If you are a registered nurse (RN) with some experience under your belt, you may be ready to make a job change in the new year. Some of the most interesting and rewarding role advancements in nursing are also some of the hottest specialty career choices in the health care field. Many of these roles will allow you to keep wearing your nurse stethoscope and favorite scrubs, while others will require that you trade them in for offices and business clothes. Check out each of the career choices on this list to discover which new role may be right for you.
1. Nurse Informaticist
The field of nursing informatics is one of the most interesting specialty careers for RNs. While it may take a few years for you to land your dream job, it will be worth it. Nurse informaticists are critical members of today’s hospital system and clinics. Job responsibilities for these analytical minds include analyzing and reporting about the critical data that will help to increase a hospital’s efficiency and enhance patient care. Some nurses are also asked to interpret data to help cut unnecessary costs in a medical facility.
To be successful in this role, you should have technical skills and an interest in problem-solving.
Along with a few years of experience, nurse informaticists are expected to have a Bachelor of Science in Nursing (BSN). Some roles may allow nurses to have an RN license with a degree in health care or information technology. The responsibility comes with a reward. According to ZipRecruiter, nurse informatics professionals make an average of over $102,000 per year. As the field of technology evolves, you are also sure to be challenged throughout your career.
2. Nurse Case Manager
If you want to help patients but prefer working in an office, a nurse case manager role may be the best specialty career choice for you. These professionals work with patients, families, and their physicians to coordinate resources and deliver the right health care services. They also collaborate with insurance companies to ensure all services are rendered appropriately. At a minimum, you must hold an RN license, but most employers in this high-demand field will prefer a BSN. The more education and experience you receive, the better.
According to the Commission for Case Manager Certification, nurse case managers with a BSN earn an average of $80,000 per year. Over half of those nurses who are executive-level certified case managers earn more than $100,000 annually. To begin making the transition to this career, gain experience in management roles and switch to practice settings.
3. Legal Nurse Consultant
A legal nurse consultant has the unique opportunity to combine the fields of law and health care. Those RNs who have excellent organizational and critical thinking skills would make great medical consultants for attorneys and clients. Legal nurse consultants use their communication skills and knowledge of legal terminology to review documentation and analyze it against medical records. They are also asked to conduct research, identify standards of care and draft medical-legal documents.
Other responsibilities for the legal nurse include participating in client interviews, assembling trial evidence, and providing expert court testimony. Benefits of this specialty role include regular work hours, the ability to work in the comfort of an office, and a higher salary than many other RNs. Search job openings in your area for more information. The role may even inspire you to become a nurse with a law degree in the future.
4. Psychiatric Nurse
If you want to work in a clinical environment but do something different, psychiatric nursing is a growing and rewarding field. You will work alongside a team of psychiatrists, psychologists, and social workers to provide mental health care to patients. While some psychiatric nurses work in hospitals and outpatient facilities, others work as consultants. Primary responsibilities include assessing patients’ needs, creating treatment plans and managing medications. They may also provide counseling services or educate families.
As a psychiatric nurse, you will gain additional skills in problem-solving, communication, and empathy. You can also prepare yourself to earn a Master of Science in Nursing (MSN) or a Doctor of Nursing (DNP) and become an advanced practice registered nurse (APRN). Benefits of becoming a mental health nurse include good pay, career security, and job satisfaction. You will also get to work in a variety of patient care settings.
5. Certified Dialysis Nurse
A certified dialysis nurse (CDN) cares for patients with advanced kidney disease. Some of their primary responsibilities include educating patients and families about their condition, recording patients’ medical information, and assessing patients before they receive treatment. They also monitor for adverse reactions during dialysis, manage fluid balance, and communicate treatment needs or changes to physicians. Since they are part of such an essential specialty with the need for advanced knowledge and skills, RNs will need to obtain certification as a CDN, as well as at least 2,000 hours of experience caring for nephrology and dialysis patients over two years.
To stay certified, it is essential to complete 15 hours of continuing education in nephrology. While you are an important part of your patients’ life-saving treatment, you will also be a part of an in-demand specialty career. According to the Bureau of Labor Statistics (BLS), all jobs in nursing are expected to grow by seven percent in the next several years, while you can earn an average of $72,000 per year.
Find a New and Exciting Nursing Career
Ready for a fresh, flexible, or challenging role as an advanced nurse? One of these specialty careers is sure to make you feel rewarded both personally and professionally. Match a job that you are interested in with your educational goals, your personality and your patient values. You will be amazed at just how exciting and life-changing a new role in nursing can be.
As a highly specialized skill set, nursing is in high demand. As such, nurses can make a lucrative career by their full-time work alone, and by supplementing it with a variety of nursing side hustles. For those entrepreneurial spirits, there is seemingly no limit to the possibilities.
Home Health Care
There are certain areas of nursing where per diem work is more abundant. Many specialties within the hospital, such as critical care, emergency, surgery, and telemetry, require specific skill sets that the only nurses who fill in are already trained in that specialty. This is because per diem work comes with the expectation that minimal training is required.
