What to do if you think your care is unsafe
By Sharon LaDuke, RN
Patient Documentation Analyst
Claxton-Hepburn Medical Center
Ogdensburg, NY
[Editor’s note: This is a two-part series on liability risks for emergency department (ED) nurses. This month’s column gives steps to take if you feel care is unsafe in your ED because of inadequate staffing or skill level. Next month, we give you important steps to take to reduce liability risks as an ED nurse.]
Nurses are standing on a solid foundation when they report their concerns in ways that reflect standards of practice and facility policies.
For example, it is not unusual for ED nurses to find themselves responsible for the care and safety of patients who meet criteria for admission to a specialty setting, but for whom a bed is not immediately available. You may then find that these patients require skills that you do not have or divert your prompt attention from other ED patients. Such situations create dangers for patients and liability for nurses, and they call for problem-solving and self-protective behaviors. (For more information on caring for critical care patients in the ED, see "Are you uncomfortable caring for ICU patients in the ED? Here are strategies," ED Nursing, June 2002, p. 101, and "9 ways to improve care of ED hold’ patients," ED Nursing, July 2002, p. 115.) Here are some steps to take if you are concerned about safety in your ED:
1. Inform your supervisor about your concerns pertaining to volume.
There are times in any ED when the number of nursing interventions required exceeds the number of nurses available to perform them. In such situations, prioritize the needs of all patients based on standards of practice, not physician preference or some other indefensible criteria. Perform only those interventions that are most critical first.
Notify supervision in a professional, matter-of-fact manner that care is no longer safe, and follow hospital policy. Be prepared to state exactly what kind of help you need.
You may want to offer to help call off-duty ED nurses to see if someone will come in, or suggest that an experienced nurse who lacks ED-specific training be floated over to perform the same skills she normally performs in her regular department. For example, an intensive-care unit (ICU) nurse may care for the ICU-destined patients lining the halls, while a medical/surgical nurse can care for patients awaiting general admission. Even if these nurses cannot assume total care of patients, they can at least carry out tasks, such as the insertion of various tubes and lines, with the oversight of the ED nurse.
2. Inform your supervisor about your concerns regarding the nature of care required.
If you are uncomfortable with a very low-volume, high-risk procedure, you may not be competent to perform that procedure, even if you have all the time in the world to do it. If harm were to result to the patient as a result of your involvement, internal discipline, professional misconduct proceedings and/or a civil suit could result.
Therefore, it’s imperative that you clearly communicate lack of the required skill to the nurse supervisor, who is in a position to make alternate staffing arrangements to ensure patient safety, and who is responsible for ensuring that the skills of nurses caring for patients match the skills those patients need.
Tell the supervisor, "I am not competent to perform this procedure." If you hedge by saying, "I don’t feel comfortable," a supervisor may misjudge the seriousness of the situation, or even think you are simply trying to escape the work involved. After all, nurses are not legally required to be comfortable giving patient care. They are legally required to be competent.
If the supervisor is not able to provide a nurse who is competent, and the care in question is considered emergent or lifesaving, you simply may have to perform to the best of your ability. To refuse could be construed as grounds for discipline. In some cases, it could constitute abandonment. The refusal of an assignment may be justified only "when the risk of harm to the patient is greater by accepting the assignment than by rejecting it."1
3. Work through organizational channels to bring clinical liability issues to the attention of administration.
What puts the nurse at risk for liability also puts the employing facility at risk. Know and follow your hospital’s chain-of-command policy for reporting such issues. In some instances, additional notifications by the nurse are required when a supervisor does not correct a patient-safety problem.
If a nurse advises a supervisor that he or she is not competent to provide specific care, but is required to provide the care anyway, putting this in writing can be useful. Giving a copy to nursing administration as soon as possible after the event in question can help "spread the blame" if the patient is harmed and the nurse is sued.
However, putting things in writing also can work against the nurse by giving others the wrong impression, especially if hastily worded. Before you do this, enlist the help of credible organizational resource people, such as nurse educators, clinical specialists, quality specialists, legal counsel, corporate compliance officers, risk managers, or administrative physicians. These individuals have the expertise and system-savvy to help you decide how best to take an issue forward. This enhances the effectiveness of your efforts and protects you from a backlash.
[Editor’s note: LaDuke can be contacted at Claxton-Hepburn Medical Center, 214 King St., Ogdensburg, NY 13669. Telephone: (315) 393-8880, ext. 5283. E-mail: [email protected].]
Reference
1. The American Nurses Association. Position Statement. The Right to Accept or Reject an Assignment. Accessed at www.nursingworld.org/readroom/position/workplac/wkassign.htm.
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