When You See Something, Say Something

I chose to make a difficult decision.  I voluntarily left a job I was 150% passionate about because I could not accept discrimination, devaluation, and disrespect for myself and the nursing profession, from an employer who places their Nurses, their patients and potentially their organization at risk.

A LITTLE ABOUT MY BACKGROUND

Before I share what happened, I’d like to offer a little about my background, not to be a braggart, but rather, to reinforce my devotion to the nursing profession. I earned a Masters in Nursing from the University of Arizona and a board certification in Nurse Coaching from the American Holistic Nurse Credentialing Corporation and I am faculty with the International Nurse Coach Association.  I have over 20 years of nursing experience with most of it being critical care nursing- or intensive care. 

I am a Nurse Entrepreneur with a 501c3 business that protects fellow human’s brains from dementia and neurodegenerative disease through lifestyle strategies and Nurse Coach driven health coaching. I volunteer in my community and share pro-bono health promotion educational events. Thankfully, my nursing career has been rewarding and successful.

Life as a solo entrepreneur is isolating and I missed daily collaboration with fellow healthcare colleagues.  I was not in search of extra money, I was looking for a progressive, supportive environment that shared my passion for improving the health and wholeness of fellow human beings, so I sought employment with X Organization as they are leaders in disease prevention and health promotion.

MUST BE LICENSED AS A REGISTERED NURSE

After six interviews I accepted a role as a part time RN Health Coach, …’what a thorough process’, I thought. One job requirement was, “…must be licensed as a registered nurse with a minimum of 3 years professional, clinical experience”, among other qualifications that I exceeded.  The role included travel health coaching in states I was not licensed in, so I prepared to submit for state licensing to practice legally.

AS A RULE…

As a rule, a nurse must be licensed to practice in the state a patient resides. Since part of my job required me to care for patients living in Washington, Arizona and California, I prepared to submit my qualifications for nursing licensing according to law, and professional responsibility.  I am already fully licensed in the states of Washington and Texas, so California would be the only new state I would apply for licensing in.

Texas and Arizona are part of the Enhanced Nurse Licensure Compact (eNLC), and an eNLC allows RNs to obtain a single multi-state nursing license, to provide care and telehealth services in their primary state of residency and other compact nursing states.  I share this and the following details so you understand licensing is not simple but it is entirely necessary and is a nurse’s professional responsibility.

AN IMPORTANT DISTINCTION

Nursing licensure is an important distinction and the National Council of State Boards of Nursing reminds us that the, “…purpose of a professional license is to protect the public from harm by setting minimal qualifications and competencies for safe entry-level practitioners”. 

Like pilots, attorneys, physicians and teachers, nurses are also regulated by government agencies since these professions can pose a risk of harm to the public if practiced by someone unprepared and/or incompetent.  The strict licensing process, “provides assurance to the public that the nurse has met predetermined standards”.  

These predetermined standards are many and vary state to state.  All states require nursing education verification, and passing of the national licensing exam (NCLEX). Most states require fingerprints, criminal back ground checks, self-disclosure about legal and professional issues, and medical conditions that may impair practice; legal information, like juvenile and adult offenses, and proof of continuing nursing related education credits.

States also require verification of past nursing licenses. Lastly, “…the responsibilities of a licensed nurse include knowledge of, and adherence to, the laws and rules which govern nursing as outlined in the nurse practice act and regulations”.  These are logical requirements since nursing is a profession that will pose risk of public harm if practiced by an unprepared and/or incompetent person.

150% DEDICATED

I was 150% dedicated to my new employer and excited to work with them, for I want all humans to be free from disease and to live with vitality. Disease prevention strategies help people achieve a high quality of life, and I commend X Organization for committing to this work.

I too, have devoted my life and career to disease prevention, as evidenced by my nursing career, yes, and in addition to nursing, I am a certified personal trainer, a certified group fitness instructor and a certified yoga teacher.  I have many certificates in nutrition, meditation, specialized population fitness training, and diverse complementary modalities and I strive to live as a role model for what I hope for my patients. 

