Is there a law protecting a nurse doing something they are uncomfortable with?

RNbrent · Jan 31, 2011

Nurse shouldn't have to perform something she doesn't feel comfortable / competent in. It's a matter of patient safety, and the nurse can be held responsible for incompetency. I'd take the issue up with your supervisor and if that doesn't work, go to the DON.

LegzRN · Jan 31, 2011

Nurses are good at what they do and paramedics are good at what they do. Working together they back each other up. Although it is a little shady that they just threw that into the policy overnight, I actually think it would be fun!

merlee · Jan 31, 2011

You may want to get clarification, and ask that if people who want to do this get some extra training. There doesn't seem to be anything out of the RN scope of practice.

Call your BON if you are unsure. Also, find out how they expect to cover for the person who gets pulled to ride, and important things like forced OT. Say it is a 2 hr drive, and you won't be back 'til after your shift ends.

Ah, the adrenaline rush - my heart beats faster just thinking of this!

Best wishes!!!

nurse2033, MSN, RN · Jan 31, 2011

I think the fear of a crash is very reasonable. You are being exposed to a risk that you did not choose. As for being uncomfortable, I would ask you to ask yourself why you are uncomfortable. You will not be doing things out of scope. You will just be without your usual support system. As an ER nurse you should be capable of running a patient by yourself. The paramedic can be trusted to do that as well. In my experience the nurse usually only deals with nursing stuff, i.e. that bag of heparin or whatever, and the paramedic handles the rest. I agree that a good written policy must exist and should include some criteria as to who will go. I don't think anyone who doesn't want to do it should be forced to. The hospital must take on the liability of anyone injured in a crash. Good luck.

JKL33 · Jan 31, 2011

Have done this. In my experiences it has been volunteer only, as far as I know no one has been forced/told they must go. The patient's ED nurse is given first option as they know the patient best; if they can't go or choose not to, someone else will volunteer. It is usually the more experienced nurses who go....if the patient's ED nurse has less experience and a seasoned RN has been helping them with the patient, the more experienced nurse will go. In my experiences, nurses want to go....it is usually a situation where their specific expertise and experience with the patient will (likely) be of significant benefit to the patient, i.e. managing medications that need to be titrated en route, or recognizing subtle changes in condition, or bringing PRN medications that EMS does not have on-board and does not have experience with using, etc. It is viewed as kind of a privilege to be asked to ride w/ patient....in my facility. But, nurses generally have a great deal of support at my facility.....not everyone is in that situation. I would say the manner in which your facility instituted this policy kind of calls their support of nurses into question!

One of the bigger issues with this type of policy is the idea of 'whose job is what'. For instance, if the patient is maintaining own airway at start of transport but then requires intubation during transport, everyone on board should understand who is going to be primarily responsible for accomplishing the intubation. If the paramedic has trouble intubating and the RN has never performed an actual intubation (let alone while bumping down the road in the rig), does the RN then get sucked into the liability of that situation? Yep, especially since RN is also ACLS certified and 'should' be able to intubate in an emergent situation. So.....these are the kinds of things that need to be explicitly laid out.

You should have easy access to communication w/ your ED physician (cell phone). If an emergency arises, speak to your physician on your ED's recorded line. What to do if the patient goes downhill during transport or an emergent situation arises should be explicitly part of the policy. Also, it needs to be specifically stated what 'types' of situations call for a nurse to ride. IMO it should be used conservatively, or in specific situations where there is a clear benefit to the patient.

I agree you should not have to do something that you feel you have not been adequately trained to do, or something that is outside of the scope of nursing practice. I agree you need to see evidence that your facility backs you in this role (implicitly they do, since they have a written policy on it....but still....).

Hopefully others who have done this will comment on their experiences so you can hear both good and bad. So far, I have had no catastrophes (or near-catastrophes). But there are two sides here that could be equally argued. Yes, it is a liability...so is being a nurse, in general. One of the biggest tests (for me) would be how your supervisors/administration respond(s) to the 'feedback' they are getting from staff at your facility. Will they make effort to give additional training if it is necessary? Will they adequately address concerns and get accurate answers to questions the nurses have? Will they consider making this a special 'check-off' certification that is not mandatory (i.e. would then be volunteers only)? Will they explicitly (in writing) cover the legal aspects of having their RNs work in this capacity? The answers to those questions will help you decide whether this can be a SAFE thing for you to do while employed at this facility.

