refusing to care for clients

Sharon · Oct 7, 1998

Carolyn,

You have brought up a topic I have been dealing with in many situations and from many angles over the past 15 years. I have never refused care of a patient because of a communicable disease. Since I have had an interest in communicable diseases I have always been willing to accept them when other nurses have refused. I have participated in many interesting cases including survivors of Ebola. I believe some of the fear comes from not being informed the of the status of the patient. I have taken report on patients with active infectious states were not reported by the previous nurse or doctor too many times to count.

My last occupational blood exposure was made worse by the fact that the previous nurse gave me false information. I slipped in a pool of blood becoming soaked head to toe from a confused patient who had pulled his 14 fr foley out at the beginning of the shift The previous nurse did not attempt to control the bleeding and reported the confusion was due to Alzheimers. In reality patient's confusion was due to Tertiary syphilis and Neuro TB.

Unfortunately this year I have been diagnosised with IGG subclass deficiency. I have also not had many of the childhood illnesses so I no longer have vaccination titers and cannot produce them. The IGG deficiency is believed to be partially environmental, exposure to allergens in the home I used to live in, and occupational. I have had repeated iatrogenic infections from work despite correct technique and PPE. When I was diagnosised I had moved into a position in an area of nursing not doing direct patient care, so I am not confronted with refusing care at this time. My future work opportunities are extremely narrowed now.

One lesson I learn in pre-hospital care was if the rescuer is dead so is the patient, so be prepared. When I am in a situation where I may be called to render assistance I am sure to have appropriate PPE with me. Basically I have it with me at all times, even to treat family members.

Carolyn M · Oct 17, 1998

Thank you for your reply, as well as for responding to my message. I appreciate you sharing your experience with me. I hpe you are doing well. I know that you no longer work directly with patients, but if you were in the situation where a coworker refused to care for a client, how would you approach them? I'm curious to see how nurses react to other nurses who are afraid to work with clients with these diseases. Any ideas on how to make the whole floor overcome any anxiety or fear with working with these clients? Or, do you have any other related suggestions that I can use when writing this paper?

Thanks again!

Sharon · Oct 20, 1998

Carolyn,

Nursing has a double standard for refusing care. There are situations in which refusing care is considered acceptable by many in nursing. For instance when a woman is having a voluntary termination of a pregnancy. Many nurses feel it is appropriate to refuse to care for a women terminating a pregnancy if it violates their religious values.

When I had a nurse or student who refused to care for a patient I would approach it as a process. In my supervisory experience the immediate emotion behind the refusal is a flight or fight response. Anyone who is having a flight or fight response is not going to do something well immediately.

The first step to handling the situation was to reassign the nurse the first night and to discuss in depth with the nurse why they refused to care for the patient.. If the reason was appropriate, the nurse was not reassigned to that patient. The most recent example of this was that the patient had struck the nurse's brother killing him. The death occurred less then a month ago.

If the request is due to lack of correct scientific knowledge, the correct information is provided the first night. The second night the nurse is assigned the patient with another nurse to be a support/mentor for the situation. The third night the nurse is assigned the patient independently and the previous night's mentor is available for a crises.

Changing a belief or fear does not happen just because you order someone to do something. First correct behavior needs to modeled. Then support must be available for the nurse who is trying to cope with the role stress of changing beliefs and values.

Good luck on your paper.

dlc · Oct 20, 1998

I am a Rn and work on a med/surg floor. This situation has came up a few times. In most instances it was with a new nurse who didn't feel comfortable in handling patients with a communicable illness. The best way to handle this is to first find out what the nurse's fears, feelings and anxieties are about taking care of this patient. The first night it might be best to re-assign this patient to another nurse. On some occasions though,this is not possible due to staffing. Using universal precautions is usually the best way to prevent from getting these illnesses. Goggles are also available. Gowns are available. These are all useful items that are available on the floors. Myself, I have never refused to care for a patient. I protect myself using all the available resources at my disposal. Good luck on your paper!

Carolyn M · Oct 21, 1998

Thanks again for your replies. So, it seems the first thing that you would do when managing a situation like this would be to re-assign the nurse when possible. However if not possible, we should talk to this nurse and see what it is that is keeping them from caring for the patient? Education about the illness and universal precautions should be discussed, but can you think of other things? What about within the realm of microbiology and the modes of transmission, etc? How hard should one try to encourage a nurse to change his or her mind, or should we just allow the refusal? Can you think of any other aspects that might be neat to include in this paper that pertains to the subject? Thanks so much for all your help!

Sharon · Oct 23, 1998

Carolyn,

In my experience knowledge of Universal Precautions in infection control is not the issue. Like all other problems in nursing the supervisor or co-worker must assess the problem to determine what is the problem. I believe that in most situations when a nurse refuses to care for a patient with an infectious disease it is because it is a new situation that they do not have previous experiences in to fall back on for coping.

For instance every new nurse has been taught and had the experience to control bleeding when they graduate. When confronted for the first time in practice with active bleeding there is some feeling of control because of prior student experiences. Many instructors do not have the time to spend with a single student with a patient assignment who is infectious. I have seen and heard instructors say that they do not have the time to supervise the a student caring for a patient with a highly communicable disease. Also in the U.S. there are few highly communicable patients in a hospital. Independently caring for a patient that is infectious is a new and novel experience for many nurses despite their years in practice.

