The Murky Waters of Nursing Insubordination

J.Adderton, BSN, MSN

Insubordination can result in serious disciplinary action by employers and licensing boards. The unique characteristics of nursing may be a prelude to insubordinate actions and behaviors. This article will explore the definition, criteria and triggers for nurse insubordination.

What is Insubordination in Nursing?

Insubordination in the workplace occurs when an employee intentionally refuses to obey a direct, lawful and reasonable order or directive. Such refusal is often a reason for disciplinary action and possibly termination. Defining insubordination is often tricky, especially in the nursing profession. There are 3 factors that may be used to determine if a nurse is insubordinate:

The nurse must be given a direct, reasonable and ethical order relating to their job role.
The nurse must fully understand what is expected of them.
The nurse must refuse to obey the order and doesn’t perform the task.

An insubordinate nurse may verbally or physically disobey an order or simply ignore the request. Although these guidelines seem straight-forward, the unique characteristics of nursing are complex and often further muddy the waters surrounding the issue.

Insubordination or Misconduct?

People often confuse insubordination with insolence and employee misconduct. This is because insubordination often leads to conduct violations. Insolence is behavior that undermines a manager’s authority by swearing, making fun of and mocking them. Misconduct is fairly straightforward and is more serious than insubordination or insolence. It is characterized by an offensive and/or unacceptable action that is purposeful and not by mistake or carelessness. Misconduct typically requires swift disciplinary action and may also have legal or criminal consequences.

Dissatisfaction, The Prelude to Insubordination

The nursing profession is riddled with stress and dissatisfaction. We have all heard these declarations from nursing leadership, “We must do more with less”, “We must improve our outcomes” and “We need to be good stewards of the company’s money and work with what we have.'' Unfortunately, “working more with less” often takes us away from why we entered nursing and what we find most rewarding about the profession. Workplace dissatisfaction often leads to counterproductive and emotionally driven behavior that sets the stage for insubordination.

The Zone of Acceptance

Nurses are often triggered when given a task perceived to be outside of traditional nursing work. Surely you have heard, or even stated, these words of protest, “that is not within my job description!”. Managerial theorists, Simon and Barnard, describe employees using a “zone of acceptance” when processing orders and directives. This means employees have in their minds what activities the supervisor has a right to ask them to do. If ordered a task that falls outside of this zone, there is a higher chance the order be disobeyed. With the nature of patient care, it is common for orders to fall outside of what the nurse considers ethical.

The Unique Dilemma of Nursing

Patient care is at the center of nursing care, therefore, there are times when insubordination is a result of a legitimate ethical concern. The American Nurses Association (ANA) released a position statement regarding nurse rights and responsibilities. The statement includes a few key points contributing to a potential grounded reason for a nurse’s order refusal.

The ANA published “Patient Safety: Rights of Registered Nurses When Considering a Patient Assignment” states “nurses have the professional right to accept, reject or object in writing to any patient assignment that puts patients or themselves at serious and immediate risk for harm”

The ANA Code of Ethics for Nurses with Interpretive Statements (2001) and Nursing: Scope and Standards of Practice (2009) outlines a nurse’s obligation to raise concerns regarding any patient assignment that puts patients, or themselves, at risk for serious harm. Also outlined is the professional obligation of nurses to promote, advocate for and protect the rights, health, and safety of the patient. The issue of insubordination becomes complex when a nurse’s rights and responsibilities conflict with orders or directives.

The Fine Line Between Obligation, Ethics and Insubordination

In my many years of nursing, I have rarely witnessed a nursing refusing an order or assignment. When I did, the refusal usually centered around a legitimate patient or nurse safety concern. The following are common reasons nurses refuse patient assignments:

Lack of training and preparation to meet the patient’s needs
High patient load
Not receiving report on a patient
Patient acuity too high

It is possible a nurse refuses an “unethical” assignment but the real underlying issue is their own discomfort with the environment or patient care.

Consequences

When a nurse refuses an order, the consequences can be severe. The employer may discipline or even terminate the nurse. Depending on the circumstances, the nurse could be reported to the state’s governing board of nursing for patient abandonment or other discipline.

Part 2: Conscientious Objection

Part 2 of this article will explore the role of conscientious objection in protecting nurses from assignments that are against personal moral or religious beliefs.