Ayeloflo · Jan 31, 2011

As you know, in nursing, we are always pushing ourselves outside of our comfort zone for the sake of the patient's wellbeing. "Uncomfortable" might be unacceptable excuse for many managers. When you put it that way, it makes me think: luxery, queen bees, and other terminologies. I mean no disrepect. Please dont be offended.

Remember that nursing students are required to check of skills in the Clinical Skill Competency form at the end of each semester. The schools are covered if you checked all of it and signed it. You were required to learn those skills in your clinical time. So when you are licensed, your employer expects you to perform those duties. If it's within your scope of practise, your are expected to be capable of doing it. That is why many nurses still carry procedure books and still ask for help from fellow nurses. If the IV order was not carried out because the nurse is uncomfortable starting IVs, the nurse is written up. Foley order not carried out cos you haven't done it before? Delay of service. You get written up. Fair or unfair. It happens all the time.

If anything happens, in court or whatever, we are looking at your legal scope of pratice. Same applies to nurses who are IV certified, Ventilator certified, etc. Once there is evidence that you have been trained and certified, you are expected to get it done somehow.

The hospital is insured as a business entity. They consider that before making policies. When you comply with the policy, the consequence is the hospital's problem. They know they are covered by insurance. So, get it done and keep your job :)

Bumashes, MSN, APRN, NP · Jan 31, 2011

We do this in my ER. Generally it is more fun than anything. Getting out of work for a while and getting to hang out with the EMS team. We do it on a volunteer basis, but there is never a want for volunteers. If you're not comfortable, I would ask for either further training or a more descriptive policy on what to do in these situations. You pretty much do the same things that you would do anyway in the ER just in a moving vehicle. Takes a minute to get used to, but it's okay.

Editorial Team / Moderator · Jan 31, 2011

I've had to do this a few times from our ED (freestanding) to the hospital, usually because the patient is on a vent and the critical care medic was too far away to respond, or the patient is on certain drips. I love it! Probably because I was a medic first. :) If you use the same transport company on a regular basis, perhaps it would be helpful to ask if you could familiarize yourself with the set-up in their medic unit -- it might be helpful to know where some essential equipment is (airway, suction, etc.) so at least you'll know you've got the basics covered.

cmh05 · Jan 31, 2011

Our ER makes tranfers like this and it all depends on the situation as to who rides along to help manage the patient during the transfer. Sometimes respiratory therapy rides along for the transfer, sometimes it requires an RN or one of our on staff paramedics. I have not had the opportunity to do a transfer like this. Even when it has been my own patient, the charge RN will decide who will go with the patient. It's a matter of who can appropriately care for the patient and who she needs to keep in the ER. If the situation were to arise that I would need to accompany a patient and I did not feel comfortable that I could appropriately care for the patient, I would speak up. You shouldn't be made to do something that you are not comfortable with or don't feel adequately trained for. If something were to happen and you were to have to give a deposition, the hospital may not back you if you say "I didn't feel comfortable, but it's policy." You may ask if there can be any scenario type training, or if you could do some ride alongs with EMS to get a feel of what it's like in the ambulance.

TraumaSurfer · Jan 31, 2011

If the paramedic has trouble intubating and the RN has never performed an actual intubation (let alone while bumping down the road in the rig), does the RN then get sucked into the liability of that situation? Yep, especially since RN is also ACLS certified and 'should' be able to intubate in an emergent situation. So.....these are the kinds of things that need to be explicitly laid out.

First I want to say this statement is absolutely false. No ACLS class "certifies" you for intubation. In fact, intubation is not even emphasized in ACLS. I would hope that as a nurse you would know there is much more to intubation than what is in an ACLS class.

In some of my other posts I have mentioned this same topic several times.

EMTALA requires a "qualified" team to transport a patient to the next facility. Many times an ALS truck (Paramedics) do NOT quite meet the requirements for them to be "qualified" for these IFTs. It could be the medications, the equipment or the continuing care. It could also be that just one Paramedic is not enough for that particular patient. Also, do not let the title "Critical Care Paramedic" lead you to believe they are actually critical care trained or experienced to that level. It can be a cert obtained in as little as two weeks or just a title given out to justify a higher charge on a "CCT" truck as SCT by CMS.

But, some RNs are not aware of what they have gotten themselves into when they are required or volunteer to do these transports. It truly should not be considered just fun and games with a good adrenaline rush. In this situation it is good the hospital now has something in writing. There will be less arguing over who is responsible for insurance and liability when something does happen. There should be a discussion for what your protocols will be. The local hospital here have designated RNs for transport who work off protocols for titrating and initiating certain meds much like they would in the ED or ICU. They are cross trained in both the ICU and ED. They also have a phone for direct contact with the physician if there are any questions. Their orders may supercede what a Paramedic can do. Never assume about the other crew members but have a good idea what their protocols consist of. Assuming may lead someone coming up short and that'll probably be the patient.

