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Facebook fracas

Two nurses I work with have been feuding over some personal and work-related issues. One nurse (I'll call her Clara) aired her grievances on her Facebook page, discussing a dispute over a patient's care and identifying the other nurse by name. Hospital administration got wind of it and, to make a long story short, Clara was fired and she was reported to the Board of Nursing.


Although I don't condone Clara's behavior, I think it's unfair to punish a nurse so severely for a legal activity conducted on personal time. What do you say?-W.M., ILL.


Nurses may believe that what they do on leisure time is their own business, but unprofessional behavior outside the scope of their employment can have far-reaching implications. State Nurse Practice Acts describe in general terms the expectation that nurses will uphold ethical and legal behavior whether on or off the job. For this reason, each state's Board of Nursing has an interest in maintaining high professional standards for nurses.

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Similarly, an employer is justified in not allowing employees to battle out their differences over the Internet because unprofessional behavior by employees can undermine the institution's reputation. Nurses have been fired for unprofessional behavior that's contrary to the institution's culture, even if the behavior is legal. For example, nurses have been fired for posting revealing photographs on Internet sites.


Employers are also rightfully concerned about violations of privacy provisions in the Health Insurance Portability and Accountability Act (HIPAA) that might occur during an employee's leisure time. If confidential information about a patient is discussed inappropriately by a nurse at any time, a HIPAA violation has occurred.


Nurses posting comments on the Internet may believe they're anonymous or think they've sufficiently disguised a patient's identity, but these are dangerous assumptions; others may not be fooled by a few changed details. Employers face high fines for HIPAA violations, and fines increase with each additional violation. For this reason, many employers have a no-tolerance policy and can fire an employee for just one HIPAA violation.


National Gallup polls consistently show that the public considers nursing to be the most ethical profession. We have the public's trust, and we must continue to earn it.



Injection technique: Ditch the pinch

I have a question about the proper technique for giving a subcutaneous injection. In nursing school, I learned to pinch a fold of skin before inserting the needle only if the needle is long or the patient is thin. Some RNs who work in my unit pinch the skin routinely for all patients. Which technique is better?-D.D., N.M.


You're correct to gently pinch a fold of skin only if the patient is very thin to lift the adipose tissue away from the underlying muscle and tissue. Release the skin fold before administering the medication to avoid injecting the medication into compressed tissue. If the skin is pulled taut, it provides easy, less painful entry into the subcutaneous tissue.


Use only short needles for subcutaneous injections-5/8 inch or less. Because subcutaneous tissue contains few blood vessels, you needn't aspirate for blood before injecting the medication.


Reference: Taylor CR, Lillis C, LeMone P, et al. Fundamentals of Nursing: The Art and Science of Nursing Care. 6th ed. Philadelphia: Lippincott Williams and Wilkins; 2008.



When experience isn't the best teacher

I'm a new grad RN who recently started working in a long-term-care facility. Most of the nurses, including my supervisor, are LPNs. On several occasions during my orientation, my LPN supervisor, who's an experienced nurse, gave me instructions that I believe are contrary to good nursing practice. One example occurred when I was performing intermittent closed urinary catheter irrigation for a patient with bladder cancer whose indwelling urinary drainage catheter was obstructed. The LPN told me to "pull back" to aspirate any clots that might be present. In nursing school I learned to allow the irrigant and urine to drain by gravity, so I disregarded this instruction. Now I'm wondering-if I'd followed her direction and harmed the patient, would I be liable?-R.S., N.H.


Yes. As an educated and licensed professional, you're expected to meet the standard of care, which includes never jeopardizing patient safety by performing a procedure you know to be unsafe or incorrect. You'd be liable for any harm resulting from any substandard nursing practice you perform.


But you raise another, equally serious, issue here. In most states, the Nurse Practice Act specifies that RNs supervise LPNs-not the other way around. As an RN, you're held to a higher standard than an LPN because of your more advanced education. Experience isn't always the best teacher.


Check your facility's policies and procedures to see if they're in line with the Nurse Practice Act, and consider contacting the Board of Nursing for advice on this issue. If LPNs are truly supervising RNs in your facility, our legal consultant believes your state's Department of Licensure and Nurses Association would take a dim view of the policy.


Discuss the issue with your nurse manager and go up the chain of command, if necessary. Work within the system to bring facility policies in line with the law. From a risk management standpoint, it's in the facility's best interests to correct substandard and legally risky policies.



Time for a (needle) change?

After I draw up an injectable drug with a needle and syringe, should I change the needle before administering the drug? This is what I learned to do in nursing school, but my manager says it's unnecessary. What's best practice?-V.E., ILL.


Most authorities recommend changing the needle, for several good reasons.


* After being used to puncture a stopper, the needle may be less sharp, which could make the injection more painful.


* The needle used to withdraw medication may carry residual medication that could irritate skin or subcutaneous tissue, increasing pain at the injection site.


* If you withdraw the medication with a large-gauge needle, switching to a smaller gauge will make the injection less painful.



Injecting insulin is an exception. Studies have found decreased accuracy of delivered insulin doses with syringes that had detachable needles compared with nondetachable needles.


Sources: Craven RF, Hirnle CJ. Fundamental of Nursing: Human Health and Function. 6th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2008; Erstad AJ, Erstad BL, Nix DE. Accuracy and reproducibility of small-volume injections from various-sized syringes. Am J Health-Syst Pharm. 2006;63:748-750.