As some of my colleagues know, I have been on the fence with this issue. Not willing to jump on the bandwagon, so to speak, for or against the case of Amanda Trujillo, ARNP. If you are not familiar with the case, you can learn more: http://www.nurseup.com/amanda.trujillo.rn.vs.banner.health.del.e.webb.medical.center.sun.city.arizona.htm
Before I talk about red flags and questions I see in this case, I’d like you to know a few things about me:
A). I know that nurses are abused by some doctors, administrators, patients, families & other nurses. I have been myself. It is NOT OK! EVER!
B) Historically, I have worked many hours as an Occupational Health Nurse and as such, have been involved in numerous workers’ compensation cases and employee/employer issues. In my experience, hearing the perspectives of different stakeholders is key to learning more about the truth and often very complicated.
C) My Masters is in Organization & Management with emphases on group dynamics and emotional intelligence. I believe that most big problems in our healthcare systems involve underlying individual, group AND organizational behaviors. As a facilitator, especially with conflict or sensitive situations, I see my role as helping all parties feel safe and making room for their voices to be heard and spoken respectfully.
So what are the red flags that are nagging at me?
The incident occurred on the night shift prior to a transplant review. Much of the publicity around this case seems to suggest that invasive surgery was imminent and that Amanda’s advocacy was urgent. My understanding of the review is that this patient was being considered as a possible transplant candidate not the surgery itself.
I wonder if more collaborative approach would have been to acknowledge the patient’s concerns, encourage her to express them and make it a priority to ensure that the physician was aware them. In the course of doing this, Amanda could have recommended rather than “ordered” the case management consult. Was there not time for this? If not, some attempt to include the physician in the course of this change of plans before he gets to the hospital to find out seems warranted.
From what I know, we have little information about what led up to this juncture in terms of the patient, family or physician needs/wants/plans/hopes. And I wonder, how complicated is it to schedule a transplant review? In my opinion, not having a conversation with the physician could be construed as passive-aggressive or antagonistic behavior on the part of the nurse. Whether or not the “order” for case management can be justified w/o the physician’s OK seems less important to me than the underlying dynamic between the doctor and nurse or nurse and hospital. Regardless of who initiated Case Management, wouldn’t it have been much healthier for this patient to know that her healthcare team was working together on her behalf?
Amanda Trujillo is an ARNP yet was practicing as an RN. Now maybe there is a perfectly good explanation for this. Third shift is typically tough to staff and given our economy and the financial needs and family commitments, perhaps this was a perfect job opportunity for Amanda. But, honestly, I wonder why she wasn’t practicing as an ARNP rather than an RN? Scope of practice is an important issue in the case and quite different for RNs and ARNPs. Banner health could face serious liability issues if their RNs on duty are practicing out of scope. I agree that a primary RN role is to educate patients, yet I wonder what else is going on here? In my opinion, potential ARNP/RN scopes and potential confusion raise concerns worthy of a closer look.
When the issue first came out, I was angry too and supportive of Amanda. But the more I read, the more I wanted to step back. What I perceived as inflammatory comments on line, statements of opinions as fact and oversimplification of the situation felt more polarizing to me than helpful.
I want to know, did this nurse and this doctor have a history of conflict? What about the doctor, does he have a history of disruptive behavior? Why was a Psychiatric Evaluation ordered for Amanda? It seems that her legal representation has changed and I wonder why? What else is going on here that Banner and the Arizona BON can’t talk about?
On the other hand, I want to acknowledge Andrew Lopez from Nurse Friendly who has steadfastly brought this issue forward in a variety of media venues. And other Nurse Bloggers for their commitment to raising awareness about the case and providing forums for discussion such as Brittney Wilson, at Nerdy Nurse, Jenifer Olin at RN Central and Donna Wilk Cardillo at Nurse Power, and many others! My heart goes out to the patient and family as well as the nurse and the physician and others involved.
For me, when situations like this get to this point, it is difficult if not impossible to create safe opportunities for truth seeking conversations outside a courtroom or hearing with the BON. Preventative measures, the kind of stuff I do, such as facilitating, training and coaching in conflict management, communication skills, and culture change efforts from toxic to positive, provide opportunities for lessons learned for the future, but do little for the current situation.
So I’ll stay tuned, a little skeptical and pretty clear in my own mind that this issue is more complicated than it appears!
Thanks for considering my opinion and I look forward to hearing yours.