I RESPECT THE PROCESS OF NURSE COACHING

I respect the process of health and/or Nurse coaching, in fact, in this model, I have witnessed more positive patient involvement, dedication, and patient success than in any other nursing role in my 20+ years of service.  Nurses who are board certified Nurse Coaches, combine the skills of medicine and the art of nursing.  They understand the intricacies of the health care system and are fierce patient advocates. Nurse Coaches practice the skills of deep listening with presence and we become partners with our patients, never giving them orders, instead, we help them acknowledge their wisdom to articulate what is most important in their health and well-being.  I am passionate about this work because I have witnessed its power!

I’ve mentioned I was a critical care RN for decades and cared for patients and their families at their sickest, and rarely saw them improve. I applaud the healthcare system for sustaining life, yet I also boo the healthcare system for its lack of preventing and mitigating disease.  And then, I discovered Nurse Coaching. 

Nurse Coaching (aka health coaching done by Nurses) is an imperative role for Nurses to lead, for it invites patients to be active partners in the prevention and mitigation of illness. This is the work I was born to do for I have been called to support human beings to live their full potential, and I was thrilled to be offered a spot with X Organization to do it!

A PRUDENT REGISTERED NURSE

Of course, being a prudent Registered Nurse, I began the state licensing process to practice legally as a RN Health Coach. I asked my supervisor, “What happens if I don’t get my license in time to meet contract deadlines?”  This might not happen, but due to things beyond a state board of nursing (or my own) control, sometimes licensure approval can be delayed.  I wanted to uphold X Organization’s contracts, fulfill employment obligations, and satisfy my responsibilities as a sensible, professionally licensed Registered Nurse, so I proactively asked the question- just in case.  

Luckily due to the eNLC, I could legally practice to the full extent of my education in Arizona, and made travel arrangements to fulfill that contract first. I held back on scheduling California contract dates, as I was still working on getting fingerprints and documents for the California State Board of Nursing. It didn’t seem appropriate to make arrangements until I was licensed in that state.   

MAYBE THEY DIDN’T KNOW

Although I was only employed for a few weeks with X Organization, I felt a deep need to share my concerns; maybe they didn’t know Registered Nurses needed a license to practice in each state.  I received a call from a peer RN assigned to support me.  She wanted me to understand X Organization’s traveling coaches guidelines and to answer questions. 

I expressed that I felt practicing in a state without yet meeting their qualifications would not be in the best interest of the patients, the organization, the company we were contracted with, or myself. She explained that at X Organization, it was normal for Nurses to go to a state they are not yet licensed in, and instead of practicing as a Nurse, they would practice as ‘health coach’. 

I WAS CONFUSED

I was confused. I had been hired under the title of RN Health Coach and I wondered what practicing as a health coach for X Organization entailed. I am a rare breed, for I am a Registered Nurse who also has a nationally accredited board certification in Nurse Coaching.  I wasn’t sure what duties a health coach would do, I could try to assume (I know that can make an a$$ out of you and me), but what about other Nurses working at X Organization?  Would they know?  I felt a deep need to protect my colleagues faced with this decision. 

BOARD CERTIFIED NURSE COACH

A board certified Nurse Coach is a Registered Nurse who undergoes extensive, additional education and supervision to meet requirements to take (and pass), the American Holistic Nurses Credentialing Corporation Nurse Coach exam. Nurse Coach Certification training. The Nurse Coach education and practice is steeped in nursing science, its art and practice, nursing standards of care, theory, ethics, communication, therapeutic environment, leadership, research, professional accountability, self-awareness and accountability and the theories and principles of health and behavioral change coaching. 

Even with a broad understanding of what a health coach might do, I was very unclear about how to eliminate my nursing knowledge and experience from practice, and act only as a health coach. Red flags kept flying. The peer RN asked if I would like to speak to the Nurse in charge of traveling coaches and I said, “Yes please!”. She also emailed me a copy of X Organization’s Traveling Coaches Manual.

EXPLAIN THE RED FLAGS

I read the Traveling Coaches Manual hoping it would explain the red flags. It served as a resource and guide to help health coaches serve patients at remote client sites, and included topics such as what to consider when traveling, how to arrange travel, how to engage patients etc.  Mid document, two pages were devoted to licensed providers serving as health coaches in multiple states. It listed that licensed clinicians must abide to certain guidelines when providing care in states they are not licensed.  Here it is, certainly it will describe the process clearly!  I read on.

