IPN

 While listening to the rain pound the roof of my car, I contemplated the blank affidavit my lawyer had instructed me to sign and to have notarized. She would fill it in for me, she said. 

   Before I was accused of diverting or stealing my patient’s narcotics and sedatives by my ex-nurse manager, I didn’t know IPN existed. And now, here I sat, contemplating sending a blank affidavit to a woman I couldn’t pick out of a crowd. My lawyer seemed competent enough, and I had to admit she had gotten me this far in the process. Although, to be honest, I had done all of the chart reviews and other work myself. One by one, I took apart the charges. Proven they had been manufactured. The pharmacy and medical records were altered in a way that made me guilty.

I was a nurse for over 20 years before I became aware of the Intervention Project for Nurses, or IPN, as it is popularly known. I was made aware of the program when about a month after I quit my job as a local travel nurse with one of the largest hospital systems in the Tampa Bay Area, my ex-nurse manager called me and told me that there had been a narcotics discrepancy. And since I was no longer an employee, hospital policy demanded that I be drug tested by IPN. Unfamiliar with the program and knowing that quitting a nursing job could be like trying to break up with a stalker, I did a quick Google search. And my first thought while reading about the program was: Why would this even be a thing?  

The IPN (Invention Project for Nurses) is a Florida State Board of Nursing-sanctioned monitoring process for “impaired” nurses.  Impaired, meaning that the nurse in question may have a physical, mental or substance abuse problem that could interfere with their ability to provide safe patient care. And rather than address the issues within the profession that would drive Saint Maximilian Kolbe (Patron of drug addiction and political prisoners) to drink, the state of Florida in a misguided effort to provide help and support to these “impaired” individuals created IPN. 

Most nurses accused of diverting drugs or abusing alcohol end up in IPN. Anyone can make an allegation: an employer, a hospital, another professional, law enforcement, an ex-husband, or my next-door neighbor. Anybody. The accused is guilty until proven innocent: as a presumption of guilt is in best interest of the people of the state of Florida.  

Once a charge of “impairment” is made, the defendant is subjected to an investigation by the Agency for Health Care Administration (the nurse police). At this point, a Probable Cause Hearing is almost guaranteed, and the Probable Cause Hearing usually results in the professional nurse being given three options: to enroll in IPN for “treatment,” to relinquish their right to practice nursing, or to request an administrative hearing. Rather than enduring the ordeal of an investigation and trial most nurses accused of diversion “voluntarily” enroll in IPN. I chose to fight. The blank affidavit my attorney was asking me to return was my plea. Guilty or Not Guilty. Drug-addicted thief who stole from the infirm; or not. 

According to the American Nurses Association, up to ten percent of the RN workforce may be dependent on drugs or alcohol. And again, rather than address the issues within the profession that would test the patience of Saint Max, the Association has launched and supported a national campaign to inform Registered Nurses of their responsibility to identify and to report colleagues who may be impaired. The state of Florida has embraced this may be through duty to report legislation.  Under this Mandatory Reporting Law, all licensed nurses are required to report any suspected impairment to the Department of Healthcare Administration or to IPN. This law (intended or not) protects informants from the legal consequences of false accusations or malicious motivations.

“What do you want, Mildred?” I had not talked to my ex-nurse manager since the morning I quit my job.

“Well, there’s been a little problem with the narcotics count.”  My ex-nurse manager answered. “It’s just a little thing, the pharmacy report came back, and it looks like you failed to properly waste two narcotics. And well, since you no longer work for me, I had to make a report to IPN. Normally we would drug screen you ourselves; but since you quit, you have to do it through them. No big deal. It really shouldn’t take too long.”

“Okay.” I replied and  hung up the phone. Then, I Googled IPN.  

