Operation Nightingale’s Impact on the Nursing Community

Inside a far-reaching scandal, and the steps facility leaders should take to stay safe.

The healthcare industry heard the jarring news in January: 7,600 people bought bogus nursing diplomas with cash from three South Florida schools and were now applying for work — or already working — at facilities across the country. 

Twenty-five people were arrested and Siena College, Palm Beach School of Nursing and Sacred Heart International Institute were immediately closed for doling out fake transcripts and diplomas. The damage had already been done. Now the nursing workforce, already reeling from national shortages, had even more to contend with. Its stellar reputation was tarnished by the potential of imposters in their midst and organizations had to find out if any of the fraudulent nurses had passed the board in their states and made it onto their employment rolls. 

‘Simply deplorable’

The sentiments of American Nursing Association (ANA) President Jennifer Mensik Kennedy, PhD, MBA, RN, NEA-BC, FAAN, summed up the national sentiment. In an ANA statement, she called the scandal “extremely unsettling” and “simply deplorable.” “This undermines everything the nursing profession represents and stands for and is in direct opposition to the Code of Ethics for Nurses,” says Dr. Mensik Kennedy. “Furthermore, these unlawful and unethical acts disparage the reputation of actual nurses everywhere who have rightfully earned the title of the ‘Most Trusted and Ethical Professionals’ through their education, hard work, dedication and time.”

Top law enforcement officials in Florida issued similar comments when they announced the arrests in the case they dubbed “Operation Nightingale.” The 25 defendants each face 20 years in prison for their alleged crimes because the documents they issued allowed those who purchased them to sit for national nursing board exams and, if they passed, to obtain licenses and jobs as registered nurses or licensed practical/vocational nurses in multiple states across the country, according to a release from the U.S. Attorney’s Office.

“Not only is this a public safety concern, it also tarnishes the reputation of nurses who actually complete the demanding clinical and course work required to obtain their professional licenses and employment,” says Southern District of Florida U.S. Attorney Markenzy Lapointe. “A fraud scheme like this erodes public trust in our healthcare system.”

“What is disturbing about this investigation is that there are more than 7,600 people around the country with fraudulent nursing credentials who are potentially in critical healthcare roles treating patients,” adds Chad Yarborough, acting special agent in charge of the FBI’s Miami office.

The Miami Herald reported the scam ran from 2016 to 2021 and the students paid a total of $114 million for the fraudulent documents. The Associated Press cited federal officials who said about 2,400 purchasers passed licensing exams, mainly in New York, making them eligible to practice in multiple states. Many will likely lose their certification but might not be criminally charged, federal officials told the AP.

The U.S. Attorney’s Office release did not note any incidents in which patients were harmed by the healthcare workers in question. The office didn’t respond to a request for additional information. Multiple states have taken action in their efforts to identify whether graduates from the now-shuttered schools were among the 7,600 people who obtained their transcripts and diplomas fraudulently, or if they were actual students there who obtained legitimate credentials. Their efforts are ongoing.

Associations stress vigilance

While the events of Operation Nightingale are certainly shocking, how could the nursing diploma scandal impact the day-to-day operations of healthcare facility leaders — particularly those in the outpatient space? And have any of these fake nurses been linked to HOPDs or ASCs? Reports of ASCs being duped by nurses with false credentials are scarce. However, two state-level ASC associations did speak with Outpatient Surgery.

Beth LaBouyer, RN, CNOR, CASC, executive director of the California Ambulatory Surgery Association (CASA), says her organization is not aware of any California ASCs that have experienced the “Operation Nightingale” problem at this point. However, she reminds ASC administrators to refresh their vigilance when it comes to whom they hire.

“ASCs must do their due diligence in hiring to ensure the potential new hire is fully qualified and credentialed,” she says. “The hiring process should include confirmation of an applicant’s references and degrees, as well as license verification with the California State Board of Registered Nursing and through the National Council of State Boards of Nursing nationwide data system. The California Board of Registered Nursing also maintains a list of Approved California RN Nursing Programs.”

She says ASC administrators should be aware of the names of the schools involved in the fraudulent diploma scheme. “Communication during the interview and hiring process should acknowledge that providing misinformation or false credentials is grounds for dismissal,” she says, adding that it’s always wise to do a quick search of news and social media to see if there is any concerning information regarding a potential new hire.

For any ASCs that hired a nurse with false credentials or diplomas and didn’t realize it until after the fact, she advises administrators to address the situation but to handle it with care. “ASCs need to have established policies for employment and for firing to provide a clear process for addressing deception or misbehavior by an employee,” says Ms. LaBouyer. “If an ASC discovers that an employee has lied about their credentials, then it is important to connect with HR counsel and legal counsel to ensure that next steps, including dismissal, are handled correctly to minimize the risk of unnecessary delays or lawsuits.”

Like CASA, the New Jersey Association of Ambulatory Surgery Centers is not aware of any of its member centers needing to deal with the scandal, according to Board President Meg Stagliano, MBA, MSN, RN. She offers similar advice for centers seeking to determine if a potential hire possesses legitimate credentials. “In addition to seeking legal counsel, there should be more due diligence in hiring, background checks and independent verification of credentials as a best practice,” says Ms. Stagliano.

If centers are skeptical of a current employee’s credentials, they should address it with appropriate transparency. “Centers should look at their policies and procedures annually to make sure there are no changes in the regulations or hiring practices,” she adds. “New Jersey does have a website where we can verify licenses: the New Jersey Division of Consumer Affairs’ License Verification Website (osmag.net/njverification).”

