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Oversight from nonclinical staff?

Nurses   (553 Views | 10 Replies)

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I have a question.  I practice in CA and have a new CEO (business degree) I am wondering how much clinical decision making this CEO should or shouldn't have with regard to nursing actions.  Is there a legal requirement for clinical oversight to be from nursing?  I am having issues with a HR person wanting me to have the CEO make decisions on if/when nursing practice was acceptable.  thank you in advance for any help.

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Sour Lemon has 9 years experience.

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This is an impossible question to answer without details, although it may be unwise to provide them here and now. 

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Daisy4RN has 20 years experience and specializes in Travel, Home Health, Med-Surg.

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Agree, depends on what you mean by "clinical practice". Would I ever let anyone, even my CEO, make me do something unsafe/unprofessional? That is most definitely a NO! Do they make changes that we dont like bc they are creating an unsafe environment, yes, but there is not much we can do about it (unfortunately!).

Edited by Daisy4RN
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Hani is a BSN, RN, EMT-I and specializes in NICU, L&D, Public Health.

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Inversely I wouldn't let a CEO make me do anything nursing-wise even if it were "safe".

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akulahawkRN has 5 years experience as a ADN, RN, EMT-P and specializes in Emergency Department.

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If the CEO is trying to get you to do or not do something that is within your nursing practice to determine, then the CEO is basically trying to do Nursing without a license. The CEO is there to handle non-clinical business aspects of running a business. 

Here's an example: My CEO isn't an RN or MD and therefore isn't in my Medical or Nursing chain of command. If my CEO came into my patient's room and told me to take the patient off BiPAP with Heliox because it's too expensive, I might have to tell my CEO to look into billing practices. This is an extreme example and my CEO wouldn't do this because my CEO very much understands limitations. If my CNO did that, I'd happily give report and have my CNO do it and take the responsibility for what happens. My CNO also knows better, very experienced, but knows better. 

Now if my CEO wants to remove all the chairs in the area because us Nurses look more professional when we're standing (and clearly aren't therefore sitting around playing cards), that's well within their decision to make. That CEO would also have to deal with any other legal issues with removing all the chairs from an area, but again, that's their responsibility. 

So, a non-clinical manager can oversee non-clinical aspects of your job but their authority ends there. You could lose your job because your manager doesn't like what you're doing clinically and you push back against that, but disciplining you can put said manager on shaky legal HR grounds.

This is why hospitals that have non-clinical CEOs will have a CNO and CMO in the "C-suite." 

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73 Posts; 1,686 Profile Views

ok, I am asking because we have a disciplinary process at my place of employment as the director of nursing I report to the Chief Nurse Executive.  We (CNE and myself) have made some clinical judgment calls regarding discipline, training, or need for improvement in emergency response which an HR representative is now stating (and it is also in policy) that we need to bring poor performance to the CEO who will then determine the level of disciplinary action (or lack thereof).  The issue is these are clinical encounters and the nuances of patient care don't always translate well...Also...the CEO hates nursing and did a huge project on reducing nursing overtime, so any chance she gets she throws nursing under the bus and my nurses with it.  I am asking for legal precedent so I can go into the meeting armed with actual facts and deter this line of future second guessing of every move I make.  She is new and will likely be here just a short time but in the meanwhile my nurses are getting hammered by someone who has no ability to make clinical judgment but in our policy it states it is her right to do so.  We have a CNE and CME but the opinion of the CNE is not being considered and is being consistently overridden.

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beachynurse has 35 years experience as a ASN, BSN and specializes in School Nursing.

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I totally understand where you are coming from. I am supervised by a non-medical administrator which has made things rather "difficult" for the last 3 years. She has undermined my nursing judgement, insisted that I accept medication orders that are incomplete, or unsigned, because the parents "are upset". I am labled difficult because I refuse to go against what I know is unacceptable nursing practice. She is practicing nursing withut a license to do so, and I have told her so. Sadly, our nursing coordinator is powerless because she has let the non-medical admins take her power from her. Just document, document, document. Keep all your recordsand don't be afraid to throw them under the bus. 

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hppygr8ful has 15 years experience and specializes in Psych, Addictions, Elder Care, L&D.

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It usually is the province of HR to be included in all disciplinary matters as they are responsible to make sure such discipline id done in a manner that meets the requirements of local labor laws. The process everywhere that I worked was a nurse manager would contact HR and let them know the offense/error etc...HR and the NM would then collaborate on the appropriate measures to be taken. And no HR people are generally not clinitions.

