Dishonesty in health care professionals

Honesty, a reflection of self-respect and respect for others, is essential to maintaining trust with clients and undermines the trust necessary for clients to be candid with health professionals. Dishonesty can take a variety of forms. Below are some examples of dishonesty, in professional  and personal settings.  

Theft

About a month ago supplies started going missing from the unit – masks, gloves, bandages. Recently, clients have been reporting that items are missing from their personal belongings. The employer launches an investigation.

During the investigation Jane, a nurse who has worked at the hospital for seven years, is observed on the hospital's security camera leaving with large bags after her shifts. When questioned about it, Jane admits to stealing. The employer firs Jane and  submits a complaint to BCCNM. An investigation is initiated by the college.

So what?

Honesty is an important quality for nursing professionals. When a nurse exhibits dishonest behaviour such as theft, it negatively impacts the public's trust in the profession and may present a risk to public safety.

Case Analysis

Using the HONEST framework (Gallagher & Jago, 2016) we can analyze Jane's case to demonstrate the aspects of dishonesty and the consequences of it.   

Highlight the type of dishonesty - Jane’s dishonest behaviour is stealing. This behaviour directly relates to her nursing practice as she stole from the hospital and clients, resulting in harm to the clients she has a duty to care for.
Organizational issues that may have impacted the offence -   It is unclear whether there were any organizational factors contributing to Jane's theft. Could the employer implement policies and protocols for ensuring clients' belongings are stored securely?   
Negative individual factors that contributed to the offence -  Jane told her employer and the BCCNM investigator that she was experiencing financial difficulties and was selling the stolen items for cash.
Explanations offered by Jane - Jane explained that her extraordinary personal circumstances led her to steal. She said that she could not sleep knowing that she had been dishonest with her employer or clients. Does Jane's remorse for her actions mitigate the severity of the offence?
Sanction applied - Jane is fired by her employer. After their investigation, BCCNM’s Inquiry Committee requests that Jane agree to:

• a written reprimand
• agree not to repeat the dishonest behaviour
• complete education courses in Professional Ethics
• participate in consultations with a Regulatory Practice Consultant to reflect on her behaviour and how it negatively impacts the public's trust in her as a nurse
• limit Jane's practice to day shifts
• direct supervision for a period of one year to ensure Jane does not have unsupervised access to clients or their personal belongings

Training or professional education that may remedy - As outlined above, the Inquiry Committee requests that Jane participate in remedial education. Her remorse and accountability indicate that Jane may benefit from courses and consultations and that she likely recognizes the importance of honesty in her nursing practice.

Reflections for your practice
What would the public think if they witnessed this type of behaviour by a nurse? What happens to your nursing registration if you engage in dishonest behaviour like theft?

Dishonesty can affect your clients, the nursing profession, and your nursing registration. By stealing from an employer and from clients, a nurse fails to meet many of the Standards of Practice. Review  your Professional Standards as they relate to ethical practice,  honesty and integrity.

Lying

On Wednesday, Eric forgets to administer medications to four of his twenty clients. To cover his error, Eric documents that he administered the missed medications. Eric justifies his action to falsify documentation by telling himself that the medications he had missed wouldn’t result in harm if not taken. On Friday, Eric’s manager approaches him and says that four clients had complained of not receiving their usual medications on Wednesday. The manager asks Eric if he had administered the medications. Fearing for his job, Eric said he did.

What happens next?

Eric's manager investigates and finds enough evidence of dishonesty to file a complaint with BCCNM. The concerns submitted by the employer include that Eric:

• Falsified the documentation of medication administration
• Lied to his manager about the medication administration
• Lacked insight into the significance of not administering the medications and documenting that he did when he didn’t

The BCCNM Inquiry Committee investigates. The investigator interviews Eric and reviews all the relevant documentation. In the interview, Eric admits that he had not administered the medications, had falsified the documentation, and had lied to his manager. Eric also says he felt bad for being dishonest, and he doesn’t consider himself a dishonest person.

Ultimately, Eric is accountable for his actions. Eric expresses remorse for his dishonesty. The Inquiry Committee requests that Eric:

• Complete Professionalism and Ethics courses to remediate the dishonesty concerns
• Participate in consultations with a Regulatory Practice Consultant to give him an opportunity to reflect on his conduct, the relevant Standards of Practice, and to understand how to prevent a similar situation from happening again
• Agree to not repeat the conduct for the remainder of his nursing career

Discovering his error, Eric should have assessed the clients for any impacts from the event and reported the error as per employer policies. The Documentation practice standard  requires that nurses complete an incident report following events such as medication errors or falls. The incident report is not part of the health record; record event facts affecting the client in the client's health record.

The Medication practice standard requires that nurses take action, including following organizational/employer policies and processes, when an error or near miss occurs at any point of a medication-related activity.
The Professional Standards require that nurses be accountable and responsible for their own nursing decisions, actions and professional conduct,  demonstrating integrity at all times, including being honest when a mistake is made. Lying about the medication administration and falsifying the documentation compromises the continuity of care and puts clients at risk.

Reflections on your practice
Think of a time when you have made a mistake - were you honest with yourself, your employer, and your clients? Could you have handled the situation differently?

Deception/Fraud

Dr. Smith discovers that a nurse, Pieter, forged Dr. Smith’s signature on a medical certificate.  Pieter then submitted the medical certificate to his employer to get three months paid ‘sick’ time off work. Pieter was really on vacation in Mexico. Dr. Smith makes a complaint to BCCNM.

So what?

Pieter’s behaviour does not uphold BCCNM’s Professional Standards. Pieter’s conduct outside of work needs to be in line with the Professional standards, demonstrating honesty and integrity at all times. While Pieter’s behaviour isn’t directly related to his care of clients, forgery is dishonest, unethical and damages the public’s trust in the profession.