MUST NOT PROVIDE CLINICAL ASSESSMENT

It detailed that licensed providers not yet licensed in a state must not provide any clinical assessment, monitoring of chronic conditions or clinical advice.  What?! How does a highly trained Registered Nurse-no matter years of experience-remove all of their clinical assessment skills, when it is embedded in them? In addition, it indicated that all references to professional licensing must be removed from communication materials, like email signatures, business cards, voicemail messages and recordings, notices, and reminders or welcome packets.

But, the title of health coach could be used.  It even included a bullet point stating, ‘create a sign to cue what capacity you are providing care’.  WHAT?!  A reminder to the Nurse that (in this situation), you are not a Nurse despite all the years of education, dollars spent, time devoted and skills developed. Instead, you are a health coach.  Red flags all around.

DISCLOSURE

A heartfelt disclosure. There is ABSOLUTELY nothing wrong with doing the work of a health coach! This is not what this article is about. Health Coaches do incredible work supporting the community in the prevention of disease, they are indeed educated and 100% valued by me and all Nurses. But, there is a distinct difference between a Health Coach and a Nurse Coach and you can read about the differences here.

A LONG TIME SINCE I’VE FELT BULLYING

The next person up the chain had been working for X Organization for over a decade (I do appreciate the longevity of employees at this company). It has been a long time since I’ve felt bullying and incivility from a fellow nurse, but I distinctly remember its negativity in my heart, as it can (sadly), be a ‘rite of passage’ for a new critical care nurse. 

It is a sickening feeling in the pit of one’s stomach that one is ‘less than’ another, that one has little control over the situation, or that one feels vulnerable. It was in this conversation that I re-experienced that sense of helplessness and ‘less than’ once felt in my past.  I had only been working for X Organization for under a month, yet somehow I still mustered up the courage to speak up.

I asked clarifying questions using the coaching style of motivational interviewing, so I could understand the expectations as one of X Organization’s travel RN Health Coaches.  My hope was to glean clarity on license vs. non-license travel coaching, and how the role of Nurses in X Organization would directly impact patient safety.  I asked some hard and assertive questions, as any licensed professional should do when faced with decisions that will affect the outcome of a patient or the profession.

NURSES MUST SAY SOMETHING IF THEY SEE POTENTIAL HARM

I was professional and passionate, for I believe Nurses must say something if they see potential harm. I asked questions like; why do you hire RNs for health coaching?  What happens if someone presented with symptoms requiring a Nurse to use nursing assessment, but they were only to function as a health coach?  Are Physicians asked to practice in states to a lesser standard than their education?  Could Nurses practicing without licenses in the role of health coach be seen as flying under the radar of professional practice?  Was this a good idea for X Organization? I thought they were appropriate and thoughtful questions.

OVER THE LINE

I was told I was over the line, stretching the issue, cut off from asking full questions, and squashed to fully declare my concerns. I felt I was not heard. I felt disrespected for my intention to ‘do no harm’. Some memorable rebuttals to my concerns were; “It’s only for 4 days, Nicole.”, “Nothing is going to happen.”, “No one is going to trust you enough to share anything with you in such a short time anyways.”,  “You accepted the position knowing you would have to travel.”,  “We’ve been doing this for 10 years.” And, “The organization is completely comfortable with this practice and it has been legally vetted.”

ABOUT THE POTENTIAL RISK

I then attempted to express my concern about the potential risk if someone presented to my office with an acute emergency like a heart attack.  Would a health coach know the signs and symptoms? Could a Nurse who was to only practice as a health coach use nursing assessment skills in situations like this- even though they weren’t yet licensed by the state they were in? The Travel Coaching manual says…Health coaching is rarely a life or death situation, but I was confused and needed clarity.

WHAT IF?

But, WHAT IF someone presented and a Nurse (who was told to be a health coach, and not use assessment skills) used standard nursing physical assessment and critical thinking skills-because those skills are embedded in our veins-to determine the client was having a myocardial infarction? Would they be allowed to use their innate knowledge if they were supposed to only practice as a health coach? Would there be penalization?

Or, on a less emergent issue, could a Nurse offer education that a health coach might not know?  How could they know the difference, and could they cross the line?  What would happen if something went wrong?  Who is responsible?  I could think of a million other What If ? situations, because I have learned through experience, knowledge and skill that ‘what if’s happen and if we are unprepared tragedy occurs.

