Lessons from Radonda Vaught: Nurses need to raise their voices [PODCAST]

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“One thing is hard to ignore – nurses need better treatment. Nurses need a seat at the table and advocacy. Nurses need to raise their voices, listen to each other, and unify to achieve the progress that we need to improve our workplace safety, manage and prevent burnout, and promote patient safety.

Nurses have traditionally operated with our patients’ best interests at the core of our professional life. Now is the time to advocate for our best interests as strongly as our patients. If not us, then who? If not now, then when?”

Jessica Reeves is a nurse practitioner.

She shares her story and discusses her KevinMD article, “Florence Nightingale. Clara Barton. Radonda Vaught?”

This episode is sponsored by the Stanford Physician Leadership Certificate Program.

For the aspiring physician leader, leadership skills are one of the most important and influential traits that will elevate your overall success. 
 
Leadership impacts nearly every aspect of your career in a complex and diverse health care system. Including how you effectively communicate and influence those around you, how you respond to conflict and make important key decisions, how you develop your team, and even how you navigate social dynamics in your workplace. 
 
Stanford Medicine recognizes the need to foster physician leaders in health care. That is why they developed the physician leadership certificate program. This 6-month cohort-based program includes live virtual sessions, self-paced learning modules, professional coaching, a capstone project, and much more: Providing C-suite education for the non-C-suite physician leader.
 
They encourage all early career and aspiring physician leaders to apply. To find out more about the program or apply, visit physicianleadership.stanford.edu.

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow.

Today on the show we have Jessica Reeves. She’s a nurse practitioner, and her KevinMD article is titled “Florence Nightingale. Clara Barton. Radonda Vaught?” Jessica, welcome to the show.

Jessica Reeves: Thank you. Thank you for having me.

Kevin Pho: So we’ll get into your article in a little bit. First off, briefly share your story and journey to where you are today.

Jessica Reeves: Yeah. So I’m a nurse practitioner, and nurse practitioner is actually a second career for me. Before becoming a nurse practitioner, I worked in the nonprofit space, performing arts stuff, for about 10 years, 15 years altogether with nonprofit stuff. So I shifted over to the health care piece and became a nurse practitioner working primarily in primary care, family medicine. I’ve always had an interest in keeping several plates spinning, and so one thing that I very much like about my current career, where it stands right now, is that I’m able to scratch a few different professional itches, so to speak.

Kevin Pho: And we’ve been talking offline a little bit about your practice, and it is a micro practice, which is a little bit different from a lot of typical primary care practices. So tell us more about that.

Jessica Reeves: Yeah. So I did the corporate medicine thing, seeing 18 patients a day and charting and doing all the runaround, and the kind of, I don’t want to say hamster on a wheel, but that’s how it felt. I did that, been there, done that, and I didn’t quite get to the point of burnout, but I could see it on the horizon. And I realized that nonprofit piece that I brought with me, where you’re always understaffed but you’re doing it for the right reasons, and you’re always stretched a little thin but you’re doing it for the right reasons, and it’s just sort of the mission, just serving the common good or whatever the particulars are, I really wanted to get back to that. I wanted to be a little less of the things that I have to do and more of the things that I want to do, and to be able to develop longitudinal relationships with patients instead of feeling very transactional. That was important to me, and so was feeling like I didn’t have to see a certain number of patients to reach the overhead. In a big practice, you have a lot of support, but somebody has to pay those bills, and that comes from the revenue generated from visits.

So by doing an intentionally low-volume, low-overhead practice, it’s more work in some ways, right, because I’m doing everything myself, but it’s more gratifying, because I’m able to spend time with patients and really dig into the co-production of health care, which is important to me. That’s not impossible in a corporate medicine setting, seeing a high volume of patients, but for me it’s much, much harder. So I feel that my satisfaction has increased. The amount of work I do is probably the same, but I’ve shifted much more into the driver’s seat, and for me that was important.

And yeah, it has also opened me to other opportunities. I was able to write a piece that you ran earlier this summer, thank you. I don’t know that I would have had the bandwidth to do that if I was just full time on that wheel. So that has been a nice thing too. Work-life balance, we talk about that a lot, but I feel like I’m edging closer to that in this setting.

Kevin Pho: I’m a primary care physician myself, and I always want to encourage more of my clinician listeners to go into primary care, so I think that you’ve found a setting where you’ve rediscovered some of that joy in primary care. Now, tell me, how difficult was it for you to start a micro practice? And if someone were, for instance, wanting to switch to a practice like yours, tell us about some of the challenges that you faced in doing that.

Jessica Reeves: I think the biggest challenge was, I don’t want to say confidence. We have to have a certain clinical confidence and a certain willingness to just fly without a net. I work on that every day. And it’s nice to get a steady paycheck. I could definitely say that my bank account was a lot happier when I was working in a nine-to-five environment, but there were trade-offs, and for me those weren’t worth it. So that was a big piece, really just digging deep and really thinking about what was important to me and what was going to work for me in the long term.

