exception. For instance, many of us are familiar with the federal Combat Methamphetamine Epidemic Act of 2005 (CMEA), which sought to stem the rise of methamphetamine abuse by restricting the sale of products containing the nasal decongestant pseudoephedrine (PSE).

PSE is not a prescription drug in most states, but the CMEA limited how much PSE a customer could buy at one time, mandated behind-the-counter placement in stores, required photo identification for purchase and forced sellers to maintain logbooks of sales and customer information. Those measures have had little impact on the meth epidemic. At a conference this February, DEA Office of Diversion Control Deputy Assistant Administrator Joseph Rannazzisi admitted that “NEITHER of these systems [tracking or rescheduling PSE] will have ANY impact on methamphetamine availability in the United States.” [emphasis in the original]. In short, these restrictions  have not curbed the meth supply, but have added a considerable bookkeeping burden for retailers while inconveniencing millions of cold and allergy sufferers.

The effects of the state medical board’s response to the outrage over opioid-related deaths may be far worse. Some of the suggestions I heard at a recent meeting of the board’s Prescribing Task Force left me wanting to tear out my hair in frustration.
the role of alcohol

California’s medical community has good reason to be embarrassed by the L.A. Times expose, which linked a substantial number of overdose deaths in Southern California to a surprisingly small number of doctors.

The story also raised serious questions about the medical board’s effectiveness in responding to complaints about excessive or reckless prescriptions. The board seldom suspends a doctor’s prescribing authority even if he or she is being actively investigated or has already been disciplined for reckless prescribing.

Given all that, you might expect that the Prescribing Task Force’s focus would be on improving the medical board’s oversight of its own members. Instead, I listened to hour after hour of experts proposing new restrictions on patients. The suggestions ranged from requiring patients to sign a contract with their physician prior to receiving prescription opioids to forcing all patients to submit to pill counts and random urine tests. Such measures would be tantamount to treating patients like criminals!

There were more sensible proposals calling for greater patient education, but overall, I was dismayed by the lack of clear-headed perspective on the issues involved. For example, one expert pontificated at length about the evils of opioid abuse without once mentioning the role of alcohol in many painkiller overdose cases. When I asked him about it, he replied that he would touch on that point at the end of his presentation, suggesting that he considered alcohol a trivial footnote rather than a significant contributing factor in many overdose deaths.


As a nurse and as one of the estimated 100 million Americans living with some degree of chronic pain, I am well aware of both the power and the dangers of opioid painkillers. There’s no argument that opioids carry a high potential for abuse and can kill if misused.

However, I’ve also witnessed the consequences of overzealous protocols that prevent patients from getting needed medication. If you suffer chronic pain, draconian limits on how much painkiller you’re allowed do not protect you; they just reduce your ability to function and increase the chances that you’ll find some other way to self-medicate — possibly with lethal consequences.

Tools like pill counting or contracts may be appropriate in certain cases, but imposing such restrictions on all patients would only have a chilling effect on the provider-patient relationship. If our approach to patients defaults to suspicion and mistrust, we only discourage our patients from communicating openly with us about issues like abuse and addiction.
comprehensive approach

So, what should be done? A better solution would include all of the following:

  • Improved education for patients about the dangers and proper use of opioids, including the risk of adverse interactions with alcohol or other drugs.
  • Better educating physicians and their healthcare teams about the signs of opioid abuse, including how to recognize potential risk factors like addictive personalities.
  • Fully implementing a real-time prescription drug monitoring program that can flag suspected prescription shoppers and physicians who may be recklessly prescribing opioids or running “pill mills.” California’s CURES (Controlled Substance Utilization Review and Evaluation System) could be but currently isn’t used for that purpose due to a lack of resources and interest.
  • More effective sanctions for doctors whose prescription history suggests a pattern of reckless or inappropriate prescribing.
  • Finding and funding alternative treatments for chronic pain and conditions that cause it. If you remove the source of the pain, you also remove the need to treat it with opioids.

Obviously, many of these are long-term solutions. In the short term, it’s important that nurses get involved in the debate. The Prescribing Task Force’s next meeting is in May. (See for a schedule.) The meetings are open to the public and I urge readers to attend and participate.

This is an issue that directly affects many of us, our loved ones and our patients. We should not sit idly by while the medical community devises quick-fix solutions that may ultimately do more harm than good.

Genevieve Clavreul’s earlier article on this topic, “The Great Opioid Debate of 2012,” was published in WN127, Sept. 3, 2012.