This unnecessary second guessing leads to mistakes or near misses that could hurt someone, and I and other Nurses are not willing to place anyone in harm’s way! 

IT’S ONLY FOUR DAYS

“It’s only 4 days, Nicole.”  Who could have imagined that a youthful patient would arrive to my office, sweating, short of breath, with a very fast and irregular heart beat and I would need to use nursing assessment skills and call 911?  

This happened on my first day of employment with X Organization (in a state I was licensed). I used fundamental nursing skills to keep the patient safe and to determine to call for emergency measures (911). But, given the same situation, what would a Nurse do if they were told they could only practice as a health coach?  I can’t answer this, because, as I am not just a health coach, I am a professionally licensed Registered Nurses with real concerns.

WHO WOULD HAVE THOUGHT

Who would have thought that two Registered Nurses would be held in violation of their state’s nursing professional conduct requiring that nurses must take appropriate action to safeguard patients?  They chose to dispense (very expensive) pills that had fallen on the floor because a pharmacist and physician told them to. 

THE NURSES SHOULD HAVE OBJECTED

The court ruled the Nurses should have “objected to what was happening or taken steps to avoid it.”  They were in violation, even though someone ‘higher than them’ told them to do it. Nurses are obligated to practice and “exercise independent judgment” in their nursing practice, and in this case, they did not safeguard their patient from potential harm.  Read more about this case here

In my case, I was objecting, and trying to take steps to avoid harm, but I was belittled and essentially ignored.  The final part of this conversation ended with her asking if I’d like to speak to the clinical director of X Organization “…but, she will likely tell you the same things.”  

MORAL DISTRESS

I thought long and hard about how to handle this situation; should I stay and accept the process of X Organization, or should I go?  There is a well-known healthcare concept called moral distress.  Moral distress originally defined in 1984 by Andrew Jameton as, “knowing what to do in an ethical situation, but not being allowed to do it”. 

A more current definition, moral distress is, “the stress that occurs when one knows or believes the right thing to do, but institutional or other constraints make it difficult to pursue the desired course of action”.  Nurses experience moral distress often, and it is one of the leading causes of attrition and burnout. I was definitely feeling its toll too.

But I also mustered up the moral courage to speak up and share my concerns, despite the fear of repercussions. And I urge all Nurses to do the same, even if it means having to quit a job you love.

TWO WEEK RESIGNATION

I gave my two week resignation.  A day afterwards, I received a call from my direct supervisor (the first person I had shared my concerns with) who asked me why I had given only two weeks and could I stay longer because they had a contract to fulfill. 

I gave two weeks because it is customary, and I could not stay longer at a company that opposes my values as a nurse and human.  She offered me an additional $500 a month bonus and a $750 final bonus to stay longer. This was additional insulting disrespect and reverting to the ‘old model’ of nurse recruitment- ‘throw money at them’. 

Now, if someone had truly heard my concerns, they might have said, “Nicole, we have reviewed your concerns and would like to discuss them further. Would you consider helping us re-write our travel coaching policy so we do not disrespect, or de-value the education, skill, and expertise our Nurses bring? And that we do not inadvertently place our employees in situations that may go against legal practice?”  But that didn’t happen- it was only my wishful thinking, but I could have made an additional $1750 if I stayed longer and went against all my moral and ethical beliefs.

NURSES ARE NOT NURSING FOR THE MONEY

Nurses do not nurse for the money.  Nurses truly care for people at their core.  Nurses want the best for their patients, their communities, their colleagues and the world. Nurses vow to keep people free from harm, do the right thing, at the right time, and do it well.  Throwing money their way will not solve the problems that healthcare faces, but truly listening and collaborating with them to improve the system will.

NURSES ARE KEY CONTRIBUTORS

Nurses are key contributors to the success of the healthcare system, and yet often, they are not asked to contribute their opinion, even with issues directly affecting them!  A report from the American Hospitals Association noted that nurses make up only 5% of hospital boards, yet they are the bulk of the healthcare workforce and understand the intricacies of the healthcare space innately. 