There were definitely things about working in a high-volume setting that were beneficial for me. You definitely ramp up that clinical experience very quickly, right? But you get to a certain point where that trade-off starts to happen, and you really start to think, is this sustainable? For some people it is. Some people will do that for their entire career and retire and be happy about it. That’s not me. And realizing that was what was true, being true to myself, and then finding a way to make it work for me. So if this isn’t working for me in this high-volume, kind of corporate setting, then what would work for me? What do I really want, and what’s important to me?

And then having the support systems, having a very supportive spouse, and I’m fortunate in that way, but having supportive friends, having that confidence, and having the skill set. Having come to medicine, to being a nurse practitioner, as a second career, before that I had been in nonprofit management for a long time, so knowing that kind of administrative piece and feeling confident there helped. But you can learn that. So even if it’s someone whose experience has been exclusively clinical, there are definitely resources out there. There are tons of groups on Facebook, there are tons of courses that you can take, and there are books that you can read. But at some point, you just rip that Band-Aid off and fly. So it’s sink or swim, but I think more people will swim than they think. A lot of people think they’re going to sink, and no, not necessarily.

Kevin Pho: All right, let’s transition into the piece that you wrote this past summer on KevinMD, titled “Florence Nightingale. Clara Barton. Radonda Vaught?” Now, for those who aren’t familiar with Radonda’s story, just give us a little bit of the background, and then you can lead into your article.

Jessica Reeves: Sure, sure. So what happened with Radonda is something that has happened to most people, right, working in some sort of clinical setting. At some point, you’re going to make a mistake. She made a very unfortunate mistake, and the patient ended up passing because of it. But she made this mistake and did the things that you’re supposed to do when you do make a mistake: She reported it to her employer. They did their investigation, and other parties were brought in to be a part of that investigation.

What’s different about her case, and what I think is, think about it, really frightening, is the fact that she was brought up on criminal charges because of this negligence. And her employer was investigated as part of this because of the nature of the error. She gave a wrong medication. She pulled the wrong medication out of her Pyxis machine, or similar, and ended up giving a medication that caused the patient to die. And it was found that while she was the person responsible for delivering that wrong medication, there were a lot of contextual, cultural issues within the organization that were factors as well. And the employer, which was Vanderbilt’s health system, was investigated by their pertinent authorities and was found to have some really serious issues. They were able to settle out of court.

Kevin Pho: What were some of those issues? You mentioned that there were some contextual issues on the part of the employer. What were some examples of some of those issues?

Jessica Reeves: Yeah. So there had been some upgrades to their Pyxis, and I’m not sure if it’s actually Pyxis, but it was the locked medicine cabinet. There were some issues there. They had been upgrading it; they were assuming Epic or similar. So every time you go to pull the medication, you get this error message, and here’s the workaround for that. And the workaround in this case ended up costing a patient their life. Yes, it’s much more convenient in terms of time, being efficient, delivering the medication, keeping the wheels moving, but at a really extreme cost.

And as the Department of Health and Human Services investigated Vanderbilt, they found that there were some serious issues that were putting patient safety in jeopardy, and in this case, the patient’s life. They presumably have corrected those, but they weren’t brought up on criminal charges. Radonda was the individual who definitely had a share of responsibility and was really made the scapegoat for something that was not exclusively her fault.

Kevin Pho: And when you heard about this case, and you heard that Radonda was brought up on criminal charges, what was going through your mind? Why was it so scary?

Jessica Reeves: Yeah, “Who’s next?” was the first thing. This could happen to anyone, anyone with access to a Pyxis machine, anyone with access to patients, anyone who is overworked, understaffed. This is an issue. This happened before the pandemic. Things have gotten even more intense and even worse in terms of staffing and shortages and just the volume of patient care that’s happening at the bedside and in the clinic. And “Who’s next?” Those are some of the first things that I thought of. And what sort of precedent does this set for the profession, for the industry? This is a really slippery slope.

I also think of the loss, the potential loss, of institutional knowledge, right? This is scaring nurses out of practice, is the bottom line. We’ve also had nurses who are burning out. They’re leaving the bedside. They’re leaving the profession entirely. The pandemic has exacerbated that. This is another major, significant chip in that armor, and that loss, yeah, we’ll have new nurses that’ll come along, but that loss of experienced nurses, of the institutional knowledge that goes with these nurses who are maybe taking an early retirement, that’s scary.

And in my title, where I talk about Florence Nightingale, Clara Barton, and Radonda Vaught, Florence Nightingale and Clara Barton were these huge figureheads, positively. Maybe not at the time; Florence Nightingale was not necessarily accepted on the first try. But now, looking back, we realize she had this huge impact, obviously, on nursing. I fear that the same will be true of Radonda, and that she will have this impact, her case will have this impact, on nursing for years and possibly generations. I think this is something we’ll look back on in the future and say that was this inflection point.

Kevin Pho: Now, you have a connection with that nursing world, being a nurse practitioner. Have you talked to some nurses about how that case has affected what they do or changed what they did on the job?