Agreeing to enter into an IPN contract would mean that I could be required to sign myself into a drug or alcohol treatment center for what could become an indeterminate period of time. I would also have to participate in at least two to five years of monitoring that could include weekly counseling sessions, regular psychiatric visits, random urinalysis testing, mandatory daily check-ins with a case manager, notification to my employers that I was enrolled in IPN, a court-mandated prohibition on drinking or taking medication of any kind to include over the counter medications. I could lose my privilege to administer narcotics and other “controlled substances” or to work 12-hour shifts. The state could require that I only be allowed to work under the direct supervision of another registered nurse. And most concerning to me was the fact that my immediate supervisor, a.k.a, some future nurse manager, would ultimately be the person to determine my readiness to leave IPN. Someone like my ex-nurse manager. And if  that was not bad enough,  I would be responsible for all costs associated with the prosecution and administration of the program. So much for due process.

As a float pool nurse with the largest hospital system in Tampa Bay, it was my job to provide temporary staffing to five of the system’s largest hospitals. I preferred being a float or local traveler. It kept me out of the politics and allowed me to make my own work schedule. A running joke among my peers is that the difference between being a traveler and being a staff nurse was like the difference between dating and being married. When you’re dating, your date dresses up for you. Takes you out to dinner. Smells good. Holds open the door. But after the wedding, your new spouse strips down to their underwear, plops down in front of the TV, and demands dinner.

As my employer acquired more and more of the smaller community hospitals surrounding Tampa Bay, my ex-nurse manager began to require her float pool nurses to staff these facilities. In order to avoid paying the float nurses travel pay, the schedulers limited our commutes to a 50-miles radius.

The first time I was floated to a hospital outside of my contracted facilities I didn’t complain. Told the scheduler to let the hospital know that I would be a little late. I was flexible; I could float almost anywhere, and do almost anything. I was a good nurse. I got things done. And I loved being that person. 

According to my car’s navigation system the hospital was a little over 48 miles away. I would be late but not too late. However, the drive turned out to be more complicated than I expected. And at 0800 (my shift started at 0700) my GPS announced that I had arrived at my destination. The hospital was nowhere in sight and while sitting in a strip mall parking lot, I called the unit to tell them I was lost. The woman who answered the phone was not surprised. I was only a few blocks from the hospital, it had happened before. Then with the precision of an air traffic controller the woman, who turned out to be the unit secretary, guided me to the hospital.

“You’re not the first nurse to have trouble finding us.” Smiling as she rushed me through the process of obtaining access to the various locked doors of medication and supply dispensing machines, she continued to reassure me, “We’re just happy you found us.” An abbreviated tour of the unit and I was off and running. Nine o’clock meds were already late. I would never catch up. By the time I found the unit, the night nurses I was diverted to relieve had already left. They had children to pick up or drop off. So not being unable to wait for me they wrote out a change of shift report and went home to other responsibilities. 

Because the first morning med pass is the heaviest it usually starts an hour before its scheduled time. One patient can require administration of as many as 15 pills. And that’s only scheduled oral medications, not pain meds or anxiety meds or emergency meds. There is no time during that first med pass for interruptions. No time for interruptions from physicians, or family, or the lab, or the code blue down the hall for the 98-year-old patient admitted with acute respiratory failure, or maybe sepsis, or congestive heart failure, or some other age related disorder. No time for the rapid response for the confused alcoholic who fell and broke their hip while trying to climb over the side rails. No time for the incessant ringing of the cell phones we are required to carry. My record for answering the phone while trying to give one person their morning medications is 10. There is no time for breakfast, or lunch, or bathroom breaks. There is a nursing shortage, there has always been a nursing shortage, and from what I can see there will always be a nursing shortage. 

 While skimming the written change of shift reports, I got to know the people who were now my responsibility while preparing and documenting their morning medications. Made my nursing assessment appear to the people now under my care to be a casual conversation, about the course of their illness. The day was a blur, but I got through it. All my patients got the right meds and no one died. It was a good day.  But traffic during the drive home was worse than the drive to work. I passed three accidents and a car chase. I didn’t get to bed until after 12 a.m. and had trouble sleeping. I got up the next morning at 5 a.m. and put in another 14-hour shift at one of my regular hospitals. 