There are however, some areas where skills do translate from one area of nursing to another. This is especially true outside the hospital. For example, adult inpatient nurses can work as a home infusion nurse, or in other home health care work, such as overseeing ancillary nursing staff, doing intensive assessments, and advocating for patients with their providers and insurance carriers.
Home health care is a growing field of opportunity as it benefits the patient by allowing them to maintain quality of life in their home; it can also help reduce the logistical strains on the health care system to provide inpatient care.
For nurses with an eye for beauty, aesthetic nursing offers a wealth of opportunities. As technology advances, there are more and more non-surgical procedures with anti-aging and aesthetic benefits. Nurses are increasingly able to perform or assist physicians with such procedures in medical spas and dermatology clinics. Furthermore, often this work is available as part-time or per diem. This allows nurses to build up a clientele through a side hustle that works with their schedule and is generally high-paying. Qualifications and credentialing for work as an aesthetic nurse vary by location, but frequently nurses go through certification programs in order to attract employers for this type of work.
Working as adjunct faculty is the side hustle of the teaching world. Many nursing schools offer opportunities to instruct a limited number of courses per semester on a part-time basis. This allows nurses with specialized knowledge or skills to disseminate what they know to the next generation of nurses. There are opportunities for both online and classroom teaching today. Requisites for teaching vary by state, school, and specific courses. For example, many nursing schools require five years of experience in a given specialty or an advanced degree in nursing, in order to teach.
Coaching is another growing field for nurses. For coaches who are nurses, they mostly function as health coaches or career coaches to other nurses. In the former role, nurses work with clients to mobilize them in the direction of their own personal and health goals. This is done through motivational interviewing, establishing accountability, goal-setting, and most of all-empowering the client to be experts on their own lives and bodies.
This role does not involve medical oversight and instead draws on the nursing skill of patient education combined with the holistic approach to patients that is fundamental to nursing. Nurse career coaches are often experienced and successful nurses who have built lucrative and fulfilling careers in nursing and coach other nurses or aspiring nurses to do the same.
Legal Nurse Consultants
Legal nurse consultants (LNCs) serve as expert nurses that work in medical-legal matters. LNCs are usually experienced nurses that can address technical matters specific to nursing, which a layperson may not know. They may work in law offices, HMOs, hospitals, risk management, workers’ compensation, and so on.
The legal nurse consultant utilizes their clinical and logistical expertise to extrapolate or clarify matters related to medical-legal cases. There are many full-time legal nurse consultants but it is incredibly valuable as a side hustle because it allows the nurse the opportunity to simultaneously work clinically, honing expertise and skills, while contributing the value of such real-time experience to their work in legal matters.
Nursing is a growing field for many reasons, not the least of which is that it offers a multitude of avenues by which to obtain a high income and a fulfilling career. For the nurse who wants to branch out beyond what they specialize in full time, there is certainly no lack of side hustles in nursing for them to explore.
What should you do if you find yourself the target of a formal board complaint? Based on my experience handling these types of cases, I’ve addressed a number of common issues, taking you through the beginning stages of the process.*
First things first
You learn that a licensing board has received a complaint against you. The first thing you should do is review your insurance coverage for board complaints, provided you have such coverage. In my experience, most nurses rarely if ever carry this type of insurance. If you fall into the uninsured or underinsured group, I suggest you re-examine this issue and consider carrying such coverage. Most nurses go their entire careers without any type of professional malpractice insurance or insurance to specifically protect against board complaints.
There are a number of reasons nurses forgo malpractice insurance, including costs (too prohibitive) and thinking that they will simply never need it. However, I would highly suggest nurses consider purchasing insurance to protect them in the event of a potential malpractice claim or board complaint affecting their licensure. Insurance rates for this type of coverage are relatively inexpensive, compared to the costs of facing a malpractice claim on your own.
If you do have malpractice coverage, do not assume that it also covers licensing board complaints; this coverage is typically purchased separately. Be sure that you check carefully and contact your carrier if you have any doubts or questions.
Contact legal counsel
Regardless of whether or not you have insurance, you should contact a lawyer immediately—one knowledgeable in administrative law and/or professional license defense. Your attorney should be familiar with licensing boards and the disciplinary process. Just as there are different types of nurses, from perianesthesia to L&D nursing, there are attorneys who specialize in different areas of the law. You will be best served by an attorney familiar with this particular area.
In my experience, your initial response to a complaint is crucial. Address the issue with care. It is completely understandable to be shaken upon learning of a complaint. That highly emotional early period makes consulting with a highly trained and experienced attorney particularly critical. I believe that consulting a lawyer to review the facts almost immediately affords nurses the best chance of having the complaint dismissed without a hearing or resolved on the most positive terms.
The biggest hurdle I see is nurses delaying or altogether failing to contact someone who can help them because they do not want to broadcast that they have received a complaint. This is often complicated by the fact that the charges may include serious or embarrassing allegations. These things should not stop you from reaching out to people who may be able to help you through this difficult time.
