NB: The following resources grew out of the INANE presentation by Charles Graeber and Diana Mason at INANE 2014 in Portland, ME. Faculty, editors, and other interested colleagues are free to use these resources, with proper credit to Charles Graeber, author of The Good Nurse, Diana J. Mason, PhD, RN, FAAN Co-Director, Center for Health, Media & Policy, Rudin Professor of Nursing, and INANE 2014.
~~
PART I: Editorial Notes Outline:

Takeaways:

• In the book “The Good Nurse,” eight years of investigative journalism uncovers the shocking story of a serial killer nurse, and the hospital administrators who passed him on, hospital to hospital, for 16 years. It also highlights the attempts of several brave whistleblower “good nurses” to stop Cullen along the way.
• Serial Killer Charles Cullen is in prison for what he did. Many of the administrators who passed him on got promoted.
• New Health care employee reporting laws, designed to stop another serial killer like Charles Cullen, in fact treat truly “good nurses” like criminals.
• Meanwhile it’s still business as usual for the health care executives.
• We should know the truth and demand common sense laws that respect nurses, protect patients, and don’t force executives to choose between protecting their institution from lawsuits, and protecting patients from harm.

PART 2:

TALKING POINTS RE: LESSONS FROM THE GOOD NURSE

• The book details how nurse Charles Cullen was able to selectively or randomly kill an admitted 40 patients, though expert estimates of the real number of Cullen’s victims to be closer to 400, making him the most prolific serial killer in United States history.
• But as lurid as these details are, more troubling are the descriptions of how Cullen was able to go from hospital to hospital in Pennsylvania and New Jersey–often facilities with stellar reputations, including Magnet designation—without being reported to the police, the state boards of nursing, and state departments of health (until a coworker reported her suspicions to police, against the expressed wishes of her hospital’s administration and lawyers).
• The book describes situations in which top executives and administrators stymied detectives’ investigations into the suspicious deaths, including misleading them about the medication system and record-keeping.
• When Cullen’s actions (serious repeated nurse practice issues, delivery of non-proscribed meds, bizarre behavior, patient complaints) were uncovered by hospital authorities, he was either removed from the schedule, fired or allowed to resign. But never was he stopped.
• Example: At one hospital, Cullen was the only suspect in a rash of insulin overdoses. He was removed from the schedule, and so applied for a job at another hospital, where he commenced overdosing patients. At another hospital, Cullen was caught red-handed by his fellow nurses, stashing empty vials of deadly paralytic drugs which he had used for murder during his shift. Outside council was brought in, and Cullen was allowed to resign, rather than be fired, so that he could receive a neutral recommendation.Cullen quickly found a new job, and began killing again.
• Instead of opening themselves to outside scrutiny- at the risk of reputation, donor money and massive lawsuits- the hospitals, intentionally or otherwise, operated in a manner which protected the institution, but put their patients at risk.
• When Cullen’s suspicious behavior was brought to the attention of the authorities by a whistle-blowing nurse, the hospital drove the nurse whistle-blower out of the state, and later, counter-sued families of patients who were suspected dying at Cullen’s hand, and have tried to intimidate the book’s author.
• None of the hospital executives and administrators were held accountable for their actions or their failure to report Cullen in a timely fashion, if at all; several, including a risk management administrator who obstructed a police investigation, were promoted.
• There has never been a criminal investigation into the actions of these administrators, but it’s not too late; nurse leaders and patient advocates can still demand the truth. (Somerset County NJ Police detectives also called for a Grand Jury).
• New Jersey and Pennsylvania quickly passed broad laws (see below) in the wake of Cullen’s prosecution and life jail sentence, but there appears to be little enforcement of these laws requiring hospitals to report a dismissed employee.While ineffective at inspiring change at a corporate level, they appear to be overloading the nursing board review process, and can brand the career of an inexperienced nurse who makes a simple mistake.

• Questions that this book raises include:

1. How do we prevent another Cullen from going undiscovered in our midst?
2. What policies and procedures are needed to ensure that health care organizations take the proper and ethical actions that are needed to prevent employees from continuing to do harm to patients?
3. How do we tell nurses to blow the whistle on unsafe practices when their employers skirt doing so, even when required by law to report these?
4. What are the local and national conversations that need to happen around institutional priorities (patient welfare versus financial health of the institution) accountability for patient safety in health care?
5. What are the ethical dilemmas that nurse administrators face when becoming aware of potential criminal activity with their facilities, but are told by executive leadership that they must not investigate further, nor report it? How does this nurse weigh the legal requirement for reporting unsafe practitioners versus the institution’s interest in maintaining its fiscal health by preventing the information from becoming public?
6. Exercise> CASE STUDIES: Students form groups to report and present case studies related to the practice and ethical issues raised.

PART 3:

A Closer Look: Systemic Issues Uncovered in The Good Nurse: The Enabling Patterns of Dysfunction

The investigation revealed several factors which contributed to perpetuating Cullen’s nursing/murder career for 16 years and 9 different health care facilities.

• Hospitals were slow to react, understandably fearful of lawsuits, and repeatedly chose laborious and ineffective internal investigations, rather than outside attention from regulatory agencies and detectives. During these investigations, Cullen continued working, and killing patients.
• Cullen exploited the space between the business of health care and the care itself.  In moving Cullen out of their employ and back into the job pool, many of the hospital administrators who dealt with the “Cullen problem” did their job as business people, but not their duty as patient advocates.
• The trend toward outsourcing and use of staffing agencies increasingly allowed hospitals to treat nurses as disposable employees, and discouraged recognition or ownership of the Cullen problem.
• Nurses who voiced concerns with Cullen’s behavior were marginalized, ignored or dismissed. Those who spoke up said they did so at the risk of their jobs. The whistle blowers identified in the book not only left the hospitals at which they had worked, and also the state.
• Information flow was guarded, making problem solving slow, if impossible.
• Outside investigators, who usually lacked familiarity with the healthcare setting and terms of art, were not given full information and didn’t even know what to ask for.
• Family members of Cullen’s victims were sometimes not told of overdose levels of drugs found in their loved one’s bodies, and thus did not request autopsy.
• Outside agencies, in the rare instances they were contacted regarding Cullen-related incidents, did not communicate with each other, or across state lines.
• Penalties for non-reportage of sentinel events were rare and minimal, especially compared to  the perception that potential lawsuits would result from admitting to the problem.

“The Good Nurse” is available in hardbook, paperback, and e-book versions, anywhere that fine books are sold.