Nursing board far removed from patients
RICHMOND – Pixieish behavioral health nurse Julie Nowak enters a second-floor conference room of the Perimeter Center and sits facing five members of the Virginia Board of Nursing.
She has traveled to Richmond from Tennessee with her cousin on this day in September so she can defend her Virginia license.
Before Nowak had come Mary Jones, a registered nurse hoping to have her license reinstated after being convicted of embezzlement, and James Borror, a licensed practical nurse armed with two attorneys and Winchester hospital colleagues.
In the audience, some 30 George Washington University nursing students, a court reporter, board investigators and caseworkers wait for the registered nurse to speak.
"Pull that mic a little closer to you," Jane Ingalls, the board president, tells Nowak as she calls the hearing to order.
"Bear with me, I'm a little nervous," the nurse apologizes in a tiny voice.
An officer says: "The evidence today will show that Ms. Nowak failed to enter into the Health Practitioners' Monitoring Program."
In 2007, Nowak forged five prescriptions for herself for Percocet and Vicodin, narcotic painkillers similar in effect to morphine. The board agreed to take no disciplinary action if she entered monitoring.
But Nowak never entered the program — a misstep the board didn't notice until 2014, when it turned up on a random audit of case files. Now the nurse was there to explain herself to the reviewers. No one on the panel mentions that the state lost track of Nowak for six years.
LOOKING FOR ANSWERS
Nowak is no stranger to drug monitoring. When a previous employer reported her for substance abuse in 1996 — the same year she got her RN license — she enrolled in the confidential program with a stay of discipline from the board. After completing it, her license was cleared.
Why didn't she enroll in the program a second time after her felony charge, as the board ordered her to do, they ask her now? "I honestly didn't recall from 2008," Nowak struggles to explain. "I had gone through court counseling and was on probation."
Because she was a first-time offender, Virginia law enforcement had deferred her guilty verdict while she went through supervised probation and substance abuse treatment. On completion, the criminal charges were dismissed.
The board members keep probing about why she didn't enter the monitoring program. "I really don't have a good answer," Nowak says.
Whether first-time visitors to Richmond or experienced ones like Nowak, nurses know what the reviewers want to hear — own up to your actions, show you're cooperating with your recovery — and the reviewers know what to ask them.
"What are your triggers?" asks a panel member, testing to see if the nurse is aware of the stresses that could cause her to relapse.
"Anger." Nowak's voice sounds stronger. "Being upset with myself. Not accepting this whole thing. It's difficult to accept when you look back at the things you do."
FAMILIAR PATTERNS
During the cases heard on different days at the board, the details from individual nurses varied, but the dance was the same.
Nowak wants the panel to know she understands her disease now. "I can't contest much of that about not following up," she admits, "but I'm taking steps to do what I need to do to be healthy. I'm getting there. I don't want to go back — I really don't — but only I know that. I know it's going to take time for everyone else, because I have relapsed."
She touches the crux of the substance-abuse conundrum. While experts understand addiction's causes and can pinpoint it in the brain, the cravings that cause people to relapse vary by person, and continue long after the substance is removed.
Of 188 nurses who were given stays of discipline between 2008 and 2013 so they could enter drug monitoring and rehab, half later lost that privilege due to relapses, according to Virginia Department of Health Professions data.
Ingalls gives the nurse a chance to tell her side of her story, and as she does, the nursing students in the audience stop fiddling with their phones and listen with pained expressions. Describing the separation from her marriage of 22 years to a law enforcement officer — "That was part of me taking care of me. I've got two children that I raised." — Nowak's presence fills the room.
As she testifies, it comes out that Nowak has been practicing nursing unmonitored for years. No one talks about how her patients were served by someone struggling with addiction. Here, in the meeting room in Richmond, the patients seem far away, more conceptual than real.
"I care about my patients," Nowak offers at one point. But all the energy and intensity in the hearing room is focused on her and her personal journey.
"How can I guarantee it won't happen again? I can't," Nowak says. Summing up, she stresses, "I feel good about where I am for the first time. I'm doing it for me. That's where it's got to come from."
DECISION TIME
The questions and testimony conclude. It's decision time, and while the board confers behind closed doors, Nowak waits nervously with her cousin outside the conference room in the hall. She sounds angry, talking about being fired from her employer of 15 years. She smirks slightly at the board having lost track of her.
It's been tough finding work in Tennessee, she says, expressing hope the board will give her a break.
"Is there a motion regarding Ms Nowak?" Ingalls asks the panel members when the case is reconvened.
"Yes, Madam Chair, the board orders to reprimand, and issue an order to place on indefinite suspension, with said suspension stayed …"
The nurse's eyes widen. Her hand flies to her mouth. She had expected no conditions on her license.
"… based upon entry and compliance with HPMP or similar program in Tennessee."
Back in the hallway, Nowak wonders angrily how long she'll have to keep paying for her mistake. For six years, she enjoyed the liberty of nursing outside the monitoring program's scope. Only by chance had the board discovered its lapse on a random case audit, Nowak says.
Now, she'll have to submit to monitoring again in order to practice in Tennessee.
The day of hearings continues as it began: with only nurses, nursing students, administrators and journalists present.
HIGHER CASELOAD
•The nursing board decided 417 cases in 2007, the first year covered by our investigation, compared with the last year, when 1,116 cases were decided; a 167 percent increase. (The case loads overwhelmingly involved registered and practical nurses, but also included others such as nurses' aides.) With a growing caseload and more hands in the mix — for example, board members now delegate more cases to subordinates — it's easy to see how some like Nowak can fall through the cracks.
•The cases range from poor judgment and neglect to criminal convictions for larceny or substance abuse, and could result in a wide range of actions — from no action to a stay of discipline to suspending a license.
SYSTEM AT WORK
Like the segments of a rattlesnake's tail that must play together to sound a warning, the state's disciplinary and monitoring systems consist of many moving parts.
Nurses with substance-abuse problems come to the board's attention mainly through law enforcement or employers. The board may order them into monitoring, but the program is run by the psychiatry department of Virginia Commonwealth University, which coordinates reports from the nurse, labs, employers and treatment providers, and communicates with the board. The VCU-run program doesn't offer treatment — it refers nurses to treatment from a list of recommended providers or those their insurance will cover.