Scott Glover and Lisa Girion, “Dying for Relief: A Times Investigation,” Los Angeles Times:

Part 1 (“Legal Drugs, Deadly Outcomes,” 11 Nov. 2012)

Part 2 (“Reckless Prescribing, Lost Lives,” 9 Dec. 2012)

Part 3 (“Rogue Pharmacists Feed Addiction,” 20 Dec. 2012)

Part 4 (“Unused Tool Could Help State Flag Deadly Doctors,” 30 Dec. 2012)


CDC, “Drug Overdose in the United States: Fact Sheet,” last updated 10 February 2014. The fact sheet says 60 percent of 2010 overdose deaths were pharmaceuticals, of which 75 percent involved opioids and 30 percent involved benzodiazepines.

Physicians for Responsible Opioid Prescribing, “Cautious, Evidence-Based Opioid Prescribing.”

The American Academy of Pain Management, cites 100 million chronic pain sufferers in America, per Institute of Medicine Report, “Relieving Pain in America.”

Transforming Prevention, Care, Education and Research (Washington, D.C.: The National Academies Press, 2011.

What to expect and when you need a lawyer

By Genevieve M. Clavreul, RN, Ph.D.

The mere mention of an investigation by the California Board of Registered Nursing (BRN) can strike fear into the heart of any nurse, and for good reason. A BRN investigation can turn your life upside down and even end your career.

With that in mind, I thought it would be worthwhile to explain what you can expect if you become the target of such an investigation.
by the numbers. Nurses can take some comfort in knowing that only a small percentage of RNs wind up in the BRN’s investigative sights each year.

Look at the Numbers

According to the BRN, there were 392,458 actively licensed RNs in California in September 2013. During the 2013 fiscal year (July 2012 through June 2013), the BRN’s Complaint Intake office recorded a total of 8,330 new cases, of which 7,714 were assigned for investigation.

The majority of last year’s new investigations — more than two-thirds — were initiated because the BRN learned that a nurse had been arrested for or convicted of a felony or misdemeanor related to his or her nursing duties or qualifications. The most common offense was driving under the influence (DUI).

Only 2,876 BRN complaints were filed by consumers in fiscal 2013 and 508 of those complaints were closed without an investigation. That means only about 0.6 percent of California RNs — one in every 163 nurses — faced a BRN investigation last year due to a consumer complaint.

First Steps

Let’s imagine that worse comes to worse and someone files a complaint against you. The BRN’s first step is to review the complaint to determine if it falls within the board’s jurisdiction. If not, the complainant may be referred to a more appropriate agency, but the case is considered closed as far as the BRN is concerned.

If the complaint does fall within the board’s purview, the next step is to determine if there is reason to refer you to the Diversion Program. This is a voluntary, confidential program for nurses struggling with mental illness or problems with drugs or alcohol. Obviously, that isn’t relevant in many cases and even if it is, the BRN may not offer you the option. Also, you can’t practice while you’re enrolled, so while the program might let you keep your license, you will probably lose your job.

If you aren’t offered that option or you decline, the board assigns the complaint for further investigation. Depending on the nature of the allegations, a complaint might be investigated by BRN staff, the Division of Investigation of the California Department of Consumer Affairs (of which the BRN is a part) or an outside investigator.
harsh questioning

Make no mistake — a BRN investigation can become a nerve-wracking examination of your professional and private life that makes a TSA strip search look like a friendly pat on the back.

Adding to the stress is the fact that investigators aren’t obliged to tell you exactly what they’re after or even the full details of the complaint. You won’t usually know who the complainant is or what they said, which can leave you scrambling to defend yourself without really understanding what kind of trouble you’re in.

BRN investigations are considered administrative actions, not criminal investigations, so many of the legal tidbits you’ve gleaned from watching TV dramas like “Law and Order” don’t apply here. Nevertheless, there are two rules that do apply: You have the right to remain silent and anything you say is likely to be used against you!

Call Your Lawyer

You are allowed legal counsel when speaking to the BRN investigators, and if you’re facing an investigation, hiring an attorney may be a wise move. Unfortunately, it can also be expensive. Many malpractice insurance policies don’t protect you in the event of a board complaint or will impose caps on how much the insurer will pay to assist in your defense. Still, if the investigation results in a formal accusation, your entire nursing career may be on the line, so the cost might well be worth it.

If you don’t know how to find a lawyer with expertise in this area of law, the American Association of Nurse Attorneys ( may be able to help. This is an association comprised of RNs who are also attorneys, many of whom have experience representing nurses in cases like these and understand both the legal and professional issues involved.

The Formal Investigation

An investigation is just that: examining the evidence related to a complaint to determine if it has any substance. Not all investigations result in an accusation, much less disciplinary action. Sometimes, investigators conclude that the allegations were false or at least that there is insufficient evidence to substantiate them. In other instances, the board might decide the allegations are substantiated, but opt to let you go with a citation and a fine.

If you’re not so fortunate, the board’s next step is to issue a formal accusation that you have violated the Nursing Practice Act. This accusation is public record and anyone can look it up on BreEZe or the BRN website. In most cases, the accusation will be followed by an administrative hearing, which is like a trial.

