On October 11 2016, the Nursing and Midwifery Board of Australia responded to a number of complaints regarding anti-vaccination material and advice being disseminated by registered nurses, enrolled nurses, and registered midwives, by publishing a new position statement on anti-vaccination misinformation:
NMBA position on nurses, midwives and vaccination
The NMBA has become aware that there are a small number of registered nurses, enrolled nurses and midwives who are promoting anti-vaccination statements to patients and the public via social media which contradict the best available scientific evidence. The NMBA is taking this opportunity to make its expectations about providing advice on vaccinations clear to registered nurses, enrolled nurses and midwives.
The NMBA recognises the Australian National Immunisation Handbook 10th edition as providing evidence-based advice to health professionals about the safe and effective use of vaccines and the public health benefits associated with vaccination. The NMBA supports the use of the handbook by registered nurses, enrolled nurses and midwives who are giving vaccines. The handbook is available from the Immunise Australia Program website.
The NMBA expects all registered nurses, enrolled nurses and midwives to use the best available evidence in making practice decisions. This includes providing information to the public about public health issues.
All registered nurses, enrolled nurses and midwives are required to practise in accordance with professional standards set by the NMBA, including the codes of conduct, codes of ethics and the standards for practice, in particular the social media policy and the guidelines for advertising regulated health services.
What should I do if I notice a nurse or midwife is promoting anti-vaccination material?
If you have concerns about a nurse or midwife you can make a complaint to AHPRA. The NMBA will consider whether the nurse or midwife has breached their professional obligations and will treat these matters seriously. Any published anti-vaccination material and/or advice which is false, misleading or deceptive which is being distributed by a registered nurse, enrolled nurse or midwife (including via social media) may also constitute a summary offence under the National Law and could result in prosecution by AHPRA.
Marr-Bolton was identified as a registered nurse in March 2017, when she trolled the Stop the Australian (Anti) Vaccination Network Facebook page, throughout March and April 2017, with anti-vaccination misinformation. Marr-Bolton stated to SAVN page members that she was a registered nurse and that she had over thirty years of nursing experience, including working in ICU.
After being identified as a registered nurse, Marr-Bolton went on an abusive posting spree, continuing to post anti-vaccination misinformation, even after acknowledging warnings that she was in breach of the NMBA position statement included above.
Marr-Bolton’s initial Facebook username – tracey.marr.180 – indicated her real name to other Facebook users:
Marr-Bolton attempted to hide her anti-vaccination activism by changing her Facebook username to traceleochella:
SAVN page members sought out Marr-Bolton’s AHPRA registration so as to verify her claim of being a registered health practitioner.
Marr-Bolton was initially registered under the name Tracey Anne Marr, until early April 2017:
Marr-Bolton then changed her registration name to Tracey Anne Bolton, in an attempt to further conceal her anti-vaccination activism:
Marr-Bolton also sent abusive private messages to a SAVN page member, claiming that her privacy had been breached by SAVN page members searching the public AHPRA register of practitioners. She then continued to troll the SAVN page, even after changing her Facebook and registration names.
From March 30 2017, messages from Marr-Bolton to a SAVN page member:
Marr-Bolton’s comment, above, that the “hospital came out second best for their lies”, refers to a previous employer that terminated her employment, as outlined in this Maribyrnong Leader article, from 2015:
Western Health nurse dismissed for administering wrong dosages
A NURSE has been sacked for administering the wrong drug dosages to critical-care patients at a hospital in Melbourne’s west.
Footscray Hospital intensive care nurse Tracey Marr lodged an application in January to the Fair Work Commission for unfair dismissal.
But the commission rejected her claim and upheld Western Health’s decision to sack Ms Marr.
The hospital argued she had made potentially life-threatening errors on three separate occasions.
On March 6, 2013, Ms Marr gave the incorrect dosage of the drug Tirofiban, which helps reduce the rate of thrombotic cardiovascular events, to a patient.
On September, 26, 2013, she administered Oxynorm, a painkiller, to a patient who was using a patient-controlled analgesia pump, when their medical chart indicated the drug not be administered if they were using a PCA pump.
On August, 4, 2014, she gave Actrapid, an insulin drug, to a patient despite already administering it two hours earlier.
Ms Marr, 54, was employed by Western Health in the ICU at Gordon St between 2006 and the date of her dismissal on December 24, 2014.
The commission found her contract termination wasn’t “harsh, unjust or unreasonable.”