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On 1/8/2020 at 4:43 PM, nursesunny said:

I am asking because we have a disciplinary process at my place of employment as the director of nursing I report to the Chief Nurse Executive.  We (CNE and myself) have made some clinical judgment calls regarding discipline, training, or need for improvement in emergency response which an HR representative is now stating (and it is also in policy) that we need to bring poor performance to the CEO who will then determine the level of disciplinary action (or lack thereof).  The issue is these are clinical encounters and the nuances of patient care don't always translate well

So, if I understand, the issue (for an example) is that you and the CNE have come to a conclusion that some action X (performed by nursing staff) was not the best action or needs revision or etc. You have decided what that next step should be.

But HR is telling you that you must present the scenario(s) to the CEO, and the CEO will determine what the next step should be. And your belief is that the CEOs recommendations and/or demands regarding how the follow-up must be handled will be inappropriate (for example demanding the termination of some employees for some failure or some incorrect action, while you and the CNE believe the most appropriate course of action will be education).

Do you have a process for something like RCAs? Do you perform them regularly when appropriate? It seems like this should help you; you will have a record of the committee having already examined the causative and contributing factors in a scenario. RCAs should help with your concern that the nuances of patient care don't always translate well (to a CEO), since the RCA will uncover and  make note of factors beyond just individual error (if those exist).

Beyond that you would need to look for resources, specifically nursing/medical literature and studies that examine the relevant issues and trends and their rationales (discipline vs. education vs. other intervention for x, y, z types of performance issues in the healthcare world). Do you have access to a librarian who can help with this?

Another thing you need to think about is that point where the line is crossed between clinical supervision and administrative supervision. IANA lawyer or business person, but at some point an administrative supervisor (like a CEO) has a rightful place in overriding your disciplinary judgment calls even they are in regard to a matter of clinical practice. To make this point clear, say that one of your nurses decided to initiate chemotherapy for a patient because s/he believed it would help and s/he felt the treatment team was taking too long to come up with a plan. Now you and your CNE could theoretically decide that the best course of action for this nurse is to take a course in ethics (or some other related education). But at some point a non-clinical administrator is allowed to say "the action in question is beyond the pale, it will not be tolerated in this organization and this employee is to be terminated immediately and reported to the BON. I am overriding you and the highest level of discipline will be rendered in this situation." At some point you can't argue "Well, you're not a nurse so you have no business telling us what to do with this employee."

For that type of reason ^ I am not sure that it is always correct to say that a non-clinical person may never have any part in these matters.

Edited by JKL33

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llg has 43 years experience as a PhD, RN and specializes in Nursing Professional Development.

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I agree with JKL33.   While you nurses are the ones to decide whether the staff's actions were clinically appropriate or not ... it is the administration's role to determine the level of legal risk the institution is willing to tolerate.   For example, they have a right to fire someone who brings more than an acceptable level of risk to the institution even if the you and the CNE would rather give the "guilty" person another chance.

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akulahawkRN has 5 years experience as a ADN, RN, EMT-P and specializes in Emergency Department.

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14 hours ago, llg said:

I agree with JKL33.   While you nurses are the ones to decide whether the staff's actions were clinically appropriate or not ... it is the administration's role to determine the level of legal risk the institution is willing to tolerate.   For example, they have a right to fire someone who brings more than an acceptable level of risk to the institution even if the you and the CNE would rather give the "guilty" person another chance.

If a nurse is fired from an organization for commission of an act that may or may not have been clinically appropriate but the administration deems that the nurse is too great of a legal risk, then the termination is going to be OK as long as the administration can show that the legal risk to the organization is the reason for the termination and not the "act" per se. However, in those instances, there will be much discussion by HR and others in the matter before definitively deciding on a termination as a wrongful termination becomes a costly endeavor. Terminations can end up taking a while because the administration wants (and needs) to have all the proper things documented properly before going forward with a termination. They're avoiding risk. 

From the "nursing" end of things, that would include the nursing management doing their documentation that would show that an RN employee is engaging in actions that is outside the established norms of acceptable practice and therefore is a risk to the patient and/or hospital along with (perhaps) an assessment of whether or not the RN can be adequately "rehabilitated/re-educated" into following the established norms and a less risky pattern of behavior. 

Most organizations are "risk-adverse" so they generally will choose the least risky path when dealing with an employee. That's one reason why sometimes a person who should be let-go is retained, their position modified, or whatever until such time as it becomes clear (and clearly documented) that termination is appropriate (and less risky). 

All that being said, it still doesn't give non-clinical management the legal authority to provide clinical oversight. 

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