Take it seriously
You should always treat a formal complaint as a serious matter, warranting immediate and thoughtful action. Yet, invariably, some nurses will dismiss licensing board complaints or other allegations as frivolous, without basis, or the fabrications of an ill-advised complainant. They may become outraged at being accused of unprofessional and/or inappropriate conduct. Worse, some nurses inexplicably go into denial mode, pretending nothing happened.
Some nurses may assume that once they explain what happened, the licensing board will see the complaint as not worth the paper it is printed on. But even in situations where this is true, nurses must take the complaint seriously.
Regardless of fault, the single biggest mistake a nurse can make is ignoring the complaint or to take the complaint too lightly. Based on the discipline a licensing board may impose, a shower of negative effects may flow from a single complaint. Depending on the alleged offense and the board’s conclusion, a nurse’s reputation and livelihood may be irreparably damaged. Truly, the importance of properly and adequately responding to a licensing board complaint cannot be overstated. In light of the serious nature of board disciplinary matters, many nurses, nonetheless, continue to make crucial mistakes after a board complaint has been filed, which needlessly expose them to additional professional risk.
Beat the deadlines
Nurses must pay close attention to response deadlines. Do not ignore or miss the deadline to reply to the complaint. As a nurse, you know the importance of following orders and the far-reaching consequences of failing to do so. In the disciplinary context, this is no different. When a complaint is filed, the board generally sends a notice of the complaint to the nurse. In that notice, there is almost always a deadline for the nurse to file a written, narrative response to the allegations and a deadline to produce relevant and germane records and/or documentation.
Let’s face it: nurses are busy people. Gathering the relevant information, obtaining the necessary advice, and preparing an appropriate response are time-consuming activities, most of which cannot be delegated to someone else. Compounding these problems is human nature, as we put off dealing with unpleasant activities. As a consequence, the deadline for producing records and filing a response often creeps up on the nurse before he or she has prepared a proper defense. Missing that important deadline can at best harm the nurse’s credibility and at worst result in additional sanctions or disciplinary action. Nurses should never ignore, fail to respond, or miss the response deadline. Usually, additional time is granted if necessary, but you must file a request with the board, usually in writing, prior to the deadline.
Keep it to yourself
Should you speak with the board, investigators, complainant, or witnesses on your own? Short answer, no. Again, the first—and only—person you should contact upon receiving a board complaint is an attorney experienced in handling these types of matters. You need proper advice and an outline of your options. You also should never assume that you can simply explain the complaint away, even if you’re working with a seemingly friendly investigator. If asked, politely decline discussing the matter with anyone without your attorney present.
Although some complaints can be resolved quickly without adverse action, don’t allow yourself to be lulled into a false sense of security. I often encounter nurses who believe licensing boards exist to serve their interests, to protect them and their licenses. This isn’t the case. Licensing boards exist to protect the public. Statements you make at the beginning of an investigation, without adequate reflection or thought, can come back to haunt you.
Furthermore, you should also avoid having conversations with third parties, including potential witnesses. These interactions could damage your defense, and they are not protected from disclosure by the attorney-client privilege. Put another way, saying the wrong thing in the wrong way to anyone (except your attorney) can significantly inhibit your defense and lead to unfavorable consequences.
Finally, do not discuss the issue with the complainant unless your attorney agrees you should. The complainant represents great risk to you, and you generally should not discuss the case with him or her. You may think that if you could just talk to the complainant, you would have a productive, levelheaded discussion that would help the complainant understand your point of view and convince the complainant to dismiss the charge. In my experience, this almost never works; in fact, it can lead to damaging evidence against you. Worse, it may be portrayed as your having tried to intimidate the complaining party. It bears repeating that under no circumstance should you attempt to discuss the complaint with the person who filed it without first consulting the proper legal advice.
Overcoming a bad situation
The complaint and disciplinary processes can be daunting, especially for those unfamiliar with them. Defending and protecting your reputation and livelihood can generate anxiety and angst, and dealing with a complaint can exact a high emotional as well as economic toll. Familiarity with the process itself with timely and proper handling is crucial to obtain the best possible outcome.
With any luck, you will never have a complaint filed against you or go through a disciplinary hearing, but should that come to pass, I hope this article equips you with information that will enable you to make thoughtful and informed decisions.
*Please note that this article is not intended as formal legal advice and should not be used as such. Every case is different, and should you have questions specific to your own situation, I urge that you contact an attorney for further discussion.
As a registered nurse and lawyer with training in medical bioethics, Gloria Ramsey, JD, BSN, RN, knew a lot about end-of-life planning. Yet as her mother lay dying in a hospital after suffering a stroke, Ramsey’s knowledge didn’t save her from distress when it came to making final medical decisions for her.
“I will always remember [how my stomach dropped] when the attending physician asked me the question,” she recalls.
Fortunately, Ramsey knew her mother’s wishes and had the support of family members. But what about others, she wondered, who didn’t have a medical background or family to back them up? Today the question fuels her mission to educate minorities about the importance of planning for end-of-life care in advance—before they suffer a serious illness or become incapacitated.
Although most Americans believe patients should have the right to direct their medical treatment at the end of life, less than a quarter of the general population has completed advance directives. And Americans of color are even less likely to have expressed their wishes in writing.