In a Fair Work Commission transcript, posted on the Australasian Legal Information Institute website, Ms Marr disputed the August 4 incident claiming the term QID (four times a day) wasn’t written before 1am and 3am on the patient’s medication chart as the hourly frequency for the administering of Actrapid and was added sometime after 6am.
She gave evidence that there was a culture in the ICU whereby doctors, on occasion, don’t give the hourly frequency, leaving it up to the nurse to decide when to administer the drug.
But the commission was satisfied QID was written on the chart and didn’t accept the claim that when a doctor doesn’t state the frequency they could be intending to leave it up to the nurse to determine. Doctor Patrick Dunne, who prescribed the drug, told the commission he wasn’t in the practice of writing blank prescriptions.
“Insulin is not a medication that I would ever leave as an open PRN (when-necessary order), i.e. without an interval frequency, due to the potential harm that could be caused to a patient from over-treating,” Dr Dunne said.
The latest Health Department data confirms medical mistakes are extremely rare with only 3 per cent of 23 reported events accounting for a medication error.
On March 5 2017, Marr-Bolton posted an anti-vaccination conspiracy theory to the SAVN page:
On March 25 2017, Marr-Bolton posted an anti-vaccination paper which asserts, wrongly, that Australian vaccines contain “thiomerasil” [sic], and went on to accuse doctors of being liars:
On March 28 2017, Marr-Bolton posted a link from an anti-vaccination website to bolster her arguments:
On March 30 2017, Marr-Bolton accused SAVN page members of being hackers, and stated that she would inform AHPRA of her activities on the SAVN page:
On March 31 2017, Marr-Bolton accused a named medical practitioner of acting illegally, and continued to abuse other page members and accuse them of breaching her privacy:
On March 31 2017, Marr-Bolton posted to the SAVN page a second time to make accusations of illegal activity against page members:
On March 31 2017, Marr-Bolton posted to the SAVN page a third time and stated that she would be lodging vexatious AHPRA complaints against two named registered health practitioners:
On April 13 2017, Marr-Bolton returned to accuse the medical profession of being dishonest:
On April 15 2017, Marr-Bolton returned to start posting anti-vaccination and other abusive comments on the SAVN page reviews section:
On April 15 2017, Marr-Bolton posted a CDC conspiracy link to the SAVN page:
On April 17 2017, Marr-Bolton posted a debunked and retracted anti-vaccination paper to the SAVN page:
On April 17 2017, Marr-Bolton posted an article about the Disneyland measles outbreak, not realising that it argued against her anti-vaccination position:
On April 17 2017, Marr-Bolton posted an article criticising the stockpiling of Tamiflu and other antiviral medications, not knowing that these medications have nothing to do with vaccines:
The following addenda contain excerpts from the Nursing and Midwifery Board of Australia’s competency standards, codes, guidelines, and social media policy from which readers may wish to choose when lodging any complaint regarding the anti-vaccination activism of Tracey Marr-Bolton.
Thanks for reading.
Relates to the professional, legal and ethical responsibilities which require demonstration of a satisfactory knowledge base, accountability for practice, functioning in accordance with legislation affecting nursing and health care, and the protection of individual and group rights.
1 Practises in accordance with legislation affecting nursing practice and health care
1.1 Complies with relevant legislation and common law
1.2 Fulfils the duty of care
1.3 Recognises and responds appropriately to unsafe or unprofessional practice
2 Practises within a professional and ethical nursing framework
2.1 Practises in accordance with the nursing profession’s codes of ethics and conduct
2.2 Integrates organisational policies and guidelines with professional standards
2.3 Practises in a way that acknowledges the dignity, culture, values, beliefs and rights of individuals/groups
2.4 Advocates for individuals/groups and their rights for nursing and health care within organisational and management structures
2.5 Understands and practises within own scope of practice
2.6 Integrates nursing and health care knowledge, skills and attitudes to provide safe and effective nursing care
2.7 Recognises the differences in accountability and responsibility between registered nurses, enrolled nurses and unlicensed care workers
Critical thinking and analysis
Relates to self-appraisal, professional development and the value of evidence and research for practice. Reflecting on practice, feelings and beliefs and the consequences of these for individuals/ groups is an important professional bench- mark.
