Ethics for nurses in everyday practice: Insubordination in the ICU?

  1. 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 hospital. Various diagnostic tests were done. At about 2:00 a.m. on November 13, Mr. Doe went into respiratory arrest and was intubated and ventilated manually. Dr. Jones* decided to admit Mr. Doe to the ICU stat, and called the ICU to advise the nursing staff of the admission. The nurse who took the call said, “Dr. Jones, we are very busy. We need more help if we are to admit another patient. Do you want to call the night supervisor, or should I?” Dr. Jones indicated that he wanted the ICU nurse to call the supervisor and let him know what she said. Meanwhile, Dr. Jones called Dr. Smith*, the intensivist on call, to apprise him of the patient’s condition and his need to admit him to the ICU as soon as possible. The ICU had been chronically understaffed for months.

    click to read entire article: http://www.americannursetoday.com/Ar...=7922&fid=7870
    leslie :-D and herring_RN like this.
  2. 19 Comments so far...

  3. 10
    Insufficient staffing results in expecting too few nurses to care for too many patients. The result is at best: less than optimal care. . . at worst: unsafe conditions for both patients and nurses alike.

    Nurses must refuse to accept unsafe assignments. It is necessary to insure patient and nurse safety.
    Last edit by Ruthfarmer on Jun 22, '11 : Reason: typo
  4. 11
    Essentially the same scenario happened in our ICU tonight, obviously not resolved yet.

    It was interesting to read the different viewpoints of responsibility. What I see most often is the nursing administration gets involved and operates under the premise that "whoever is yelling loudest must be right". We think it's wise to learn as much as you can about the details involving a situation before you start hitting your knee with a hammer.

    The above poster mentioned that nurses must refuse to accept unsafe assignments. Our chief pulmonologist made the exact same suggestion. It sounds good in theory, but what about when nursing managment makes it clear they will fire you if you ever refuse to accept any assignment, regardless of the circumstances? that's the way it is here, and I don't work in a draconian system or anything like that...but I do see where nursing administration talks about patient safety and supporting nurses but in practice they do very little besides making posterboards.
  5. 8
    The one comment states "Personality clashes and power plays are the problem." As I stated in my respone on the site of the article, that is a bit off. They are the symptoms. The problem/issue is staffing.

    Just one nurse, in the ED or ICU would have solved this problem. With one more ICU or ED nurse, the patient is cared for and this article never gets printed.

    I know exactly what happened too. The pt. census at 11Pm was "X" in the ICU, probably one patient less than what was necessary to keep their nurses. A nurse gets sent home or floated to another unit, then they get 3 admits (not counting the one the article is about) within two hours of shift change.......the point in which the staffing is determined for the unit. The nurses were spread thin, already working above ratio and couldn't absorb another admit.

    This is not the fault of the nurses though. As the article states, it was their duty to be assertive and insist on being helped so proper care could be maintained. No wrong doing on their part at all. No wrong doing on the part of the ER nurses who wanted said pt. outta there either...........no good leaving "John Doe" in the ER till the AM if they are facing conditions even worse than the ICU.

    The wrong doing lies with administration here. Of course, they threw the nurses under the bus...........they don't know any other way of handling system faults. Having rigid staffing charts that sends needed help home simply because a unit is 1 or 2 patients short of the magic number needed to keep a nurse is short sighted (and many other adjectives I'm not allowed to use).

    This stone age system of staffing is only accepted because, from a business standpoint, it works..........most of the time.........often enough to have the hospital's butt covered via very expensive insurance. It breaks down and creates problems frequently though. Acuity is not taken into account at all, there is no consideration of pt. intake that will occur during the shift and the staffing is poor even without any complications arrising.
  6. 9
    Quote from getoverit
    Essentially the same scenario happened in our ICU tonight, obviously not resolved yet.

    It was interesting to read the different viewpoints of responsibility. What I see most often is the nursing administration gets involved and operates under the premise that "whoever is yelling loudest must be right". We think it's wise to learn as much as you can about the details involving a situation before you start hitting your knee with a hammer.

    The above poster mentioned that nurses must refuse to accept unsafe assignments. Our chief pulmonologist made the exact same suggestion. It sounds good in theory, but what about when nursing managment makes it clear they will fire you if you ever refuse to accept any assignment, regardless of the circumstances? that's the way it is here, and I don't work in a draconian system or anything like that...but I do see where nursing administration talks about patient safety and supporting nurses but in practice they do very little besides making posterboards.
    I've refused patient assignments before, when I was a travel nurse. Didn't get fired, even got renewed. That, of course, was long before the recession hit. Not so sure what would happen today.