There are two kinds of advance directive documents: a health care power of attorney (also known as a health care proxy), which identifies the person whom patients select to make medical decisions for them if they cannot speak for themselves, and living wills, which spell out patients’ preferences for end-of-life medical treatment, such as the right to refuse life-prolonging care.
“[Advance directives] help avoid the worst thing that can happen—family members left to make agonizing choices because they don’t know what the person wanted,” says Kathy Brandt, MS, vice president of professional leadership, consumer and caregiver services for the National Hospice and Palliative Care Organization (NHPCO). “If you don’t choose for yourself, the choice will be made for you.”
Removing Cultural Barriers
Nurses can make a profound difference by educating patients about the importance of end-of-life care planning. And when it comes to closing the gap of advance directive disparities, minority nurses can play a key role because they bring to the table cultural knowledge and understanding that helps establish trust in communities of color.
Gloria Ramsey, JD, BSN, RN
“Nurses are on the front lines,” says Paul Malley, president of Aging with Dignity, a nonprofit organization in Tallahassee, Fla., that promotes better care for people facing the end of life. “These are questions people feel comfortable asking a nurse.”
Minorities are less likely to complete advance directives for a variety of reasons, including a lack of access to culturally and linguistically appropriate information. Mistrust of the health care system, misperceptions about advance directives and difficulties in understanding medical terminology can also create barriers. Given the long history of racism in this country, some older African Americans suspect they will get inferior medical treatment if they complete advance directives. Many of them have not forgotten the infamous 1932-1972 Tuskegee syphilis experiment, in which 399 African American men with syphilis were misled by researchers and were not given the treatment they needed; 128 died of the disease or related complications as a result.
Ramsey, who has conducted research on African Americans’ perspectives on end-of-life planning, says that some black Americans don’t complete advance directives because they believe their families will know what to do when the time comes. Others view end-of-life treatment planning as giving up hope, or giving up on God. African Americans who do complete advance directives tend to request more aggressive life-sustaining treatment than whites.
In the Chinese culture, talking about death is taboo, and Western concepts of end-of-life care, such as hospice, may be unfamiliar to patients who are immigrants from mainland China. Some Chinese elders may have the fatalistic belief that advance end-of-life planning cannot change the future, according to NHPCO, whose Caring Connections outreach program offers informational resources on end-of-life issues developed specifically for Chinese American and Latino populations.
In focus groups with Latinos, NHPCO found that most participants were unfamiliar with the idea of advance health care planning. There were also linguistic misunderstandings about certain terms, such as “caregiver,” which in the Latino community implies a professional role rather than one undertaken at home by family members. Some Latinos have not heard of hospice and may equate it with nursing homes, which have a negative connotation because they go against the traditional cultural belief that it is the family’s responsibility to care for their sick and elderly relatives.
Still other barriers stem from legal red tape. Each state has its own advance directive laws, and some states require advance directive documents to be notarized in the presence of a lawyer. This can be a problem for minorities who live in low-income or rural communities where there is little or no access to notaries and legal services.
“Although the advance directive laws were written with good intentions, they have created hurdles that are insurmountable for many patients,” says Rebecca Sudore, MD, assistant professor of medicine at the University of California, San Francisco.
Simplifying Advance Directives
In a study published in the June 2008 issue of the Journal of the American Geriatrics Society, a team of researchers headed by Sudore recommended that oral advance directives, based on patients’ discussions with doctors, be made legally binding in all states. The study also emphasized the need for health care professionals and policymakers to facilitate opportunities for discussion about advance care planning in minority communities.
Anna Terrell, MSN, RN, BC
Of the 173 subjects who participated in the study, the majority (73%) were persons of color, and 31% had less than a high school education. The researchers found that subjects who had talked with family, friends or health care professionals about their end-of-life care preferences were more likely to take the next step and complete a written advance directive. Especially in communities where there is distrust of the health care system, says Sudore, the emphasis should be on getting people to think and talk about end-of-life planning rather than looking only at whether they have signed the legal documents.
She also stresses the need for advance directive documents that are easy-to read, easy-to-understand and culturally and linguistically appropriate. In a previous study, Sudore’s research team found that patients in California overwhelmingly preferred a simplified advance directive form to the standard form used in the state. The simplified version, which Sudore created with input from health literacy experts, patients, social workers, nurses and attorneys, uses short sentences, large type and helpful graphics that illustrate the text. Of the 205 people recruited for the study, 40% had limited literacy and 30% spoke only Spanish. Participants were able to complete greater portions of the simplified form, and almost three-quarters said they preferred it. Six months later, 19% of the group assigned to the simplified form had completed an advance directive for their personal use, compared to only 8% of those who were given the standard form. The simplified form, which is written at a fifth-grade reading level, is now legally valid in California and is available in English, Spanish, Chinese and Vietnamese.