If you haven’t already hired a lawyer by this point, you should seriously consider doing so. Administrative hearings have their own terminology, rules and procedures; a simple misunderstanding could be career-ending. If you don’t promptly file a notice of defense after receiving the accusation — in which case the board will assume you’re forfeiting your right to a hearing — or if the board rules against you, you may be kissing your license goodbye. Depending on the allegations, you might even face criminal charges.

Keeping the BRN Fair

We like to think that the BRN represents nurses’ interests, so ending up on the receiving end of the board’s suspicion can feel like a betrayal. However, we should keep in mind that the BRN is not in the business of protecting RNs — it’s in the business of protecting the public from RNs!

If the BRN has reason to believe a nurse has stepped out of line, the public and our elected officials have every right to demand that the board act swiftly and firmly to investigate and correct the situation.

That doesn’t mean that nurses have to stand by helplessly or be railroaded. By educating ourselves on the BRN’s policies and disciplinary procedures, we can exert our influence to ensure that the board acts fairly and justly. BRN meetings, including the meetings of the Diversion/Discipline Committee, are open to the public and allow for public comment on any issue relevant to the committee’s business, even if the item isn’t on the agenda.  (You can find a schedule of meetings here.)

Another option, and one I always recommend for nurses, is to get involved with the legislative process. Remember, the BRN’s function is to enforce state law and regulations. If you feel those rules are unjust, it only makes sense to address your complaints to the lawmakers with the power to change them — or consider running for office yourself.


As nurses, we’re familiar with eight-, 12- and even 24-hour shifts, but our profession has developed another unpleasant permutation that not all of us have yet encountered: split-shift floating.

Split-shift floating means that a nurse starts his or her shift in one unit and then at some point during the shift is moved to a different unit. Shift-splitting is most often done with registry or traveling nurses, although it occasionally happens to staff nurses as well.

Thankfully, shift-splitting is relatively rare, but it can be a sign that something is seriously wrong with the way a hospital manages its nursing staff.

Why It Happens
I know that a lot of readers have strong prejudices against registry nurses, but there’s no denying that they are a fact of life in many hospitals. In a perfect world, there would be no need for registry nurses, but in a perfect world, no staff nurse would ever call in sick, have to leave in mid-shift due to an emergency or quit at an inopportune time. Unfortunately, in the real world, those things happen all the time and when they do, many hospitals turn to registry nurses (also called travel nurses or just “travelers”) to pick up the slack, particularly in states like California that mandate minimum nurse/patient ratios

Registry nurses typically work through a staffing agency that contracts with the hospital to provide temporary nursing services. Because hospitals aren’t usually in a strong bargaining position in these negotiations, travel nurses are often hired on “pay or play” contracts, meaning the hospital is obliged to pay for a predetermined number of hours or shifts regardless of how many hours the traveler actually works.

That’s why when the patient census drops, staff nurses sometimes find themselves sent home while the registry nurse stays — the hospital is on the hook for the traveler’s time whether he or she is working or not! For the same reason, travelers may sometimes find themselves shifted from one unit to another during a single shift to make up nursing shortages in different areas of the hospital.

Where It Goes Wrong
Floating nurses from unit to unit on different shifts is not itself a bad thing and there are occasions where shift-splitting is unavoidable, albeit far from ideal. However, if they become commonplace,  “Houston, we have a problem.”

Splitting shifts can have very negative consequences for the hospital and patients as well as the nurses. Having to change units during a shift can lead to a whole assortment of errors ranging from incomplete charting to missed or late medication. Worse, if something does go wrong, other nurses may have to step in to fix it, taking time away from their other duties and potentially compounding the bigger problem.

Behind the Eight-Ball
To illustrate the disruptive nature of shift-splitting, here’s a recent night in the life of a travel nurse named Charlene, who has given me permission to share her story with you.

Charlene was scheduled to spend the first half of her eight-hour shift, from 19:00 to 23:00, in Unit A and the remainder of the shift in Unit B. Here’s a small sampling of her duties during her four hours in Unit A: One patient presented with glucose of over 400 with no order for a sliding scale, had a wound V.A.C. to address ulcers on one foot and needed a leg ulcer dressing change at hours of sleep.

Charlene managed to track down the physician and get an order to administer a stat dose of 15 units of NovoLog while caring for three other patients, one of whom presented with a persistent fever and prompted Charlene to seek a doctor’s order for straight catherization for urine culture and sensitivity.

Charlene managed to accomplish and document all these tasks and at 23:05 was ready to brief the nurse assigned to relieve her. Five minutes later, while giving that report, she got a call from the assistant nurse manager of Unit B demanding to know why she wasn’t there yet!

This is a common dilemma for nurses working a split shift: If they don’t take the time to make a full report to their relief, patients’ continuity of care is likely to suffer, but taking that time almost certainly means being late to the next unit and being chewed out by the manager there. Charlene aptly describes the whole situation as being “behind the eight-ball.”