    Fact is, our BON (w/e state you are in) can set w/e parameters it wants about when it's ok to refuse and when it is not, but its the business facilities who decide what the law is. If the institution wants to put its foot down, not much the BON can do about it, regardless of whether they agree or disagree with the institutions stance.

    Its one of those things, it'll keep happening (nurses getting fired for exercising their right to refuse) until some institution loses big in a lawsuit for it. Then, for awhile, they will be more mindful of it until the smoke has cleared, and they'll go back to their old ways then.
  7. 2
    Quote from eriksoln
    I've refused patient assignments before, when I was a travel nurse. Didn't get fired, even got renewed. That, of course, was long before the recession hit. Not so sure what would happen today.

    Its one of those things, it'll keep happening (nurses getting fired for exercising their right to refuse) until some institution loses big in a lawsuit for it. Then, for awhile, they will be more mindful of it until the smoke has cleared, and they'll go back to their old ways then.
    Yeah, in the distant past I've refused too. And you're exactly right speculating about the lawsuit, then returning to their old ways. It would take a lot to go up against them. We can fill out report of contact for unsafe practice/conditions, but we are still required to accept whatever assignment we're given or face being fired.
    imintrouble and herring_RN like this.
  8. 15
    Quote from getoverit
    Essentially the same scenario happened in our ICU tonight, obviously not resolved yet.
    The above poster mentioned that nurses must refuse to accept unsafe assignments. Our chief pulmonologist made the exact same suggestion. It sounds good in theory, but what about when nursing managment makes it clear they will fire you if you ever refuse to accept any assignment, regardless of the circumstances? that's the way it is here, and I don't work in a draconian system or anything like that...but I do see where nursing administration talks about patient safety and supporting nurses but in practice they do very little besides making posterboards.

    It is said that people demonstrate the ethics and moral values they think they can afford. This results in situational ethics. By situational ethics, I refer to a person participating in something they know to be wrong or unacceptable in one case where they would not participate in the same wrong or unacceptable thing in another case. For example, a nurse believes the patient to staff ratio is unsafe, but accepts the unsafe assignment because of fear of firing.

    There's enough that can go wrong without the consequences of situational ethics coming into play. Those who practice these situational ethics will find themselves stuck holding the bag when being so short staffed contributes to a horrible outcome. I have seen this time and time again. Before becoming a nurse, I worked as a medical malpractice investigator (defense work) for the state of Louisiana. I have seen nurses in deposition and in court confronted with the state nurse practice act that holds them responsible for accepting or refusing unsafe assignments. Those nurses certainly wish they had refused the unsafe assignment.

    Fear of firing should NOT figure into a person's decision making process. If that's the case then practicing situational ethics will result in all sorts of bad nursing care. If employers don't want to provide adequate materials or supplies or want nurses to cut corners, the nurse who fears being fired will do it. That nurse is trying to keep a job--NOT keeping the patient's safety and well-being a priority.

    When nurses or other employees allows themselves to be manipulated to do one small wrong thing, they make it harder on themselves to refuse to do bigger wrong things. Wrong things add up to catastrophes for patients. A nurse's fear of losing a job can cost patients their lives, limbs, livelihoods, or quality of life.

    At my first nursing job, I kept a copy of the state nurse practice act in my clipboard. The charge nurse was flabbergasted when I pulled out the nurse practice act and presented it to her when I refused an unsafe assignment. The other nurses were stunned to the point that they didn't speak up and volunteer to take on an unsafe assignment. All the nurses behaved as if they had never heard of the state law. The charge nurse called the nurse manager and they got busy and found staff to come help. I don't know if the nurses were called in or if they floated from another unit. That did not matter to me. My patients were safely provided care.

    An employer can fire an employee at any time over anything. For those with strong beliefs about what's right and what's wrong, it's better to be fired and unemployed and able to sleep at night knowing you did the right thing. I know it for a fact. I am living it. I was instructed by my employer to falsify a medical record, and I refused. I was fired. That was five months ago and I'm still unemployed because the economy is circling the bowl. Lest anyone think I'm living "high on the hog" on unemployment, I'm certainly not. I was denied the $247 per week unemployment benefits and I am appealing it.

    I have bills and responsibilities just like everyone else. I do not regret refusing to falsify records and I will not regret it. That wasn't my first rodeo. Long before I became a nurse, I worked in other fields. In those situations I faced the fall out and the consequences for doing the right thing. I paid the cost both financially and professionally, and it was worth it to me. Eventually my efforts resulted in changes that were a great benefit to many people. I have always slept well.