What happens next?

Pieter is fired by his employer.

BCCNM’s Inquiry Committee investigates Pieter’s case and reviews all the evidence, including:

• Dr. Smith’s signature and the forged signature on the medical certificate
• Pieter’s employer’s documentation of the paid sick benefits received
• Pieter lack of accountability and forthrightness, only admitted to the dishonesty when confronted with the evidence
• Pieter financial benefit from his dishonest behaviour
• Pieter’s failure to fulfill his professional obligation to demonstrate honesty and integrity at all times

Because Pieter’s behaviour and dishonesty could negatively impact the public’s trust in the profession, BCCNM’s Inquiry Committee determines that Pieter demonstrated conduct unbecoming of the profession. After considering the impact on the public’s perception of the profession and the seriousness of the conduct, the Inquiry Committee requests that Pieter agree to:

• A two week suspension of his registration
• Accept a written reprimand
• Complete remedial education on ethics
• Not repeat the dishonest conduct
• Participate in consultations with a BCCNM Regulatory Practice Consultant

Reflections for your practice

As a nurse, you are responsible for recognizing the ethical implication of every activity you engage in – whether it is personal or professional. Take a moment to think about dishonest behaviours you may have seen. How do these behaviours reflect on you and the rest of the profession?

Review the Professional standards to find out which behaviours nurses must demonstrate in their practice and how honest, ethical behaviour fits into your practice.

Impersonation

Leila, a recent graduate and BCCNM registrant, forgets to renew her registration during the renewal time. Unaware of the oversight, she continues to work as a nurse. In July, Leila realizes that she did not renew her registration and has been practicing without registration for the last five months! Leila immediately calls the college to let them know and ask for guidance. Leila is told to go online and complete a reinstatement application and to disclose the information in the application. Leila is informed that because she practiced for five months without registration, her application will go to the Inquiry Committee for investigation.

What happens next?

The BCCNM Inquiry Committee reviews Leila’s case and considers the following:

• Leila failed to meet:
• Professional Standard 1: Responsibility and Accountability
• Use of Title practice standard
• Leila committed an offence under the Health Professions Act by using the title ‘nurse’ without authorization form BCCNM
• Leila acted immediately to reinstate her registration when she found out she was not registered
• Leila told BCCNM she had practiced without registration
• Leila stated she was new to the registration process and had unintentionally practiced without registration

BCCNM’s Inquiry Committee issues Leila warnings for 1) practicing without registration and 2) using the title ‘nurse’ without authorization. The Inquiry Committee also requests that Leila participate in consultation with a Regulatory Practice Consultant to give her an opportunity to reflect on her conduct, on the Standards of Practice and to understand how to prevent a similar situation from happening again.

Reflections  on your practice

Did you know that practicing without registration is one of the most common forms of dishonesty that BCCNM sees? Practicing without registration, either through oversight or intentionally, puts your clients, your employer, and yourself at risk. You can only work/volunteer and call yourself a ‘nurse’ if you maintain practicing registration. Remember – you have liability insurance only when you have a current practicing registration.

Good Character

Usha is a newly graduated nurse and is passionate about helping people; however, she struggled with the theoretical parts of her nursing program and was caught cheating on an exam. She was given another opportunity to write the exam, but the cheating incident stayed on her permanent record and was reported to BCCNM by the school. When Usha applies to BCCNM for registration, the cheating incident is included as part of her application.

What happens next?

All applications to BCCNM are assessed on several criteria, one of which is good character. When determining whether an applicant is of good character, BCCNM reviews:

• The circumstances of criminal charges and/or convictions, the results of an applicant’s criminal record check, and any other information the applicant wishes to have considered related to the matter
• The completeness, correctness and accuracy of the information the applicant provided on the application form
• Information related to other applications for registration or previous registration history
• Information related to previous employment, or employment while holding provisional registration
• Information from the educational institution

Good character refers to a combination of personal qualities and traits, such as:

• Moral or ethical strength
• Integrity, candour, empathy and honesty
• An appreciation of the difference between right and wrong
• The moral fibre to do what is right, no matter how uncomfortable the doing may be, and not to do wrong no matter what the consequences may be to oneself
• The character to properly deal with the numerous and weighty demand placed on the professional

Case Analysis

So how does Usha’s dishonesty in school affect her ability to meet BCCNM’s good character requirement? When assessing Usha’s application, the Registration Committee must determine if Usha meets the above criteria of good character by considering some of the following questions:

Is there a pattern of dishonesty or untrustworthiness in Usha’s past?

• The Registration Committee determined that this behaviour seemed to be an isolated incident.

What explanations and reflections were offered by Usha?

• The Registration Committee asked Usha to provide a personal statement about her conduct, provide character references, and attend a Hearing before the Committee. Usha demonstrated remorse for her conduct and insight into how the public’s perception of her behaviour could negatively impact their trust in the nursing profession. In addition, Usha knows that by making choices based on self-interest did not demonstrate good character.

Is there any training or professional education that may remediate Usha’s dishonest behaviour?

• The Registration Committee looked at all the facts of Usha’s case to determine if it was possible to remediate the dishonest conduct Usha showed in school. The Committee reviewed courses already taken in her nursing program to determine if she could use further education in professional ethics.

After reviewing the information and Usha’s statements, the Registration Committee decided to deny Usha’s application for registration until she completes a course in professional ethics.

Reflections on your practice

It is important for student and applicants to be aware of the requirements for registration and that there is more to the assessment process than just successful completion of the nursing education program. Dishonest behaviour in a professional or personal setting can impact whether you meet the requirements of good character and whether you will be admitted into the nursing profession.

For more information on BCCNM’s registration requirements, visit the registration page.