Tuesday, December 25, 2012

Happy Holidays To All!

To my beloved readers,

I want to take this opportunity to thank you all for your encouragement, readership, comments and obvious passion for the best in nursing and healthcare. It's my joy to continue to bring Digital Doorway to you as its eighth anniversary approaches in January of 2013!

Meanwhile, my coaching practice at Nurse Keith Coaching will be marching into its second exciting year, and I'm thrilled to be developing new programs and initiatives that will deliver even more benefits to nurses seeking self-renewal and enhanced wellness.

As I take a blogging break until the New Year dawns, please feel free to read my most recent newsletter for my year-end wrap-up.

Thank you for being here, thanks for returning time and again, and please come back and visit me in 2013!

With gratitude,

Nurse Keith

Wednesday, December 19, 2012

Of Tragedy, Courage, Compassion and Love

America has been in the grip of grief and shock since news of the senseless and violent massacre in Newtown, Connecticut. The loss of so many innocent children is difficult to comprehend, and we mourn with those who are bereft of their loved ones.

Wednesday, December 12, 2012

Hang in There, Nurses--The Tsunami is Coming!

Many new nurses and nursing students are voicing a great deal of concern over the lack of positions and competitive salaries in the current job market. While this may be disconcerting to some, I encourage all nurses to hang in there as we wait for the economy to rebound and the "Silver Tsunami" to reach its peak.

Saturday, December 08, 2012

Nursing and Social Media

Social media is central to many of our lives in this most technologically oriented century, and nurses are no exception. Nurses' use of social media has boomed, and the benefits of this explosion are still being measured.

Wednesday, November 28, 2012

Coaching For the Future of Nursing

Sometimes, when I tell people that I'm a coach who coaches nurses, they ask me why nurses need coaching in the first place. I tell them that nurses are the backbone of the healthcare industry, and that healthy, happy nurses are the key to successful outcomes and happy patients! Nurses are key to the delivery of care, so it serves to maintain a healthy nursing workforce that can withstand the stress of nursing and the demands of the profession.

Thursday, November 22, 2012

Book Review: "Last Acts of Kindness"

Judith Redwing Keysarr is the Director of Palliative and End of Life Care of Jewish Family and Children’s Services of the San Fransisco Bay Area. Her book, “Last Acts of Kindness: Lessons for the Living From the Bedsides of the Dying” was recognized as the American Journal of Nursing Book of the Year in 2011. Ms. Keysarr will appear as our guest onRN.FM Radio on Monday, November 26th, 2012. (As always, I received no compensation for this book review.) 

Friday, November 16, 2012

Nursing: What Is Our "North Star"?

Many of us nurses often refer to our profession as a "calling". We discuss how being a nurse becomes part of our personal identity, and that reporting for work means more to us than just a paycheck. But then there are nurses who approach their work like any other employed person, with no acknowledgment that there is anything more to be gained than remuneration and a means to a financial end by fulfilling the tasks required of our position. This apparent dichotomy is not surprising, but it's certainly worth exploring.

Tuesday, November 06, 2012

A Nurse Mensch Is Something to Be

According to the annual poll by Gallup, nurses are the most trusted professionals in the United States, and those of us who love nurses understand why. We're the backbone of the healthcare system, and we interface with consumers more than any other members of the healthcare team. But when it comes to being the best we can be, the notion of being a "nurse mensch" is one worth exploring.

Wednesday, October 31, 2012

Magnet Hospital Study Says So Much

A recent study conducted by the University of Pennsylvania School of Nursing shows a dramatically lower mortality rate and better patient outcomes at Magnet hospitals. The authors concluded that these results are largely due to "measured nursing characteristics". It's yet another feather in nurses' (non-existent) caps.

Sunday, October 21, 2012

Book Review: "The Comfort Garden: Tales From the Trauma Unit"

Once in a while, a book comes along that makes one look long and hard at one's own relationship with work, the role of the caregiver, and the ways in which caring for others can take a toll on one's own personal and professional life. Laurie Barkin's "The Comfort Garden: Tales From the Trauma Unit" is a heartbreaking, inspiring and deeply thoughtful book that has done just that for me--and so much more.

Friday, October 12, 2012

Nurses Know the Score

Recently, a study funded by the Robert Wood Johnson Foundation (and recently published in the journal Research in Nursing and Health) demonstrates very clearly that nurses are excellent judges of the quality of care delivered in the facilities where they are employed. In fact, the study concludes that nurses' honesty and keen perception of what actually goes on in their workplaces could (and perhaps should, I would add) be a source of useful information regarding patient outcomes, quality of care, and other important factors.

Wednesday, September 26, 2012

A Grieving Ode to Tina

With the recent loss of my 17-year-old dog just under a week ago, I am, of course, quite conscious of the issues of loss and grief once again. Whether it's human loss or the loss of a beloved pet, the pain can run deep as we ride the waves that grief delivers to our doorstep.

Wednesday, September 19, 2012

Patients and Self-Advocacy

Several recent studies have brought to light some disturbing issues regarding patients, medical providers, and the relationships between them. These studies underscore the importance of positive relationships between patients and providers, and how important it is that healthcare consumers feel empowered to advocate for themselves.

Tuesday, September 04, 2012

Martine Ehrenclou and "The Take-Charge Patient"

Martine Ehrenclou is a well-known and talented writer whose books "Critical Conditions" and "The Take-Charge Patient" have received well-deserved attention and praise. I have been happy to become acquainted with Martine through our connections on social media, and I'm happy to provide this review of "The Take-Charge Patient", published by Lemon Grove Press in 2012. As always, I received no compensation for this post other than a review copy of the author's book.

Monday, September 03, 2012

Nursing: More Than Meets The Eye

Many of my online endeavors put me in contact with a growing number of nurses, and what strikes me most is that nurses are an incredibly diverse, passionate, talented and interesting group of people. I'm honored to be a nurse, and find the profession simply blossoming with richness and diversity.

Saturday, September 01, 2012

August Greetings From Nurse Keith

The August newsletter from Nurse Keith Coaching is now available online for those who would like the latest Nurse Keith news. Please click here to read the online version, and feel free to sign up for my mailing list at NurseKeith.com. Thank you!

Friday, August 31, 2012

RN.FM Radio Continues to Grow!