On March 16, 2013, Beth Jasper an Ohio hemodialysis nurse died in a single car crash when she fell asleep while driving home from work. A lawsuit, filed by her husband Jim, claimed that his wife had been worked to death by her hospital. In interviews with various news agencies, Beth’s husband stated that from 2011 until the day Beth died, she was regularly called in on her days off and forced to work overtime without adequate meal or bathroom breaks. Both the Ohio Nurses Association and the National Nurses United (the largest nurse’s union in the United States) provided statements in support of the claims made by Beth’s husband. Everyone rushes in after the fact, that doesn’t help Beth. 

The second time the scheduler tried to divert me to the same hospital, I refused the assignment. “You have to go!” She shouted into the phone. 

“I’m not going. Find somebody else.”

“Mildred is going to call you.”

“Fine. I’m still not going.”

“I hate to lose such a good nurse.” My ex-nurse manager sighed into the phone.

“Then, don’t make me drive two hours to work. That’s not what I signed up for. That’s not in my contract, Mildred.”

“Yes, it is. It is a requirement of your contract that you float to any hospital within the system.” 

“No, my contract is for 5 hospitals. And if this is going to be the new normal, then I guess it’s just time for me to move on. You can consider this my two-week notice.”

As far as most employers are concerned nurses drop their humanity at the hospital door.

 The original complaint filed by my then nurse manager with the state of Florida alleged that I had not properly disposed of (wasted) two narcotics.  

American drug epidemics are not new. I can mark the decades of my life by the American drug of choice. While growing up in inner-city Detroit in the 70’s, the smell of marijuana was ubiquitous. And memories of my paternal grandfather are always accompanied by a flash and the odor of Johnnie Walker Red Label. 

At the beginning of my nursing career in the early 90’s, the drug of choice was quite a variety of stimulates. Cocaine and methamphetamines marked my introduction to the consequences of the pursuit of the American Dream. I learned the meaning of and became familiar with the smell of meth mouth and was vigilant about the signs and symptoms of a cocaine-induced myocardial infarction. And my own education and socialization into the world of nursing facilitated a development of a tolerance for sleep deprivation that encouraged an addiction to caffeine. Between husbands and housework, babies and boyfriends, aging parents and teenage angst most of the nurses I knew (myself included) were more inclined to knock off a Starbucks than to divert narcotics or sedatives.

During my military career I, as expected, often drank too much. My brief affair with alcohol ended on my last night on the island of Okinawa, Japan. Memories of that celebration of my return to civilian life with the five other women assigned to my barracks, still occasionally assault me with the force of a flashback. Piling clown car style out of someone’s white mini; landing at the feet of a Japanese police officer’s black polished lace-ups. Taking over the dance floor at the Purple Haze, a bar where only Jimmy Hendrix music was played. Drinking too many of the bar’s black licorice flavored signature cocktails. Ending up passed out on the barracks pool table where my friend Phillip “Strawberry” Fields found me. Deciding I had had enough, he half carried, half dragged me to my room. Locked me in. Took the key. Alone in the dark, I stuck out my leg to stop the bed from spinning. Threw up in the trash can because I could not figure out how to open the locked door or remember where to find the common bathroom. Falling back onto the bed I decided, “You can’t do this your whole life.” How I made it to my flight the next morning is a mystery I would rather not recall. That was in 1986. I was 24 years old, and it was the first and last time I have ever been that out of control. 

I chose my attorney because she was also a nurse. But that wasn’t really accurate. Before my lawyer became a lawyer, she was a nurse administrator, someone’s ex-nurse manager. Bedside nursing is not glamorous. And some people who lack the humility to wash another person’s feet (or other unmentionables) find it demeaning, and move up to more prestigious occupations.

 The original complaint filed by my then nurse manager with the state of Florida alleged that I had not properly disposed of two narcotics. When I refused to enroll in IPN, the hospital increased that number to seven. My lawyer then began the process of requesting copies of the pharmacy and patient records. It was when I had to explain to her that patient medications were scanned and opened at the patient’s bedside and not in the medication room that I realized I would be responsible for my own defense and asked her to forward me a copy of everything she had received.