Dirty Curtains
Obviously, this is not good or sound nursing practice. Unfortunately, nurses in that position don’t have much recourse. When Charlene spoke up, she was given a dressing down and warned, “When you’re in someone’s home, you don’t tell them that their curtains are dirty.” A travel nurse who complains too much about a hospital’s practices is likely to be rewarded with a “do not send” note in her agency file.

Staff nurses may not fare any better. How many of us have been (or seen colleagues) reprimanded or otherwise punished for pointing out an unsound or unsafe practice? Such punishments send a message to the rest of the team that they should keep their mouths shut or share a similar fate.

A Better Way
During my various tenures as a director of nursing, one of the first things I always tried to put in place was an in-house pool of floater nurses. This pool wasn’t simply plucked arbitrarily out of the nursing staff; it was a group of talented and adventurous nurses who had been carefully recruited and, most importantly, had volunteered for this unique and challenging assignment.

Building those pools took work (each nurse had to be a generalist with the right personality and the ability and desire to take on a diverse and ever-changing array of duties), but it allowed our leadership to respond to each unit’s day-to-day staffing needs with nurses who were up to the task — without needing to rely on travelers or shift-splitting.

The point is not that hospitals should  never float nurses between units or hire registry nurses, but it is vital that the nursing chain of command not allow short-term solutions to become routine practice. Responding to an occasional emergency is one thing, but regular shift-splitting or constantly relying on travelers rather than addressing ongoing staffing issues will just mean higher costs and more mistakes.

It’s also crucial for nurse managers to create a climate where the staff is not afraid to offer constructive criticism. At the same time, nurses must have the courage to speak up when they see an unsafe situation and not throw each other under the bus just to make it through the workday.

If more nurses made it clear that we as a profession won’t stand for unsafe nursing practices like shift-splitting (and won’t stand for colleagues being capriciously or unfairly punished for a valid complaint), it will make our hospitals safer, saner environments for nurses and patients alike.


~Geneviève M. Clavreul, RN, PhD

From The Floor

Working Nurse Magazine

The AFL-CIO just released an announcement that heralds the following: “Catholic Bishops, Health Providers, Unions cooperate to support workers’ rights”. The headline and the subsequent list can easily leave the reader believing that employer, workers and union organizers have agreed to a set of very good and positive principals. However, you’d be wrong because according to the AFL-CIO blog post that details this accord “the new guidelines cover seven principals for employers when workers seek a union”, the operative word here is employers. In short, the guidelines only apply to employers, not to the employee in favor or opposed to unions, or the union organizers themselves. And though this is not quite as egregious of an agreement as the odious Tenet/C.N.A. (an affiliate of the AFL-CIO) neutrality agreement, which handed over the personal information of registered nurses (without the knowledge of those same RNs) at C.N.A.-targeted hospitals it’s still nonetheless a one-sided accord.

The seven principals for employers when workers seek a union:


Access to information;

Truthful communication;

Pressure-free environment;

Expeditious process;

Honoring employee decisions; and

Meaningful enforcement of these principals

How can I tell? because of the term employers in the sentence, and not phrases such as all parties, everyone, all concerned and so forth. So once again unions have found a way to stack the deck. What’s truly sad is that the guidelines suggested above are well meaning, but without them being applied to all, and I mean all parties (that would include employee both in opposition to and in favor of union representation and the union organizers) this then leaves the door open for union and their supporters to engage in bad behavior without fear of repercussions (this would also go for the employees who are in opposition to union representation).

Additionally several of the phrases are subjective rather than objective. For example, how are we defining truthful communication, pressure-free environment and meaningful enforcement? I ask this since one person’s pressure could be another person directly asked question. Truthful communication? What does that mean? For example in a recent flyer put out by the C.N.A., an AFL-CIO affiliate, numerous duplicate signatures, unidentified employee signatures, terminated employee signatures, and signatures of people in favor of decertification were found on a “petition” to encourage Cy-Fair nurses to vote against decertification. When a C.N.A. representative was asked why such a flyer was even being distributed the response was oh well it was a printing error; but to many individuals including myself this flyer was less than truthful, but apparently to the C.N.A. there was nothing “untruthful” about it.

So though the accord that seems to have been reached, I think it’s once step above an Election Procedures Agreement (EPA). If unions and employers were all about supporting the workers then these guidelines should’ve used more objective language and should’ve been written to include ALL parties. All too often unions accuse non-union nurses as being surrogates for management thus putting into question the motives of these nurses; and pro-nursing union nurses are often found exhibiting less then positive adult like behavior. The union gets the option of pointing the finger of blame to the first and ignoring the bad acts of the later; while employers do the same in reverse – meanwhile it’s the nurses themselves that suffer in the end. Or you have experiences such as the nurses in Houston and Philadelphia where hospital management was so cowed by the EPA that they decided to not respond to any questions that nurse had that remotely referenced the union, and barred any message by pro-union messages going so far as to give the union a glass covered bulletin board, but no such favor to the “No to the union” nurses. Is this fair? Does it fall in line with the above AFL-CIO guidelines?