Safety: Are you familiar with securing yourself and the equipment in the back of a truck? Most injuries and deaths will occur to those in the back at even a minor accident since you or the equipment will become flying objects with a great probability of colliding with something or someone. The lights and sirens present even more danger. With a patient on board and headed towards a hospital, they usually mean you have no clue what to do and just want to get somewhere fast. Ever hear the term "Diesel medicine"? Lights and sirens get your adrenaline rushing to where you may make incorrect decisions as will those driving in the path of the ambulance who try to quickly move out of the way of a speeding truck.

It will also be a decision which may need to be resolved by the state or county EMS authority as to who is the most liable on an ambulance. The Paramedic may be in charge of the truck but it may be determined the RN is the higher level of medical care especially if they were placed on the truck to make up for what a Paramedic can not do. That does put you in a precarious position for liability as the RN. Protocols may also conflict between EMS and the ED. Know what medications you must take which may not be on an ALS truck. Make sure there is a proper signout policy for narcotics. Remember that Paramedics may not be able to help you give or set up some of these medications. They could also risk their license in these situations.

Now that your hospital has this in writing that someone goes, get them to elaborate on the policy and offer whatever extra training needed. Since there is extended liability you might even be offered the extra premium bonuses some transport team members are afforded. But above all BE SAFE. Transporting a critical patient is not all fun and games.

usalsfyre · Feb 1, 2011

First I want to say this statement is absolutely false. No ACLS class "certifies" you for intubation. In fact, intubation is not even emphasized in ACLS. I would hope that as a nurse you would know there is much more to intubation than what is in an ACLS class.
In some of my other posts I have mentioned this same topic several times.
EMTALA requires a "qualified" team to transport a patient to the next facility. Many times an ALS truck (Paramedics) do NOT quite meet the requirements for them to be "qualified" for these IFTs. It could be the medications, the equipment or the continuing care. It could also be that just one Paramedic is not enough for that particular patient. Also, do not let the title "Critical Care Paramedic" lead you to believe they are actually critical care trained or experienced to that level. It can be a cert obtained in as little as two weeks or just a title given out to justify a higher charge on a "CCT" truck as SCT by CMS.
But, some RNs are not aware of what they have gotten themselves into when they are required or volunteer to do these transports. It truly should not be considered just fun and games with a good adrenaline rush. In this situation it is good the hospital now has something in writing. There will be less arguing over who is responsible for insurance and liability when something does happen. There should be a discussion for what your protocols will be. The local hospital here have designated RNs for transport who work off protocols for titrating and initiating certain meds much like they would in the ED or ICU. They are cross trained in both the ICU and ED. They also have a phone for direct contact with the physician if there are any questions. Their orders may supercede what a Paramedic can do. Never assume about the other crew members but have a good idea what their protocols consist of. Assuming may lead someone coming up short and that'll probably be the patient.
Safety: Are you familiar with securing yourself and the equipment in the back of a truck? Most injuries and deaths will occur to those in the back at even a minor accident since you or the equipment will become flying objects with a great probability of colliding with something or someone. The lights and sirens present even more danger. With a patient on board and headed towards a hospital, they usually mean you have no clue what to do and just want to get somewhere fast. Ever hear the term "Diesel medicine"? Lights and sirens get your adrenaline rushing to where you may make incorrect decisions as will those driving in the path of the ambulance who try to quickly move out of the way of a speeding truck.
It will also be a decision which may need to be resolved by the state or county EMS authority as to who is the most liable on an ambulance. The Paramedic may be in charge of the truck but it may be determined the RN is the higher level of medical care especially if they were placed on the truck to make up for what a Paramedic can not do. That does put you in a precarious position for liability as the RN. Protocols may also conflict between EMS and the ED. Know what medications you must take which may not be on an ALS truck. Make sure there is a proper signout policy for narcotics. Remember that Paramedics may not be able to help you give or set up some of these medications. They could also risk their license in these situations.
Now that your hospital has this in writing that someone goes, get them to elaborate on the policy and offer whatever extra training needed. Since there is extended liability you might even be offered the extra premium bonuses some transport team members are afforded. But above all BE SAFE. Transporting a critical patient is not all fun and games.

Glad to see your on this site bashing paramedics as well.