Online Resources Nurses and nursing associations can participate in National Health Care Decisions Day (NHDD), an annual initiative held each April to encourage Americans around the country to talk about their future health care decisions and complete an advance directive. The NHDD Web site, www.nationalhealthcaredecisionsday.org, contains educational resources, ideas for community outreach activities, promotional materials and links to national and state-specific information, including copies of advance directives. The Center for Practical Bioethics’ Caring Conversations® consumer education initiative (www.practicalbioethics.org) offers a free advance care planning guidebook to help families share meaningful conversations while preparing to make decisions for end-of-life care. The guide, which includes advance directive documents, is available in English, Spanish and Braille. Aging with Dignity, www.agingwithdignity.org, provides information and resources for end-of-life care planning, including free copies of Five Wishes, an easy-to-understand advance directive available in 20 languages. Caring Connections, www.caringinfo.org, a program of the National Hospice and Palliative Care Organization, offers a variety of free downloadable resources, include state-specific advance directives and consumer education brochures in English, Chinese and Spanish. Key Topics on End-of-Life Care for African Americans, www.iceol.duke.edu/resources/lastmiles/index.html, an “electronic book” published by the Duke Institute on Care at the End of Life’s Initiative to Improve Palliative Care for African Americans, is a collection of papers presented at the Last Miles of the Way Home conference in 2004, the first national conference focusing on end-of-life care issues in the African American community. The Chinese American Coalition for Compassionate Care, www.caccc-usa.org, provides educational resources and advance directive forms in Chinese and English. Free copies of the simplified California Advance Health Care Directive developed by Rebecca Sudore, MD, of the University of California, San Francisco are available in English, Spanish, Chinese and Vietnamese from the Institute for Healthcare Advancement (IHA), www.iha4health.org. Bulk copies can be ordered by contacting IHA at (800) 434-4633 or [email protected]. What Y’all Gon’ Do With Me? The African American Spiritual and Ethical Guide to End of Life Care by Gloria Thomas Anderson, LMSW, can be ordered from her Web site, www.hearttones.com, or by emailing her directly at [email protected]. The Web site www.DoYourProxy.org offers a free online tool that helps people quickly and easily create a health care proxy and/or a living will.
Other organizations have also been working to make advance directives simpler. In 1998, Aging with Dignity introduced Five Wishes, an easy-to-use advance directive written in plain language. The document includes a health care proxy and lets people state their preferences regarding the kind of medical treatment they want or don’t want, how comfortable they want to be and what information they want their loved ones to know.
“It asks all the right questions and doesn’t make any assumptions about where someone is coming from,” Malley says. Five Wishes is valid in 40 states, and it can be used as a helpful guideline in states where the document does not meet legal requirements.
Two years ago, Aging with Dignity launched the 500,000 Wishes campaign, an outreach program designed to raise awareness of the need for advance care planning in minority communities. Funded by a $200,000 grant from the United Health Foundation, the campaign translated Five Wishes into 20 languages—including Arabic, Hindi, Hmong, Somali and Korean—and offered them for free. So far 250,000 have been distributed to individuals, community organizations, hospitals and hospices nationwide—halfway to the campaign’s goal of reaching a half million minority Americans. “Having this type of document available in so many languages is a first,” Malley says.
“It’s written in a positive and loving light,” says Leslie Piet, RN, MA, CCM, a nurse case manager in Bel Air, Md., who distributes Five Wishes to her patients. In some cases, she reads it aloud to patients. A passionate advocate for end-of-life planning, Piet was prompted by the 2005 Terri Schiavo right-to-die case to host a “living will party” for her family and friends. People gathered to discuss end-of-life choices and complete the Five Wishes document.
“[In our society,] we plan for bringing our children into this world. Now we need to get into the mindset of preparing for transition from this world,” she says. “When good end-of-life care is done well, patients and their families tend to be at greater peace.”
To reach people from a variety of cultures, education about advance directives must be framed in a positive way, Piet emphasizes. “It’s not about the things you don’t want. It’s about what you do want.” Most health care facilities are required by the federal Patient Self-Determination Act of 1990 to inform patients about their health care decision-making rights and ask if they have completed an advance directive. But too often this communication with patients becomes a checkbox item.
“It needs to be about more than policy and procedure,” says Anna Terrell, MSN, RN, BC, a retired nurse in Kansas City, Missouri. “It takes some time to sit down with patients and discuss end-of-life care.”
Before her retirement, Terrell educated nurses on advance care planning, served on her hospital’s ethics committee and worked with the Center for Practical Bioethics in Kansas City to learn more about African Americans’ experiences with end-of-life care. She developed a script to use with hospital patients during the admission summary process and tailored it to each patient’s needs, always mindful of their cultural and religious backgrounds.
“You have to be culturally knowledgeable about how to introduce the subject,” she says. “Many African Americans believe that if you bring up the subject of end-of-life care, you’re trying to rush the death.”
Misunderstandings can occur when doctors and nurses don’t consider the issue from their patients’ perspectives. Gloria Thomas Anderson, LMSW, a social worker in Kansas City, recalls how one of her elderly family members became upset and had to be restrained after a nurse asked if she had completed an advance directive.
“She interpreted that to mean that the hospital staff was trying to put her in a nursing home,” Anderson says. “She had avoided medical treatment for over 20 years, because she feared doctors and hospitals.”