You may wonder why I even decided to address the AFL-CIO accord with the Catholic Bishops et al; simple the link was sent to be by someone identifying himself or herself as:


Submitted on 2009/07/09 at 3:24am

I’d like to know your thoughts on this:

I found the query trapped in my spam folder since both the name and email appeared suspicious to my spamblocker. I did a quick whois search and found that it had been sent from the servers at the California Nurses Association (see copy of search here). I wonder what ulterior motive the C.N.A. had in sending me this link to their affiliated organization? Are they contemplating adopting a similar, somewhat more restrained approach to their well know aggressive organizing? Well who’s to know the real reason, but respond I have with my opinion.

Imagine finding flyers posted all over a hospital sounding the “alert that a professional union buster was on site”, and that flyer used to identify a nearly 70 year old great grandmother who has to use an electric scooter to get around. What power this person must have to send the California Nurses Association (C.N.A.) in paroxysm’s of fear and panic and to engage in their usually tactics of lies and misinformation. I was met with just such exhibitions fear-mongering and hysteria by C.N.A. recruiters, representatives and supporters when I made a recent visit at the invitation of a fellow nurse from Cy-Fair Hospital in Houston.

Their flyer identified me as a professional union buster, which I guess is a recognition of how much they fear my presence; but truth be told I’m not a professional union buster, and in particular I’m not a nursing union buster. The C.N.A. and many other pro-union people love to use the word union-buster since it tends to invoke images of a Simon LeGreed character replete with requisite black hat and clock and evil laugh.

I have nothing against unions for the blue-collar worker, but I’m far from convinced that professionals such as registered nurses need unions to represent them.   So when nurses contact me for my opinion and advise about how to speak for themselves I am always happy to help my fellow RN in advocating for our profession and for themselves. I’m happy to help in the effort of showing nurses they can and do have a strong voice as both an individuals and as a group without paying a nursing union dues of upwards to $80.00 a month for the favor.

In the case of two recent nursing union attempts, one nursing staffs attempt to stay free from the C.N.A. and one nursing staff attempt to decertify from the C.N.A. As fate would have it, I was in a position where I could help both in spirit and in person so I did. At the first hospital my fellow nurse and I found C.N.A. representatives playing shenanigans with hospital elevators so that the floor where a “No to the C.N.A.” nurse had been given a meeting room was locked out. This malfunction only affected the one floor that we had to reach on both days, what a coincidence. You may wonder why I think C.N.A. representatives capable of such underhanded techniques. Simple, I still haven’t forgotten a C.N.A. strike in the San Fernando Valley where pro-C.N.A. nurse locked out much need medical equipment, hiding/destroying manuals, etc., so that the relief nurses were hard pressed to provided nursing care to patients many of whom were in intensive care; and the C.N.A. strike was suppose to be all about their concern for patient safety — go figure! And at the second hospital I got treated to the experience of being stalked by not one, not two, but upwards to three C.NA. representatives at a time. The situation became of such concern that hospital HR and security had to become involved; but I guess I should feel honored that the C.N.A. felt the need to have so many people watching my every move.

Whether or not nurses chose a union to represent them or not should be up to the nurses themselves but this seems to rarely be the case these days. As in the case of the Tenet Healthcare/C.N.A. neutrality agreement Houston nurses that had opposing views to the C.N.A. material, propaganda or message had no one to turn to; at least that’s what the C.N.A. representatives thought, except they overlooked a grassroots network of informed RNs that were available for these nurses to reach out to; which they did and we responded. One would think that the C.N.A. representatives would be excited to learn that nurses were empowering one another, oh that’s right it only counts if the nursing unions are doing the empowering.   So sorry, we didn’t get that memo. One would also think that the C.N.A. would invite and encourage an open and lively discussion about the benefits of a nursing union, but they couldn’t be bothered to even accept the invitation extended by one group of nurses to present their viewpoint in an open debate. Instead they skulked about passing out flyers full of misstatements and lies since it so much easier to insult the intelligence of nurses rather than respect them.

In the case of the flyer (CYFair_NNOC_Alert1) they suggested that the nurses ask me a set of questions, and I responded with an open letter (OpenLetter1). One pro-C.N.A. nurse chose to mark up my open letter with graffiti instead of addressing me nurse to nurse. But then again it’s become common practice for pro-nursing union nurses to engage in such childish behavior. It’s a sad day when our honorable profession is marred by such immature behavior. However, I see these as indicators of how much the organizational structure of the C.N.A. fears nurses who chose to take back or carry on with their own voice. In the past several years their membership has been declining (their last official report in 2008 has their membership at just over 72,000 almost a full 8,000 or 13,000 drop depending on which C.N.A. official report you read). I think it’s this drop that has them scrambling for new members in the other 49 states.