Many of my own school memories of dealing with infectious diseases are of my instructors saying: " Universal precautions will handle most of the infectious diseases you will see in practice and the rest are so rare you will probably never see them in a U.S. hospital." In my first three years of practice I cared for patients who had contracted Rabies from inhalation, Pneumonic Plague, RSV (which we later learned travels on clothing and so it was transmitted to other hospitalized children), Miliary TB, two unidentified viral encephalitis out breaks in a high school that had a 20% case fatality rate and whose mode of transmission was never officially identified. I used to keep a list of items my instructors said I would probably never see during my first 5 years in practice once everything was checked off I trew the list away.

More recently we have had the emerging of Hanta Virus and secondary E. Coli spread that has resulted in deaths. It is hard to feel in control in a life and death situation even when you really know what you are fighting against, but not panicking when confronted with a threat you don't have sufficient knowledge or previous experience with is a skill that many never master.

At one point in my nursing career before I taught nursing, I worked in EMS. I learned more about nurturing and mentoring of new workers in one month then all of my experiences I had in nursing school or working as a nurse. The nurturing went something like this: If the responder had less then 2 years of experience when sent out on an unusual call or potentially emotionally devastating call a more experienced responder accompanied them. There was follow up after the call and depending on the younger responder's handling of the call they may not go on the next unusual or potentially devastating call. There were certain calls that a new responder never went on in the first six months: DOA's, infant resuscitation, injuries to other rescuers, front line rescue in a disaster. By limiting the exposure and nurturing the new responders there was less burnout and better development ofprofessional skills.

Patients with infectious diseases are such unusual cases in nursing because of how little exposure and information we receive about them. (My epidemiology course was an elective and it was not full.) I think when confronted with such a situation the benefit of the doubt should be given to the nurse who has refused care and she should be nurtured through the situation. All fears are real and should be handled appropriately by other nurses and not just dismissed as uninformed and uneducated. As EMS has learned the hard way, just telling someone to toughen up does not work and leads to a loss of valuable experience through burnout.

Also remember it may not be lack of knowledge. For six months after I received an oral polio booster there were patients who had overwhelming infections I felt better about not handling because I was infectious and did not want to be the source of a patient acquiring an additional infection. This stance was supported by the hospitals Epidemiologist.

Carolyn M · Oct 31, 1998

Does anyone know how the Care Theory can apply to this subject? According to the Code for Nurses, we are obligated to care for clients. Any other suggestions on how I can utilize this theory?

WillsRN · Jun 22, 1999

You can quote all the theories you want and they are just that, theories, peoples unproven ideas. If you are a health care

provider you are required by law to provide

reasonable care to any one in need regardless of your personal beliefs, religion, creed,or any other excuse for failing to do so.Anything short of that is negligence. If you can't do that you should find another field of work.

The only exception is if the patient releases

you from that responsibility by refusing

your help.

If you don't belief in helping with an abortion, don't work in that field. If you

are a Jehovah's Witness don't put yourself

in a position where you might have to give plasma to save someone's life.

You have NO right to try imposing your so

called ethical beliefs on someone trying

to obtain what they have a medical right to.

_____________________________________________

BTW: Its solely because of nurses and doctors

thinking they have a "right" to refuse care

to someone that we now have the paradox of

us not having the right sometimes to know a

patient full history particularly infectious

diseases like HIV. That only serves to increase the risk to real professionals who

don't shun their patients over imagined

rights.

You have a right as a health provider to

work in some other field if you don't feel comfortable taking care of sick people.

[This message has been edited by WillsRN (edited June 22, 1999).]

WillsRN · Jun 24, 1999

Sharon.. Sorry if I sound a bit harsh so

I apologize in advance to you and those like you. You sound like a thoughtful,skilled,

compassionate nurse who has had a very

laudable career and are now paying a very

high price for all your dedication. Its just

that I've worked with some very stupid

providers and they always seem to be searching for excuses on why they didn't do their job.

Christie H. · Jul 24, 1999

I am the manager of a busy 32 bed med-surg unit. HIV, MRSA, and other com. dieases come to our floor almost exclusively. I find that most new nurses refuse patients due to poor education of the particular disease process. An example is a nurse saying " I don't want to take MRSA home to my children". They fail to understand or remember the patient is terribly debilitated or immune-compromised and that is the main reason the Staff infection runs rampant. I have seen refusals reverse after educating staff.Find their fear and show them the fears of unneeded if proper precautions are taken. Students come out of school with "textbook" fears.

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Christie H.

VitoinTN · Oct 30, 1999

When you start 'picking' who you'll treat, it starts the ball rolling on 'Selective Health Care'. This has a tendancy of decreasing the quality of health care the less fortunate may receive.

All players in the health care arena have a responsibility to keep each other informed of potentially communicable diseases. This serves the dual purpose of protecting employees, and preventing the accidental spread to other patients.

We're all obligated to provide the best care possible. No one deserves any more or less care than anyone else.

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