Jump to content

The Murky Waters of Nursing Insubordination

Professionalism Article   (918 Views 6 Replies 932 Words)
by J.Adderton J.Adderton, MSN (Member) Writer Verified

J.Adderton has 20 years experience as a MSN .

7 Followers; 51 Articles; 26,965 Visitors; 258 Posts

advertisement

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.

The Murky Waters of Nursing Insubordination

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:

  1. The nurse must be given a direct, reasonable and ethical order relating to their job role.
  2. The nurse must fully understand what is expected of them.
  3. 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.  

What are your thoughts on insubordination in nursing?  Do you have a management perspective to share?

Resources:

Disciplinary Issues: What Constitutes Insubordination (Article)

ANA Code of Ethics for Nurses

ANA Scope of Practice

Managing the Insubordinate Nurse (Article)

I am a nurse with over 20 years experience in a variety of settings and roles. I enjoy writing about issues and topics I experience in my own nursing practice. I am a nurse in recovery and share my story to help another nurse experiencing the fear, shame, guilt and hopelessness of substance abuse. This month, I am celebrating 3 years of sobriety. Visit my blog to read about my journey.

7 Followers; 51 Articles; 26,965 Visitors; 258 Posts

Share this post


Link to post
Share on other sites

morelostthanfound has 27 years experience as a BSN and specializes in CVOR, General/Trauma Surgery.

1 Follower; 4,900 Visitors; 206 Posts

Nice article and thank you for the clarifications.  I think that what confounds the question even more are the many, inherent subjective interpretations that arise.  The old exemplar used to be, "what a reasonably prudent practitioner would do".  However, commonsense dictates that what is 'reasonable' or 'ethical' for one person may not be so for the next and these standards fail to capture a plethora of variables that come into play in one's decision to obey an order.

Edited by morelostthanfound

Share this post


Link to post
Share on other sites

FolksBtrippin is a BSN, RN and specializes in Psychiatry, Pediatrics, Public Health.

1 Follower; 13,376 Visitors; 1,503 Posts

Since when does the BON investigate insubordination?

Share this post


Link to post
Share on other sites

beachynurse has 33 years experience as a BSN.

987 Visitors; 97 Posts

Would you consider it insubordination to refuse to follow a directive to accept an MD order that was unsigned, or improperly filled out from a non-medical supervisor, after you had told a parent that the order could not be accepted and must be corrected in order to be accepted. The parent goes to the supervisor who comes to you and tells you that you ARE going to accept the order, and you refuse stating your rationale? Yes, I am a school nurse..

Share this post


Link to post
Share on other sites

1,374 Visitors; 154 Posts

On 6/11/2019 at 7:40 AM, beachynurse said:

Would you consider it insubordination to refuse to follow a directive to accept an MD order that was unsigned, or improperly filled out from a non-medical supervisor, after you had told a parent that the order could not be accepted and must be corrected in order to be accepted. The parent goes to the supervisor who comes to you and tells you that you ARE going to accept the order, and you refuse stating your rationale? Yes, I am a school nurse..

I wouldn't.  But go join the fb page School Nursing and ask there!

Share this post


Link to post
Share on other sites

9 Followers; 22,853 Visitors; 3,023 Posts

On 6/11/2019 at 7:40 AM, beachynurse said:

Would you consider it insubordination to refuse to follow a directive to accept an MD order that was unsigned, or improperly filled out from a non-medical supervisor, after you had told a parent that the order could not be accepted and must be corrected in order to be accepted. The parent goes to the supervisor who comes to you and tells you that you ARE going to accept the order, and you refuse stating your rationale?

 

No. Not according to the definition of insubordination presented in the article above, anyway. Demanding that a nurse accept (for the purposes of acting upon) an improper/incomplete order is not reasonable, and it would be unethical for the nurse to do so. I would assume it would be a violation of most NPAs as well and would not be considered prudent by the majority of peer nurses.

Share this post


Link to post
Share on other sites

J.Adderton has 20 years experience as a MSN.

7 Followers; 51 Articles; 26,965 Visitors; 258 Posts

On 6/10/2019 at 7:15 PM, FolksBtrippin said:

Since when does the BON investigate insubordination?

If the act of insubordination  resulted in patient consequences.  For example, refusing to call report on a patient you had been caring for.  Refusing a reasonable physician order to administer medication ect.  Acts of abandonment could potentially be reported.

Share this post


Link to post
Share on other sites
  • Recently Browsing 0 members

    No registered users viewing this page.

×