Call out unsafe practices
EDITOR'S NOTE: Nancy J. Brent, MS, JD, RN,'s legal information columnist, received her Juris Doctor from Loyola University Chicago School of Law and concentrates her solo law practice in health law and legal representation, consultation and education for healthcare professionals, school of nursing faculty and healthcare delivery facilities. Brent has conducted many seminars on legal issues in nursing and healthcare delivery across the country and has published extensively in the area of law and nursing practice. She brings more than 30 years of experience to her role of legal information columnist.
A reader asked about an ethical dilemma in nursing that may be an all-too-familiar experience in your everyday practice. A new nurse who is the only RN in a small community ED (two other inpatient RNs are available for assistance) has observed troubling conduct on the part of an ED physician.
The physician orders inappropriate dosages of medications, contradicts himself in his documentation of patient care and gives narcotic pain medications to almost every patient for any complaint.
The new RN has voiced her concerns with management but there has been no change in the physician’s conduct. The RN is concerned about her patients, especially since she is new in this area of practice and is not seasoned enough to know what might be acceptable practices and what are not. She also is concerned about her own potential liability if she makes a mistake because she is unfamiliar with ED nursing.
There is no question the ED nurse needs to be concerned about her practice setting as it now exists. First and foremost, her duty is to protect patients’ safety and well-being. Several aspects of her practice setting are not conducive to fulfilling that legal and ethical duty.
Being the only RN in an ED — however small — is not acceptable staffing. The two RNs who assist in the ED may not be able to leave their inpatient positions because of the critical nature of the patients they are caring for. As a result, any injury to or death of a patient will most certainly result in the ED nurse being named in a suit alleging professional negligence for care not provided, or if provided, in a negligent manner.
The RN’s obligations under the state nurse practice act and rules also must be considered. With the RN’s factual knowledge of the physician’s conduct and the staffing issue, the state nurse practice act may require additional action on her part to protect both the patients’ safety and her own license, even though she has voiced her concerns to management. It appears administration is not interested in these occurrences nor has it initiated an investigation into them.
Despite being a new nurse in ED practice, the RN has fittingly experienced internal moral distress with her work circumstances. And internal moral distress occurs when a nurse feels faced with interpersonal value conflicts. It is manifested as feelings of frustration, anxiety, anger and an inability to act as one sees fit because of many factors, one being the constraints of the organization.
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Despite being a new nurse in ED practice, the RN has fittingly experienced internal moral distress with her work circumstances.”
— Nancy Brent, RN
The nurse seems to be the only one observing this behavior and administrators are seemingly ignoring her worries, which raises an affirmation problem. With whom can she share her concerns and gain feedback? Who can help her decide what she can do about the physician’s conduct? Her isolation results in self-doubt about her observations and feelings.
Although this nurse decided to demonstrate moral courage and speak up about the physician and his consistent practices in the ED, a resolution seems far from being established. If not resolved, further internal conflict for this RN may grow, resulting in frustration with her work, anger, missing critical patient signs and symptoms that need intervention, or simply leaving the job.
Although not easy, it is a nurse’s obligation to advocate for patients when unethical, illegal or unsafe practices occur.
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How to address the unethical conduct of healthcare colleagues
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