After her relative calmed down, Anderson explained that the purpose of the document was not to put her away or to take things from her, but to make sure her family knew her wishes if she were not able to speak for herself. The woman agreed to complete an advance directive, giving one of her adult children power of attorney over her health care needs.
Anderson, who researched end-of-life care for her master’s thesis in 2006, received a grant from the Women’s Council at the University of Missouri-Kansas City to create and produce the booklet What Y’all Gon’ Do With Me? The African American Spiritual and Ethical Guide to End of Life Care. She is now partnering with Kansas City Hospice in a joint effort to distribute the booklet as a free educational resource for African Americans in the Kansas City area. This fall, Anderson will introduce an accompanying outreach training kit that health educators and organizations can use with the booklet to increase awareness of end-of-life issues in the black community.
Forming Coalitions, Building Trust
Sandy Chen Stokes, MSN, RN
Collaborating with other health care professionals and organizations can help nurses make an even bigger difference in closing advance directive knowledge gaps in minority communities. Three years ago, Sandy Chen Stokes, MSN, RN, a public health nurse in El Dorado County, Calif., founded the Chinese American Coalition for Compassionate Care to address the lack of linguistically and culturally appropriate end-of-life care information available to California’s Chinese community. Today the coalition includes more than 50 organizations (including NHPCO), provides training for Chinese-speaking volunteers and family caregivers, and offers advance directives, booklets and other educational resources in Chinese and English.
Less than 1% of Chinese Americans have completed advance directives, Stokes says. In focus groups with Chinese American health consumers, the coalition found that many families did not have adequate information for making informed medical decisions at the end of life, and most believed their choices were limited to either aggressive life-sustaining measures or simply “giving up.”
The coalition’s future plans include developing training for health care professionals, expanding its speakers’ bureau and partnering with additional U.S. and international organizations.
“My hope is that [what we are doing in the Chinese American community] can become a model program for other minority groups,” says Stokes.
As part of her research into African Americans’ attitudes about advance care planning, Gloria Ramsey partnered with a large African American church in Harlem, where she provided education on end-of-life issues and advance directives. Ramsey, now an associate professor at the Uniformed Services University of the Health Sciences Graduate School of Nursing in Bethesda, Md., was on the faculty at New York University at the time. She soon realized that even when nurses share the same ethnicity and culture as the community they’re working with, they must still establish trust and credibility before their outreach efforts can succeed.
“Although I am an African American, and the community saw me as African American, I still had to work hard at gaining their trust,” she says. “I had to show that I had no ulterior motives.”
The church was already receiving numerous requests a month to participate in research projects, and it had recently had a bad experience with another researcher. In situations like this, Ramsey advises, “it is imperative to have a local champion, a key person who can [serve as a gatekeeper].”
She partnered with the parish nurse, who acted as a liaison with the pastor and church members. Ramsey also immersed herself in the community by attending services every Sunday and volunteering with the church’s health ministry. She was careful about how she introduced her project. The parish nurse warned her not to use any language about death and dying, for instance.
Ramsey earned the trust of the congregation, although she hit a roadblock early on when she distributed a bulletin insert mentioning organ donation, a question that’s part of the New York advance directive document. The board of trustees, concerned that she was trying to get something from church members through the back door, requested a meeting. Ramsey addressed their concerns and explained her intentions, and the project moved forward.
But she says in hindsight she would not have brought up organ donation so soon without first providing education to put the issue in perspective.
Ramsey conducted focus groups and used that input to design a comprehensive, multifaceted health education program for the church. It included information on health risks, healthy living, spirituality and health, grief and bereavement, and advance care planning, using Five Wishes. She also shared her own story of making end-of-life decisions for her mother, which brought the issue home to church members on an emotional level. Suddenly she was perceived as not just an academic but also a loving daughter confronting the challenge of carrying out her mother’s wishes.
Today Ramsey continues to think of her mother as the inspiration for her work. “This was her last gift to me,” she says. “By sharing my story with communities of color, I am able to empower them.”
Gloria Blackmon, RNC, BSN, LNC, LNHA, never met the young man who lost his legs, but after reading over his medical records, the compassion she felt for him was as strong as if he had been her own patient. The young man had been living in an intermediate care facility for developmentally disabled adults when circulation problems in his legs became so severe that both limbs had to be amputated. His parents sued the facility and it was Blackmon’s job, as a legal nurse consultant for their attorney, to review the records and determine if they had a valid case.
In poring over the reams of documents, she discovered signs that the staff had overlooked the classic early symptoms of circulation loss. Had they addressed the problem sooner, the young man might be walking today. Blackmon’s findings strengthened the family’s case, which led to a substantial settlement.
“It was one of those cases that spoke to my heart,” says Blackmon, principal of Blackmon & Associates, a legal nurse consulting business in Topeka, Kansas.
Although legal nurse consultants don’t work directly with patients, their behind-the-scenes work on medical-related legal cases can make a huge impact on the quality of health care patients receive.
“The most rewarding part of this work is being able to help somebody, whether we find merit in the case or help the person move on with their life by validating that the doctor and the staff did everything they could,” says Rose Clifford, RN, CLNC, a legal nurse consultant in Cynthiana, Ky.
