1. Sheets, Vickie JD, RN, CAE
  2. Kappel, Dawn M. MA

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Year after year, nursing consistently tops national polls of the most widely respected and trusted professions. The results of these polls reflect the special relationship and bond between nurses and those under their care. In almost all cases, this trust and respect is well founded, but in a growing number of documented cases the trusted nurse is actually an imposter.


It is difficult to determine whether the problem of imposter nurses is increasing or whether advanced verification technology and more rigorous employer background checks and diligent reporting of imposters by state and territorial boards of nursing are contributing to catching these pretenders in the act. Although the number of imposter nurses may be small, the potential for harm is quite high.


Boards of nursing regulate the nursing profession by granting licensure to qualified individuals and are charged with protecting the public from unsafe and incompetent professionals. The National Council of State Boards of Nursing (NCSBN) is a not-for-profit organization whose membership comprises the boards of nursing in the 50 states, the District of Columbia, and 5 United States territories-American Samoa, Guam, Northern Mariana Islands, Puerto Rico and the Virgin Islands. Through the NCSBN, boards of nursing act and counsel together on matters of common interest and concern affecting the public health, safety, and welfare, including the development of possible approaches for educating employers and the community about imposter nurses. They also develop potential strategies for preventing these imposters from having access to patients such as the possible creation of a national database identifying all known imposter nurses.


Imposter nurses pose a special problem to boards of nursing because if there is no nursing license, most boards have no jurisdiction and must refer the case to the state's attorney general or district attorney for prose- cution. Many state boards do issue "cease and desist" letters. State boards of nursing and prosecuting authorities often work closely to identity and remove imposter nurses from practice. There is, however, disparity from state to state in terms of how the imposter nurse is charged. In some states, practicing nursing without a license is a gross misdemeanor and in other states it may be a felony. In Texas, first-time offenders are charged with a misdemeanor. Anthony Diggs, MSCJ, director of enforcement at the Texas Board of Nurse Examiners, comments, "I would like to see all imposter nurses charged with a felony on the first offense. That charge speaks to the serious nature of the crime and the potential for damage." Imposter nurses are often easy to catch but hard to prosecute. Convictions are most often obtained when the imposter is employed by healthcare facilities that receive Medicare or Medicaid funds and the imposter can be prosecuted for Medicare or Medicaid fraud.


What motivates individuals to misrepresent themselves as nurses when they lack the appropriate education, skills, and credentials is unknown, but the lure of relatively high incomes and benefits; the prestige associated with the profession; easily obtained patient information and fellow healthcare facility employee personnel records; and access to prescription drugs may play a role in spurring these deceptions. Likewise, the imposter's own conceit in assuming that their knowledge is equal to legitimately licensed nurses may also be a contributing factor.


Imposters can be categorized in several ways:


One category of imposter includes those who practice as a nurse but are not legally authorized to be a nurse. Examples of this grouping include an unlicensed person who poses as a nurse; a person who claims to be a nurse who has completed some, but not all, licensure requirements so is not eligible for nursing licensure (eg, a person completes nursing education but has never passed the NCLEX(R)).


The second category includes those instances where the license is fraudulently obtained and a person gains licensure illegally based on false credentials. Examples of this category can vary from a person who presents fraudulent credentials that are not identified as fraudulent and the person is ultimately licensed illegally to a person who is licensed legally in one capacity but represents himself or herself as having a different license, such as a licensed practical nurse (LPN) representing oneself as a registered nurse (RN) or an RN represents oneself as an advanced practiced registered nurse (APRN).


The third type of imposter involves identity theft, a person who is practicing or attempting to practice by assuming the identity of a properly licensed nurse. In this situation, the imposter is both practicing without authority and presenting illegal credentials.


Imposters with no healthcare-related experience or training are extremely rare; however, some egregious examples exist. One such case involved a family who posed as healthcare professionals across 6 states. Among their many crimes, the imposters stole the identities of nurses and targeted adult care homes and dialysis centers. Nidia Jimenez, the nominal head of the family, was finally arrested in December 2004 in Arizona for embezzlement of funds from the dialysis center where she was employed and for the attempt to obtain a credit card using the name and identification of another dialysis center employee. At the time of her arrest, she was in possession of patient names, information, and other identification documents.


David Wayne Rhodes of Mesquite, Texas was recently convicted of 2 felonies and a misdemeanor for practicing nursing without a license and tampering with government documents. Rhodes worked for more than 14 years as a nurse before being caught in December 2004. Ironically, before Rhodes was fired from his position as a clinical services director at a nursing home for not having a nursing license, he was responsible for verifying licensure.


