10 Ethics for nurses in everyday practice: Insubordination in the ICU?
About 10:30 p.m. on November 12, John Doe* was admitted with irregular breathing and heart rate to the emergency department (ED) of a large teaching hospital. Various diagnostic tests were done. At about 2:00 a.m. on November 13, Mr. Doe went into respiratory arrest and was intubated and ventilated manually. Dr. Jones* decided to admit Mr. Doe to the ICU stat, and called the ICU to advise the nursing staff of the admission. The nurse who took the call said, “Dr. Jones, we are very busy. We need more help if we are to admit another patient. Do you want to call the night supervisor, or should I?” Dr. Jones indicated that he wanted the ICU nurse to call the supervisor and let him know what she said. Meanwhile, Dr. Jones called Dr. Smith*, the intensivist on call, to apprise him of the patient’s condition and his need to admit him to the ICU as soon as possible. The ICU had been chronically understaffed for months.
Meanwhile, the ICU nurse called the house supervisor and apprised her of the new admission — who also was a ventilator patient — and of the need for more nurses in the ICU before this patient could be given safe care — in fact, any care at all. The supervisor told her to “do the best you can” and promised to call the ED to see if they could “hold’ the patient until the day shift arrived. She did so, and Dr. Jones made it clear that ED could not adequately care for this patient. The nursing supervisor responded that if Dr. Jones admitted Mr. Doe, he would have to be responsible for his care — a remark that seriously irritated Dr. Jones, who hung up and called Dr. Smith again to tell him that the nurses were giving him a “hard time,” and he needed Dr. Smith’s help getting care for this patient.
Dr. Smith called the ICU and reprimanded the nurse who answered the telephone for giving Dr. Jones “flack” about admitting Doe: she did not know what he was talking about, and assured him that she was not giving Dr. Jones any “flack.” She did, however, tell him that the ICU was at the saturation point and couldn’t take any more patients until they got more help. Smith called the nursing supervisor and told her that Doe was being admitted to ICU, and he expected more staff would be there ASAP.
At 5:20 a.m., Mr. Doe was escorted to the ICU by an ED nurse, Dr. Jones, and Dr. Smith, who transferred Mr. Doe to the one empty bed in ICU. However, when the nurse attempted to give report to any of the ICU nurses, they refused to take it, saying they were too busy. The room Mr. Doe was placed in was not equipped for his care, and the two physicians attempted to assemble the necessary equipment with the occasional help of an ICU nurse, who did, in fact, appear to be swamped. The physicians were angry and overwhelmed. The nurses were angry and overwhelmed. And John Doe was desperately ill. Later in the day, all three RNs on duty in the ICU were suspended without pay for three days for insubordination.
* All names are fictitious to protect privacy.
This situation does not lend itself to a single-issue analysis. For example, one must consider: 1) John Doe’s right to treatment; 2) The rights and responsibilities of nurses as providers of care; 3) The rights and responsibilities of the healthcare agency to make decisions about who shall admit patients, who shall care for which patients, and what the nursing workload will be; 4) The rights and responsibilities of physicians to admit patients and to make decisions affecting the practice of nursing. Mr. Doe had a legal and a moral right to receive the care he needed — and the care the hospital “promised” to provide to citizens of this community: This right includes a right to both the medical and nursing care required.
The registered nurses in the ICU have an ethical — and statutory — responsibility to exercise generally accepted standards of practice for the performance of nursing services. The responsibility includes making professional judgments about their ability or inability to accept certain responsibilities, and a duty to convey this to their nursing managers. Both the ED and the ICU physician agreed that Mr. Doe needed intensive care — and they had a right and a duty to make a medical decision about the level of care the patient needed.
The nursing superviser knew the conditions in the ICU: No charge nurse was on duty, and the nurses already carried a patient load that strained the limits of safe care. Telling the nurses to cope, and disappearing when what appeared to be a frontal assault on the ICU (having a nurse and two physicians escort a patient to the ICU) occurred, indicated an inability (or unwillingness) to fulfill her leadership responsibilities. Moreover, if an ED physician and registered nurse had the time to escort a patient — and the physician could stay and care for the patient himself in the ICU — one can be fairly certain that things were not so busy in the ED that the patient could not have been held another few hours until the ICU day shift arrived.
The nursing supervisor could have: 1) gone to the ICU herself to ascertain whether or not the nurses were able to safely care for another patient, 2) called the ICU nursing director at home to apprise her of the problems, 3) visited the ED to determine whether or not the patient could safely stay there for another 3 hours — and help to gather whatever equipment was needed to ensure the patient’s care, and 4) if ED really could not keep the patient, she could explore a) calling in ICU staff early to care for Doe, b) calling in the on-call post anesthesia team to care for Mr. Doe until day shift arrived, c) notifying the administrator on call that none of the above was possible (if that, indeed, was the case) and/or d) suggesting that the patient be stabilized and transferred to another hospital that had adequate staffing in the ICU.
The hospital, which had a contractual obligation with Mr. Doe’s insurer, had a duty to provide care, including staffing levels adequate for safe patient care. Moreover, any hospital that participates in the Medicare program and has an ED must provide an appropriate medical screening examination to any patient who presents in the ED. Necessary stabilizing medical care must be offered if an emergency medical condition is found to exist.
The nurses in the ICU have a duty to give safe care to their patients, they have a duty to themselves and their patients to ensure, in so far as possible, that conditions are such that they can give safe care to patients, and they have a duty to their employer to render safe care as well as to obey the legitimate authority of their employees representative (in this case, the nursing supervisor). While the physicians have authority over the medical care of the patients, the nursing supervisor is their organizational superior — and the only “order” she gave was to tell them to do “the best you can…” In the professional judgment of these nurses, that meant they should not — must not — accept another patient. Thus, in no way can they be charged with insubordination.
Clearly, this entire situation could have been appropriately resolved if management had appropriately exercised its legitimate role and authority. Mr. Doe was put at risk by the ED staff who insisted on transferring him to the ICU where there was inadequate staffing, and by the nursing supervisor’s poor leadership and inability to negotiate a solution to this problem. The nursing supervisor and the ED staff are employed by the hospital itself; thus the hospital failed in its duty.
1. Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) (Public Law No. 99-272), in a section titled Emergency Medical Treatment and Active Labor Act (EMTALA) (§ 9121(b), codified at 42 U.S.C.A. § 1395dd).
Dr. Leah Curtin, RN, ScD (h), FAAN, is Executive Editor, Professional Outreach, American Nurse Today. An internationally recognized nurse leader, ethicist, speaker, and consultant, she is a strong advocate for both the nursing profession and high-quality patient care. Currently she is Clinical Professor of Nursing at the University of Cincinnati College of Nursing and Health. For over 20 years, she was the Editor-in-Chief of Nursing Management. In 2007, she was appointed to the Standards and Appeals Board of DNV Healthcare, a new Medicare accrediting authority. Dr. Curtin can be reached at LCurtin@healthcommedia.com.