For those of you who have been following the evolution of RN.FM Radio--our Internet radio station focused on nursing, nurses and nurse entrepreneurs--we continue to grow and expand the scope of the show concurrent with our growth as hosts and producers.

Wednesday, August 22, 2012

A Soft Landing for New Nurses

In speaking with a number of new nurses over the years, something that I consistently hear is that new nurses are often not given the guidance, nurturing and mentoring that they truly need to move beyond surviving to thriving in their new careers. New nurses need a "soft landing" as they enter the field, and it's up to us seasoned nurses to make sure that they get it.

Tuesday, August 14, 2012

The Consequences of Nurse Burnout

So, my friends, the votes are in and the verdict is clear. Nurse burnout has real consequences and a ripple effect that is far-reaching and pervasive. Now that we clearly know that the impact is real, just what will we do about it?

Tuesday, August 07, 2012

Work-Life Balance and You

I'm honored to be this week's featured guest blogger on the Georgetown University School of Nursing blog, and I'd like to take this opportunity to share the link to the post as well as some excerpts from the post itself. The subject is work-life balance for nurses, and many of you may relate to this common challenge faced by nurses and healthcare professionals.

Monday, August 06, 2012

Book Review: "Minding the Bedside"

Jerome Stone, a Registered Nurse, researcher, author and practitioner of meditation, has shared his vision of the intersection of nursing, meditation and mindfulness in his excellent book, "Minding the Bedside: Nursing From the Heart of the Awakened Mind". The following is a review posted in advance of his appearance on RN.FM Radio.

Wednesday, August 01, 2012

Of Doctors, Humility and Humanity

Just recently, someone I know entered medical school with great hopes, expectations and vision for a future in medicine, and what I'm hearing about his initial experiences brings me great joy and hope. 

Friday, July 27, 2012

Of Tragedy, Heroism and Recovery

In the wake of the recent mass shooting in Aurora, Colorado, our hearts indeed go out to the victims, their families and loved ones, and the many people impacted by this horrific and inexplicably nefarious event. When senseless terror such as this is visited on innocent citizens, it is a shocking reminder of the ways in which violence can tear open the heart of a community—and a nation—in a matter of moments. 

Tuesday, July 24, 2012

Nurse Self Care: The Secret Ingredient

In my coaching practice, I talk to so many nurses who seem to burn out and hate their work when they don't put their own needs first. Nurses appear to have an ingrained sense that they must subjugate their own needs to the needs of their patients and loved ones. This is a belief and a practice that must change in order to prevent burnout and increase work-life balance and satisfaction.

Wednesday, July 18, 2012

Digital Doorway Wins Accolades

Once in a while, Digital Doorway wins attention and praise that brings me professional pride coupled with humility. This month, Digital Doorway has received such attention from three separate organizations, and I'd like to share those with you, my readers.

Nurses' Occupational Health

This week, Laura Wenger of Practice Greenhealth and The Healthier Hospitals Initiative stated on RN.FM Radio that nurses have the highest rate of occupational asthma in the United States. I was taken aback by this simple statement, and have been thinking about this statistic ever since.

Saturday, July 14, 2012

Doctors and Nurses: We All Can Win

Interactions between nurses and doctors can be entertaining, frustrating, enlightening, symbiotic, neutral, competitive, or otherwise charged with emotion or energy. Just recently, I've had several interactions that were all interesting in their own way.

Sunday, July 01, 2012

One More Week to Vote for Digital Doorway!

Dear Readers of Digital Doorway,

I'm in the running to win a nursing blog contest sponsored by California Casualty Insurance, and it would be my honor, privilege and delight to win the grand prize of $200 that will be automatically donated to one of my favorite charities--Madre--an organization that helps improve the lives of women and children around the world. Please be kind enough to vote for Digital Doorway and help me win this modest but meaningful contest! Voting ends July 8th! Thank you so much!

Tuesday, June 26, 2012

The ANA Speaks Out

Perusing the internet today, I noticed an article that described how a recent American Nurses Association House of Delegates meeting ended with several notable resolutions being passed. Let's take a look at those resolutions and their potential impact.

Saturday, June 23, 2012

Book Review: "The Real Healthcare Reform"

Note: As with all of my book reviews here on Digital Doorway, I received no payment for this review other than a copy of the book from the authors in order to expedite the review process. 
According to Linda Leekley, BS, RN and Stacey Turnure, RN--the authors of "The Real Healthcare Reform: How Embracing Civility Can Beat Back Burnout and Revive Your Healthcare Career"-- incivility "infects" healthcare workplaces in epidemic proportions. Based on that premise, the authors maintain that it is through embracing civility that true healthcare reform will take place.

Tuesday, June 19, 2012

What Do Nurses Glean From Coaching?

When I work with nurses via my coaching practice at NurseKeith.com, there are a variety of life aspects upon which we can focus. Whether it's addressing work-life balance or managing a change in the trajectory of their careers, nurses come to coaching for many reasons, but the goal is always centered on what the client truly wants.

Saturday, June 16, 2012

Please Vote For Digital Doorway!

Digital Doorway has been chosen as a contestant in a "Best Nursing Blog" contest sponsored by California Casualty Insurance, a company that offers insurance for firefighters, nurses and many other service providers. The winning blogger gets to donate a $200 prize to the charity of his or her choice, my choice being Madre, an organization that demands "rights, resources and results for women worldwide"!

Please click here to vote for Digital Doorway! Thank you!

Wednesday, June 13, 2012

Homelessness: Action or Complicity?

With the recent revelations that the homeless population in New York City is now at its greatest numbers since the Great Depression, we are again face to face with a public health crisis of astronomical proportions.

Tuesday, June 05, 2012

RN.FM Radio is Truly Unleashed!

For those of you who follow Digital Doorway regularly, you've no doubt heard about RN.FM Radio, the new internet radio station that was founded by yours truly and two dynamic nurse colleagues early in 2012. The official moniker of the station, "RN.FM Radio: Nursing Unleashed", is an apt title as the show continues to draw high-quality guests and engender energetic and enlightening conversation.

Tuesday, May 29, 2012

Book Review: "The Craft of Compassion at the Bedside of the Ill"

Disclaimer: As always, I received no payment for this book review, only a copy of the book from the author in order to facilitate the writing of this post.