Jessica Reeves: Yeah, I’m finding that a lot of nurses can relate to this case. They’ve experienced something, maybe not to the extreme, where they’ve pulled the wrong medicine, or they’ve had to do a workaround, and, oh wait a minute, looking back, that was really probably a pretty dangerous situation. So nurses can relate to this. If they haven’t experienced it directly, they’ve known someone else who has, or they can see the potential. But at the same time, we’re being stretched so thin, and it’s this, maybe, that initial spark that starts the wildfire, potentially. I think that’s some of the thinking for the nurses who do want to talk about it. And some nurses just don’t even feel comfortable to talk about it. They want to just get through the day, and that’s as far as they can see, and that’s understandable too. These are really tough times to be in any kind of patient-facing role. It’s a very challenging time, but things like this definitely don’t bring us together.

And to think about the context, she was practicing in an environment where she was being really asked to do some things that ended up being really harmful. That’s something that a lot of nurses can relate to as well. And to think of that, then, with the pandemic on top of it. We’re very used to advocating for our patients and keeping the patient’s best interests in mind, and that’s important, and that should not change. But who’s advocating for us? And I say that for any patient-facing profession, not exclusively nursing, but that’s the lens that I see it through. Who’s advocating for us, and who’s making sure that the situation we’re operating in is safe, professionally safe, personally safe? Workplace violence is a huge issue for nurses. There are so many examples that can be given, but the examples of the advocacy that we have for ourselves, for each other, I think are much fewer, and that concerns me as well. I think there’s really a need for us to advocate for ourselves and for one another as strongly as we do for our patients.

Kevin Pho: Now, does criminalizing medical error actually improve patient safety, in your opinion?

Jessica Reeves: I don’t think so. I think that the biggest thing in this case, using Radonda as the example, that really improved patient safety was her surrendering her license and stopping practicing. Is this going to happen again? Yes. And no one is necessarily thinking of potential criminal charges when they make a mistake, because no one’s intentionally making a mistake, so it’s called a mistake. So I don’t think that criminalizing it, I don’t know who that satisfies. You don’t know whose situation that improves, really, maybe the folks who are bringing charges, or the family in this case. But I don’t think that’s the solution.

I think the solution is really to be looking at the upstream factors. What led to this mistake being made? Was she simply a nurse who made a mistake, or were there some other factors too that deserve to be addressed, deserve to be acknowledged, and held as much to account as Radonda was?

Kevin Pho: So just to be clear, after Radonda made that mistake, did she do anything wrong, or anything that could have been different, in the aftermath?

Jessica Reeves: I don’t believe so. It’s important, which she did, to follow the code of ethics, the state statutes as they are, and she’s in Tennessee, but yeah, it’s going to be a surrender of a license, and that’s what happened. She reported it. She didn’t deny it. She was forthright, and she was transparent. From her perspective, and the things that were within her control, I think that she did everything correctly.

Could other things have been done differently? Looking back, hindsight, of course, is always 20/20. Could other things have been done differently? Yes. But in her case, I think that she did what we’re trying to do. If you do something wrong, you have to own up to it and accept the outcome. But I don’t know that we’ve ever been trained to think that criminal charges could be a part of that outcome.

Kevin Pho: We’re talking to Jessica Reeves. She’s a nurse practitioner, and her KevinMD article is titled “Florence Nightingale. Clara Barton. Radonda Vaught?” Jessica, you mentioned one thing earlier, that we in health care, nurses, clinicians, everyone involved in the health care spectrum, need to better advocate for ourselves. So what are some of your ideas on how we can do that?

Jessica Reeves: Not surprisingly, it’s not a super popular idea, and I don’t think it’s a perfect idea, but I think that the concept of unions has been something that’s been the most effective in the past for other professions in similar situations, who don’t have that advocacy and don’t have that agency. I don’t know how often physicians and nurses will compare themselves to Amazon workers or Starbucks workers, but I think in a lot of ways there are some similarities to be analyzed, at least, between the two.

In private practice, it may be different, but if you are working for an employer, you don’t necessarily have the level of agency that you might think. And who is looking out for your own professional interests? Is it the employer? I think that’s a tough question to answer. If there’s a third party, such as a union, that can represent proactively, or earlier in the chain of events, I think that has the capacity to benefit a lot. And I think that’s something that should be, and I hope will be, a growing conversation within the profession.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Jessica Reeves: That’s our job, but you can’t do it at your own expense. Don’t be a hero. You need to, like the oxygen mask analogy, right, you can’t save somebody else. You have to put your own oxygen mask on first when the plane is going down. And I think that for too long, and in these very complex times, we’re not putting our own oxygen masks on first. That’s my analogy for advocacy. I think we need to look at that and look for opportunities for that.

And I don’t think it’s going to change with one big movement. I think it’s small, incremental changes over time, and broad-based, where we see those improvements, or we have the potential to see those improvements. So I hope that those in the field, those practicing, anyone facing a patient, can find ways to support one another and to support yourselves, so that you can put your own oxygen mask on and advocate for yourself, so that you can continue to advocate for your patients.

Kevin Pho: Jessica, thank you so much for sharing your time and insight. Thanks again for being on the show.

Jessica Reeves: Thank you.

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