Thousands still out there

Lack of direct ties to surgery centers notwithstanding, facilities with nurses on staff are still in a position that warrants direct action. “Legal actions demand that both institutions and healthcare providers act reasonably to protect the health of those they serve,” says William Duffy, RN, MJ, CNOR, FAAN, director for the Nursing and Healthcare Administration MSN at the Marcella Niehoff School of Nursing at Loyola University of Chicago. The key word here is “reasonably,” given so many of the fraudulent nurses are still unaccounted for. “Both nursing leaders and their organizations are now aware that there are thousands of individuals with fake degrees,” says Mr. Duffy. “The reasonable thing to do is to perform an audit of their employees to make sure their credentials are legitimate.”

To be safe, he says, leaders really need to do their due diligence and look into where their team members earned their degrees. While this is no doubt an administrative headache, it’s worth it given the stakes. Reason: Any facility that has or has had one of the individuals with fake nursing diplomas on staff could be in legal jeopardy in unrelated lawsuits if a patient’s attorney discovers they were cared for by a non-nurse — even if the care itself wasn’t in question. “Remember, the determining factor for a negligence lawsuit is the preponderance of the evidence,” says Mr. Duffy.

It’s already an uphill battle for any facility to show that it behaved reasonably when it hired nurses who did not complete an approved pre-licensure program and had “unqualified” nurses providing patient care. “This would be even more difficult to defend if the public was aware an organization didn’t do anything to fix the issue,” says Mr. Duffy. “If it was revealed that the organization had these individuals working for them after the news [of Operation Nightingale] broke, many juries would find it unreasonable.”

Mr. Duffy, a past president of AORN who currently serves on its board of directors, believes the big-picture implications are what healthcare leaders should care most about: The scandal’s impact on the nursing profession at large. “Nurses and nurse leaders need to be engaged in protecting our profession and our licensure,” he says. “People trust that we went through a process and received a certain level of education and training. If we lose control over how individuals enter the profession, we can lose public trust and potentially the gains we have earned to practice at the height of our license.”

While the scope of the diploma scandal spearheaded by an FBI investigation is eye-opening, there’s nothing particularly novel about individuals looking to bypass the stringent education and training requirements inherent in a respected healthcare career. As Mr. Duffy puts it, “nursing is not a lucrative field, but it is a field where members can earn a decent salary and where there is money, and there are always folks who will want to be part of the process without earning the degree or license.”

In fact, some facility leaders have sadly already dealt with it long before the issue made national headlines. For instance, Carson McCafferty, MSN, RN, CNOR, CNAMB, CSRN, clinical director at Eye 35 ASC in Schertz, Texas, had one surgical technologist applicant submit fraudulent documents that Ms. McCafferty was luckily able to identify just prior to hiring.

“A few years ago, a surgical technician gave me a letter about waiting for her certification card that she had just renewed. It was on letterhead and signed, so it looked legitimate,” recalls Ms. McCafferty. “I went to the certification agency’s online portal to verify the information, but I couldn’t find her.” That immediately set off a red flag for Ms. McCafferty, and she reached out directly to the agency, who told her the prospective surgical tech wasn’t in their system, which led McCafferty to keep pressing until eventually she got in touch with the person who had supposedly signed the document. “They asked me who was on the signed letter, and she was in the office,” she says. “I was actually able to get on the phone with the person whose name the applicant had forged on the letter, and that person confirmed the fraudulent activity.” Ms. McCafferty says leaders should verify all licenses and certifications prior to hiring new staff. “The lesson here is that fraud can happen to anyone at any time, so take the time to verify everyone,” she says.

Role of the nursing boards

What role do the nursing boards play in this whole mess? It’s a question that’s debated online, with prominent nurse advocates and social media influencers in the healthcare sector claiming the diploma scandal is a perfect example of the need for change.

One such influencer is a nurse advocate who goes by “The Nurse Erica” on various social media platforms. “There needs to be oversight over the boards of nursing,” says Nurse Erica, who is a board-certified registered nurse. “We have 50-plus individual boards of nursing, and they all operate independently. There is no oversight.” She adds that although the national nursing database Nursys was created in recent years, not all states currently participate.

The result of this operational independence of the various nursing boards is a lack of cohesion. “On one end of the spectrum, you have Florida, the epicenter of the scandal, who hasn’t said word one about it, and then you’ve got New Jersey where dozens of licenses have already been rescinded,” says Nurse Erica.

What’s next?

No one knows for sure what the long-term implications of the scandal will be, but many believe it’s bound to impact the hiring process. Nurse Erica believes it will have a markedly negative impact. “I’m already starting to hear about the ramifications happening with nurses trying to get hired at new jobs,” she says. “The delay in employment is going to be out of control because inevitably, healthcare organizations are going to require you to provide your diploma, your degree and your transcripts, and some nurses who have been practicing forever don’t even have those documents on hand,” adding that some even attended schools that have subsequently closed.

Mr. Duffy, however, is focusing on the long game, pointing out the resilience and grit of the nursing community in overcoming seemingly insurmountable challenges — challenges dating all the way back to the days of the pioneer for whom the FBI named its investigation. “We’re in a period of tension, but we’ve done this before,” Mr. Duffy says. “We will overcome this.” OSM