"The Craft of Compassion at the Bedside of the Ill" is a poetic and moving discourse on compassion by nurse, author and medicine man Michael Ortiz Hill. In this stirring book, Mr. Hill presents his view of compassion as a craft that can be learned, honed and developed, a notion that many in the nursing and medical fields would be wise to heed.

Friday, May 25, 2012

Nursing, NPR, and Where to Go From Here

Nurses and nursing are consistently in the news these days, and with issues surrounding health care continuing to come to a boil in the U.S. and elsewhere, we can expect more stories that include nurses to bubble to the top.

Tuesday, May 15, 2012

Nursing: Trouble in Paradise?

Despite the consistently wonderful press about the trust that Americans place in the nursing profession, not to mention the heady days of new nurses being assured a plethora of jobs upon graduation, the nursing zeitgeist seems just a little diminished and subdued these days. At least for now, many new grads are hard pressed to find work and there is little to cheer about when it comes to nurses' economic standing.

Wednesday, May 09, 2012

"The Nurse's Story" by Carol Gino

In honor of National Nurses Week, I am offering a review of "The Nurse's Story" by author Carol Gino. As with all book reviews on Digital Doorway, I have received no payment from either the author or the publisher in exchange for this blog post. I have only received a copy of the book from the author in order to facilitate the review process. 

Tuesday, May 08, 2012

I Should Only Be So Lucky

I walk into the home and am welcomed warmly by the client's two sons, as well as the home health aide that I'm ostensibly there to supervise. The client sits in his wheelchair, quietly fingering a towel that was previously placed in his lap as a diversion. I greet the client---John---and then take a seat on the couch, late morning sun streaming through the living room window.

Partners in Health and Nurses Week

Thursday, May 03, 2012

What Will You Do....For National Nurses Week?

Well, it's that time of year again, and National Nurses Week is just around the corner. Now, before you get too excited about the hearts, flowers and monogrammed mugs that your supervisors will leave in the nurses station (I just received a terribly ugly pin in the mail from one of my employers), the question of the day is: What will you do---for yourself---for National Nurses Week?

Friday, April 27, 2012

"Googling" Our Workplaces?

It seems to be common knowledge these days that employees at places like Google, Apple and other Silicon Valley success stories enjoy perks that many of us in the healthcare industry can only dream of. Even other companies---like biotechs and others---have learned that small perks can go a long way toward employee well-being and morale. Why don't we healthcare workers---who save lives every day---enjoy even a fraction of these sorts of benefits?

Sunday, April 22, 2012

A Speech for Graduate Nurses

Since this is the time of year when nursing students are preparing for their graduation and entry into our esteemed profession, I am choosing to republish a commencement speech that I delivered at Holyoke Community College on June 23rd of 2005 for my graduating LPN students for whom I had served as lecturer during their course of study. This post is the most popular ever published on Digital Doorway, and it has received over 5,000 pageviews since its first publication. Enjoy.

Tuesday, April 17, 2012

Self Compassion and Empathy

Last night on RN.FM Radio, nurse and well-known author Carol Gino spoke eloquently about the need for nurses to develop self compassion before they can truly experience empathy for their patients. She was so right.

Wednesday, April 11, 2012

Nurses Face the Wounds of War

In a surprising and welcome announcement, 450 nursing schools have pledged to improve and expand training for nurses and nursing students on the "invisible wounds of war", including Post-Traumatic Stress Disorder (PTSD), post-combat depression and Traumatic Brain Injury (TBI).

Tuesday, April 10, 2012

Happy Patients vs Healthy Patients

Recently, I published a blog post entitled "The Disneyfication of Nursing" wherein I examined the relatively new practice of "scripting" nurse-patient interactions, demanding that nurses communicate with patients in a specific manner.

The reality is that hospitals now want to provide care with an eye towards positive scores on patient satisfaction surveys upon which Medicare will soon begin basing some of their payments. While this is an understandable---yet short-sighted--reaction on the part of facilities that receive payments from Medicare, it is clear that there is a slippery slope that may very well backfire when it comes to achieving desired patient outcomes.

Wednesday, April 04, 2012

Nursing Students and Self Care

Nursing school is a lot like boot camp. The student nurse is pushed to his or her limits, personal resolve is continually tested, students bond in their misery, and the majority come through the other side with new skills and a new career, perhaps a little worse for wear. But are they fully prepared---to care for themselves?

Wednesday, March 28, 2012

Nurses, Caring, and Oxygen Masks

Nurses are generally very good at caring for others, and many of us fall flat on our faces when it comes to caring for ourselves. So, aren't we going against the popular wisdom of the "oxygen mask theory" when we give and give without meeting our own needs?

Saturday, March 24, 2012

The Disneyfication of Nursing?

A recent article on Boston.com describes efforts by hospitals to offer specialized training to nurses in customer service and courtesy. According to some reports, many hospitals are hiring outside consultants in order to boost customer satisfaction surveys in response to Medicare's new ruling that they will begin basing a small percentage of payments to hospitals in accordance with facilities' "patient experience" scores.

Tuesday, March 20, 2012

Nurses Need Support

The more nurses I talk to, whether in my clinical nursing work or as a coach for nurses, it's increasingly obvious to me that nurses simply need support. While "Nurses Day" and the accompanying flowers, buttons and pens may be nice gestures, Nurses Day and other such celebrations would mean a whole lot more if meaningful support---not platitudes---were offered to nurses who so desperately need it.

Tuesday, March 13, 2012

Gender, Healthcare and Communication

Last night on RN.FM Radio during a discussion with Beth Boynton, the nurse author of "Confident Voices: The Nurses' Guide to Improving Communication and Creating Positive Workplaces", we touched on the subject of gender and its effects on communication. Countless books on communication between the sexes have been written---the ones most readily coming to mind being those by Deborah Tannen, including "You Just Don't Understand" and "That's Not What I Meant"---and I am keen to point out that there is currently no book on the market of which I am aware that specifically discusses the gender aspects of communication within healthcare.

Thursday, March 08, 2012

The Burden of Medical Bills

A recent study released by the CDC (and reported on Medscape and other sites) states the blunt fact that 20% of American households have difficulty paying their medical bills. And the National Center for Health Statistics states that 1 in 5 Americans has lived in a family that could not pay its medical bills in the last 12 months.