The most common imposter is an individual who does have some training, education, or experience in healthcare but represents himself or herself as having credentials they lack. Little training, coupled with arrogance, allows the imposter's belief that he/she has greater knowledge and ability than the imposter actually has. This can pose a serious threat to patient welfare.


Drawn directly from the Arizona Board of Nursing's newsletter is the case of Melissa Addison. Addison was employed at least 3 months as an LPN after claiming to have graduated from an LPN program and producing a photocopy of an LPN license that had been altered with her name. Following repeated requests for Addison to show her employer her original license, the employer performed an online verification identifying that Addison had an expired CNA certificate and not an LPN license. Addison reportedly gained access to the LPN license through a personal relationship with the actual nurse. In addition to presenting fraudulent credentials, Addison's inability to perform at a level consistent with acceptable LPN practice raised suspicion at her place of employment.


A more benign case, in the sense that the imposter never gained access to patients, occurred at University Medical Center in Tucson, Arizona. Richard Puczko, a respiratory therapy student, was hired as an RN. Fortunately, his deception was discovered during the 2-day orientation period. Although not charged, Puczko will remain on the Arizona Board of Nursing's "Imposter Nurse" list indefinitely.


Some healthcare facilities, pressured by the demands of a nursing shortage, are not as diligent in their verification process as they need to be to ensure that only licensed nurses are permitted to work. In the past, applications for nursing positions were carefully examined by nurse managers; today, that task often falls to human resources personnel who may be less familiar with what inconsistencies to look for in resumes and applications.


Meticulous examination of the resume and job application is vital to make sure that the dates, positions, salaries, and experience are consistent within the accepted parameters of the nursing profession and do not reflect wide variation from acknowledged norms for the duties and responsibilities of each position. Simply ensuring that the names on various documents provided for verification match will help prevent imposters from being hired.


Boards of nursing have several recommendations designed to detect nurse imposters before they have opportunity to harm patients:


Employers must insist on viewing the original source document of nursing license and refuse to accept photocopies as verification.


"Because photocopies can be so easily altered, it is imperative that employers require that the original license be presented at the time of application," comments Valerie Smith, MS, RN, associate director, Arizona State Board of Nursing, she continues, "The best analogy I can provide is if someone is stopped by a police officer for a traffic violation, the presentation of a copy of a drivers license is not going to be acceptable; likewise a copy of a nursing license is unacceptable because of the high potential for fraud."


When nurses are working under a privilege to practice granted through a state's participation in the Nurse Licensure Compact (NLC), employers should verify the nursing license and/or privilege via NCSBN's Nursys(R) online database (where licenses issued by any of the states in the interstate Nurse Licensure Compact may be verified1) or through the individual state board of nursing verification process.


Employers should also periodically check their state board of nursing's Web site and read the newsletter that many state boards of nursing produce that list imposter nurses. "Periodically, I receive phone calls from healthcare facilities telling me that they found 1 of their employees on our list," remarks Smith, "We know that the list is an invaluable community service."


The fact that the number of imposter nurses appears to be increasing may be a sign that employers, despite the pressures inflicted by the nursing shortage, are availing themselves of the resources provided by the boards of nursing in their respective states. NCSBN and its member boards recognize the need to inform the general public about services that the public may use to verify that the nurses who care for their loved ones are appropriately licensed and in good standing with the state board of nursing. The aging population in the United States and the large number of chronically ill patients that require private long-term homecare increase the number of people needing access to nursing services. Spouses, adult children, and guardians of patients need to be made aware of the dangers of hiring imposter nurses, especially when they do not use the services of home health agencies, but rather seek out individual arrangements with nurses to care for their loved ones. Family caretakers need to be as proactive in employing nurses, as they are when they hire babysitters for their children and contractors for their home.


Protection of the public remains the principal charge of boards of nursing. Boards continually strive to shield the public from imposter nurses through the various mechanisms for verification. Other systems are currently under development that are designed to support boards in their vigilance to detect any persons who seek to violate the trust between patients and nurses.


1The mutual recognition model of nurse licensure allows a nurse to have 1 license (in his or her state of residency) and to practice in other states (both physical and electronic), subject to each state's practice law and regulation. Under mutual recognition, a nurse may practice across state lines, unless otherwise restricted. [Context Link]