3 Practises within an evidence-based framework
3.1 Identifies the relevance of research to improving individual/group health outcomes
3.2 Uses best available evidence, nursing expertise and respect for the values and beliefs of individuals/groups in the provision of nursing care
3.3 Demonstrates analytical skills in accessing and evaluating health information and research evidence
3.4 Supports and contributes to nursing and health care research
3.5 Participates in quality improvement activities
4 Participates in ongoing professional development of self and others
4.1 Uses best available evidence, standards and guidelines to evaluate nursing performance:
4.2 Participates in professional development to enhance nursing practice
4.3 Contributes to the professional development of others
4.4 Uses appropriate strategies to manage own responses to the professional work environment
Provision and coordination of care
Relates to the coordination, organisation and provision of nursing care that includes the assessment of individuals/ groups, planning, implementation and evaluation of care.
5 Conducts a comprehensive and systematic nursing assessment
5.1 Uses a relevant evidence-based assessment framework to collect data about the physical socio-cultural and mental health of the individual/group
5.2 Uses a range of assessment techniques to collect relevant and accurate data
5.3 Analyses and interprets assessment data accurately
6 Plans nursing care in consultation with individuals/groups, significant others and the interdisciplinary health care team
6.1 Determines agreed priorities for resolving health needs of individuals/groups:
6.2 Identifies expected and agreed individual/group health outcomes including a time frame for achievement
6.3 Documents a plan of care to achieve expected outcomes
6.4 Plans for continuity of care to achieve expected outcomes
7 Provides comprehensive, safe and effective evidence-based nursing care to achieve identified individual/group health outcomes
7.1 Effectively manages the nursing care of individuals/groups
7.2 Provides nursing care according to the documented care or treatment plan
7.3 Prioritises workload based on the individual/group’s needs, acuity and optimal time for intervention
7.4 Responds effectively to unexpected or rapidly changing situations
7.5 Delegates aspects of care to others according to their competence and scope of practice
7.6 Provides effective and timely direction and supervision to ensure that delegated care is provided safely and accurately
7.7 Educates individuals/groups to promote independence and control over their health
8 Evaluates progress towards expected individual/group health outcomes in consultation with individuals/groups, significant others and interdisciplinary health care team
8.1 Determines progress of individuals/groups toward planned outcomes
8.2 Revises the plan of care and determines further outcomes in accordance with evaluation data
Collaborative and therapeutic practice
Relates to establishing, sustaining and concluding professional relationships with individuals/groups. This also contains those competencies that relate to nurses understanding their contribution to the interdisciplinary health care team.
9 Establishes, maintains and appropriately concludes therapeutic relationships
9.1 Establishes therapeutic relationships that are goal directed and recognises professional boundaries
9.2 Communicates effectively with individuals/groups to facilitate provision of care
9.3 Uses appropriate strategies to promote an individual’s/group’s self-esteem, dignity, integrity and
9.4 Assists and supports individuals/groups to make informed health care decisions
9.5 Facilitates a physical, psychosocial, cultural and spiritual environment that promotes individual/group safety and security
10 Collaborates with the interdisciplinary health care team to provide comprehensive nursing care
10.1 Recognises that the membership and roles of health care teams and service providers will vary depending on an individual’s/group’s needs and health care setting
10.2 Communicates nursing assessments and decisions to the interdisciplinary health care team and other relevant service providers
10.3 Facilitates coordination of care to achieve agreed health outcomes
10.4 Collaborates with the health care team to inform policy and guideline development
Code of Professional Conduct for Nurses in Australia
1 Nurses practise in a safe and competent manner.
2 Nurses practise in accordance with the standards of the profession and broader health system.
Conduct Statement 2
Nurses practise in accordance with the standards of the profession and broader health system
1 Nurses are responsible for ensuring the standard of their practice conforms to professional standards developed and agreed by the profession, with the object of enhancing the safety of people in their care as well as their partners, family members and other members of the person’s nominated network. This responsibility also applies to the nurses’ colleagues.
2 Nurses practise in accordance with wider standards relating to safety and quality in health care and accountability for a safe health system, such as those relating to health documentation and information management, incident reporting and participation in adverse event analysis and formal open disclosure procedures.
3 Nurses practise and conduct themselves in accordance with laws relevant to the profession and practice of nursing.
Conduct Statement 3
Nurses practise and conduct themselves in accordance with laws relevant to the profession and practice of nursing
1 Nurses are familiar with relevant laws and ensure they do not engage in clinical or other practices prohibited by such laws or delegate to others activities prohibited by those laws.
2 Nurses witnessing the unlawful conduct of colleagues and other co-workers, whether in clinical, management, education or research areas of practice, have both a responsibility and an obligation to report such conduct to an appropriate authority and take other appropriate action as necessary to safeguard people and the public interest.