Tuesday, March 06, 2012

Is True Preventive Care a Reality?

Last night on RN.FM Radio, we were discussing the challenges of delivering true preventive care at a time when the economics of health care often seem to be moving us in the opposite direction. Mountains of research have shown that preventive medicine and interventions can dramatically decrease the cost of health care over time, but it seems that some insurance companies still don't bite the preventive medicine bait.

Tuesday, February 28, 2012

Refreshed and Renewed

In my last post, I announced that my wife and I were going on retreat, and we have now returned, renewed and refreshed after two weeks away. When we're able to afford to do so, we attend retreats, conferences or workshops several times each year---individually or as a couple---that serve our personal, emotional, spiritual or physical well-being.

Saturday, February 04, 2012

On Retreat

Dear Readers,

In our coaching practices, my wife Mary and I consistently talk about the importance of self care and personal well-being, and how crucial this is for us to be most effective out in the world. Without self care, we can't be at our best, and our energy is dissipated and less powerful.

At this time, we are choosing as a couple to "walk our talk" by going on retreat ourselves. We are taking several weeks to rest and rejuvenate away from the workaday world, and we'll return on February 21st.

Until then, I send you my best, and wish you a Happy Valentine's Day. Many blessings to you and yours, now and always.


Tuesday, January 31, 2012

Internet Radio for Nurses Takes Off!

Our newly birthed internet radio station for nurses---RN.FM Radio---is maturing into a reliable weekly source of inspiration, encouragement, interviews and nursing news that many nurses are flocking to every Monday evening at 9pm EST. 

Wednesday, January 25, 2012

My Letter to the Arizona Board of Nursing in Defense of Amanda Trujillo

Arizona State Board of Nursing
4747 North 7th Street, Suite 200
Phoenix, AZ 85014-3655
602-771-7800 Phone
602-771-7888 Fax
arizona@azbn.gov Email


To the Arizona State Board of Nursing:

I am a nurse, coach, nurse blogger and professional writer, and I have been following the case of Amanda Trujillo quite closely.

Having read the legal brief, Ms. Trujillo's statements, as well as other facts about the case, it is clear to me that Ms. Trujillo was acting completely within her scope of practice as a nurse when she provided the patient in question with information regarding her choices vis-a-vis her pending surgical intervention.

The fact that Ms. Trujillo is now being forced to undergo a psychiatric evaluation further supports the contention that no stone is being left unturned in efforts to undermine her credibility and her history as an exemplary nurse. It is ironic that the surgeon who demanded the suspension of her license and her ability to practice in the state of Arizona is undergoing no such evaluation or rigorous vetting process. The Arizona Board of Nursing and Ms. Trujillo's employers easily caved to demands by the surgeon that Ms.Trujillo be fired and lose her license, an action that once again demonstrates how the disparity of power between physicians and nurses continues to undermine nurses' ability to perform their duties according to a clearly stated scope of practice.

Ms. Trujillo was taken to task for "messing up" the surgeon's "hard work" of preparing for the scheduled surgery. Why was Ms. Trujillo not praised for providing necessary education to a patient who clearly demonstrated a startling knowledge deficit regarding what this surgery would entail for her? Nurses are trained to provide education and resources to patients, and that includes situations wherein physicians themselves fail to educate patients properly. Ms. Trujillo may have "messed up" this physician's "hard work", but she refused under these circumstances to "mess up" this patient's life by failing to educate her and provide the information that would elicit true informed consent, something that the physician in question clearly failed to accomplish.

The nursing community is rallying around Ms. Trujillo due to the facts that clearly demonstrate how Ms.Trujillo acted within her scope of practice and documented her actions clearly and concisely following her interactions with the patient. If the physician was inconvenienced by her actions, this issue could have been addressed by the facility's ethics committee. Instead, the Board of Nursing and Banner Health agreed to the physician's outrageous demands, allowing his power to prevent a measured and intelligent response to the situation at hand.

It would indeed have a chilling effect on the entire nursing profession if the Arizona Board of Nursing sets a precedent that redefines our profession and the collaborative health care model that has been the touchstone of professional nursing for decades.

As you by now understand, the actions against Ms. Trujillo and the suspension of her nursing license have ignited a firestorm of criticism regarding how this case has been handled by both the Arizona Board of Nursing and Ms. Trujillo's employer. The support is only growing, and those who are incensed by this situation will use the power of social media and the traditional media to bring the egregious nature of this case to the attention of the wider public.

I respectfully request that you consider dropping the complaint filed against Amanda Trujillo’s license and the case against her.


Keith Carlson, RN, BSN, CPC

A Letter to the AZ Board of Nursing Regarding Amanda Trujillo

Here is the text of a letter to the Arizona Board of Nursing posted by Anna Morrison of I Coach Nurses. Please disseminate widely. The original post can be found by clicking here.

Arizona State Board of Nursing
4747 North 7th Street, Suite 200
Phoenix, AZ 85014-3655
602-771-7800 Phone
602-771-7888 Fax
arizona@azbn.gov Email

To whom it may concern,

In the case of Amanda Trujillo, RN, a profoundly negative and chilling precedent threatens to silence nurses in their efforts to uphold their solemn oaths to protect, educate and advocate for their patients.

Additionally, a patient’s Right to Know and Right to Self-Determination are directly in jeopardy.

National Nursing groups, Patients’ Rights Advocacy groups, and the media have been put on alert and are watching this case carefully, hoping that the AZ BON makes the right choice to support the education and interventional activities of a nurse, who discovered a severe knowledge deficit in her patient and operated within her scope to rectify it.

It would be a shameful to set a precedent that re-defines our profession and the collaborative health care model that we thought we operated in for the good of our patients.

I respectfully request that you consider dropping the complaint filed against Amanda Trujillo’s license and the case against her.

Best regards,

Anna Morrison, BA, BSN, RN, CLNC

Tuesday, January 24, 2012

Amanda Trujillo: A Fellow Nurse on the Ropes

Some readers of Digital Doorway may have already heard the story of Amanda Trujillo, an Arizona nurse who has lost her license based on nursing actions taken that were apparently fully within her scope of practice.