I began with the pharmacy reports. Cross referenced the narcotics discrepancies with my charting and the patient orders. What I found made the hair on the back of my neck stand up.

The first charge alleged that I removed 100 mcg of intravenous Fentanyl from the electronic medication dispensing machine. Documented administration of 50 mcg to the patient and did not account for the additional 50 mcg by recording a waste of the excess. Wasting of controlled drugs requires a second nurse to witness the disposal of what is left over from a partial dose. This patient did not have intravenous fentanyl ordered. The order was for a 25 mcg Fentanyl patch. It would have been impossible for me to access a controlled substance that was not ordered for this patient without immediately alerting the pharmacy and engaging safety measures that have been put into place to prevent such practice.

The second charge alleged that I had pulled an oral Ativan that had been discontinued. Again, it would have been impossible for me to remove this medication without an active order. 

All in all, there were seven charges. One by one I proved that what I was accused of doing was impossible. It is unlikely that I was even working on at least one, possibly two, of the days on which the alleged diversions occurred. 

Listening to the rain pound the roof of my car, I took out my pen and carefully filled out the affidavit, pleaded not guilty to all charges. I had it notarized and faxed it directly to the prosecutor. I decided to take my chances with a judge.

My husband and I were having trouble financing my defense. Justice is expensive. We had already spent $15,000 dollars. And we were running out of money. But after reviewing the evidence that the board of nursing had accepted from my employer, I flat out demanded a trial. A trial would be another $25,000 dollars, my lawyer informed me.

As part of my pretrial preparation, I was evaluated by a psychiatrist specializing in addiction. That one hour session added $700.00 dollars to my defense bill. On the day before my appointment with the doctor, I received a call from her office. Confused and outraged by the lack of information contained in my medical records, the office nurse responsible for coordinating my presumed admission into IPN practically screamed into the phone, “There are no narcotics listed on your medical records. As a matter of fact, there are no prescriptions listed at all. I need the names and contact for every doctor you’re seeing.”

“I don’t see other doctors, and there aren’t any prescriptions because I don’t have any.” I explained. “Well, I do take a multivitamin for my hair.”  It was pretty clear by the way she slammed down the phone that she didn’t believe me.

That’s the problem with IPN. Once accused. Guilty. Any defense of my character would be viewed as part of the pathology of addiction. Any denial of the charges is just that, denial. It’s all a part of the disease, you know.

Before taking on my case, my lawyer gave me a one-hour dissertation on the process of IPN. Whether I was guilty (which I was presumed to be) or not, I was pretty much screwed.

After I quit my job as a float nurse for the corporate hospital system that was now charging me with diversion, I took a job with hospice, as an admission nurse. No more direct patient care or bat shit crazy nurse managers for me. I was done. A point that I had to clarify with the physician responsible for assessing the extent of my addiction. In my administrative position as an admissions nurse, I no longer had access to drugs of any kind. Surprised by my lawyer’s failure to pass on information I believed was relevant to my defense (why would a drug addict give up access to drugs) I began to wonder just whose side she was on.

Sitting in my car, listening to the rain, I thought about my time at the veteran’s hospital in Palo Alto, California. I’d always wanted to see San Francisco. The nurses in the ICU took great pleasure in telling new graduates that Nurse Ratched was a real person and that every word written about her in the novel, “One Flew Over the Cuckoo’s Nest” was true. At the time, I smirked and shrugged it off as a fairy tale told to frighten new nurses. I should have listened. Got liability insurance. It never occurred to me that I would ever have to protect my ability to practice my profession from my employer. 

The day after I faxed my not guilty plea to the prosecutor in charge of my case, I received a call from my lawyer. “I told you to just sign it and mail it back to me. The prosecutor just called me and asked if you were turning down the deal.”