    I don't believe you can go wrong when you try to do the right thing and keep patient safety and well-being your priority. It may make you unpopular and it may cost you your job, but losing a job is not the end of the world. Losing a patient because you compromised care because of fear of losing a job could certainly result in the loss of your license and the end of your practice in the nursing world. Who wants to contend with that sort of regret?
    Twiggi, leslie :-D, gonzo1, and 12 others like this.
  9. 5
    Quote from Ruthfarmer
    It is said that people demonstrate the ethics and moral values they think they can afford. This results in situational ethics. By situational ethics, I refer to a person participating in something they know to be wrong or unacceptable in one case where they would not participate in the same wrong or unacceptable thing in another case. For example, a nurse believes the patient to staff ratio is unsafe, but accepts the unsafe assignment because of fear of firing.

    There's enough that can go wrong without the consequences of situational ethics coming into play. Those who practice these situational ethics will find themselves stuck holding the bag when being so short staffed contributes to a horrible outcome. I have seen this time and time again. Before becoming a nurse, I worked as a medical malpractice investigator (defense work) for the state of Louisiana. I have seen nurses in deposition and in court confronted with the state nurse practice act that holds them responsible for accepting or refusing unsafe assignments. Those nurses certainly wish they had refused the unsafe assignment.

    Fear of firing should NOT figure into a person's decision making process. If that's the case then practicing situational ethics will result in all sorts of bad nursing care. If employers don't want to provide adequate materials or supplies or want nurses to cut corners, the nurse who fears being fired will do it. That nurse is trying to keep a job--NOT keeping the patient's safety and well-being a priority.

    When nurses or other employees allows themselves to be manipulated to do one small wrong thing, they make it harder on themselves to refuse to do bigger wrong things. Wrong things add up to catastrophes for patients. A nurse's fear of losing a job can cost patients their lives, limbs, livelihoods, or quality of life.

    At my first nursing job, I kept a copy of the state nurse practice act in my clipboard. The charge nurse was flabbergasted when I pulled out the nurse practice act and presented it to her when I refused an unsafe assignment. The other nurses were stunned to the point that they didn't speak up and volunteer to take on an unsafe assignment. All the nurses behaved as if they had never heard of the state law. The charge nurse called the nurse manager and they got busy and found staff to come help. I don't know if the nurses were called in or if they floated from another unit. That did not matter to me. My patients were safely provided care.

    An employer can fire an employee at any time over anything. For those with strong beliefs about what's right and what's wrong, it's better to be fired and unemployed and able to sleep at night knowing you did the right thing. I know it for a fact. I am living it. I was instructed by my employer to falsify a medical record, and I refused. I was fired. That was five months ago and I'm still unemployed because the economy is circling the bowl. Lest anyone think I'm living "high on the hog" on unemployment, I'm certainly not. I was denied the $247 per week unemployment benefits and I am appealing it.

    I have bills and responsibilities just like everyone else. I do not regret refusing to falsify records and I will not regret it. That wasn't my first rodeo. Long before I became a nurse, I worked in other fields. In those situations I faced the fall out and the consequences for doing the right thing. I paid the cost both financially and professionally, and it was worth it to me. Eventually my efforts resulted in changes that were a great benefit to many people. I have always slept well.

    I don't believe you can go wrong when you try to do the right thing and keep patient safety and well-being your priority. It may make you unpopular and it may cost you your job, but losing a job is not the end of the world. Losing a patient because you compromised care because of fear of losing a job could certainly result in the loss of your license and the end of your practice in the nursing world. Who wants to contend with that sort of regret?
    Ruthfarmer,
    I needed to read your post today. I can't do it either but I have changed jobs to the point where I probably look like a bad risk to hire. When I was a new nurse I stayed at my first job a year then moved to another state and stayed at that one a year then I got into LTC and cant get back into acute care. No hospital here will hire me and its been a revolving door.
    If I could just not do the right thing and turn my eyes I could stay at some of these ***** jobs but they are awful and the things that management expects us to do is wrong for patients first of all and us too.. Thank you for posting this . I don't feel alone my daughter cant understand why I change jobs so much she thinks I am unreliable and a quitter well I raised three kids being a military wife and I have never had any patients complain about me over the years but last few years of my nursing career have been a nightmare. I dont want to quit being a nurse but all the ethical things that are swept under the rug are great in number and nothing is done about it and if you say anything you are fired .
  10. 2
    I so sorry that you had to deal with this kind of unprofessional behavior .I was always told to do the right thing always. In nursing , I am amazed of how many nurses do not follow nurse practice Act. Nursing would be a hold better if nurses fought for better working conditions. pt safety is number one for nurse and patient..I know people need to pay your bills. but doing the right thing is the most important ....to many nurses in management and shortstaffing regarding bedside nursing results in increase medications errors and unsafe practices...Good luck toyou.keep the faith:heartbeat
  11. 2
    Quote from getoverit
    .but I do see where nursing administration talks about patient safety and supporting nurses but in practice they do very little besides making posterboards.
    herring_RN and rockwell108 like this.


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