1. Mason, Diana J. PhD, RN, FAAN, AJN Editor-in-Chief

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More than 30 years ago, as a new RN on a medical-coronary intensive and transitional care unit, I met Rita, a middle-aged woman with amyotrophic lateral sclerosis (ALS) who was cared for by a devoted sister. She was relatively happy because of the exquisite physical and emotional care provided by her sister. Rita was admitted to my unit on several occasions for pneumonia. Unable to speak, she made sounds only her sister understood. The nursing staff communicated with her by asking her yes-or-no questions, which she would answer by blinking-once for yes and twice for no. Our major challenge was to ensure that she didn't choke to death on her secretions.


I thought a lot about Rita and the quality of her life. I realized that ALS had to be one of the worst illnesses-you're unable to move but feel everything, unable to converse but keenly aware of your world slipping away. But my colleagues and I grew close to Rita, and her sister provided attentive care and comfort to both.


One day, I arrived at work to find Rita's bed empty. Joan, the charge nurse for that shift, said Rita had choked to death on her secretions. "She'd been through enough," Joan said, "so I didn't suction her. She and her sister are both better off this way."


I was appalled and enraged. I spoke to a colleague. Neither of us liked Joan, and her decision reinforced our distaste. I don't know why, but we didn't report her, and I let the incident fade from memory.


A decade later an acquaintance was diagnosed with ALS, and the memory of Rita came flooding back. Haunted by my failure to report Joan, I struggled with why I had not done so. I realized that within those first years of practice I had already witnessed incidents of malpractice by physicians that neither they nor nurses had reported to administrators, let alone patients or their families. I was complicit in a code of silence well known among physicians but less recognized among nurses.


My memory of Rita and my participation in that code reemerged recently when the news media reported that Charles Cullen, an RN in Pennsylvania, had admitted to killing 40 patients who had been entrusted to his care at 10 health care institutions in two states. I received a call from a journalist wanting me to comment on whether the government needs to do a better job of regulating nurses. I didn't think so at that moment, but now I'm not so sure. Some people have called for better use of the National Practitioner Data Bank to track nurses who are fired or charged with malpractice or criminal behavior. Employers would be able-and expected-to check the database. Some employers say they have become reluctant to provide other employers with frank evaluations of former, and even fired, employees, for fear of libel suits.


What about this code of silence that permeates many institutions? Some cover up incompetence and errors. Some nurses and physicians will not report a dangerous colleague for fear of being ostracized, scrutinized, or criticized for their own work. A few nurses have written to me that they have been censured for reporting incompetent colleagues. The ANA and other groups are working to secure passage of whistleblower protection laws, and perhaps the Cullen case will draw and renew support for such legislation.


But I'm convinced that we need to talk among ourselves about the code of silence, how to end it, what the ramifications would be, and how to support nurses who report incompetent or potentially dangerous colleagues. I am not calling for a witch hunt. Rather, institutions need to create systems for reporting and tracking such reports. Once in place, discussions of the code of silence could be included in new employee orientations, as well as the focus of nursing and medical grand rounds and unit meetings.


I applaud the few nurses who are reported to have blown the whistle on Cullen within their institutions. I deeply regret my own lack of courage with respect to Rita. Perpetuating the code of silence will only undermine the public's trust in nurses.