But in some parts of our country nurses don’t want anything to do with them, and even when Tenet handed the C.N.A. the proverbial keys to the kingdom providing C.N.A. organizers unfettered and unprecedented access to RNs on the floor, scheduling information and even home addresses and telephone numbers; the C.N.A. has found resistance to their siren song. They couldn’t even gather enough cards at Park Plaza and Northwest Hospitals in Houston to even call an election and they slunk out of Houston so quietly that few even knew they had abandoned their organizational efforts. They accused one, that’s right ONE, nurse of trying to take away the union at Cy-Fair Hospital. What power this one nurse must have, I guess the well over 30% of eligible nurses that signed decertification cards meant nothing, it was all that one nurse’s fault. And this morning we learned that Hahnemann Hospital (another victim of the nefarious Tenet/C.N.A. neutrality agreement) had rejected the union. The C.N.A. had such access to the RNs at Hahnemann that nurses that opposed the C.N.A. had to get the NLRB to intervene just so they could get a meeting room in the bowels of the hospital and finally a table in the cafeteria (shortly before election day) and the union spokespeople whined that this was unfair.

So if our network of nurses, and me, in particular can help our fellow nurses when confronted with such behavior and that makes us professional nursing union busters in the eyes of the union then I guess that’s a cross we’ll just have to bear. I see it as the desperate actions of an organization that knows that people have begun to look behind the curtain that is the California Nurses Association/National Nurses Organizing Committee and they don’t like what they see. The more they howl about RNs empowering each other the more I know that I’m their bête noire and that’s a role I think I shall relish.

The nurse’s of Hahnemann University Hospital in Philadelphia just got the news — they won in their election fight against the California Nurses Association (C.N.A.)! The vote count was 309 RNs against to 267 RNs in favor of unionization.

I wonder how the C.N.A. and their supporters will spin this election loss. No doubt they’ll issue a press release touting the narrow loss and I’m sure the press will parrot this statement. Just like when the C.N.A. won the vote at Cy-Fair in Houston by a margin of 8 (now that was a slim victory), but the C.N.A. touted the vote as though it was a resounding victory for nurses across Texas. So if we use their own reasoning then we can only conclude that if an 8-vote margin is a resounding win; then a 42-vote margin is one major whooping on behalf of the nurses in their rejection of the C.N.A. Maybe the Pennsylvania nurses might’ve been more receptive to the idea a nursing union if it had been a local nursing union that was courting their vote and not the carpet bagging C.N.A. and their well-known bullying tactics that was courting them?

To put things into perspective for folks, the nurses that weren’t keen on a nursing union had a very hard row to hoe. Like in Houston they found that their hospital and nursing management were in essence prohibited from offering them assistance thanks to a so-called neutrality agreement (for more one this agreement see “Like Thieves in the Night”) that had been signed between Tenet and the C.N.A. The agreement gave all the cards to the C.N.A. and their representatives to spread their message, but withheld equal support for the nurses that wanted to get their counter-message out. Things were so blatantly unfair that the NLRB actually intervened on behalf of the No to the C.N.A. nurses and granted these nurses a couple concessions: such as a meeting room that was somewhere in the “bowels” of the hospital so that only the most stalwart of nurses could find the meeting room and of course finally a table in the cafeteria. Throughout the process nurses, such as Nurse Hummel were stalked, photographed, and pilloried by the C.N.A. representatives. The C.N.A. pulled out all the stops even going so far as to paying for a pro-C.N.A. nurse from Cy-Fair hospital to come out and make the rounds through the hospital and producing a flyer depicting Hahnemann nurses attending a big pro-union rally in DC organized by the C.N.A. The only problem with the flyer was that the nurses pictured from Hahnemann Hospital never attended that event and had been plucked out of another photograph and pasted into this C.N.A. propaganda material. Nurse Hummel even made sure to invite the C.N.A. to attend a debate so that interested nurses could have an open discussion, but the C.N.A. was a no-show, which seems to be par for the course when it comes to dealing with the C.N.A.

I think that the C.N.A. finally met their match when RNs from several other states came out to offer their support, expertise and knowledge with those who simply wanted to be able to have their side of the story heard. I know that several nurses came out on their own dime and time; and as one of those nurses, I found the time I spent at Hahnemann enlightening and enjoyable. I was both pleased and honored to have met with not only Nurse Hummel (after so many telephone conversations) and the countless other RNs that came to our table or met us in the hallways and meeting rooms to share their story and to give me an opportunity to answer their questions.

