Howard is an acute care nurse practitioner committed to patient safety. Not infrequently, one of the intensivists, Ann, will give Howard her password, and ask him to enter an order set or note into the electronic record, because she is “too busy” to do it herself. She promises to look at the record “as soon as she gets time.”
Howard has tried to decline, knowing that this violates agency policy and it could get him in trouble. Ann, however, is insistent and he values the working relationship they have and is pleased that she trusts him. Howard thinks no harm can come of this. One of the ICU nurses is aware of this practice and anonymously alerts the nurse informaticist about this breach in protocol using the safety hotline. Patricia, the nurse informaticist, alerts the unit’s medical director, nurse manager and enterprise risk manager. The hospital has only just begun to work on disciplinary guidelines and there is no consensus yet about how best to address these violations. Patricia suspects that Howard and Ann are not the only clinicians guilty of these violations.
Guidance from the ANA Code of Ethics
Provision 6.3 of the ANA Code of Ethics for Nurses (2015) makes it clear that “Nurses are responsible for contributing to a moral environment that demands respectful interactions among colleagues, mutual peer support, and open identification of difficult issues. … Unsafe or inappropriate activities or practices must not be condoned or allowed to persist. This same provision recognizes that unless the workplace is a morally good environment, safe, quality patient care and professional satisfaction for nurses and nurse integrity are at risk.
The medical director tells Patricia he will take care of the issue and make sure it does not happen again. He confronts Ann and tells her she is not to continue this practice. He confronts Howard separately, tells him he is never to enter the EMR using a password other than his own, and explains that if this happens again he will be terminated with cause. A note about this violation is being entered into his work record. Patricia follows up with Howard who believes Ann got off with a “slap on the wrist” while he “took the fall.” Howard is definitely not happy.
Patricia meets with Ann and Howard and suspects that there are no bad actors here, just busy clinicians unfortunately ignoring rules designed to protect patients. Patricia suggests that the three of them meet with the medical director, nurse manager and risk manager to think together about how best to respond to this violation. At the meeting, the nurse manager suggests that Ann and Howard share their story at an upcoming Safety Friday noon session. In addition to describing how and why the breach occurred, they are to share with their peers the importance of following agency protocol about entering the medical record and why these guidelines matter. Not eager about doing the presentation, Ann and Howard are nonetheless grateful for being given the chance to improve their practice and to share this learning with their peers. They also plan to give a “shout out” to the anonymous nurse who cared enough to report them. Patricia recruits Ann and Howard to work on the task force preparing the disciplinary guidelines for this and other related transgressions.