Protect your practice: curious nurse discipline case is a win for nursing profession

It’s a situation most nurses can relate to. You’re standing up for your patients, your license, your job—and you’re overruled by a physician. An administrator. A pharmacist. What do you do?

In an odd twist, one of the most instructive cases on this point incidentally establishes a legal opinion on the 5-second rule. As the court in question put it, when it comes to nursing practice, “th[e] eyeball test, consistent with the five-second rule some might use to determine whether to eat food… is not… a professionally recognized practice.”

Much more importantly, the court found that when it comes to the practice of nursing, nurses, not anyone else, own the profession and its standard of care.

To wit: in a Delaware jail, two nurses were in the process of counting controlled medications, when one accidentally spilled 10 expensive hepatitis C pills (i.e. Sofosbuvir) onto the ground. Consistent with standard practice, the nurses disposed of the spilled medication in a sharps container. Insofar as the medication costs approximately $1,000 a pill, the nurses also notified the pharmacist on duty.

A jail physician, in turn, eventually contacted a different nurse and instructed her to “retrieve the pills from the sharps container”—which that nurse did. Out of the sharps container also came syringes, lancets and testing strips.

The on-site pharmacist gave the pills an “eyeball test,” determine they were good to go… and the nurse administered them to the patient.

Many things went wrong in this situation. The physician never should have instructed anyone to empty out a sharps container. The nurse should not have followed that instruction. The pharmacist should not have assessed the pills as acceptable for consumption. The nurse should not have followed the pharmacist’s instructions to administer the medication.

However, as unfair as it seems, one thing went right: the courts upheld the Delaware Board of Nursing’s discipline of the nurse in question. Here’s why: no physician, pharmacist, or administrator is responsible for your license, or your practice.

Only you are.

Physicians do not practice nursing. Pharmacists do not practice nursing. Administrators are not responsible for your nursing practice. The piece of paper that you worked your tail off for, spent countless hours studying for, paying for, shedding tears for and standing up for is yours, and only yours—and as the Delaware court found, you are responsible for your practice.

At the end of the day, this is a blessing and a curse. On the one hand, it’s difficult to stand up for yourself in your practice in the face of a physician ordering you to do one thing when it’s obvious that your practice dictates another. On the other hand, this case should empower you: the physician does not control your license or your practice.

It’s an apples and oranges comparison. Physicians and other health care professionals practice their art, while we practice ours. They are responsible for their side of the house, and us ours. Realtors and home inspectors both work on houses but have vastly different jobs outside of each other’s jurisdiction despite the overlap.

So, what can you do in these types of situations? I always recommend that nurses use their independent professional judgment to act in the best interests of the patient—protecting your patient enables you to protect your license.

Ultimately, you might decide that protecting your license may be more important to you and your patients than protecting your job.

Following an inappropriate order has the potential to place the nurse in jeopardy of legal liability. As the Washington Administrative Code on Standards of Nursing Conduct or Practice states, “the nurse shall be responsible and accountable for the quality of nursing care given to clients.” By protecting the patient, you will be able to more effectively defend your practice and your license.

Tips for consideration if you disagree with an order or treatment plan:

1. Prepare: Personalize your standard response for use when inappropriate delegation(s) arises. “Dr. Jones- what you’re directing me to do does not seem to align with standard/best practice. I’ll need to investigate further before I proceed”. This should be done “off-stage,” away from other providers and the patient.
2. Check facts: Assess data and details; access relevant facility policies/procedures; know best practice.
3. Consult: Seek perspective by discussing the situation with a trusted colleague and/or union representatives and stewards.
4. Escalate: Include your supervisor/manager/director to protect your patients and profession. This is especially important when the event is associated with imminent harm.
5. Activate resources: Contact the risk manager or safety officer and use resources to “stop and resolve,” “stop the line,” etc.
6. Document: Capture what happened, what you are being asked to do, and why you are objecting. Put it in writing and ask the other individual or a witness to sign it.

Other Key Principles:

• If an order or treatment plan requires a nurse to exceed scope of practice, the nurse has a legitimate basis for refusal to carry out the order or treatment plan.
• Avoid following orders/treatment plans that result in non-compliance with facility policy/procedure
• Refusal to follow a physician’s order must be based on evidence and standard of care, not on a difference of opinion.
• Do not relinquish under pressure. As a profession, nurses must stay true to the purpose of safe and quality patient care. Avoid actions that are not best for the patient or the nurse’s license.

Deploy the safety technique of Stop and Resolve when orders/treatment plans/delegation:

• Require practice beyond registered nurse scope
• Conflict with facility policy/procedure expectations
• Is inaccurate or erroneous
• Is unsafe with potential harm to the patient/care provider
• Lacks training to perform orders/treatment plans/delegation