4 Nurses respect the dignity, culture, ethnicity, values and beliefs of people receiving care and treatment, and of their colleagues.
5 Nurses treat personal information obtained in a professional capacity as private and confidential.
6 Nurses provide impartial, honest and accurate information in relation to nursing care and health care products.
Conduct Statement 6
Nurses provide impartial, honest and accurate information in relation to nursing care and health care products
1 When nurses provide advice about any care or product, they fully explain the advantages and disadvantages of alternative care or products so individuals can make informed choices. Nurses refrain from engaging in exploitation, misinformation or misrepresentation with regard to health care products and nursing care.
2 Nurses accurately represent the nature of their services or the care they intend to provide.
3 Where a specific care or a specific product is advised, nurses ensure their advice is based on adequate knowledge and not on commercial or other forms of gain. Deceptive endorsement of products or services or receipt of remuneration for products or services primarily for personal gain, other than remuneration in the course of a proper commercial relationship, is improper.
7 Nurses support the health, wellbeing and informed decision-making of people requiring or receiving care.
8 Nurses promote and preserve the trust and privilege inherent in the relationship between nurses and people receiving care.
Conduct Statement 8
Nurses promote and preserve the trust and privilege inherent in the relationship between nurses and people receiving care
1 An inherent power imbalance exists within the relationship between people receiving care and nurses that may make the persons in their care vulnerable and open to exploitation. Nurses actively preserve the dignity of people through practised kindness and respect for the vulnerability and powerlessness of people in their care. Significant vulnerability and powerlessness can arise from the experience of illness and the need to engage with the health care system. The power relativities between a person and a nurse can be significant, particularly where the person has limited knowledge; experiences pain and illness; needs assistance with personal care; belongs to a marginalised group; or experiences an unfamiliar loss of self-determination. This vulnerability creates a power differential in the relationship between nurses and persons in their care that must be recognised and managed.
4 Nurses fulfil roles outside the professional role, including those as family members, friends and community members. Nurses are aware that dual relationships may compromise care outcomes and always conduct professional relationships with the primary intent of benefit for the person receiving care. Nurses take care when giving professional advice to people with whom they have a dual relationship (e.g. a family member or friend) and advise them to seek independent advice due to the existence of actual or potential conflicts of interest.
9 Nurses maintain and build on the community’s trust and confidence in the nursing profession.
Conduct Statement 9
Nurses maintain and build on the community’s trust and confidence in the nursing profession
1 The conduct of nurses maintains and builds public trust and confidence in the profession at all times.
2 The unlawful and unethical actions of nurses in their personal lives risk adversely affecting both their own and the profession’s good reputation and standing in the eyes of the public. If the good standing of either individual nurses or the profession were to diminish, this might jeopardise the inherent trust between the nursing profession and the public necessary for effective therapeutic relationships and the effective delivery of nursing care.
3 Nurses consider the ethical interests of the nursing profession and the community when exercising their right to freedom of speech and participating in public, political and academic debate, including publication.
10 Nurses practise nursing reflectively and ethically.
Conduct Statement 10
Nurses practise nursing reflectively and ethically
1 Nurses practise nursing reflectively and ethically, in accordance with the Code of Ethics for Nurses in Australia, in order to learn from experience and contribute to personal and professional practice.
2 Nurses develop and maintain appropriate and current quality nursing advice, support and care for each person requiring and receiving care and their partners, families and other members of their nominated social network. This responsibility also applies to colleagues of nurses.
3 Nurses evaluate their conduct and competency according to the standards of the nursing profession.
4 Nurses contribute to the professional development of students and colleagues.
5 Nurses participating in research do so in accordance with recognised research guidelines and do not violate their duty of care to persons receiving nursing care.
6 Nurses advise employers and any persons in their care of any reduction in their capacity to practise due to health, social or other factors, while they seek ways of redressing the problem.
Code of Ethics for Nurses in Australia
1 Nurses value quality nursing care for all people.
2 Nurses value respect and kindness for self and others.
3 Nurses value the diversity of people.
4 Nurses value access to quality nursing and health care for all people.
5 Nurses value informed decision-making.
Value Statement 5
Nurses value informed decision-making
Nurses value people’s interests in making free and informed decisions. This includes people having the opportunity to verify the meaning and implication of information being given to them when making decisions about their nursing and health care. Nurses also recognise that making decisions is sometimes constrained by circumstances beyond individual control and that there may be circumstances where informed decision making cannot always be fully realised.