Legal nurse consultants put their nursing backgrounds to work in the legal arena. They work on contract or on salary for attorneys, insurance companies, government agencies and risk management departments, and they can provide a variety of services. Among other things, they review records to identify standards of care, conduct research and summarize medical literature, identify and apply regulatory requirements, educate attorneys about medical issues, assist with depositions and trials, and screen initial cases to see if they have merit.
“You can draw from all your bodies of education,” comments Rosalyn Harris-Offutt, CRNA, BS, LPC, BCETS, CLNC, a legal nurse consultant in Greensboro, N.C. “No one knows medical care in terms of the service provided for patients better than nurses.”
Through her consulting business, Prima Medical Legal, Harris-Offutt is a testifying and consulting expert on medical malpractice, product liability and workers compensation cases. Her background as an advanced psychiatric nurse and licensed professional counselor with expertise in post-traumatic stress disorder enables her to also testify in personal injury and criminal cases. In addition, Harris-Offutt—whose father was Cherokee and African American and whose mother was Creek Indian—strives to bring cultural competence to her consulting work. She networks with minority attorneys to serve their clients and provides consulting to Native Americans both on and off reservations. “That work is important to me because it allows me to serve all my people,” she explains.
Making a Real Difference
“Many people think it’s a new specialty, but nurses have been doing legal consulting for decades,” says Donna Cardillo, RN, a career adviser and creator of “Career Alternatives for Nurses,” an audio and video cassette educational program.
The field has grown more prominent in the last 10 to 15 years as more nurses have gone into full-time private practice and demand for their services has risen. “Lawsuits definitely have been on the rise, and nurses are also looking for alternatives to bedside nursing,” Cardillo points out. Nurses’ specialized knowledge and experience are highly regarded and respected in the legal arena, she adds.
The American Association of Legal Nurse Consultants (AALNC), founded in 1989 and headquartered in Glenview, Ill., has more than 4,000 members. Another professional association, the Houston-based Medical-Legal Consulting Institute, Inc., claims to have trained more than 20,000 legal nurse consultants since it was founded in 1985 by Vickie Milazzo, RN, MSN, JD. Yet many nurses remain unaware of the opportunities this specialty offers.
“A doctor told me I’d be very good at this, but at the time I didn’t know what she was talking about,” recalls Rosie Oldham, RN, DS, LNCC, president of the AALNC. She had been a director of nursing at a children’s psychiatric hospital, responsible for risk management and quality improvement, when she heard about legal nurse consulting. After researching the field and networking, she started her own business, R & G Medical Consultants, Inc., in Phoenix, which now employs three nurses plus 15 who work as independent subcontractors. Oldham works with attorneys and insurance companies on cases involving medical malpractice, toxic torts and product liability; she specializes in large class-action suits, which can involve hundreds of individual cases at a time.
One of the greatest rewards of the work, Oldham says, is the knowledge that she is making a difference. For instance, there was the case that involved a 45-year-old woman who had died because the abnormal results of her mammogram were never relayed to her doctor. One year after the test, her cancer was discovered, but by then it was too late. Through Oldham’s research of the medical records, she was able to determine that someone had filed the mammogram results away before the doctor had a chance to see them. As a result of that case, Oldham says, Phoenix-area hospitals changed their notification procedures for mammogram results. Now hospital radiology departments, which used to notify only the doctors’ offices when there was an abnormality, also notify patients of the test results and direct them to their physicians.
An important part of Blackmon’s career is the work she does for advocacy groups for the elderly. These groups represent medically underserved clients who have little or no financial resources and whose cases would probably not be addressed without the assistance of attorneys and expert consultants who are willing to work pro bono or on a sliding fee scale. While Blackmon says she approaches this work with the same level of objectivity that legal nurse consultants must bring to all their cases, these special efforts provide the extra reward that comes from helping people whose voices might otherwise go unheard. “The same assistance legal nurse consultants bring to the legal world needs to be brought to the pro bono and advocacy world as well,” she believes.
Variety Is the Spice of LNCs
The work that legal nurse consultants do varies according to their interests and backgrounds. “I love what I do,” Oldham asserts. “Every case is different, so you never get bored.”
Blackmon became a legal nurse consultant five years ago after working in nursing management at long-term care facilities. In her consulting work, she focuses primarily on long-term care and rehab nursing issues. Much of her work involves reviewing patient records to determine what really happened. The work is intense and full of surprises.
“Every record I receive is like a mystery novel,” she says. “You never know the answer until you get to the last page. Sometimes I’ll find something in a lab report that makes me go back and realize that the case is much more complicated than I first thought.”
A patient fall, for instance, at first may appear to be a case about whether a facility took proper safety precautions. But the records may reveal that it was, in fact, related to overmedication of the patient.
Legal nurse consultants work in a variety of settings as well. About half of the AALNC’s members are in independent practice, 25% work in law firms and another 25% are employed in industry, government, HMOs, hospitals or insurance companies. Many legal nurse consultants work part-time when they are first getting started and then switch to full-time once they have built a client base, according to the association.