In the course of caring for a patient who was facing the potential of a liver transplant, Amanda offered this patient information regarding the availability of hospice as an alternative to this risky surgery with an uncertain outcome. It was clear to Ms. Trujillo that the patient did not understand the risks involved in this procedure, and she saw it as her professional duty to provide the appropriate resources and referrals to the patient so that she could make a fully informed decision. The patient subsequently chose to not undergo the procedure, and the physician who had planned and scheduled the surgery filed a complaint against Amanda and demanded that her license to practice be revoked.

Many of us in the nationwide nursing community are advocating for Amanda, and calling for the Arizona State Board of Nursing to cease and desist their actions which have deprived Amanda of her nursing license, brought her before the Board for disciplinary action, and requiring that she undergo a psychiatric examination. These actions are depriving Amanda and her daughter (she is a single mother) of their means of financial support, putting this small family at great risk of economic disaster.

The following is an open letter to the Arizona Board of Nursing, and was written by Kevin Ross of Innovative Nurse. I echo Kevin's sentiments, and urge all nurses and non-nurses who support Amanda's right to practice as a nurse to contact the Arizona Board of Nursing at 602-771-7800 or arizona@azbn.gov, informing them that we are watching this case closely and will not allow Amanda to be treated unfairly or unjustly.

Below Kevin's letter is a legal briefing describing the events in question. After reviewing the case details, please feel free to contact the Arizona State Board of Nursing on the behalf of Ms. Trujillo. The Board can be reached at 602-771-7800 or arizona@azbn.gov.


An open letter to the Arizona State Board of Nursing.

Disclaimer, I have not been directly contacted by Amanda Trujillo, MSN, RN, DNSc-NP(s), nor do I know her personally or professionally. I am also writing to you based on the information that I have available to me.

To the Arizona State Board of Nursing:

To whom it may concern,

I am writing to you on behalf of Amanda Trujillo, MSN, RN, DNSc-NP(s) regarding the case attached below. I have not been contacted directly by Amanda Trujillo, and I have neither a personal or professional relationship other than that she is a fellow nurse in need of my support.

Based on the information I have (to my knowledge the same case documents that you also have), I would like to ask the board to carefully consider the information presented by both Ms. Trujillo and her legal team. From my understanding, it appears that Amanda Trujillo evaluated the health status of her patient based on her own clinical assessments and also data collected while being treated by the medical team at Ms. Trujillo’s place of employment during this time. It also appears from the information that Amanda Trujillo provided health teaching, counseling, and advocacy for her patient, which to my understanding of the Nurse Practice Act is well within her scope of practice.

As a nurse and patient advocate, I make certain that each and every patient I provide services to does in fact receive the highest quality nursing care while on my case. It should go without saying, but part of this care involves my ongoing support to ensure that my patient is knowledgeable about their diagnoses, medications, and ordered treatment plan. It is my job to protect the health and safety of each and every patient that I come into contact with, and to advocate for their needs based on my clinical judgement.

I am not in any way assuming that the treating physician was negligent, however considering that this is, and should have been a collaborative approach in the patient’s care, Amanda Trujillo was making her own nursing diagnosis based on her clinical assessment, which again to my knowledge is within her scope of practice as a registered nurse. She apparently discovered a deficit in her patient’s knowledge about their treatment options, and it appears that she acted ethically in supporting her patient’s wishes to seek additional information, and referred the patient to a case management specialist as per protocol.

I realize that these cases can carry with them a great deal of emotion due to the sensitive nature that our number one priority as licensed nurses is to protect our patient’s health and safety. It seems that Amanda’s duty to uphold the rights of her patient is being challenged, and the circumstances in which this transpired seems to have been initiated and fueled by emotion, and not based on facts. I just ask that you please consider all of the information presented to you, evaluate this case objectively, and if Amanda Trujillo is exonerated from these allegations, that she have the opportunity to continue to practice professional nursing.

Thank you in advance for your time and your consideration in this matter.


Kevin Ross, R.N., BSN


Please see the following for further details of the case: 


In the Matter of Registered Nurse License No. RN137552 issued to:
Amanda Trujillo, Respondent. )



(Nurse Practice Consultant, Ann Schettler)

Respondent Amanda Trujillo, by and through undersigned counsel, submits this Description of Events in response to a complaint filed against her in June of 2011 with the Arizona State Board of Nursing (“Board”) by Banner Del E. Webb Medical Center (“Webb”).

Description of Relevant Events
The allegations contained in the complaint arise from events that occurred on April 12th, 2011, when Ms. Trujillo was caring for a patient with end stage liver disease in the 3D Telemetry unit of Webb.  Ms. Trujillo had been a registered nurse with Webb for approximately six months prior to the date of the alleged conduct and she normally worked the night shift from 7 a.m. to 7 p.m.

After assessing and communicating with the patient, Ms. Trujillo’s evaluation led her to believe that the patient did not fully understand what she had consented to when (pt) agreed to go forward with an intensive transplant evaluation scheduled to begin at Banner Good Samaritan Medical Center the following day. Based on her nursing assessment,  Ms. Trujillo gathered patient education materials and spoke with the patient regarding the transplant evaluation, the waiting period and the commitment needed in following a lifelong self-care regimen.  After their discussion, the patient expressed a desire to learn more about hospice care because (pt) was uncertain she was willing to take the necessary steps to maintain a successful organ transplant.  Thus, the patient inquired into whether (pt) could speak with a hospice representative.  Ms. Trujillo then placed an “order” for a case management consult with a hospice representative.  Ms. Trujillo did not believe that requesting a case management consult was a medical order requiring physician permission; she believed the consultation was for educational purposes in order to give the patient a broad understanding of her options.

As a result of the additional information given by Ms. Trujillo, the patient determined (pt) did not want to go through with the liver transplant evaluation or resulting transplant procedure.  When the doctor treating the patient found out about the patient’s wishes to forgo the evaluation he was unhappy that the patient had changed (pts) mind and determined that the education given by Ms. Trujillo was the underlying cause of the patient’s change of heart.  He accused her of going beyond her scope of practice by entering a physician order without permission  (“ordering” the case management consultation).  As a result of the accusation, Ms. Trujillo was placed on administrative leave by her nursing director, Venus Gaines, and was eventually terminated by Webb.

