As I began writing the KeithRN newsletter this month, I settled on the theme of professional identity. We all know professional identity is important. But first, let’s define it so we are on the same page.

Evolving from a nursing student to a professional nurse requires a personal transformation. One does not learn to be a nurse; one becomes a nurse. This transformative process is known as the formation of a professional identity and is influenced by the characteristics, norms, and values of the nursing discipline resulting in feeling, thinking, and acting like a nurse (Merton, 1957; Cruess et al., 2014; Godfrey & Young, 2020).

Most, if not all of us, teach and role-model the skills and attitudes necessary to develop a professional identity. We know that accreditors address professional identity formation in their competencies, and you can find faculty development and research studies on professional identity. It’s important.

Most of what I see about forming a professional identity is positive. You will discover words like values, moral courage, sensitivity, integrity, emotional intelligence, professionalism, advocate, and leader as you peruse the literature on professional identity. As nurse educators, we want to develop these characteristics in every student who graduates from our nursing programs. So, with all these positive affirmations about nursing on my mind, why was I thinking about a nurse who admitted to giving the wrong medication that resulted in the death of a patient? One of the most traumatic scenarios a nurse can imagine!

I had to think about that for a while. My professional identity synapses were firing, but they were not wiring with a nurse causing a death. As I continued to write about professional identity and see the words moral courage, integrity, and advocate over and over, it hit me! The story of RaDonda Vaught, the nurse who caused Charlene Murphy’s death, though tragic and heart-wrenching, is a story of a nurse who made a deadly mistake but then did everything afterward correctly and honestly. 

Nurses are human. Humans are fallible. Nurses take actions that involve life and death every minute they work. Nurses are going to make mistakes that may result in adverse outcomes including death. We do everything possible to prevent it, yet it can still happen. These are the times when our professional identity as a nurse is the most important. These are the times when moral courage and integrity are the hardest to demonstrate but make the most significant impact.

In reading the facts of the RaDonda Vaught case, written in court documents and investigations, RaDonda acted with ethical comportment and moral courage when she realized she made a mistake, unlike the administration of the renowned and respected hospital system. The facts of the case are as follows (RV is RaDonda Vaught, the nurse, and CM is Charlene Murphy, the patient; ADC is automatic dispensing cabinet):

• Oct. 2015: RV begins work at Vanderbilt.
• Dec. 26, 2017: RV is working as a “Help All” nurse and as a preceptor.
• Versed was ordered and the order was placed in the ADC profile as midazolam.
• RV did not know that Versed was midazolam and uses the OVERRIDE of the ADC.
• There had been a recent ADC interface change, and OVERRIDES were common; CM had received 20 drugs via override.
• RV types Versed in the ADC.
• Vecuronium, a neuromuscular blocker that causes paralysis of all muscles including the diaphragm, appears at the top of the list, and she selects it; there were standard override warnings but no additional warning for paralytics.
• She removed vecuronium, the wrong drug, and read the back label for reconstitution instructions but did not read the front label.
• She finds the patient in radiology and attempts to find a scanner, but there are none available.
• RV accidentally gives vecuronium instead of Versed to CM. RV leaves.
• CM is found unresponsive 25 minutes later.
• CM codes and is declared brain-dead.

When RV returns the rest of the vial to the primary nurse for disposal, the primary nurse notices the vial is for vecuronium and points it out to RV. RV immediately admits the mistake, takes responsibility for her actions and makes the necessary notifications to the HCP and hospital. She acted with integrity and moral courage, knowing she made a potentially life-threatening mistake. She later found out that it was a deadly mistake. 

The story takes a lot of twists and turns, but I will abbreviate it to the following:

• After notifications were made to the hospital, the hospital decided they would not report it to officials, the medical examiner, or JCAHO.
• RV is fired.
• The hospital negotiates an out-of-court settlement with the family, forbidding public discussion of the incident.
• Shortly thereafter, a tip is received by state and federal officials that a medication error caused CM’s death.
• The Tennessee Department of Health hears the case and does not pursue disciplinary action against RV.
• CMS conducts an investigation and determines that Murphy’s death was from an accidental dose of vecuronium and that Vanderbilt violated state law by not reporting.
• The error becomes public and CMS threatens to suspend Vanderbilt’s Medicare payments.
• Vanderbilt writes a 105-page corrective plan on the many violations found.
• RV is publicly identified, arrested, and faces a public hearing.
• RV’s license is revoked and fines imposed by the TN Board of Nursing.
• She is found guilty of abuse and negligent homicide.
• The hospital faced no charges.

Many felt the hospital was negligent and did not support RV. I will not discuss this further, but for purposes of this post, it is essential to point out that the hospital did violate code multiple times, fired RV, and did not support her during the trial. Despite this, RV continued to act with integrity. She voiced remorse and regret from the beginning. She made the proper notifications from the start. She was so distraught that when fired from the hospital, she took a job that required no direct patient contact. 

Though she was convicted, the judge handed down a lenient sentence. Here is what the judge said:

“This was a terrible, terrible mistake, and there have been consequences to the defendant, serious personal consequences, financial consequences, professional consequences, and now public consequences in a criminal setting…

“Changes/modifications/responses that have occurred as a result will certainly serve a greater value in preventing a reoccurrence…” (than will being punitive)

The judge mentioned that RV accepted responsibility immediately, made every effort to remedy the situation, brought all evidence to light afterward, and showed remorse. There was no intent to violate the law, and sustained intent was not involved.

The judge saw a remorseful nurse who made a mistake and was willing to admit it and face the consequences. The judge and everyone watching saw a nurse who made a deadly mistake but retained her professional identity. Even when her RN license was revoked, her identity as a nurse who acts with moral courage in the face of devastating circumstances was not stripped. 

This is why RaDonda Vaught came to mind when writing about professional identity. She may not be the poster child for what actions we want in the clinical setting, but I can’t think of a better example of someone who did the right thing even when others were not, even when everyone pointed fingers at her as the lone villain, and even when it cost her everything. Even in the worst of times, her professional identity mattered!

As a nurse, I want nurses to be held accountable for their actions. I want there to be severe consequences for egregious errors. I want all nurses to uphold the standards of our profession. I also want recognition that we are human. We are fallible. 

We often work in impossible conditions, short-staffed, with faulty equipment, and incivility, and yet, more often than not, we make it work! Despite these conditions, we have been known as the most trusted profession in the U.S. for over a decade. 

We admit when we make mistakes and want to be part of the solution. We should all strive to teach and develop solid professional identity in every one of our students so that if the day comes that one of our students makes a mistake, they have the moral courage to admit it and do everything they can to rectify it and prevent it from happening again.

References

• Cruess, R.L., Cruess, S.R., Boudreau, J.D., et al. (2014). Refraining medical education to support professional identity formation. Academic Medicine: Journal of the Association of American Medical Colleges, 89(11), 1446-1451.
• Godfrey, N. & Young, E. (2020). Professional identity. In Giddens, J. F. Concepts of nursing practice, (3rd ed.). Elsevier.
• Merton, R.K. (1957). Some preliminaries to a sociology of medical education. In R.K. Merton, L.G. Reader, & P.L. Kendall (Eds.). The student physician: Introductory studies in the sociology of medical education (pp. 3-79). Harvard University Press.