So hats off to all the nurses (both anti & pro nursing union) of Hahnemann who turned out to vote (from what I’ve been told about 592 eligible nurses voted) that means nearly 60% of the eligible nurses voted in this election. I can only hope that the media fairly reports the outcome of the election and assuming that they even chose to report the vote outcome. For more information I invite you to visit the Hahnemann nurses website at:

Like thieves in the night . . .

They came like thieves in the night, their goal simple: to “steal” their way into one or more of the Tenet-run Houston hospitals. Their arrival wasn’t completely unexpected, it’s just that the Registered Nurses at CyFair, Northwest and Park Plaza, weren’t the ones that had invited them. Instead, the California Nurses Association/National Nurses Organizing Committee (C.N.A./N.N.O.C.) came under a rather notorious arragement known as a “neutrality agreement” and as the only union option. There would be those that might argue that a neutrality agreement isn’t such a bad thing, and it wouldn’t be if such an agreement were actually neutral. Most reasonable people would understand the term “neutral” to mean having no personal preference/bias or not supporting or favoring either side in a war, dispute, or contest; but the agreement that the C.N.A./N.N.O.C. came in under, with the consent of Tenet management was far from neutral.

When I first learned of the neutrality agreement I asked for a copy and it wasn’t long before a copy appeared in my mail, and after reading the lengthy document it was clear that Tenet and the C.N.A./N.N.O.C. had entered into an agreement that benefited not the nurses but the union leadership of C.N.A./N.N.O.C. One could easily blame the leadership of C.N.A./N.N.O.C. for crafting such a one-sided contract, but the fault for agreeing to the overly restrictive terms lay firmly in the lap of Tenet management. As any good contract negotiator will tell you, its not uncommon for one party or the other to present a tough or one-sided agreement, they do this to see what kind of or how much push back they will get from the other party; and it’s assumed that the other party will present a counter offer – hence the term contract negotiation. But if Tenet offered any counter offer to the C.N.A./N.N.O.C. agreement then I can only conclude it was a half hearted one, because the contract heavily favored C.N.A./N.N.O.C., to the point of disadvantaging Tenet’s very own nurses themselves.

For example the C.N.A./N.N.O.C. representatives were given access to the employee list, including personal contact information, of all the RNs at the three hospitals (CyFair, Northwest, and Park Plaza). Keep in mind that prior to this all three hospitals were non-union shops, thus the C.N.A./N.N.O.C. were not yet recognized as a bargaining unit for any of the RNs at these hospitals; so these strangers were given free access to this personal information and RNs discovered this only after they started receiving calls, visits and mail from C.N.A./N.N.O.C. Tenet also sold the rights of the RNs to any non-approved C.N.A./N.N.O.C. messages or information, because they agreed to a clause that required C.N.A./N.N.O.C’s. approval of any flyer that the hospital management would post regarding the unionizing efforts with their hospitals (keep in mind C.N.A./N.N.O.C. were not yet a recognized bargaining unit at any of these hospitals). C.N.A./N.N.O.C. representatives were given meeting space and permission to have information booths in employee areas; but when a group of Tenet nurses (many of whom were already members of the state’s professional nurses association, the Texas Nurses’ Association) requested the same privilege they were denied by hospital administration. So instead the nurses were expected to, and did run their own information campaign on their own dime and time. These nurses organized a truth-a-thon to provide interested nurses with another side of the “union/non-union” story; C.N.A./N.N.O.C. were so fearful that these nurses had decided to provide an alternate voice that C.N.A./N.N.O.C. representatives took photographs of the “no to” C.N.A./N.N.O.C. nurses and those nurses that requested information at the truth-a-thon.   Which is why I’m always skeptical at unions that whine about the harsh tactics of management when they often engage in the very same or even worse tactics that they accuse management.

In the end with a very small margin CyFair nurses voted to accept the union but of course C.N.A./N.N.O.C. declared an outright victory and that a new day was dawning for the nurses of Texas, because soon C.N.A./N.N.O.C. would release all RNs in Texas from the shackles of “servitude” and “oppression”. But wait; there was still Northwest and Park Plaza.   What happened to the union vote at these two institutions? Well, just as C.N.A./N.N.O.C. came into Houston like thieves in the night on April 14th they formally withdrew their petition and they slunk out of Park Plaza and Northwest, once they realized that the RNs at Northwest and Park Plaza with help from CyFair nurses were not about to abdicate their professional voices without full disclosure. These nurses launched, again on their own time and dime, an information campaign and as luck would have it they got to observe how C.N.A./N.N.O.C. representatives acted during the CyFair union organization drive and for every pro-union button that was being worn, two no thanks C.N.A. buttons were being worn as well. The Park Plaza nurses mounted such excellent information campaign that C.N.A./N.N.O.C. representatives demanded additional time to campaign and of course their request was granted – but even the additional time couldn’t turn the tide for C.N.A./N.N.O.C. Ironically C.N.A./N.N.O.C. accused the two Tenet Hospitals with colluding with the NRTW Foundation as to why their organizing efforts failed. Let me get this straight Tenet gives C.N.A./N.N.O.C., complete access to employee personnel records, unfettered access to nurses while at work, in the units, break rooms and wherever else nurses gathered in the hospital and denied nurses who opposed the C.N.A./N.N.O.C. message even the opportunity to provide their side of the story, except when those nurses did all the work themselves on their own dime and outside hospital premises and C.N.A./N.N.O.C. whines, stomps their feet and cries “FOUL”? This is just one more reason that I oppose unions for nurses, because this is not the kind of behavior I want to see exhibited by the nurse professional.