Ms. Trujillo believes she was well within her scope of practice to assess the patient’s understanding of (pts) plan of care.  She was not acting outside her scope of practice by educating the patient (deferring all questions outside of her scope to the medical team), once she determined the patient had a gross misunderstanding of what (pt) had agreed to participate in.  Ms. Trujillo believed that the case management  “order” she placed on the patient’s behalf was not a medical order that needed physician permission.  Each step of the treatment provided by Ms. Trujillo to the patient will be analyzed below.

Patient Assessment
It is standard practice for Ms. Trujillo to ensure her patients understand their medications, plan of care and treatments.  While fully reviewing the patient’s medical record Ms. Trujillo read a progress note entered by the patient’s primary care physician from earlier in the day that noted a “transplant evaluation is the only viable option outside of Hospice.”  Utilizing the standard nursing process of patient assessment (assessment, diagnosis, planning, intervention, evaluation), Ms. Trujillo asked the patient a number of open-ended questions regarding (pts) hospital stay, medications, liver disease, procedures, etc.  Ms. Trujillo asked the patient if (pt) had received any information or teaching regarding the proposed transplant evaluation.  The patient, to Ms. Trujillo’s surprise, responded that (pt) did not understand (pts) disease, plan of care or what a transplant evaluation entailed. The patient asked Ms. Trujillo if she could provide some information regarding the disease and any less invasive choices that would allow (pt) to go home and be with (pts) family. Based on this request Ms. Trujillo determined the patient had a knowledge deficit regarding (pts) disease and the choice to receive palliative care.

Patient Education
Having assessed the knowledge deficit related to the patient’s routine medications,  disease process, associated tests and procedures, the plan of care for transplant evaluation and palliative care options, Ms. Trujillo proceeded to print out patient educational material from Banner’s website that addressed those areas.  Additionally, she printed out education materials from Banner’s transplant website pertaining to what to expect during a transplant evaluation and what to expect after a transplant.  Ms. Trujillo also provided materials related to hospice care per the patient’s request.  Ms. Trujillo, concerned about the patient’s lack of understanding of (pts) treatment regimen and the option for comfort care, discussed her education of the patient with her clinical manager, Frances Fausto, who readily supported Ms. Trujillo’s plan of care and interventions.

Ms. Trujillo and the patient reviewed the materials over the course of the night.  After a full review of the materials the patient stated, “Had I known everything I would have to go through and the commitment I would have to make, I would not have agreed to the transplant evaluation.”  The patient inquired into whether there was anything else (pt) could do besides enduring more tests, procedures or surgeries.  Ms. Trujillo then explained hospice care services and the differences between symptom relief care and end of life care.  The patient expressed serious concern that (pt) would not be able to commit to an extensive aftercare regimen following the transplant by stating “at this stage in (pts) life (pt) just wanted to be around family.”  The patient requested to visit with a representative from hospice in order to ask some questions and gain additional information that would assist (pt) in making a more informed decision regarding (pts) course of care.

Ms. Trujillo placed a note in the chart pertaining to the assessment of knowledge deficit, the specific education provided and the palliative care discussion, in addition to, the patient’s request to see a case manager from hospice.  She used the SBAR (Situation, Background, Assessment and Recommendation) format of report required in Banner policy when she handed off care of the patient to the dayshift nurse, alerting the nurse that the patient requested more information prior to being transferred to another facility for a transplant evaluation.  She also alerted the dayshift nurse that there was a nursing note in the record for the doctor to read that detailed what occurred over the course of Ms. Trujillo’s shift with the patient.

Case Management Consult
As a relatively new nurse to Banner, Ms. Trujillo self-educated in order to work within Banner’s policies and procedures.  She found no specific policy or procedure regarding end of life care that prohibited her from obtaining case management consultations for her patients. She also could not find any policy or procedure that gave a formal definition of a “physician order” or what nurses could order and what they could not. In fact, Ms. Trujillo had ordered hospice consultations for her patients on numerous occasions prior to this incident without any objections from other physicians or Webb administration.  She entered the “order” with a note stating, “per patient request, patient wants to visit with hospice representative for more information.”  In fact, the computer system in place at Webb allows her to click a box that further specifies “Nurse Ordered,” which she did on this occasion.

The only reason Ms. Trujillo’s actions turned into allegations of unprofessional conduct is because the primary care physician on this case, The Dr. initiated an angry public display when he found out that the patient had changed (pts) mind regarding the transplant.  Ms. Trujillo was surprised when the nursing director, Venus Gaines, went so far as to tell Ms. Trujillo that the physician was angered because she had, “messed up all of the work they had done, and that the doctors were nowhere near going down the hospice route.”

This was not a medical order.  This was a nurse trying to help a patient become better informed about a life changing procedure and (pts) right to choose what direction (pts) care would go.  Ms. Trujillo’s actions were well within her scope of practice and she conscientiously kept her line of teaching within the boundaries of her scope of practice by taking care to utilize the proper channels to obtain patient teaching materials and advising the patient to ask the doctors about more complex questions she was unable to answer as a registered nurse.

The patient had the absolute right to self-determination regarding her course of treatment, as illuminated in Senate Bill S. 1052, the Bipartisan Patient Protection Act, after receiving additional information regarding her disease.  Ms. Trujillo, working within her scope of practice and the nurse’s code of ethics, honored and protected that right when she abided by the patient’s requests to the best of her ability.

Accommodating a patient’s request for a consultation with a hospice case manager does not require a physician’s order.  No medication was requested, no equipment was needed, and no procedures were required.  A patient simply wanted to speak with an expert regarding her options for comfort care and end of life care, so that (pt) could make the best decision about (pts) future.

It is standard knowledge that the Cerner electronic health records system in place at Webb contains a box that states, “Nurse Ordered.”  Why would this box exist if nurses were never allowed to “order” anything?  The Complainant contends that Ms. Trujillo overstepped her scope of practice by ordering the consult; however, it is standard practice of the hospital to allow nurses the freedom to do the exact thing alleged in the Complaint.

Ms. Trujillo was allowed to order case management consults on numerous occasions prior to this and was never told by the hospital that this practice was not allowed or outside the scope of her practice.  It is apparent that the hospital is simply trying to appease and placate an angry physician by filing this Complaint against Ms. Trujillo.

She looks forward to discussing this matter with the Board, if necessary, and hopes to conclude this matter expediently.