“Sorry,” I said. “I didn’t know there was a deal. What happens now?”

“I’m not sure. We’ll have to wait and see.”

A week later my lawyer called me back. “I have good news,” she announced,” the Board is going to drop all of the charges. But it will have to wait until the next probable cause hearing which is scheduled about three months from now.

“That’s great.” I replied. But what are they going to do about Mildred?”

“What do you mean?”

 “About what she tried to do to me?”

 “Nobody’s going to take that on. You’re better off just letting it go.”

The day after the charges were dropped, the prosecutor sent me a letter, thanking me for my cooperation. 

“And has it made you happy?” The young woman who asked that question was in the process of becoming a post COVID nurse. She was most likely finishing up on-line high school while the pandemic raged. A nurse who had survived COVID would never have asked that question. We were standing in the medication room, and I was in the process of counting a narcotic, when the young woman interrupted me, made me lose track of what I was doing. Annoyed, I dropped the pills back into the open drawer, started over, recorded the number into the electronic display. Straightened my back and said, “Well, it’s not a happy job is it?” I mean it’s not like we work at Disney.” The beam in her face faded and she dropped her head and studied her feet. 

She didn’t deserve that, I told myself as I thought about the meaning of “Happy.” Before IPN and COVID, if someone had asked me if being a nurse made me happy, I would have said yes. I loved being a nurse. But at that time I didn’t value the profession. Didn’t know that being capable of providing for myself was something that at all costs needed to be protected. I took for granted having the means to explore what makes me “happy.” It never occurred to me that my independence, my right of self determination was something other people could and would bother to deny me. 

Nurses are not encouraged to be self protective. Selflessness is usually an inherent trait of people who commit themselves to the helping professions. We value sacrifice. Willingly put ourselves in harm’s way; are unconditionally faithful to the greater good. Encouraged to rely on Hospital Policy and the illusion of a Just Culture to protect them from litigious patients and unavoidable errors, bedside nurses openly debate the wisdom of obtaining personal professional liability insurance.

On March 25, 2022, RaDonda Vaught was convicted of criminally negligent homicide and abuse of an impaired adult; after she mistakenly injected a patient with a paralytic instead of a sedative. She was sentenced to three years of supervised probation. To me, the circumstances surrounding the medication error made by Nurse Vaught are still murky. And as a nursing instructor who also to works as a critical care RN,  I always come back to these questions: Why even in override mode was she able to access a drug that should only have been accessible in a perioperative setting, a setting were a patient is on or can be immediately placed on life support? And even if the order was for Versed (a fast acting and sometimes unpredictable sedative) and not Vecuronium (a paralytic) were the patient’s life signs being monitored as is standard when Versed is used for sedation? Why was Nurse Vaught functioning as a critical care nurse, if she did not immediately recognize that Vecuronium was paralytic? What was it about the situation that made her so distracted or pressured that she administered a paralyzing agent instead of a sedative? And why did the Tennessee Board of nursing initially absolve RaDonda Vaught of wrongdoing?

I’m not afraid of my patients. I’m afraid of my employer. 

From year to year health spending in the United States averages approximately 18 percent of the GDP (gross domestic product) That’s about 4 trillion dollars. Hospitals and hospital associated care accounts for approximately 1300 billion dollars of that pie chart. Hospitals can function without doctors. Hospitals cannot exist without nurses. 

“I’m not sure what you mean by “Happy.” I began. “I think that when most people, especially now, talk about happiness, what they mean is euphoria. That’s not sustainable, is it?”

“No.” She answered. Her smile was back.

“When people meet us in our professional capacity it is usually on one of the worst days of their life. Becoming a nurse has given me financial independence. A sense of purpose. Made me the person that I am. Being a nurse has given me the resources to explore the things that make me “happy.” Nurses are often the first person people meet when they come into this world, and nurses are often the last person they will know before they leave it. I think that’s important.”

The young woman lifted her head and smiled.

“Don’t look for “Happiness” in your job.” I said as I left the medication room.