1 Self: Nurses make informed decisions in relation to their practice within the constraints of their professional role and in accordance with ethical and legal requirements. Nurses are entitled to do this without undue pressure or coercion of any kind. Nurses are responsible for ensuring their decision-making is based on contemporary, relevant and well-founded knowledge and information.
2 Person (health consumer): Nurses value the legal and moral right of people, including children, to participate whenever possible in decision-making concerning their nursing and health care and treatment, and assist them to determine their care on the basis of informed decision making. This may involve ensuring people who do not speak English have access to a qualified health interpreter. Nurses recognise and respect the rights of people to engage in shared decision-making when consenting to care and treatment. Nurses also value the contribution made by persons whose decision-making may be restricted because of incapacity, disability or other factors, including legal constraints. Nurses are knowledgeable about such circumstances and in facilitating the role of family members, partners, friends and others in contributing to decision-making processes.
3 Colleagues: Nurses respect the rights of colleagues and members of other disciplines to participate in informed decision-making. Making these collaborative and informed decisions includes involving the person requiring or receiving nursing care (or their representative) in decisions relating to their nursing or health care, without being subject to coercion of any kind.
4 Community: Nurses value the contribution made by the community to nursing and health care decision-making through a range of activities, including consumer groups, advocacy and membership of health-related committees. Nurses also assist in keeping the community accurately informed on nursing and health-related issues.
6 Nurses value a culture of safety in nursing and health care.
Value Statement 6
Nurses value a culture of safety in nursing and health care
Valuing a culture of safety involves nurses actively engaging in the development of shared knowledge and understanding of the crucial importance of safety in contemporary health care. Nurses who value a culture of safety appreciate that safety is everyone’s responsibility. Nurses support the development of risk management processes and a practice environment designed to reduce the incidence and impact of preventable adverse events in health care. Nurses also support the open disclosure of any adverse events to any person affected during the course of their care.
1 Self: Nurses value safe practice and a safe working environment; practise within the limitations of their knowledge and skills; and recognise and avoid situations where their ability to deliver quality care may be impaired. Nurses have a moral and legal right to practise in a safe environment, without fear for their own safety or that of others, and they seek remedies through accepted channels, including legal action, when this is not the case. Nurses value the maintenance of competence in contributing to a safe care and practice environment.
2 Person (health consumer): Nurses recognise that people are vulnerable to injuries and illnesses as a result of preventable human error and adverse events while in health care settings. Nurses play a key role in the detection and prevention of errors and adverse events in health care settings, and support and participate in systems to identify circumstances where people are at risk of harm. Nurses act to prevent or control such risks through prevention, monitoring, early identification and early management of adverse events. Nurses contribute to the confidential reporting of adverse events and errors, and to organisational processes for the open disclosure of these events to persons affected during the course of their care.
3 Colleagues: Nurses work with their colleagues to create a culture of safety. Nurses support the development of safer health care systems through non-punitive human error, adverse event management and related education. Nurses value the critical relationship between consumer safety and interprofessional competencies, including trustful communication, teamwork and situation awareness. Nurses view the detection of their own errors and risks or those of their colleagues as opportunities for achieving a safer health care system.
4 Community: Nurses, acting through their professional and industrial organisations and other appropriate authorities, participate in developing and improving the safety and quality of health care services for all people. This includes actively promoting the provision of equitable, just and culturally and socially responsive health care services for all people living, or seeking residence or asylum, in Australia. It also involves raising public awareness about the nature and importance of consumer safety programs in health care services.
7 Nurses value ethical management of information.
8 Nurses value a socially, economically and ecologically sustainable environment promoting health and wellbeing.
When using social media, health practitioners should remember that the National Law, their National Board’s code of ethics and professional conduct (the Code of conduct) and the Guidelines for advertising regulated health services (the Advertising guidelines) apply.
Registered health practitioners should only post information that is not in breach of these obligations by:
- complying with professional obligations
- complying with confidentiality and privacy obligations (such as by not discussing patients or posting pictures of procedures, case studies, patients, or sensitive material which may enable patients to be identified without having obtained consent in appropriate situations)
- presenting information in an unbiased, evidence-based context, and
- not making unsubstantiated claims.
Additional information may be available from professional bodies and/or employers, which aims to support health practitioners’ use of social media. However, the legal, ethical, and professional obligations that registered health practitioners must adhere to are set out in the National Boards’ respective Code of conduct and the Advertising guidelines.