SUBMITTED: July 11, 2011
By: ______________________
Robert Chelle
Attorney for Amanda Trujillo

Thursday, January 19, 2012

Book Review: Davis's Drug Guide for Nurses, Twelfth Edition

As always, I begin my book reviews with the disclosure that I did not receive financial compensation of any kind for this review, but did receive a free copy of this drug guide from Majors Books in order to facilitate the review process.
Some frequent readers of Digital Doorway will recall that I posted a review of the Nursing 2012 Drug Handbook on November 22nd of last year, and I was quite pleased with the overall layout and presentation of that particular drug guide for nurses. Since I happen to have both the Nursing 2012 Drug Guide and my review of said book in the forefront of my mind, the following review of Davis's Drug Guide for Nurses will be written as I take the differences and similarities between these two recently published drug guides for nurses into consideration.

General  layout

The 12th edition of Davis's Drug Guide for Nurses appears to be extremely similar to its brethren, both in size, layout and general offerings.

Both Davis's guide and Nursing 2012 use almost the exact same color scheme for their drug monograph pages, with slight differences in font size and type. I find Nursing 2012 slightly easier on the eye in terms of font choice, but Davis's is also relatively readable without strain.

Drug monograph layout

Comparing drug monograph layout, there is generally little difference between these nursing drug guides, but I will take the time to elucidate several small differences which may or may not have a great impact on the user.

If we consider indications and dosages, I appreciate that Nursing 2012 combines both of these attributes of every  drug at the beginning of each drug monograph, clearly delineating the pertinent details for both adults and children. Meanwhile, Davis's guide lists indications first and offers dosages and routes much later in each monograph. Personally, I prefer having the dosages and indications up front as soon as I begin reading about a drug, but the publishers and writers at Davis seem to feel that action, pharmacokinetics, contraindications and precautions, adverse reactions, side effects and interactions come first. I assume it is a matter of personal preference.

The Davis drug guide uses a red maple leaf symbol to specify medications that apply specifically to Canadian clinicians and nursing practice. This is a nice touch, and our Canadian brethren may very much appreciate this attention to detail on their behalf.

While Nursing 2012 uses boldly-lettered "Black Box Warnings" to indicate a warning that necessitates caution and attention, Davis prefers a red "High Alert" warning label.

Both books include the steps of the nursing process within the monographs, warnings regarding interactions of drugs with foods and herbs, and various aspects of IV medication administration. 

Drug photographs

Many drug guides now offer photographs of commonly used medications, and this can be an invaluable tool for identification of medications and patient education. Nursing 2012 offers a photo guide to 396 common tablets and capsules. The photographs are full color, life-size, alphabetized, and located in the center of the book. The edges of the pages are shaded a different color so that this section can be handily and quickly utilized.

Davis's Drug Guide offers photographs only of medications with "Tall Man Lettering Changes" which have been recently mandated by the FDA. There are 33 medications with look-alike names and spellings which have now been changed to identify them and reduce confusion and medication errors. Examples of these "Tall Man" lettering changes are CycloSPORINE and CycloSERINE or GlipiZIDE and GlyBURIDE.

While having these mandated changes delineated clearly for readers is an excellent edition that Nursing 2012 lacks, having photographs of only 33 medications compared to the 396 medications displayed photographically in the Nursing 2012 Drug Handbook leaves little room for comparison. Nursing 2012 wins hands down for its use of photographic images.

Of note, the photographs of the "Tall Man" drugs in Davis's book are lumped together with other sections of special information. The edges of the pages of all of these special information sections are shaded with the same color, thus the pages of medication photographs are awkward to find and consequently less than handy.

Digital Offerings

The Davis guide comes with a CD -ROM (compatible with both PC and Mac) that offers an audio library of drug names, a drug search program, updated tutorials on medication errors, wound care and psychotropic drugs, as well as calculators for BMI, metric conversions, IV drip rates, and other features. There is also a free mobile device download of 100 drug monographs and resources available online at DavisPLUS.

Meanwhile, Nursing 2012 delivers access to an online drug advisor, patient teaching sheets, CEUs, as as well as detailed monographs of every drug listed in the book and some medications not included in the print version. This can all mostly be downloaded or viewed on a mobile device. Still, I feel it would behoove the publishers of Nursing 2012 to consider the addition of a CD-ROM in subsequent editions.

The Summing Up

For overall readability, layout and design, I definitely prefer the Nursing 2012 Drug Handbook over Davis's Drug Guide for Nurses, Twelfth Edition. Nursing 2012's inclusion of far more photographic images of medications and its slightly better font choices make it preferable for me, however Davis's inclusion of the CD-ROM, Canadian specifications and "Tall Man" lettering changes mandated by the FDA are also important features to consider.

These two guides are quite comparable, and both offer nurses the information they need in not dissimilar formats and designs. In terms of most of the differences, personal preference may be the deciding factor for many nurses. And for those enamored of the photographic images of drugs, Nursing 2012 is the best choice. Still, a prudent nurse cannot go wrong with either guide, and both will certainly lend themselves to safer care, fewer medication errors, and nurses who have the information they need at their fingertips.


If any readers of Digital Doorway would like a 10% discount on the Davis Drug Guide from Majors Books, please use the code "nursekeith" when checking out. This offer is valid for 30 days. I receive no compensation for sales of this book through Majors Books. This is simply a gift to my readers from me, and a thank you from Majors Books for the review. 

That said, the first commenter on this post who can tell me the name of two famous nursing theorists and their main theories of nursing will win a copy of Davis's Drug Guide for Nurses from me!  The winner will be announced within the "comments" section, and that individual will need to send their mailing address to kc@nursekeith.com.

Wednesday, January 18, 2012

Seven Years of Digital Doorway

Well, it may seem like a blink of an eye at times, but Digital Doorway has been alive and well for seven years today, born from a simple suggestion by my prescient brother as we sat in front of the woodstove on a snowy New England night. I can hardly believe that so much time has passed since that January day when I dived headfirst into the blogging world with no idea of where I was going or, honestly, what I was doing.

When Digital Doorway launched, it was not clear to me that it would be a blog mostly about nursing. Although my online moniker at the time was indeed "Nurse Keith", I had no notion of branding, hadn't heard of SEO (Search Engine Optimization), and the blogosphere was an enormous and cavernous unknown.