When Nurses are invited to the table they provide a wide range of context, diversity and real life experience that shifts the way healthcare is driven. But they need to be asked, they deserve to be heard, and they need to continue to stand up and voice their concern.

WHAT SHOULD WE TELL THE CUSTOMER?

I was then asked, “What should we tell the customer?”  to which I replied, “That you an I have a difference of opinion. What would you like to tell them?”  Silence.  Pause.  “I’m not sure”.  In the end, I agreed (and should not have), that they could communicate I was leaving to develop my business. They asked me to not discuss my reasons for leaving with anyone.  Red flags.

If the process of sending unlicensed Nurses to states had been legally vetted, and X Organization thinks it is ethical, why was I being asked to lie about the real reason for my leaving with my customer? Asking me to lie, goes against my vow to protect humans, deflects my own values and does not support the fact that Nurses have been voted the most honest and ethically sound profession for 17 years.

THE FUTURE OF NURSING

In 2010, the Institute of Medicine sponsored a report called the Future of Nursing:  Leading Change, Advancing Health highlighting the importance and value of Nurses in healthcare.  The report highlighted 4 main recommendations, and I will touch on two;

1.  Nurses should practice to the full extent of their education and training.

2.  Nurses should be full partners, with physician and other healthcare professionals, in redesigning health care in the United States. 

DISRESPECTFUL TO THE ENTIRE NURSING PROFESSION

Requesting Nurses renounce their license and qualifications because they are awaiting full license, and then asking them to function to the least amount of education is insulting and disrespectful to the entire nursing profession. 

Writing a policy asking them to delete credentials and qualifications from client facing communication disintegrates their partnership with other professionals and alienates them from the skills they are fully educated and qualified to perform. It is also dishonest.

NURSES VOTED MOST HONEST AND ETHICALLY SOUND PROFESSION

Not disclosing to customers that a Registered Nurse is functioning only as a health coach is behavior that is dishonest and potentially unethical to X Organization’s customers and patients. The Gallup poll has voted Nurses the ‘most honest and ethically sound’ profession for 17 consecutive years.  X Organization’s assumption that Nurses accept working in environments while removing references to their licensing, education and qualifications from communications is dishonest and unethical and is against the grain of every Nurse’s value. 

Asking Nurses to remove their well-earned title forces them to lie and places them in conflict with their vow to protect their patients from harm.

In addition, X Organizations customer is under the impression that licensed Registered Nurses will be providing health coaching. Sending Nurses not yet licensed and asking them to perform to the least of their skills is deceitful to the contracted customer, and should be discussed with the customer, so they are aware. At minimum, the situation should be shared with the customer, so they can make an informed decision to wait until the Nurse is licensed, or not.

GENDER DISCRIMINATION

One final point is gender discrimination.  Women make up 88% of the nursing workforce in the United States, despite this, the 12% of men in nursing are generally paid more than their female colleagues. In addition, physicians are primarily men, with only 34% of MDs in one 2015 report being women. I cannot say for sure, because my supervisor said she was not privy to this information, but I am almost certain that X Organization does not ask their physicians to practice as a different profession, nor to renounce their education and qualifications.

In addition when women speak up, negotiate or point out discrepancies (as I did), they are seen as aggressive, bossy, or abrasive, and if women are seen as competent, they are seen as less likable. I spoke up, and asked difficult questions because I am highly competent.  My very valid concerns were essentially ignored. 

AFTER ONLY SIX WEEKS

After only six weeks of part time employment, I resigned.  My conversations with parties at X Organization showed me that the organization does not value Registered Nurses as full partners.  Requesting that Nurses’ practice to a lesser extent of their education and skills forces them to comply with organizational rules that places Nurses, patients and the company at risk. Asking them to lie is dishonest.

I must stand up to refute disrespect, dishonesty, devaluation and discrimination of Nurses, for myself, my colleagues and my patients.

What would you do?

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Nicole Vienneau MSN, RN, NC-BC is a Registered Nurse, board certified Nurse Coach, personal trainer, group fitness instructor, yoga instructor & founder of Blue Monarch Health and Brave Mind Living. She specializes in the prevention of brain disease, by partnering with all humans to discover their power & wisdom to enhance their health & wholeness. When she's not coaching clients, she loves being in nature, relaxing with her cats or traveling with her awesome husband.