Ethics for nurses in everyday practice: Insubordination in the ICU? - page 2

Wow. Just, wow. This is crazy! Will this kind of thing ever get fixed? About 10:30 p.m. on November 12, John Doe* was admitted with irregular breathing and heart rate to the emergency department (ED) of a large teaching... Read More

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    Where I work refusal = insubordination. Period.
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    I read your post twice and I am sorry you're having to deal with the situation you described, it does sounds like you're able to hold your head high and know that you did the right thing.

    I appreciate your example, although I think that falsifying a medical record is a different comparison than what I was describing. If you are insinuating that I have provided poor nursing care because of allowing doctors to bully their way around an ICU...then I do take exception to that and consider it an unfair statement. While I don't know your entire situation (and I do have true sympathy for you), I have 4 kids, and everything that goes along with that. If I allowed my ethics to get me fired for refusing to accept another patient, then I would have failed my family, lose my house, etc...I'm not willing to risk it.

    If someone asked me to do something illegal, then it's a totally different story. But for unsafe staffing, it's been made clear that you will accept the assignment, fill out an unsafe staffing report and turn it in to the nurse manager. If they were asking us to each take on 4 ICU patients at the same time and start stacking them up in the hallway, that's different than accepting a non-ICU 1:1 patient into our unit during a busy time. We can accomodate and flex up to meet a demand like that without it compromising the other patients. The way we do that is through a dedicated sense of teamwork that our entire team shares.

    and I have refused a few things. Mostly when they try to pull us to the stepdown floors when we are absolutely slammed, pre-coding patients, etc. I've found that instead of refusing an assignment, I try to have a conversation with the supervisor (I am the charge nurse in my unit), identify what the needs are and the available resources to handle it. then we collaborate on finding the most appropriate solution. I know this sounds like a bunch of buzzwords, but it does work.
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    Okay, what I didn't see:

    That they tried to call anyone in (chronically short staffed -- everyone probably was to tired and burned out to want to come in, I know I've been there)

    That they tried to move a patient from ICU to a stepdown unit or telemetry floor

    That they tried to get a nurse from another floor to come to ICU and help

    That nobody called the NM of the ICU to tell her what was happening.

    This is 100% a management problem. A fish rots from the head down, and the fact that these docs came bullying into the ICU and the nurses were suspended for doing the right thing (nobody else apparently got in trouble), tells me I'd never want to work there. I'd bet the word is out that this is not the place to work, and they can't get help, or if they do, it's people who have no other option. Had I been one of the three nurses, I'd have taken the 3 days to try to find another job, because this has "lose your license" written all over it.
    NRSKarenRN, herring_RN, Ruthfarmer, and 1 other like this.
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    It was not my intention in any way to find fault with you, your situation, or your opinion. I sincerely apologize for any ill will my post may have created. It seems that the written word somewhat failed me.

    Part of the point I was trying to make is that an economy that is circling the bowl and high unemployment rates CAN influence people's decision making. It's not just the nurses working in the trenches. Corporate interests see the harsh economy as an opportunity to make cuts to insure and possibly increase profits. The rah rah rah of shared sacrifice and doing more with less can certainly bring out the best in people. It is noble and springs forth from the heart of a caregiver. But, when to taken to extremes, it can be used to intentionally cultivate a culture of profit- driven hit and miss substandard care.

    There are many signs and symptoms that can indicate this sort of thing. Chronic short staffing, staffing without regard to acuity, and the cultivation of values shifting such as instructing staff to falsify records can be among those signs and symptoms. There's often a big picture that when pieced together and considered with current trends is not reassuring.

    The bottom line is that each person must decide for himself or herself what's right and what's wrong. Each person must decide what he or she can abide and what he or she is willing to live with.

    Those who would continue in nursing would be wise to take out a copy of their state's nurse practice act and review it--especially if they often find themselves in a chaotic work environment. A nurse can't work as a nurse without a license.

    Please consider your statement about how you'd be failing your family if you were fired for refusing an unsafe assignment. Fair enough. Suppose a nurse accepts the unsafe assignment and despite the nurse's best efforts, there is a breach in the standard of care and a patient is harmed. The nurse has failed the patient. The nurse could very likely lose her license. The nurse without a license can not work and can not support her family and meet other responsibilities. If the environment is one of chronic short staffing, then it's quite possible it's just a matter of whether the nurse loses the current job NOW, or if the nurse eventually loses his/her license later and has NO prospects of getting a nursing job anywhere.
    Last edit by Ruthfarmer on Jun 23, '11
    LockportRN, rockwell108, getoverit, and 1 other like this.
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    Thanks and no worries.
    I couldn't agree with you more about the culture and forces that influence it. You have a very good way of describing it.
    I see your point about losing a license and having an even worse situation to deal with. It really is a rock and a hard place. Fortunately its not a constant thing for me and I sympathize with anyone who can't say that, because when I count my blessings I know that I don't have much to really complain about.

    Thanks again.
    sjt9721, herring_RN, and rockwell108 like this.
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    I refuse assignments I do not consider Standards of Care/Practice. It is MY LICENSE. And whenever I mention, "license", "unsafe environment," "lawsuit".

    I am not pushed. I won't do it, and I have never, in my twenty years, have ANYONE intimidate me into doing otherwise.

    It's doable. However, you must learn to grow "cojones" to do it.
    eriksoln and rockwell108 like this.
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    Thank God we have mandatory ratios in CA. Amazingly insane to me, this story. Jesus.
    rockwell108 likes this.
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    "Later in the day, all three RNs on duty in the ICU were suspended without pay for three days for insubordination."

    *** Uh, I don't get it. The artical didn't describe any instances of insubornination. Rns are not subordinates of physicians so how could they be insubordinate?
    leslie :-D likes this.
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    Quote from JoPACURN
    I refuse assignments I do not consider Standards of Care/Practice. It is MY LICENSE. And whenever I mention, "license", "unsafe environment," "lawsuit".

    I am not pushed. I won't do it, and I have never, in my twenty years, have ANYONE intimidate me into doing otherwise.

    It's doable. However, you must learn to grow "cojones" to do it.
    while i admire your fortitude, how can a single parent profess to do the same, when dependents, bills, housing is all dependent on one's single income?
    seriously, how?
    (and please don't respond like that idiotic nsg supervisor who responded with, "do the best you can". oy. )
    i too, have lost a job for refusing to obey inappropriate orders...but i also was aware that there was another income in my house, affording me to make the right choice.
    sometimes we are forced to make the best choice.
    i honestly don't know what i'd do if i was doing it alone, with no support systems in place.
    ultimately, some of us are forced to choose the lesser of 2 evils...dive in and pray.

    ohioSICUrn likes this.

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