Milazzo says fees range from $60 to $150 an hour for independent legal nurse consultants, while salaries for LNCs who work for employers are comparable to nursing salaries in a clinical setting.
Legal nurse consultants must be RNs, and Milazzo recommends that they have at least three years of nursing experience. They can become trained and certified in legal nurse consulting through the AALNC or other educational programs, such as Milazzo’s institute. (See “The ABCs of Legal Nurse Consulting.”) But certification isn’t mandatory.
Both Clifford and Blackmon say the education and mentoring they received through the Medical-Legal Consulting Institute gave them the tools to get started in the field. But nurses should shop carefully before they spend money on LNC training. They should make sure the programs are nursing-based, Oldham advises, and run by legal nurse consultants. Some paralegal training programs market themselves to nurses, but they train students to do paralegal work, which pays less than legal nurse consulting and includes legal areas that have nothing to do with health care, such as divorce.
How to Succeed in Business
Cardillo thinks the opportunities in legal nurse consulting are greatest for nurses who work as independent contractors: “I know many nurses who have built successful [LNC] practices, and they tell me they have more work than they know what to do with.”
Milazzo adds that the door is wide open, whether nurses want to work for employers or independently. However, those working for themselves, she notes, have greater autonomy and never have to worry about being downsized. “There’s no limit. You can take it wherever you want to go.”
But success doesn’t happen overnight. “Just like any consulting practice, you have to build a business and develop a clientele,” Cardillo emphasizes. And that’s not always easy.
“Nurses aren’t taught how to be businesswomen and businessmen,” Blackmon says. “There is a language of business and behavior of business that is brand new to us. Legal nurse consultants often find that the marketing aspect of the business can be challenging.”
Clifford agrees. Starting a business was scary, she relates: “I hate making cold calls.”
Clifford worked nine years as a consultant for a law firm before starting her own business six years ago, focusing on medical malpractice, Medicare fraud and product liability. She has built a client base mostly through word-of-mouth referrals. She also strategically places ads in legal journals and keeps her name in play by producing a newsletter that provides snippets of useful information for attorneys.
Because of this entrepreneurial focus, legal nurse consulting isn’t for everybody. To thrive in the specialty, nurses should be self-starters, strong communicators and have highly tuned critical and analytical thinking skills. Some cases are obvious, Harris-Offutt says, but many require reading between the lines to find hidden nuances.
Persistence is critical, not just in unraveling cases but in building a business, according to Milazzo. She feels that “it’s important to feel passion about what you’re doing. That’s what will help you make it through the rough times.”
Blackmon says nurses who decide to go into business for themselves as legal nurse consultants also need to be realistic, and shouldn’t enter the specialty just for the money. Although independent LNCs can make more than $100 per hour in some areas, they also have to bear the expenses of running an office, subscribing to industry magazines and training a staff. What’s more, the workload can fluctuate dramatically. “The work doesn’t come in regular eight-hour shifts,” Blackmon explains. “You will either have so much work you can’t see straight or you’ll have no work at all. There are times when I work 12, 14, even 16 hours a day, but there are also days when I have very few billable hours.”
How Do I Get Started?
Does legal nurse consulting sound like a career change you’d like to pursue? If so, here are some tips for how to get started in the field:
Read about legal nurse consulting. The American Association of Legal Nurse Consultants’ Web site (www.aalnc.org) is a good place to start. It has general information about the specialty, listings of educational materials and conferences, and information on how to contact local chapters and at-large directors. Also check out the Medical-Legal Consulting Institute’s site at www.LegalNurse.com.
Network with other legal nurse consultants. Oldham suggests joining a local AALNC chapter to meet others in the field. This is a good way to learn more about the specialty as well as an opportunity to begin building a client base. Oldham recommends bringing your resume to the first meeting as a way of introduction. If there is no AALNC chapter near you, try contacting an at-large association director to get help in finding legal nurse consultants in your state.
Get to know attorneys. Doing volunteer work through the local bar association is a good way to network with attorneys, says Oldham.
Consider gaining experience by signing on with a company that specializes in providing LNC services, such as Advanced Nurse Consultants (www.medical-legal-nurses.com) or Legal Nurse Consulting Services (www.lcinfo.com). To find more such firms, do an Internet search on “legal nurse consulting.”
Save three to six months’ worth of salary before quitting your job to start a full-time legal nurse consulting business, Blackmon advises. It will take at least that long to build a solid client base that will provide a decent income.
Find a mentor or coach. Oldham recommends that new legal nurse consultants hire coaches to guide them through their first few cases and check their work. Some LNC education programs also provide mentoring services.
The ABCs of Legal Nurse Consulting
Confused by the different legal nurse consultant acronyms mentioned in this article? Here’s a quick guide to what the “alphabet soup” is all about:
LNC = Legal Nurse Consultant (general term for a nurse who has completed an education program that provides the skills needed to work as a practicing legal nurse consultant)
CLNC = Certified Legal Nurse Consultant (professional certification conferred by the Medical-Legal Consulting Institute, Inc.)
LNCC = Legal Nurse Consultant Certified (professional certification conferred by the American Association of Legal Nurse Consultants)
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