Where is the Texas media to report the withdrawal? All the while C.N.A./N.N.O.C. was actively organizing the newspapers could barely contain themselves and happily reported on the C.N.A./N.N.O.C. progress; but now that C.N.A./N.N.O.C. has withdrawn there has been nary a peep.

Of course, I know why C.N.A./N.N.O.C. and their supporters in the media doesn’t want it known that the nurses of Northwest and Park Plaza rejected their overtures; because God forbid should nurses be lead to believe that they can speak for themselves since the C.N.A./N.N.O.C. campaign is based heavily on “nurses are so weak, disenfranchised and oppressed” that only a union can adequately represent them. So when nurses reject the C.N.A./N.N.O.C. either by voting them down as recently happened in Fresno, or decertify as in the San Diego area, or stand-up and don’t even let them get their foot in the door as in Houston then the mythos created by C.N.A./N.N.O.C. is damaged and thus makes their propaganda much less affective.

With little fanfare this past week, nurses from Centerpoint Hospital of Independence, MO held a decertification vote. The results 226 to 78 with 24 opting not to vote at all, and the Nurses United Local 5126 (part of the American Federation of Teachers) were ousted as representatives for the RNs at the hospital. The vote took place over two days (April 23 and 24) last week, and the results were a celebrated outcome to a small core group of professional nurses that had coalesced to further professionalism versus unionism for nurses.

I learned about the nurses of Just Let Us Vote, JLUV –, and emailed the contact for JLUV, Jerilyn McDermed. She responded to my email with her telephone number and I called her and we chatted. She gave the “quick and dirty” version of the history of the unionization of Centerpoint and why she chose to launch a decertification effort. Their path to decertification wasn’t an easy one, they were targeted by members of Nurses United Local 5126, labeled the “misinformed minority”, demeaned by some of the more vociferous pro-union nurses on staff, and found little support in the local media to get their side of the story out. Yet, they persevered and after many months of foot-dragging from the union they got the green light for a decertification vote. Of course the union machine spun the story as if they had been the ones instrumental in allowing the nurses the opportunity to have the vote; and in a way that was true since the union had filed numerous complaints with the NLRB that caused the vote delay. So when the union removed their objections the vote was green lighted, but then again if the union hadn’t initially objected the vote would have taken place much, much sooner.

It’s behavior such as this that makes me suspect the true motivations behind the union’s push for the “Employee Free Choice Act”, better known as EFCA. They extol the virtues of having a majority of employees signing cards to bring in union representation, but when the tables are turned and people sign cards to end union representation then the union fights it tooth and nail. So, it’s apparent to folks like me that the union likes to make full use of the process when it serves them, but they don’t want their opponents to have the same opportunities. Maybe this simple fact is why polls show that up to 80% of union members themselves oppose the passage of EFCA. But, back to Centerpoint.

So, when I came across an article in the Independence Examiner about the upcoming vote I wrote a letter to the editor and it was published on March 31st and distributed throughout the hospital by nurses. Jerilyn shared with me that a pro-union nurse had defaced one of the letters that had been posted, and her response was to place a post-it note by the defaced flyer that asked folks not to write on her flyers, since no one wrote or defaced their flyers. Of course, she wasn’t shocked by such churlish behavior since all too often pro-union nurses will engage in such behavior with the full support of their union local – another reason why professional nurse often eschew unionization.

As the date of the vote approached the Kansas City Star did a write up and its lean was so pro-union that was more of a advertisement then a news story, so I was compelled to write a letter to the editor and contact the Reader’s Representative. He was very nice and said he would have the reporter call me, which I’m sure he did but as of the writing of this post the reporter has yet to call me. I had also left a message in his voice mail myself. Additionally, the letter to the editor reader had still not read my letter nearly three days after submission. In the end, the professional nurses of Centerpoint were able to overcome a pro-union local media and a well funded union local from the AFT to get their message out and the nurses responded with an overwhelming vote of 226 to leave the AFT with only 78 voting to remain with the AFT. Stories covering the recent decertification vote can be found at the Kansas City Star here ( and the Independence Examiner her (

One more victory in a growing movement by professional nurses to decertify from union representation and retake their voice and right to self-representation.