Over time, Digital Doorway began to distill itself into a somewhat more cohesive entity, and 1520 posts later, it has become one of the more well-known blogs in the nursing blogosphere,. Yes, it's garnered a fair amount of attention and notoriety over time, although it's still somewhat small potatoes compared to the blogging giants out there. (You know who you are!)

Back in the day, I didn't know about keywords and never gave much thought to such things. In all actuality, I still don't write my posts with keywords in mind, and I just let my blog's relative influence online do the job. However, with hundreds of backlinks that point here to Digital Doorway, it's a given that my writing will have a moderate audience out there in blogland. That said, with my new mentors, colleagues and friends over at RN.FM Radio, keywords, SEO and such animals are now making their way into my lexicon and writing practice, and as we grow RN.FM Radio and its cousin LLC, Unbound Media Group, our presence online as coaches, bloggers and nurse entrepreneurs is sure to grow. And no doubt that Digital Doorway will itself benefit from that vertical and horizontal expansion.

As NurseKeith.com continues its slow and steady launch, Digital Doorway is becoming the repository of much more focused thoughts on nursing, the profession's present and future, new books on nursing. and the impact that coaching can have on nurses' lives, among other topics of note. I look forward to continuing to deliver quality content that's informative, timely, and easy to read (and perhaps periodically entertaining).

Thank you for supporting Digital Doorway. Thanks for reading, thanks for the many comments, for following me on Facebook and Twitter, and for the encouraging words I've received since launching NurseKeith.com.

Yes, it's been a long, strange trip, and I have a feeling 2012 will be no different. Come along for the ride, and let's see what the next seven years brings!

Sunday, January 15, 2012

NurseFriendly on RN.FM Radio!

Just a reminder that tomorrow, January 16th, 2012, Andrew Lopez of Nursefriendly.com will be our guest on RN.FM Radio. Andrew is the consummate connector and promoter of nurses, and we look forward to his appearance on RN.FM Radio! Tune in or listen to the archived show afterwards.

Also, please take a peek at our new RN.FM Radio website! It's growing by the day!

"See" you there! 

Wednesday, January 11, 2012

Book Review: "Confident Voices" by Beth Boynton

A note to the reader: As always, I have received no remuneration for posting this book review. As a point of disclosure, I did, however, receive a free copy of the book from the author in order to facilitate the review process.

"Confident Voices: The Nurse's Guide to Improving Communication and Creating Positive Workplaces", was published in 2009 by Beth Boynton, RN, MS and edited by Bonnie Kerrick, RN, BSN.


In Confident Voices, Boynton strives to give nurses the understanding and skills to navigate the workplace in a way that fosters improved communication, healthier workplaces and a more supportive and safe environment for them and their colleagues. Boynton achieves her goal, and delivers information that is useful, well-organized, easy to digest, and potentially possible to put into practice immediately.

The book walks the reader through three distinct sections covering various topics of interest to the nurse who wishes to work in an environment that supports positive relationships and respectful communication.

Part I addresses workplace dynamics, and identifies the characteristics of toxic workplaces, and delves into theories that explain human behavior, especially in the context of the workplace. Organizational culture is explained and dissected, and workplace violence---be it physical, verbal or emotional---is also addressed.

Part II is focused on "building assertiveness and respectful listening skills" and explores "strategies for creating organizational cultures where effective communication and respectful relationships can thrive".

Part III integrates the theories, insights and skills covered in Parts I and II in the context of nurses' experiences which were gleaned from interviews with nurses in the field. Common toxic behaviors are described and various revisions of the encounters in question are offered as examples of improved communication and healthier outcomes for all involved.


Toxicity in the workplace is an important subject rarely given its due, and Boynton succeeds in communicating her mission clearly in this very useful book. We all know that the health care system is suffering from various forms of overload and dysfunction, and the result for nurses is that we often feel powerless in the face of old patriarchal systems of organization, entrenched methods of communication, and hierarchical relationships that apparently strip us of our power and leave us literally speechless in the face of workplace violence, bullying, top-down management, and organizational failure.

Boynton gives nurses concrete examples of common situations wherein nurses can practice their assertiveness and respectful communication skills. She also provides practical tools for nurses within a theoretical framework that takes into consideration the characteristics of toxic workplaces, the ways in which workplace violence impacts nurses, and how effective communication can cut through the static to a place of greater clarity, personal empowerment, and professional satisfaction.

In a future edition of "Confident Voices",  I would like to see the author make use of a more diverse selection of real-life scenarios in order to address potential gender and power issues that her examples fail to take into consideration.


The nurse interviews used in the book to illustrate Boynton's thesis all feature female nurses who are interacting with male physicians in the hospital setting. While this gender dynamic may be common (and may be a deeply and culturally embedded knee-jerk reaction when we think of "nurse and doctor") there are now a plethora of female physicians working alongside male nurses, and male nurses working alongside male physicians.

Additionally, it would be interesting to explore workplace dynamics when we consider male and female nurses working together, as well as combinations of male nurses alongside male nurses, and female nurses collaborating with female doctors. It could also be enlightening to explore the dynamics of workplace violence, bullying and communication when considering comparisons between male and female supervisors and administrators, and the ways in which gender differences impact communication in health care. Several books have been written about the effects of feminism on the nursing profession, most notably "Daring to Care: American Nursing and Second-Wave Feminism" by Susan Gelfand Malka. Perhaps an exploration combining the effects of feminism on nursing and changes in communication would be an interesting follow up to "Confident Voices".

Within "Confident Voices", Boynton also does not address cultural, ethnic and racial differences in communication that could greatly impact nurses and those who work in health care institutions. Asians, Native Americans, Hispanics and other groups may have cultural practices and norms vis-a-vis communication that differ widely from white American culture. From eye contact to body language, communication in the workplace also needs to take these differences into consideration.

My Recommendation

Overall, I would highly recommend "Confident Voices" to any nurse who wishes to improve his or her own communication skills, share those skills with colleagues, and attempt to understand organizational culture with an eye towards creating positive workplaces for all concerned.

On the Radio

Beth Boynton will be appearing as a guest on RN.FM Radio: Nursing Unleashed on March 12th, 2012 at 9pm EST. Please tune in and you will be able to call into the show and ask Beth questions about her work as a nurse, writer, and workplace communication expert.